Public Health Emergency of International Concern (PHEIC)
Polio this week as of 15 May 2019
:: Health leaders at the World Health Assembly last week in Geneva, Switzerland, welcomed the new Polio Endgame Strategy 2019-2023, and acknowledged that while a lot had been accomplished, more efforts were needed in order to achieve a lasting polio-free world by 2023.

:: Following the group’s meeting earlier this month, the latest report of the International Health Regulations (IHR) Emergency Committee is available.  The Committee evaluated the latest global poliovirus epidemiology and concluded that the effort to eradicate polio remained a Public Health Emergency of International Concern (PHEIC).  More.

:: In Cameroon, a circulating vaccine-derived poliovirus type 2 (cVDPV2) was detected from an environmental sample collected on 20 April 2019 in Extreme Nord.  The virus was detected in an environmental sample only – no associated cases of paralysis have been detected.

Summary of new viruses this week:
:: Pakistan – two wild poliovirus type 1 (WPV1) cases and six WPV1-positive environmental samples;
:: Afghanistan – one WPV1-positive environmental sample; Nigeria – two circulating vaccine-derived poliovirus type 2 (cVDPV2)-positive environmental samples;
:: Somalia – one cVDPV2 case;
:: Cameroon – one cVDPV2-positive environmental sample; and, Iran – one WPV1-positive environmental sample.

Polio: Statement of the Twenty-first IHR Emergency Committee
Regarding the International Spread of Poliovirus
29 May 2019 Statement Geneva
The twenty-first meeting of the Emergency Committee under the International Health Regulations (2005) (IHR) regarding the international spread of poliovirus was convened by the Director-General on 14 May 2019 at WHO headquarters with members, advisers and invited Member States attending via teleconference, supported by the WHO secretariat.

The Emergency Committee reviewed the data on wild poliovirus (WPV1) and circulating vaccine derived polioviruses (cVDPV). The Secretariat presented a report of progress for affected IHR States Parties subject to Temporary Recommendations. The following IHR States Parties provided an update on the current situation and the implementation of the WHO Temporary Recommendations since the Committee last met on 19 February 2019: Afghanistan, DR Congo, Indonesia, Nigeria, Pakistan and Somalia.

The committee commended all countries that presented on the quality of information provided, and the transparency with which countries discussed their challenges.

Wild poliovirus
The Committee is gravely concerned by the significant further increase in WPV1 cases globally in 2019, particularly in Pakistan where 15 cases have already been reported. In Pakistan transmission continues to be widespread, as indicated by the number of positive environmental isolates in many areas of the country, and the proportion of samples that detect WPV1 is rising. The recent cluster of cases in Lahore also indicates that vulnerabilities still exist outside the high-risk corridors. Notably, the increased rate of infection during what is usually the low season may herald even higher rates of infection in the coming high season unless urgent remedial steps are taken. The committee was very concerned about attacks on vaccinators and on the police protecting them. The increasing refusal by individuals and communities to accept vaccination also needs to be actively addressed. While the committee understood that the recent elections and political transition may have adversely affected delivery of the polio program, it is now essential that the new government renews its efforts, noting that the eradication program in the country is no longer on-track.

Highlighting these concerns, the committee noted the recent detection of WPV1 in sewage in Iran in an area close to the international border with Pakistan. Based on genetic sequencing, the virus is most closely linked to viruses found recently in Karachi, Pakistan. While there is no evidence currently that transmission has occurred in Iran and routine immunization coverage is high there, this finding together with the resumption of WPV1 international spread between Pakistan and Afghanistan suggests that rising transmission in Pakistan correlates with increasing risk of WPV1 exportation beyond the single epidemiological block formed by the two countries. The Iran event is the first such exportation detected since 2014 and signals that the hard fought gains of recent years can easily be reversed

Vaccine derived poliovirus 
The multiple cVDPV2 outbreaks on the continent of Africa are as concerning as the WPV1 situation in Asia. The emergence of new strains of cVDPV2 in areas where mOPV2 has been used, the recent spread of cVDPV2 into southern Nigeria, including the densely populated Lagos region, and evidence of missed transmission in Nigeria and Somalia suggests that the situation continues to deteriorate. Insufficient coverage with IPV exacerbates the growing vulnerability on the continent to cVDPV2 transmission. Early detection of any international spread from the five currently infected countries and prioritized use of mOPV2 is essential to mitigate further depletion of the limited mOPV2 supply. Repeatedly, cases have occurred in border districts (in Nigeria, close to Benin, in DR Congo close to Angola, in Somalia, close to Ethiopia, and in Mozambique, close to Malawi)…

The Committee unanimously agreed that the risk of international spread of poliovirus remains a Public Health Emergency of International Concern (PHEIC) and recommended the extension of Temporary Recommendations for a further three months. The Committee considered the following factors in reaching this conclusion:

Rising risk of WPV1 international spread: The progress made in recent years appears to be reversing, with the committee’s assessed risk of international spread the highest since 2014 when the PHEIC was declared. This risk assessment is based on the following:
:: the first WPV1 exportation outside of the single epidemiological block of Afghanistan and Pakistan since 2014;
:: rising number of WPV1 cases in Pakistan;
:: rising proportion of environmental samples that are positive for WPV1 in Afghanistan and Pakistan;
:: widespread detection of WPV1 in Pakistan in environmental samples;
:: clusters of cases in areas not considered high risk such as Lahore;
:: the fact that all of these observations have been made during the part of the year normally considered as low transmission season;
:: increasing community and individual resistance to the polio program.

