Progress Toward Poliomyelitis Eradication - Pakistan, January 2019-September 2020.

Pakistan and Afghanistan are the only countries where wild poliovirus type 1 (WPV1) is endemic (1,2). In 2019, Pakistan reported 147 WPV1 cases, approximately 12 times the number reported in 2018. As of September 15, 72 cases had been reported in 2020. Since 2019, WPV1 transmission has also spread from Pakistan's core poliovirus reservoirs (Karachi, Peshawar, and Quetta block) to southern districts of Khyber Pakhtunkhwa (KP), Punjab, and Sindh provinces. Further, an outbreak of circulating vaccine-derived poliovirus type 2 (cVDPV2), first detected in July 2019, has caused 22 paralytic cases in 2019 and 59 as of September 15, 2020, throughout the country. The coronavirus disease 2019 (COVID-19) pandemic has substantially reduced delivery of polio vaccines through essential immunization (formerly routine immunization) and prevented implementation of polio supplementary immunization activities (SIAs)* during March-July 2020. This report describes Pakistan's progress in polio eradication during January 2019-September 2020 and updates previous reports (1,3,4). The Pakistan polio program has reinitiated SIAs and will need large, intensive, high-quality campaigns with strategic use of available oral poliovirus vaccines (OPVs)† to control the surge and widespread transmission of WPV1 and cVDPV2.

Progress Toward Poliomyelitis Eradication - Pakistan, January 2018-September 2019.

Afghanistan and Pakistan are the only countries that continue to confirm ongoing wild poliovirus type 1 (WPV1) transmission (1). During January 2018-September 2019 the number of WPV1 cases in Pakistan increased, compared with the number during the previous 4 years. This report updates previous reports on Pakistan's polio eradication activities, progress, and challenges (2,3). In 2018, Pakistan reported 12 WPV1 cases, a 50% increase from eight cases in 2017, and a 31% increase in the proportion of WPV1-positive sites under environmental surveillance (i.e., sampling of sewage to detect poliovirus). As of November 7, 2019, 80 WPV1 cases had been reported, compared with eight cases by the same time in 2018. An intensive schedule of supplementary immunization activities (SIAs)* implemented by community health workers in the core reservoirs (i.e., Karachi, Peshawar, and Quetta) where WPV1 circulation has never been interrupted, and by mobile teams, has failed to interrupt WPV1 transmission in core reservoirs and prevent WPV1 resurgence in nonreservoir areas. Sewage samples have indicated wide WPV1 transmission in nonreservoir areas in other districts and provinces. Vaccine refusals, chronically missed children, community campaign fatigue, and poor vaccination management and implementation have exacerbated the situation. To overcome challenges to vaccinating children who are chronically missed in SIAs and to attain country and global polio eradication goals, substantial changes are needed in Pakistan's polio eradication program, including continuing cross-border coordination with Afghanistan, gaining community trust, conducting high-quality vaccination campaigns, improving oversight of field activities, and improving managerial processes to unify eradication efforts.

World Health Organization Guidelines for Containment of Poliovirus Following Type-Specific Polio Eradication - Worldwide, 2015.

In 1988, the World Health Assembly of the World Health Organization (WHO) resolved to eradicate polio worldwide. Among the three wild poliovirus (WPV) types (type 1, type 2, and type 3), WPV type 2 (WPV2) has been eliminated in the wild since 1999, and WPV type 3 (WPV3) has not been reported since 2012. In 2015, only Afghanistan and Pakistan have reported WPV transmission. On May 25, 2015, all WHO Member States endorsed World Health Assembly resolution 68.3 on full implementation of the Polio Eradication and Endgame Strategic Plan 2013-2018 (the Endgame Plan), and with it, the third Global Action Plan to minimize poliovirus facility-associated risk (GAPIII). All WHO Member States have committed to implementing appropriate containment of WPV2 in essential laboratory and vaccine production facilities* by the end of 2015 and of type 2 oral poliovirus vaccine (OPV2) within 3 months of global withdrawal of OPV2, which is planned for April 2016. This report summarizes critical steps for essential laboratory and vaccine production facilities that intend to retain materials confirmed to contain or potentially containing type-specific WPV, vaccine-derived poliovirus (VDPV), or OPV/Sabin viruses, and steps for nonessential facilities† that process specimens that contain or might contain polioviruses. National authorities will need to certify that the essential facilities they host meet the containment requirements described in GAPIII. After certification of WPV eradication, the use of all OPV will cease; final containment of all polioviruses after polio eradication and OPV cessation will minimize the risk for reintroduction of poliovirus into a polio-free world.

