Tuesday, July 10, 2018

PRO/EDR> Poliomyelitis update (28): (DR Congo, Papua New Guinea) cVDPVs, WHO

A ProMED-mail post
ProMED-mail is a program of the
International Society for Infectious Diseases

In this update:
[1] DR Congo - WHO, cVDPV2
[2] Papua New Guinea - Relief Web, cVDPV1

[1] DR Congo - WHO cVDPV2
Date: Tue 10 Jul 2018
Source: WHO, Emergencies preparedness, response, Disease Outbreak News

Circulating vaccine-derived poliovirus type 2 - Democratic Republic of
the Congo [10 Jul 2018]
In the Democratic Republic of the Congo, 3 different circulating
vaccine-derived poliovirus type 2 (cVDPV2) outbreaks have been
detected in acute flaccid paralysis (AFP) cases. In February 2018, the
government declared cVDPV2 to be a national public health emergency.

The cVDPV2 strain initially detected and reported in June 2017 from
Haut Lomami Province spread in late 2017 and early 2018 to Tanganyika
and Haut Katanga provinces, respectively. The same virus was confirmed
in Ituri Province in June 2018, close to the border with Uganda, from
an AFP case with onset of paralysis on 5 May 2018. Investigations are
ongoing. WHO assessed the overall public health risk at the national
level to be very high and the risk of international spread to be high
due to the proximity of the recent detection of the AFP case in Ituri
which is close to an international border and with known population

Maniema Province is affected by a separate cVDPV2 outbreak, with 2
cases confirmed in 2017. The date of onset of paralysis of the most
recent case was [18 Apr 2017]. So far, no new cases have been detected
in 2018, and there is no evidence that this virus has spread further

The 3rd and most recently detected outbreak of cVDPV2 was found in
Mongala Province and isolated from an AFP case in the Yamongili Health
Zone. The onset date of paralysis was [26 Apr 2018]. Circulation of
the strain was confirmed when the same strain was isolated in stool
specimens from 2 healthy community contacts.

Figure 1. Distribution of cVDPV2 cases from [1 Jan [?2017 vs 2018 -
Mod.MPP] through 29 Jun 2018 in the Democratic Republic of the Congo
[available at the source URL]

Public health response
WHO and partners are responding to these outbreaks, including through
the use of monovalent oral polio vaccine type 2 (mOPV2) in line with
internationally-agreed upon outbreak response protocols. However,
operational gaps in the response continue to hamper the full
implementation of these protocols, as high-risk populations remain
under-immunized, and the response thus far has not controlled the
outbreak nor prevented its spread.

The geographic extent of the outbreak response to all 3 strains is now
being re-evaluated, given the confirmed spread of one of the strains
to Ituri and confirmation of the new strain in Mongala.

Surveillance and immunization activities are being strengthened in
neighbouring countries.

In February 2018, the government declared cVDPV2 to be a national
public health emergency. The remaining operational gaps in the
outbreak response must be urgently addressed.

WHO risk assessment
WHO assessed the overall public health risk at the national level to
be very high and the risk of international spread to be high. This
risk is magnified by known population movements between the affected
area of Democratic Republic of the Congo, Uganda, Central African
Republic and South Sudan, and the upcoming rainy season which is
associated with increased intensity of virus transmission.

The detection of cVDPV2s underscores the importance of maintaining
high routine vaccination coverage everywhere to minimize the risk and
consequences of any poliovirus circulation. These events also
underscore the risk posed by any low-level transmission of the virus.
A robust outbreak response is needed to rapidly stop circulation and
ensure sufficient vaccination coverage in the affected areas to
prevent similar outbreaks in the future. WHO will continue to evaluate
the epidemiological situation and outbreak response measures being

WHO advice
It is important that all countries, in particular those with frequent
travel and contacts with polio-affected countries and areas,
strengthen surveillance for AFP cases in order to rapidly detect any
new virus importation and to facilitate a rapid response. Countries,
territories and areas should also maintain uniformly high routine
immunization coverage at the district level to minimize the
consequences of any new virus introduction.

WHO's International Travel and Health recommends that all travelers to
polio-affected areas be fully vaccinated against polio. Residents and
visitors for more than 4 weeks from infected areas should receive an
additional dose of OPV or inactivated polio vaccine (IPV) within 4
weeks to 12 months of travel. As per the advice of the Emergency
Committee convened under the International Health Regulations (2005),
efforts to limit the international spread of poliovirus must continue
as it remains a Public Health Emergency of International Concern
(PHEIC). Countries affected by poliovirus transmission are subject to
Temporary Recommendations. To comply with the Temporary
Recommendations issued under the PHEIC, any country infected by
poliovirus should declare the outbreak as a national public health
emergency and consider vaccination of all international travelers.