Rising risk of cVDPV spread: The newly emerged strains of cVDPV2 in Nigeria and DR Congo, and the increased number of infected states / provinces in these two countries, together with evidence of missed transmission in Nigeria, Somalia and Indonesia also suggests the risk of international spread of cVDPV, especially type 2, is rising.

Falling PV2 immunity: Global population immunity to type 2 polioviruses (PV2) continues to fall, as the cohort of children born after OPV2 withdrawal grows, exacerbated by poor coverage with IPV particularly in some of the cVDPV infected countries. Protracted outbreaks: The difficulty in rapidly controlling cVDPV outbreaks in Nigeria and DR Congo is another risk.

Weak routine immunization: Many countries have weak immunization systems that can be further impacted by various humanitarian emergencies, and the number of countries in which immunization systems have been weakened or disrupted by conflict and complex emergencies poses a growing risk, leaving populations in these fragile states vulnerable to outbreaks of polio.

Surveillance gaps: The appearance of highly diverged VDPVs in Somalia and Indonesia are examples of inadequate polio surveillance, heightening concerns that transmission could be missed in various countries. Similar gaps exist in Lake Chad countries and around the Horn of Africa.

Lack of access: Inaccessibility continues to be a major risk, particularly in several countries currently infected with WPV or cVDPV, i.e. Afghanistan, Nigeria, Niger, Somalia and Papua, Indonesia, which all have sizable populations that have been unreached with polio vaccine for prolonged periods.

Population movement: The risk is amplified by population movement, whether for family, social, economic or cultural reasons, or in the context of populations displaced by insecurity and returning refugees. There is a need for international coordination to address these risks. A regional approach and strong cross-border cooperation is required to respond to these risks, as much international spread of polio occurs over land borders….


Editor’s Note:
WHO has posted a refreshed emergencies page which presents an updated listing of Grade 3,2,1 emergencies as below.

WHO Grade 3 Emergencies [to 1 Jun 2019]

Democratic Republic of the Congo
:: Major cholera vaccination campaign begins in North Kivu in the Democratic Republic of the Congo 27 May 2019
:: 43: Situation report on the Ebola outbreak in North Kivu 28 May2019
:: Disease Outbreak News (DONs) Ebola virus disease – Democratic Republic of the Congo
30 May 2019
[See Ebola DRC above for detail]

South Sudan
:: In South Sudan, grandmothers breastfeed malnourished grandchildren 28 May 2019
:: The Government of Japan and WHO donate six ambulances to boost health service delivery in South Sudan 28 May 2019

:: Donations from Saudi Arabia and United Arab Emirates provide access to health care for millions in Yemen
27 May 2019, Aden/Sana’a — The World Health Organization (WHO) expressed its gratitude to Saudi Arabia and United Arab Emirates for a grant of US$ 20 million, which will support ongoing efforts to stop the spread of cholera in Yemen…

Bangladesh – Rohingya crisis – No new digest announcements identified
Mozambique floods – No new digest announcements identified
Myanmar – No new digest announcements identified
Nigeria – No new digest announcements identified
Somalia – No new digest announcements identified
Syrian Arab Republic – No new digest announcements identified


WHO Grade 2 Emergencies [to 1 Jun 2019]

:: Photo essay: WHO emergency teams at work in Libya 26 May 2019

occupied Palestinian territory
:: The Gaza trauma response: One-year analysis of trauma injuries in Gaza 29 May 2019
:: Overcoming barriers to health care access in the West Bank with mobile clinics 27 May 2019

Brazil (in Portugese) – No new digest announcements identified
Cameroon – No new digest announcements identified
Central African Republic – No new digest announcements identified
Cyclone Idai – No new digest announcements identified
Ethiopia – No new digest announcements identified
Iran floods 2019 – No new digest announcements identified
Iraq – No new digest announcements identified
Malawi floods – No new digest announcements identified
MERS-CoV – No new digest announcements identified
Niger – No new digest announcements identified
Sudan – No new digest announcements identified
Ukraine – No new digest announcements identified
Zimbabwe – No new digest announcements identified



WHO Grade 1 Emergencies [to 1 Jun 2019]

Afghanistan – No new digest announcements identified
Angola – No new digest announcements identified
Chad – No new digest announcements identified
Djibouti – No new digest announcements identified
Indonesia – Sulawesi earthquake 2018 – No new digest announcements identified
Kenya – No new digest announcements identified
Mali – No new digest announcements identified
Namibia – viral hepatitis – No new digest announcements identified
Tanzania – No new digest announcements identified


UN OCHA – L3 Emergencies
The UN and its humanitarian partners are currently responding to three ‘L3’ emergencies. This is the global humanitarian system’s classification for the response to the most severe, large-scale humanitarian crises. 
Syrian Arab Republic
:: Syria: Situation Report 3: Recent Developments in Northwestern Syria (as of 31 May 2019)
:: Over the past week, airstrikes, shelling and ground fighting intensified across the demilitarized zone in northwest Syria, exacerbating the impact of the conflict on civilians, civilian infrastructure, and humanitarian service provision in northern Hama, southern Idleb, and western Aleppo governorates.
:: Almost 270,000 displacements from northern Hama and southern Idleb governorates were recorded between 1 and 22 May.
:: A total of 24 health facilities, 35 schools, four facilities providing protection services, three IDP settlements, and one refugee camp were reportedly affected by hostilities in recent weeks…

:: Syria: Humanitarian Response in Al Hol camp, Situation Report No. 4 – As of 29 May 2019 [EN/AR]

Yemen – No new digest announcements identified


UN OCHA – Corporate Emergencies
When the USG/ERC declares a Corporate Emergency Response, all OCHA offices, branches and sections provide their full support to response activities both at HQ and in the field.
CYCLONE IDAI and Kenneth – No new digest announcements identified