Progress Toward Poliomyelitis Eradication -- Europe and Central Asian Republics, 1997-May 1998

In 1988, the World Health Assembly resolved to eradicate poliomyelitis globally by 2000 (1). In 1995, the World Health Organization (WHO) European Region (EUR), comprising 51 member states (including Israel and the Central Asian Republics), accelerated efforts toward polio eradication. Improvements in status have been reported previously (2-4). This report summarizes progress toward polio eradication during 1997-1998 *, demonstrating that polio incidence has decreased to seven cases in 1997 and two cases in 1998, and surveillance has improved substantially.

Supplemental vaccination activities. Since 1995, National Immunization Days (NIDs) ** were conducted in 18 contiguous countries of the WHO Eastern Mediterranean (eight countries: Afghanistan, Iran, Iraq, Jordan, Lebanon, Pakistan, Palestine, and Syria) and European regions (10 countries: Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Russian Federation, Tajikistan, Turkey, Turkmenistan, and Uzbekistan) as part of Operation MECACAR (Eastern Mediterranean, Caucasus, and Central Asian Republics). Reported coverage levels were greater than 95% in 1997 with two doses of oral poliovirus vaccine (OPV), similar to levels achieved during previous years (2). Beginning in the autumn of 1997 with "mopping-up" vaccination, *** coordinated activities in countries of the two regions continued as "Operation MECACAR Plus"; NIDs were conducted in April and May 1998, but final results are not available. Additional coordinated NIDs and "mopping-up" vaccination will continue through 2000 in selected countries, depending on the quality and results of local acute flaccid paralysis (AFP) surveillance.

Surveillance. AFP surveillance and virologic testing of stool specimens from AFP cases is a key strategy recommended by WHO for polio eradication. By 1998, a total of 17 countries where polio is endemic or was recently endemic have established AFP surveillance; in addition, 18 countries where polio is not endemic also report AFP surveillance data (Table_1). From January 1997 through May 1998, three countries (Albania, Belarus, and Kyrgyzstan) consistently achieved the minimum AFP reporting rate indicative of a sensitive surveillance system (at least one nonpolio AFP case per 100,000 children aged less than 15 years annually); reported rates for the Russian Federation in 1997 and 1998 and for Ukraine in 1997 are difficult to interpret because of the inclusion of cases of isolated facial paralysis. In addition, 13 other countries are close to achieving or have provisionally achieved the minimum reporting rate in 1998. The overall rate of collection of two adequate stool samples **** from persons with reported AFP cases increased to approximately 70% in 1997 and in 1998 (Table_1). During 1997-1998, few countries consistently achieved the WHO-recommended target of two adequate stool specimens collected from at least 80% of AFP cases. Beginning in 1998, a total of 29 of 35 countries are reporting case-based AFP surveillance data weekly to the WHO regional office. Completeness of reports received for weekly reporting is 83%; for the six countries still reporting aggregate counts of AFP cases monthly, completeness is 69%.

EUR laboratory network. The EUR polio laboratory network consists of 35 laboratories: 30 national laboratories, two subregional reference laboratories, and five regional reference laboratories (two of which are national laboratories) (5). WHO accreditation of national laboratories based on six objective criteria (5) is being implemented; 20 laboratories have received full accreditation. Four laboratories received provisional accreditation pending further experience or improvements in specific areas. Based on the status of accreditation, of the 1596 AFP cases reported in 1997, a total of 448 (28%) stool specimens were processed for virus isolation in fully accredited laboratories.

Incidence of polio. From 1991 through 1996, the number of confirmed polio cases ***** reported annually in EUR ranged from 177 to 297; in 1997, only seven cases from two countries (Tajikistan and Turkey) were reported. Wild poliovirus type 1 was isolated in six cases in one southeastern province of Turkey during July-December 1997 (3). To date, Turkey has reported two cases of polio from an adjoining province; one case had onset of paralysis in January and the other in April 1998. All recent isolates of wild poliovirus type 1 in Turkey are related to a single Middle East genotype. Because of inadequate stool specimen collection from some AFP cases in which there was residual paralysis, death, or loss to follow-up, 19 polio-compatible cases were reported in 1997 from seven countries.