WHO does not recommend any restrictions on travel and/or trade to the
Democratic Republic of the Congo on the basis of the information
available for the current cVDPV2 outbreaks.

Communicated by:

[The above WHO update in [1] provides an excellent overview of the
cVDPV2 situation in the DR Congo. As presented in prior posts, polio
has been an ongoing issue in the DR Congo since 2017 when 2 separate
outbreaks were identified (see prior ProMED-mail posts referenced
below). An additional worrisome occurrence was the identification of a
3rd outbreak with confirmation of a case near the border with Uganda,
and the very real threat of international spread of the virus.

There is an excellent map showing the involved areas at the source
The HealthMap/ProMED map of the DR Congo can be found at:
<http://healthmap.org/promed/p/194>. See more detailed moderator
comment below. - Mod.MPP]

[2] Papua New Guinea - Relief Web, cVDPV1
Date: Sat 7 Jul 2018
Source: Relief Web [edited]

Situation analysis
Description of the disaster
Papua New Guinea (PNG) health authorities have confirmed that the
country is experiencing its 1st polio outbreak in 18 years, after one
case of the virus was confirmed in an urban settlement in the
country's 2nd largest city. The virus was 1st detected in late April
[2018], and confirmed in late May [2018]. Experts say the virus is now
"circulating" in the affected community. PNG was certified polio-free
in 2000, and has not had a case since 1996. PNG's Department of Health
is working alongside the World Health Organisation (WHO) to respond to
the outbreak of the potentially deadly virus, which can cause lifelong
paralysis in children.

The Department of Health and World Health Organization (WHO) confirmed
in a joint statement, that the virus was 1st detected in a child in
April [2018] and a vaccine-derived poliovirus type 1 (VDPV1) was
isolated as the cause of paralysis in May [2018]. Earlier this month
[July?], the United States Centers for Disease Control and Prevention
confirmed that the virus was circulating in the community after stool
samples from 2 healthy children in the same area tested positive for
the virus.

This represents an outbreak, said the World Health Organization (WHO).
Ministry of Health priority now is to respond and prevent more
children from being infected. WHO and the Health Department have been
working together with other partners including IFRC/PNGRCS
[International Federation of the Red Cross/ Papua New Guinea Red Cross
Society] to conduct a large-scale immunization campaign and strengthen
surveillance systems that would detect the virus. National Department
of Health are also collecting stool specimens from family members of
patients and the community in a "mop-up" immunization campaign
targeting children.

As [polio] is an infectious disease which normally spreads through the
faeces of an infected person contaminate the water or food. Urban
settlements in PNG's major cities have no proper water and sanitation
facilities, also lack of health awareness in settlement areas in
towns. People living in the settlements are migrants from rural areas
for economic opportunity.

As WHO stated that the version of the virus circulating in the
settlement is a "vaccine-derived poliovirus", meaning it is a mutated
version of the weaker polio virus used in vaccinations.
Vaccine-derived polioviruses are rare, and tend to occur in
populations with very low vaccination rates. They develop when
children who have not been vaccinated come into contact with the
excrement of vaccinated children, and are exposed to the weaker virus.
The WHO and PNG authorities have launched an emergency immunization
campaign to try to prevent other children from becoming infected.

Lae is the 2nd largest city of PNG, which is located in Morobe
province. Morobe province reportedly had a polio vaccination rate of
61 per cent prior to the outbreak. PNG Health Authorities said 845
children had been immunised since the virus was 1st detected. Due to
low immunization coverage in other bordering province Madang and
Eastern Highland are also targeted for polio awareness and
immunization campaign which will start in July 2018.