Possible eradication of wild poliovirus type 3--worldwide, 2012.

In 1988, the World Health Assembly resolved to eradicate polio worldwide. Since then, four of the six World Health Organization (WHO) regions have been certified as polio-free: the Americas in 1994, the Western Pacific Region in 2000, the European Region in 2002, and the South-East Asia Region in 2014. Currently, nearly 80% of the world's population lives in areas certified as polio-free. Certification may be considered when ≥3 years have passed since the last isolation of wild poliovirus (WPV) in the presence of sensitive, certification-standard surveillance. Although regional eradication has been validated in the European Region and the Western Pacific Region, outbreaks resulting from WPV type 1 (WPV1) imported from known endemic areas were detected and controlled in these regions in 2010 and 2011, respectively. The last reported case associated with WPV type 2 (WPV2) was in India in 1999, marking global interruption of WPV2 transmission. The completion of polio eradication was declared a programmatic emergency for public health in 2012, and the international spread of WPV1 was declared a public health emergency of international concern in May 2014. The efforts needed to interrupt all indigenous WPV1 transmission are now being focused on the remaining endemic countries: Nigeria, Afghanistan, and Pakistan. WPV type 3 (WPV3) has not been detected in circulation since November 11, 2012. This report summarizes the evidence of possible global interruption of transmission of WPV3, based on surveillance for acute flaccid paralysis (AFP) and environmental surveillance.

Polio-free certification and lessons learned--South-East Asia region, March 2014.

In 1988, the World Health Assembly resolved to interrupt wild poliovirus (WPV) transmission worldwide. By 2006, the annual number of WPV cases had decreased by more than 99%, and only four remaining countries had never interrupted WPV transmission: Afghanistan, India, Nigeria, and Pakistan. The last confirmed WPV case in India occurred in January 2011, leading the World Health Organization (WHO) South-East Asia Regional Commission for the Certification of Polio Eradication (SEA-RCC) in March 2014 to declare the 11-country South-East Asia Region (SEAR), which includes India, to be free from circulating indigenous WPV. SEAR became the fourth region among WHO's six regions to be certified as having interrupted all indigenous WPV circulation; the Region of the Americas was declared polio-free in 1994, the Western Pacific Region in 2000, and the European Region in 2002. Approximately 80% of the world's population now lives in countries of WHO regions that have been certified polio-free. This report summarizes steps taken to certify polio eradication in SEAR and outlines eradication activities and lessons learned in India, the largest member state in the region and the one for which eradication was the most difficult.

Prevalence of asymptomatic poliovirus infection in older children and adults in northern India: analysis of contact and enhanced community surveillance, 2009.

BACKGROUND: In 2009, enhanced poliovirus surveillance was established in polio-endemic areas of Uttar Pradesh and Bihar, India, to assess poliovirus infection in older individuals. METHODS: In Uttar Pradesh, stool specimens from asymptomatic household and neighborhood contacts of patients with laboratory-confirmed polio were tested for polioviruses. In Bihar, in community-based surveillance, children and adults from 250 randomly selected households in the Kosi River area provided stool and pharyngeal swab samples that were tested for polioviruses. A descriptive analysis of surveillance data was performed. RESULTS: In Uttar Pradesh, 89 of 1842 healthy contacts of case patients with polio (4.8%) were shedding wild poliovirus (WPV); 54 of 85 (63.5%) were ≥5 years of age. Shedding was significantly higher in index households than in neighborhood households (P<.05). In Bihar, 11 of 451 healthy persons (2.4%) were shedding WPV in their stool; 6 of 11 (54.5%) were ≥5 years of age. Mean viral titer was similar in older and younger children. CONCLUSIONS: A high proportion of persons≥5 years of age were asymptomatically shedding polioviruses. These findings provide indirect evidence that older individuals could have contributed to community transmission of WPV in India. Polio vaccination campaigns generally target children<5 years of age. Expanding this target age group in polio-endemic areas could accelerate polio eradication.