Certification process. The European Regional Commission for the Certification of Poliomyelitis Eradication has begun reviewing comprehensive documentation on the vaccination and surveillance activities of EUR countries. All member countries have been asked to form national certification committees to objectively review country vaccination, laboratory, and epidemiologic surveillance data and submit relevant documentation to the regional commission. Documentation from the countries of Europe in which there has been an absence of reported cases for greater than 8 years will be sought in 1998, followed by review for the other countries through 2000. Reported by: Communicable Diseases and Immunization Unit, World Health Organization Regional Office for Europe, Copenhagen, Denmark; Expanded Program on Immunization, Global Program for Vaccines and Immunization, World Health Organization, Geneva, Switzerland. Respiratory and Enteric Viruses Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; Vaccine Preventable Disease Eradication Div, National Immunization Program, CDC.

Editorial Note

Editorial Note: Polio transmission has been interrupted in most EUR countries where polio was previously endemic; this status is attributed to improvements in routine vaccination coverage and the successful implementation of NIDs through Operation MECACAR. In addition, surveillance activities in most EUR countries have improved. The quality of surveillance and laboratory performance in many areas of the region needs further improvement, particularly in all areas where polio was recently endemic, to ensure that indigenous transmission has been interrupted and that any transmission secondary to imported poliovirus is promptly detected.

WHO staff and consultants are assessing AFP surveillance systems and laboratory performance in 15 countries to determine how further improvements can be made; this is in anticipation of needing to provide definitive AFP and virologic surveillance data supporting the certification process. The incidence of facial paralysis has been unexpectedly high in some countries, possibly attributed to a high incidence of borreliosis. Reporting of facial paralysis has obscured the sensitivity of some surveillance systems monitoring paralytic illnesses more consistent with clinical polio. With the collection of information about individual AFP cases, future monitoring of AFP surveillance will provide more homogeneous data across EUR.

Southeastern areas of Turkey adjacent to Syria, Iran, and Iraq remain at high risk for wild poliovirus transmission; wild polioviruses have been isolated from AFP cases throughout 1997 in Iran and Iraq (4). Most areas of Tajikistan, Turkmenistan, and Uzbekistan remain at risk for polio because of confirmed ongoing poliovirus transmission in Afghanistan (4). Importation of wild poliovirus or continuing low-level indigenous transmission may not be detected because of weak surveillance and/or laboratory deficiencies. Interregional and intercountry efforts are ongoing to coordinate surveillance and supplementary vaccination activities in these key high-risk border areas. Supplemental vaccination activities will continue to be organized through 2000 under Operation MECACAR Plus to interrupt any remaining chains of poliovirus transmission. Mopping-up campaigns will be conducted in October and November 1998 in the high-risk areas that border countries of the Eastern Mediterrean Region where polio is endemic or was recently endemic.

EUR priorities toward polio eradication by 2000 include 1) strengthening AFP surveillance systems throughout the region (including accreditation of all laboratories), particularly in the Caucasus, Turkey, and the Central Asian Republics; 2) ensuring that high-quality NIDs or sub-NIDs are conducted through Operation MECACAR Plus in selected countries with persistent high risk for wild poliovirus circulation caused by low vaccination coverage, weak surveillance, and/or administrative problems; 3) implementing coordinated supplemental vaccination activities among key border area populations; 4) maintaining and strengthening the political commitment of governments for polio eradication and certification; 5) consolidating the support of donor governments and partner agencies to ensure sufficient financial and human resources; and 6) progressing in the formal process of certification.

Polio eradication efforts in EUR have been supported by the governments of countries where polio is endemic or was recently endemic, WHO, United Nations Children's Fund (UNICEF), Rotary International, U.S. Agency for International Development, CDC, and through contributions from Canada, Denmark, European Union, Finland, France, Germany, Greece, Hungary, Italy, Japan, Luxembourg, Monaco, Netherlands, Norway, Switzerland, and the United Kingdom.

References

1. World Health Assembly. Global eradication of poliomyelitis by the year 2000. Geneva, Switzerland: World Health Organization, 1988; resolution no. 41.28.

2. CDC. Progress toward poliomyelitis eradication -- Europe and Central Asian Republics, 1991-September 1997. MMWR 1997;46:994-1000.

3. CDC. Progress toward poliomyelitis eradication -- Turkey, 1994-1997. MMWR 1998;47:116-20.

4. CDC. Progress toward global eradication of poliomyelitis, 1997. MMWR 1998;47:414-9.

5. CDC. Status of the global laboratory network for poliomyelitis eradication, 1994-1996. MMWR 1997;46:692-4.

* The report contains data reported to EUR through May 30, 1998. Surveillance data for 1997 have been updated (2).

** Mass campaigns over a short period (days to weeks) in which two doses of OPV are administered to all children in the target age group, regardless of previous vaccination history, with an interval of 4-6 weeks between doses.

