Poliomyelitis Eradication in Eastern Mediterranean Region - Progress Report 2006

This 37-page document reports on the Eastern Mediterranean Region (EMR) countries, which in 1988, with the exception of Kuwait, reported cases of polio. The report states that by the end of 2006, polio incidence had been reduced and was limited primarily to endemic countries. The report details the current (2007) situations in these countries, discussing the emergence of the wild polio virus, cross-border infection, and geographic containment in polio endemic countries. Communication aspects detailed in the document include immunisation campaigns, cross-border cooperation and strategy planning, campaigns in insecure areas, increased preparation measures regarding importation of the virus, and surveillance measures.


Due to security challenges in 2006-7 on the border of two polio endemic countries, Pakistan and Afghanistan, the following measures, as stated in the report, were implemented: "These included holding regular coordination meetings between district teams on both borders, establishing permanent cross-border vaccination posts which are active year round and conducting synchronised vaccination campaigns ensuring that border areas are covered at the same time in both countries with joint review of micro plans to ensure that no border areas are missed during campaigns. As a sign of high level commitment, the Ministers of Health of both countries inaugurated the December 2006 round together at one of the border crossing points."


Afghanistan reported success in acute flaccid paralysis (AFP) surveillance in the rest of the country, as well as 11 rounds of supplementary immunisation activities in 2006; five were national immunisation days (NIDs) and the other six were subnational immunisation days (SNIDs). In Afghanistan, a national Polio Eradication Action Group was formed by the president. Attempts, though unsuccessful in 2006, included "days of tranquility" efforts for immunisation on days designated for the cessation of conflict. Using a “Focussed District Strategy”, windows of opportunity were used to conducting one-day operations using village-based vaccination teams, leading to better community involvement for the application of polio, measles, and tetanus vaccinations.


In Pakistan, six rounds of NIDs and six SNIDs were conducted during 2006; however, as stated in the report, campaigns have not yet reached the level necessary to interrupt transmission.


The document describes the importation of the virus in the EMR countries, due to cross-border travel. It compares countries where the virus was halted and countries where it spread. For example, in countries with high levels of population immunity, such as Lebanon, Palestine, Saudi Arabia, and Syrian Arab Republic, no secondary spread or evidence of re-established circulation occurred. However, in countries with immunity gaps - Sudan in 2004 and Somalia and Yemen in 2005 - secondary spread occurred. An example of the response to the reappearance of the polio virus in Yemen is fortified rounds of immunisation in 2005 and 2006 that were able to provide 95% coverage.


However, the risks of inadequate surveillance and low routine coverage of immunisation remained in the region, particularly prevalent in the Horn of Africa, according to this document. Problems in reaching nomadic populations and high numbers of refusals based on religious beliefs, unfounded rumours, and campaign fatigue appeared to be contributing factors. The situation in Somalia was complicated by prevailing insecurity, very limited infrastructure, poor routine immunisation, a large nomadic population, and porous borders with high population movement. The main challenge was the security situation, which affected implementation of high quality supplementary immunisation activities and AFP surveillance.


Strategies for limiting importation at border crossings are evolving to supplement the ""two pillars of preparedness" which include a sensitive surveillance system and high population immunity. Saudi Arabia, for example, has enhanced its polio immunisation requirements for people from polio-infected areas intending to travel to Saudi Arabia for pilgrimage. All travellers coming from polio-infected areas are required to provide evidence of vaccination against polio before travelling in order to be granted an entry visa. These travellers also receive a dose of OPV upon arrival. To guard against spread after importation, some polio-free countries conducted campaigns addressing mainly high-risk areas and areas with low routine coverage. Such campaigns were conducted in Djibouti, Egypt, Islamic Republic of Iran, Iraq, Jordan, Saudi Arabia, Sudan, and Syrian Arab Republic.


This house-to-house campaigning included:

• Social mobilisation efforts involving community and religious leaders and ensuring political commitment to informing all families;
• Detailed micro-plans with maps, used to reach every child, with special focus on risky areas and difficult-to-reach groups;
• Control rooms at district, provincial, and national levels to report daily on progress of campaigns, to identify
  problems, and to intervene with solutions;
• Volunteers assisting as vaccinators under intensified supervision;
• Finger-marking to guarantee that no child was missed; and
• Independent monitoring of campaigns used to improve operations.

The document discusses surveillance for AFP, which is the activity for monitoring to detect immunity interruption in a population. With the support of laboratories for testing stool samples, AFP surveillance results inform technical advisory groups about where increased campaigns are needed. Certification of country polio eradication is the goal of national level documentation by the National Certification Committees (NCCs) resulting from this surveillance. It is submitted to the Regional Certification Committees (RCC) with the goal of declaring nations polio free one-by-one, until the EMR can be declared polio free.