Affordable inactivated poliovirus vaccine: strategies and progress.

After polio eradication is achieved, the use of live-attenuated oral poliovirus vaccine (OPV) must be discontinued because of the inherent risk of the Sabin strains to revert to neurovirulence and reacquire greater transmissibility that could potentially result in the reestablishment of polio transmission. In 2008, the World Health Assembly mandated that the World Health Organization establish a strategy for developing more-affordable inactivated poliovirus vaccine (IPV) options for low-income countries. In 2012, the Strategic Advisory Group of Experts (SAGE) on Immunization recommended universal IPV introduction as a risk-mitigation strategy before the phased cessation of OPV (starting with Sabin type 2) and emphasized the need for affordable IPV options. In 2013, SAGE reiterated the importance of attaining the long-term target price of IPV at approximately $0.5 per immunizing dose and encouraged accelerated efforts to develop lower-cost IPV options. This article outlines the 4-pronged approach that is being pursued to develop affordable options and provides an update on the current status and plans to make IPV affordable for developing-country use.

Progress toward global interruption of wild poliovirus transmission, 2010-2013, and tackling the challenges to complete eradication.

Despite substantial progress, global polio eradication has remained elusive. Indigenous wild poliovirus (WPV) transmission in 4 endemic countries (Afghanistan, India, Nigeria, and Pakistan) persisted into 2010 and outbreaks from imported WPV continued. By 2013, most outbreaks in the interim were promptly controlled. The number of polio-affected districts globally has declined by 74% (from 481 in 2009 to 126 in 2013), including a 79% decrease in the number of affected districts in endemic countries (from 304 to 63). India is now polio-free. The challenges to success in the remaining polio-endemic countries include (1) threats to the security of vaccinators in each country and a ban on polio vaccination in areas of Afghanistan and Pakistan; (2) a risk of decreased government commitment; and (3) remaining surveillance gaps. Coordinated efforts under the International Health Regulations and efforts to mitigate the challenges provide a clear opportunity to soon secure global eradication.

Attitudes and practices of auxiliary nurse midwives and accredited social health activists in Uttar Pradesh and Bihar regarding polio immunization in India.

Although India was removed from the list of polio endemic countries in January 2012, maintaining the focus on polio vaccination is critically important to prevent reintroduction of the virus. In 2009-2010, we conducted a study to assess the attitudes and practices of frontline health workers in India regarding polio immunization in Uttar Pradesh and Bihar. More than 95% of auxiliary nurse midwives (ANMs) and accredited social health activists (ASHAs) agreed that polio supplementary immunization campaigns helped in increasing acceptance of all vaccines. The majority of ANMs (60-70%) and ASHAs (56-71%) believed that polio immunization activities benefitted or greatly benefitted other activities they were carrying out. Less than 5% of ANMs and ASHAs felt they were very likely to face resistance when promoting or administering polio vaccine. This study provides information that may be useful for programs in other countries for polio eradication and in India for measles elimination.

Predictors of administration and attitudes about pneumococcal, Haemophilus influenzae type b and rotavirus vaccines among pediatricians in India: a national survey.