*** Focal mass campaign in high-risk areas over a short period (days to weeks) in which two doses of OPV are administered during house-to-house visits to all children in the target age group, regardless of previous vaccination history, with an interval of 4-6 weeks between doses.

**** Two stool specimens collected at an interval of at least 24 hours within 14 days of onset of paralysis. WHO recommends that greater than or equal to 80% of patients with AFP have two adequate specimens collected (4).

***** A confirmed case of polio is defined under the virologic scheme of classification as AFP with laboratory-confirmed wild poliovirus infection; in countries where virologic surveillance is inadequate, clinical cases have either residual paralysis at 60 days, death, or no follow-up investigation at 60 days. Most countries in EUR use the virologic scheme of classification of AFP cases, for which some AFP cases with residual paralysis at 60 days, death, or no follow-up investigation may be considered as polio-compatible cases.

TABLE 1. Number of reported cases of nonpolio acute flaccid paralysis (AFP), nonpolio AFP rate*, and percentage of persons with reported AFP with two
stool specimens, by year and country -- European Region (EUR), World Health Organization, 1997 and 1998 +
=============================================================================================================================================================
                                                    1997                                                               1998
                           ------------------------------------------------------------      ----------------------------------------------------------------
                            No. nonpolio     Nonpolio AFP rate    % of persons with AFP      No. nonpolio AFP      Nonpolio AFP rate   % of persons with
                              AFP cases                              with two stool                cases                               AFP with two stool
Country                                                                specimens&                                                          specimens&
-------------------------------------------------------------------------------------------------------------------------------------------------------------
Albania                           12                1.11                   83%                        3                  1.11                  33%
Armenia                           15                1.45                   93%                        4                  0.91                  75%
Azerbaijan                        13                1.08                   77%                        1                  0.24                 100%
Belarus                           34                1.53                  100%                       20                  2.13                  40%
Bosnia and Herzegovina             1                0.20                  100%                        1                  1.16                 100%
Bulgaria                           9                0.61                  100%                        9                  1.28                  38%
Croatia                            3                0.32                   67%                        0                    0
Czech Republic                     9                0.49                   78%                       10                  1.28                  50%
Estonia                            3                1.03                   33%                        1                  0.82                  0
Georgia                            7                0.55                   86%                        4                  0.77                  75%
Greece@                           --                 --                    --                         0                    0
Hungary**                         --                 --                    --                         5                  0.65                  20%
Israel                            17                1.02                   18%                        6                  0.85                  17%
Italy                             55                0.65                   36%                       30                  0.83                  33%
Kazakhstan                        35                0.69                   60%                       10                  0.61                  80%
Kyrgyzstan                        24                1.39                   63%                        8                  1.42                  88%
Latvia                             0                 0                      0                         0                    0
Malta++                            3                3.61                    0                         1                  2.85                 100%
Netherlands                       10                0.35                    0                         5                  0.50                  0
Poland                            49                0.59                   55%                       11                  0.31                  36%
Portugal                           0                 0                      0                         0                    0
Republic of Moldova                8                0.68                   88%                        9                  1.82                  56%
Romania                           39                0.89                  100%                       31                  1.67                  81%
Russian Federation               889                4.07                   71%                      223                  4.08                  92%
Slovak Republic                    3                0.25                  100%                        2                  0.40                  0
Slovenia                           0                 0                                                0                    0
Spain&&                            5                0.46                  100%                       23                  0.83                  52%
Switzerland                       15                1.18                    7%                        1                  0.19                  0
Tajikistan                         6                0.25                   71%                        2                  0.20                 100%
Former Yugoslav Republic           4                0.67                   75%                        1                  0.39                 100%
of Macedonia
Turkey                           135                0.62                   65%                       98                  1.07                  50%
Turkmenistan                       9                0.56                   56%                        5                  0.74                  80%
Ukraine                          149                1.76                   79%                       23                  0.64                  87%
Uzbekistan                        14                0.15                   86%                       22                  0.58                  91%
Federal Republic of               14                0.62                   64%                       17                  1.95                  65%
Yugoslavia
Total                           1589                1.12                   69%                      586                  1.83                  70%
-------------------------------------------------------------------------------------------------------------------------------------------------------------
*  Per 100,000 children aged <15 years. The rate for 1998 is annualized.
+  Data reported to EUR through May 30, 1998.
&  Two stool specimens collected at an interval of at least 24 hours within 14 days of onset of paralysis and
   adequately shipped to the laboratory.
@  AFP surveillance began in early 1998.
** AFP surveillance began in January 1998.
++ AFP surveillance began in July 1997.
&& AFP surveillance began in autumn 1997.
=============================================================================================================================================================

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