Standard Operating Procedures: Responding to a Poliovirus Event and Outbreak - Parts 1 and 2 - Effective 01 November 2017 until 30 April 2018

"While these guidelines offer concrete parameters for decision making, they cannot address every possible scenario. Decision makers should consider the local and national context, and their specific epidemiologic circumstances."

This 2-part Global Polio Eradication Initiative (GPEI) strategy document provides detailed guidance for polio outbreak response and preparedness, including communication-related guidance. Version 1 was published in February 2015, followed by version 2 (2.1 published April 20 2016, 2.2 published August 15 2016, and 2.3 published May 1 2017 - see Related Summaries, below). This version, 2.4, presents overall response requirements for dealing with type 1, 2, and 3 poliovirus following monovalent type 2 oral polio vaccine (mOPV2) cessation. It represents an update to: (i) emphasise quality of supplementary immunisation activity (SIA) implementation, as recommended by the World Health Organization (WHO) Strategic Advisory Group of Experts on Immunization SAGE and technical advisors within the Global Polio Eradication Initiative (GPEI); and (ii) introduce a requirement for a response preparedness dashboard and/or checklist and timeline before commencing outbreak or event response SIAs.

Part 1: General SOPs (standard operating procedures) describes the general principles, steps, and activities to facilitate timely and effective responses to poliovirus events and outbreaks, incorporating lessons learned from previous outbreak response efforts. This document summarises roles and responsibilities of national governments and GPEI partners. The main objectives of the SOPs are to: (i) establish standards and timelines for various response activities; and (ii) guide national governments and GPEI partners in key support functions. Section 2.7, in particular, reflects the increased focus of this version of the SOPs on high-quality SIAs for event and outbreak response.

As of late 2017, three countries were still fighting the endemic wild poliovirus (WPV), while these and other countries were experiencing new outbreaks or events due to the emergence of vaccine-derived polioviruses (VDPVs) in areas with persistently low population immunity. The Polio Eradication and Endgame Strategic Plan 2013-2018 calls for any poliovirus outbreak in a polio-free country to be stopped within 120 days of detection. In order to achieve this, there is a need to have common understanding of intensified eradication strategies and joint effort by national governments and GPEI partners. It is noted that 5 strategic pillars are needed to effectively interrupt transmission in an outbreak setting: (i) a fully engaged national government, (ii) a rapid risk assessment and identification of transmission risk zones, (iii) a robust immunisation response, (iv) an effective communication and social mobilisation, and (v) enhanced surveillance. Implementation of high-quality eradication strategies is the responsibility of the national government, while GPEI partners are to provide necessary guidance and support to develop effective response strategies and select appropriate vaccine options. GPEI partners support the countries in 6 key functions: (i) outbreak response and assessment, (ii) coordination and advocacy, (iii) technical and human resources, (iv) information management, (v) communication, social mobilisation, and behaviour change, and (vi) finances and logistics.

To cite an example of some guidelines offered in the document: Strategies for building polio vaccine demand and mitigating the risk of population fatigue during repeated vaccination campaigns include:

• Rapid analysis of the knowledge, attitudes, and community practices around vaccination and barriers to reaching every member of the intended population;
• Design of strategic messages and key strategies based on social profiling of polio-confirmed and zero-dose non-polio acute flaccid paralysis (AFP) cases or contact cases, as well as any other available social research;
• Mass communication messages informing the population of the outbreak, the risks and implications of contracting polio, and the need to take multiple doses of the polio vaccine for individual protection and to stop the outbreak;
• Engagement with existing humanitarian or development organisations, United Nations (UN) country teams, and/or government community social networks to ensure the coordinated and coherent dissemination of messages;
• Systematic reporting of identified social indicators, especially for missed children, refusals, and absences, as part of the overall national outbreak reporting mechanism; and
• Adjustment of communication interventions based on outcomes of monitoring data to scale and refine communication for development (C4D) intervention targeting.

As the introduction to Part 2: Protocol for Poliovirus Type 2 clarifies, since the global switch from trivalent oral polio vaccine (tOPV) to bivalent OPV (bOPV) in April 2016, the detection of any type 2 poliovirus (wild, vaccine-derived, or Sabin) in any sample from any source is generally considered to be a global public health emergency that requires rapid and high-quality coordinated action from national health authorities and the GPEI. Since April 2016, three circulating VDPV type 2 (cVDPV2) and many more VDPV2s emerged. The response to detection of a type 2 poliovirus isolate after OPV2 cessation follows the same principles to those required for investigating and responding to any polio outbreak as outlined in Part 1: General SOPs. However, the post-tOPV era requires a heightened sense of urgency, vigilant surveillance, a carefully planned risk assessment, and a specific vaccine response due to the risk of re-introduction of type 2 virus.