INTRODUCTION: According to the World Health Organization in 2008, pneumonia accounted for 20% of deaths and diarrheal diseases accounted for 13% of deaths among children under 5 in India. Vaccines are available for Streptococcus pneumoniae (pneumococcal conjugate vaccine (PCV)), Haemophilus influenzae type b (Hib vaccine), and rotavirus. Barriers to including these vaccines in routine immunization schedule in India include potential negative impacts on fragile existing immunization programs and cost. Pediatricians who are members of the Indian Academy of Pediatrics (IAP) are important stakeholders for vaccine delivery and maintaining public confidence in vaccines. METHODS: A random sample of 785 pediatricians belonging to IAP was selected for the survey conducted from June 2009 to June 2010. Descriptive analyses using sampling weights were performed to evaluate the distributions of variables assessing vaccine-related attitudes and behaviors among pediatricians. Logistic regression was used to assess factors associated with routine vaccine use. RESULTS: The majority of pediatricians reported administering PCV (85.6%), Hib (95.9%), and rotavirus (80.2%) vaccine selectively or routinely. Pediatricians who had high perceived disease susceptibility were 2.42 times more likely to report routine administration of Hib vaccine (OR 2.42, 95% CI 1.24, 4.74). Pediatricians who had high perceived Hib vaccine efficacy were 4.74 times more likely to administer Hib vaccine routinely (OR 4.74, 95% CI 2.09, 10.74). Perceptions of disease susceptibility and severity or of vaccine safety and efficacy were not associated with routine administration of PCV or rotavirus vaccine. CONCLUSIONS: Understanding predictors of routine use of a new vaccine could help focus interventions to improve the routine use of other vaccines. The importance of perceived susceptibility to and severity of diseases caused by S. pneumoniae, Hib, and rotavirus and perceived efficacy and safety of the vaccines by pediatricians presents an opportunity to design strategies to build support for new vaccine introduction and may have important implications for national immunization policy in India.

Comparison of attitudes about polio, polio immunization, and barriers to polio eradication between primary health center physicians and private pediatricians in India.

OBJECTIVES: The objectives of this study were to compare attitudes and perceptions of primary health center (PHC) physicians and pediatricians in Uttar Pradesh and Bihar toward polio disease, immunization, and eradication, and to identify barriers to polio eradication. METHODS: PHC physicians from blocks with at least one confirmed polio case during January 2006 to June 2009 were selected for an in-person survey. Pediatricians were members of the Indian Academy of Pediatrics and were selected from a national directory of members for telephone or mail survey. RESULTS: A higher percentage of PHC physicians than pediatricians reported that an unvaccinated child was susceptible to polio (82.1% vs. 63.0%, p<0.0001) and that polio disease was severe in a child aged 1-5 years (77.7% vs. 62.2%, p<0.0001). PHC physicians and pediatricians expressed confidence in the protectiveness and safety of oral polio vaccine and cited parents' lack of awareness of the importance of polio eradication as an important barrier to eradication. Strengthening routine immunization efforts was reported as the leading intervention required to eradicate polio. CONCLUSIONS: PHC physicians and pediatricians support and have confidence in the success of polio eradication efforts. These findings will be useful for policy-makers involved in the planning of eradication strategies. Providers and parents need to maintain confidence in polio vaccination if polio is to be eradicated.

Attitudes of pediatricians and primary health center physicians in India concerning routine immunization, barriers to vaccination, and missed opportunities to vaccinate.

BACKGROUND: India has some of the lowest immunization rates in the world. The objective of this study was to determine the attitudes and practices of pediatricians and physicians working in primary health centers (PHCs) regarding routine immunization and identify correlates of missed opportunities to vaccinate children. We focused on Uttar Pradesh and Bihar, which has faced some of the greatest challenges to achieving high routine immunization coverage. METHODS: A sample of pediatricians from Uttar Pradesh and Bihar was selected from the national membership of the Indian Academy of Pediatrics to participate in either a phone or mail survey. For the sampling frame, the PHCs within selected blocks were enumerated to provide a list from which individuals could be randomly sampled. In all, 614 PHCs in Uttar Pradesh and 159 PHCs were selected for in-person surveys. RESULTS: The response rate for pediatricians was 47% (238/505) and 93% for PHC physicians (719/773). The greatest barrier to vaccinating children with routine immunizations, reported by both pediatricians (95.7%) and PHC physicians (95.1%), was parents' lack of awareness of their importance. Correlates of missing an opportunity to vaccinate for PHC physicians included holding other health care workers responsible for vaccination. PHC physicians were 50% to 70% less likely to vaccinate a child themselves if they thought another type of health care worker was responsible. CONCLUSIONS: Future interventions to increase vaccination coverage should address parental knowledge about the importance of vaccines. Understanding and addressing factors associated with missed opportunities to vaccinate may help improve vaccine coverage in Uttar Pradesh and Bihar.