According to WHO, the index case is a 6-year-old boy from '4 mile'
settlement in Lae, Morobe, VDPV type 1 confirmed from child's stool -
Confirmed by VIDRL (Victorian Infectious Diseases Reference
Laboratory) on [Mon 21 May 2018]. As per WHO guidelines, the total of
22 from Morobe and 20 from Eastern Highlands children in the index
case community contacts were tested, to determine if the virus is
circulating. Figure 1 below shows the affected and immediate risk
districts identified by the National Department of Health and the
National Polio Outbreak Taskforce. [available at source URL]

On [Thu 21 Jun 2018], results received from lab that the same virus
was found in 2 contacts in Lae. This demonstrates that the virus is
circulating in Lae, Morobe; however, missed transmission in other
areas cannot yet be ruled out. The following day on [Fri 22 Jun 2018],
the National, International Health Regulations (IHR) Focal Point of
Papua New Guinea notified WHO of the index case of cVDPV1 and the
confirmation cVDPV1 among 2 asymptomatic community contacts of the
index case. A few days later on [Mon 25 Jun 2018], the National
Department of Health declared a polio outbreak in Papua New Guinea. On
[Tue 26 Jun 2018], the Papua New Guinea National Executive Council and
Cabinet declared the polio outbreak as a National Public Health
Emergency. The Government committed PGK 6.7 million ([approximately
Swiss Francs] CHF 2 million) to support outbreak response. The Global
Polio Eradication Initiative (GPEI) provided initial supported to
Papua New Guinea with USD 500 000 ([approximately Swiss Francs] CHF
497 000) for response activities. On [Wed 27 Jun 2018], the National
Department of Health activated the National Emergency Operations
Centre and formed a National Emergency Response Team.

Surveillance activities planned by WHO:
- Increase the target rate for non-polio AFP
- Increase the annualised target for non-polio Acute Flaccid
Paralysis (AFP) rate to 3 cases per 100 000 population in the
provinces of Chimbu, Eastern Highlands, Jiwaka, Madang, Morobe,
Western Highlands and National Capital District.
- Increase the annualised target for non-polio AFP rate to 2 cases
per 100 000 population in all other provinces.
- Collect stool samples from contacts of AFP cases
- Collect stool samples from 3 close family or household contacts of
all AFP cases in Goroka, Lae, Madang City and Port Moresby.
- Collect stool samples from 3 close family or household contacts of
all AFP cases with inadequate stool sample collection in the provinces
of Chimbu, Eastern Highlands (outside Goroka), Jiwaka, Madang (outside
Madang City), Morobe (outside Lae), Western Highlands and National
Capital District.

In 7 highest risk provinces, (Morobe, Madang, Eastern Highlands
Province, Jiwaka, Chimbu, Western Highland Province, National Central
- Active search of AFP cases.
- Review medical records for last 6 months.
- Training on AFP surveillance for health care workers to be
- Implement environmental surveillance, initially in National Central
District and Lae.

Table 1: Low Vaccination coverage (percentages) across the provinces:
Province: 2014 / 2015 / 2016 / 2017
Morobe: 28 / 76 / 61 / 35
Eastern Highlands: 60 / 57 / 41 / 43
Madang: 15 / 46 / 39 / 27
Overall in PNG: 64 / 74 / 73 / 47

[More information on the planned activities are available at the
source URL. - Mod.MPP]

Communicated by:
ProMED-mail Rapporteur Mary Marshall

[The Relief Web/IFRC Situation Analysis provides a more detailed
discussion on the outbreak in Papua New Guinea, involving a cVDPV1. A
major concern is that this is occurring in the 2nd largest city/town
in Papua New Guinea with documented circulation in the community. The
vaccination covereages provided in Table 1 are indicative of the
situation in the country, with vaccination coverages ripe for
circulation of polioviruses either wild or vaccine-derived.

As highlighted in prior comments, polio vaccination coverages have not
been uniformly maintained at high enough levels to prevent spread of a
poliovirus (both WPVs and cVDPVs) in many of the countries around the
world. This has especially been noted in countries after declaration
of a polio-free status of the country. Higher vaccination coverages
were maintained through the national immunization days and subnational
immunization campaigns, which decreased in frequency once polio free
status was declared in countries and neighboring countries. The
appearance of outbreaks of VDPVs in multiple countries around the
world in recent times (Syria 2017, DR Congo 2017-2018, Somalia 2017 -
environmental sample 2018 human case, Kenya 2018 - environmental
sample, and Papua New Guinea 2018).

Of interest is the identification of "at risk countries" by WHO and
available on the Global Polio Eradication Website. These countries
identified to have both low levels of vaccination coverages and
inadequate surveillance activities that are risk factors for
poliovirus introduction and circulation within the countries. Fifteen
countries identified as high risk countries include: Cameroon, Central
African Republic, Chad, Equatorial Guinea, Ethiopia, Guinea, Iraq, Lao
People's Democratic Republic, Liberia, Madagascar, Myanmar, Niger,
Sierra Leone, South Sudan and Ukraine. (see
<http://polioeradication.org/where-we-work/key-at-risk-countries/> for
list of countries and links to country specific information).
Remembering the media report on municipalities in Brazil noted to have
suboptimal vaccination coverages, there are many countries not
included on the "high risk country list" where there are pockets of
unimmunized populations that should there be a traveller introducing a
poliovirus into these pockets, there could be transmission of the
poliovirus (again both WPV and cVDPV's) (see Poliomyelitis update
(27): global http://promedmail.org/post/20180706.5890218).

There is an excellent map showing the involved areas at the source

The HealthMap/ProMED map of Papua New Guinea can be found at:
<http://healthmap.org/promed/p/188>. - Mod.MPP

HealthMap/ProMED map available at:
DR Congo: <http://healthmap.org/promed/p/194>]

[See Also:
Poliomyelitis update (27): global
Poliomyelitis update (26): Papua New Guinea, WHO, Congo DR, cVDPVs
Poliomyelitis update (25): Afghanistan (HM) WPV1
Poliomyelitis update (24): Global (Papua New Guinea, DR Congo,
Somalia), cVDPVs http://promedmail.org/post/20180628.5881311
Poliomyelitis update (23): Papua New Guinea
Poliomyelitis update (22): Global (Papua New Guinea, Congo DR,
Somalia), cVDPVs http://promedmail.org/post/20180622.5870865
Poliomyelitis update (21): global (Pakistan, Venezuela) PAHO update
Poliomyelitis update (20): (Pakistan) WPV1 conf
Poliomyelitis update (19): Venezuela, vaccine virus found, VAPP susp
Poliomyelitis update (18): Pakistan (BA) RFI:
Poliomyelitis update (17): Venezuela, cases conf. global (Pakistan),
RFI http://promedmail.org/post/20180607.5845259
Poliomyelitis update (16): Global (Afghanistan), Pakistan
Poliomyelitis update (15): Pakistan (BA) RFI
Poliomyelitis update (14): global, cVDPV Horn of Africa, PV2 post
erad. stocks http://promedmail.org/post/20180526.5819775
Poliomyelitis update (13): positive environmental samples
Poliomyelitis update (12): global (Afghanistan, Pakistan)
Poliomyelitis update (11): global (Afghanistan, DR Congo)
Poliomyelitis update (10): Congo DR, cVDPV
Poliomyelitis update (09): Afghanistan (WPV), Congo DR (cVDPV)
Poliomyelitis update (08): Somalia, cVDPV environmental samples
Poliomyelitis update (07): (Pakistan, Afghanistan, Congo DR)
Poliomyelitis update (06): Global (Afghanistan)
Poliomyelitis update (05): Afghanistan, RFI
Poliomyelitis update (04): global (Afghanistan, Pakistan), Nigeria
rumors http://promedmail.org/post/20180125.5584166
Poliomyelitis update (03): global (Afghanistan, Pakistan, Congo DR),
violence http://promedmail.org/post/20180118.5569033
Poliomyelitis update (02): (Pakistan, Afghanistan, Congo DR)
Poliomyelitis update (01): global (Afghanistan)
Poliomyelitis update (47): Pakistan, global (Congo DR)
Poliomyelitis update (46): global (Pakistan, Afghanistan), Lake Chad
Region http://promedmail.org/post/20171221.5518292
Poliomyelitis update (45): Pakistan, Afghanistan, Gabon
Poliomyelitis update (44): (Australia), pos. environmental sample,
iVDPV2 iden. http://promedmail.org/post/20171215.5506586
Poliomyelitis update (43): (Australia), positive environmental sample,
RFI http://promedmail.org/post/20171215.5506172
Poliomyelitis update (42): global (Pakistan, Afghanistan, Syria)
Poliomyelitis update (41): Syria
Poliomyelitis update (40): global (Pakistan, Afghanistan, Syria)
Poliomyelitis update (30): global (Afghanistan, Pakistan, Syria)
Poliomyelitis update (20): global (Syria, Afghanistan)
Poliomyelitis update (10): Syria (DY), Congo DR, cVDPV, WHO
Poliomyelitis (01): Pakistan (GB), global, RFI
Poliomyelitis update (21): IPV shortage, global
Poliomyelitis update (01): India, VDPV, wild type-free
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