Review of Temporary Recommendations
As global eradication is now closer than ever before, the committee concluded that it was timely to revise and update the Temporary Recommendations to re-calibrate according to current risks. At the time of the PHEIC declaration in 2014, ten countries were WPV infected, seven of them following exportation of virus resulting in re-infection (ie Syria, Iraq, and Israel in the Middle East, and Somalia, Ethiopia, Cameroon, and Equatorial Guinea in Africa) and the Temporary Recommendations particularly focused on exporting countries. However, as nearly three years have passed since the last re-infected country, Somalia, recorded its last WPV case, the global context has changed significantly, and all three endemic countries where transmission is now occurring represent a serious risk to polio eradication, irrespective of whether exportation events have been detected or not. The committee noted gaps in surveillance in many high risk areas, so that exportation events might not be detected in a timely manner. The committee also has received evidence based on modelling that the imposition of the Temporary Recommendations was cost effective, providing further justification for the extension of the relevant Temporary Recommendations to all WPV infected countries.
Based on these considerations, the committee changed the categories of countries subject to Temporary Recommendations, with the aim of strengthening them for WPV, and recognizing the changed context with respect to cVDPV2.
Risk categories
The Committee provided the Director General with the following advice aimed at reducing the risk of international spread of WPV1 and cVDPVs, based on the risk stratification as follows:
States infected with WPV1, cVDPV1 or cVDPV3, with potential risk of international spread;
States infected with cVDPV2; and
States no longer infected by WPV1 or cVDPV, but which remain vulnerable to re-infection by WPV or cVDPV.
Criteria to assess States as no longer infected by WPV1 or cVDPV:
Poliovirus Case: 12 months after the onset date of the most recent case PLUS one month to account for case detection, investigation, laboratory testing and reporting period OR when all reported AFP cases with onset within 12 months of last case have been tested for polio and excluded for WPV1 or cVDPV, and environmental samples collected within 12 months of the last case have also tested negative, whichever is the longer.
Environmental isolation of WPV1 or cVDPV (no poliovirus case): 12 months after collection of the most recent positive environmental sample PLUS one month to account for the laboratory testing and reporting period.
These criteria may be varied for the endemic countries, where more rigorous assessment is needed in reference to surveillance gaps (eg Borno).
TEMPORARY RECOMMENDATIONS
States infected with WPV1, cVDPV1 or cVDPV3 with potential risk of international spread
(Currently Pakistan, Afghanistan and Nigeria)
These countries should:
Officially declare, if not already done, at the level of head of state or government, that the interruption of poliovirus transmission is a national public health emergency; where such declaration has already been made, this emergency status should be maintained.
Ensure that all residents and longterm visitors (i.e. > four weeks) of all ages, receive a dose of bivalent oral poliovirus vaccine (bOPV) or inactivated poliovirus vaccine (IPV) between four weeks and 12 months prior to international travel.
Ensure that those undertaking urgent travel (i.e. within four weeks), who have not received a dose of bOPV or IPV in the previous four weeks to 12 months, receive a dose of polio vaccine at least by the time of departure as this will still provide benefit, particularly for frequent travelers.
Ensure that such travelers are provided with an International Certificate of Vaccination or Prophylaxis in the form specified in Annex 6 of the IHR to record their polio vaccination and serve as proof of vaccination.
Restrict at the point of departure the international travel of any resident lacking documentation of appropriate polio vaccination. These recommendations apply to international travelers from all points of departure, irrespective of the means of conveyance (e.g. road, air, sea).
These countries should further intensify crossborder efforts by significantly improving coordination at the national, regional and local levels to substantially increase vaccination coverage of travelers crossing the border and of high risk crossborder populations. Improved coordination of crossborder efforts should include closer supervision and monitoring of the quality of vaccination at border transit points, as well as tracking of the proportion of travelers that are identified as unvaccinated after they have crossed the border.
Maintain these measures until the following criteria have been met: (i) at least six months have passed without new infections and (ii) there is documentation of full application of high quality eradication activities in all infected and high risk areas; in the absence of such documentation these measures should be maintained until the state meets the above assessment criteria for being no longer infected.
Provide to the Director General a regular report on the implementation of the Temporary Recommendations on international travel.
States infected with cVDPV2s
(Currently Nigeria and Pakistan)
These countries should:
Noting the existence of a separate mechanism for responding to type 2 poliovirus infections, consider requesting vaccines from the global mOPV2 stockpile based on the recommendations of the Advisory Group on mOPV2.
Officially declare, if not already done, at the level of head of state or government, that the interruption of poliovirus transmission is a national public health emergency; where such declaration has already been made, this emergency status should be maintained.
Encourage residents and longterm visitors to receive a dose of IPV (if available in country) four weeks to 12 months prior to international travel; those undertaking urgent travel (i.e. within four weeks) should be encouraged to receive a dose at least by the time of departure.
Ensure that travelers who receive such vaccination have access to an appropriate document to record their polio vaccination status.
Intensify regional cooperation and crossborder coordination to enhance surveillance for prompt detection of poliovirus, and vaccinate refugees, travelers and crossborder populations, according to the advice of the Advisory Group.
Maintain these measures until the following criteria have been met: (i) at least six months have passed without the detection of circulation of VDPV2 in the country from any source, and (ii) there is documentation of full application of high quality eradication activities in all infected and high risk areas; in the absence of such documentation these measures should be maintained until the state meets the criteria of a ‘state no longer infected’.
At the end of 12 months without evidence of transmission, provide a report to the Director General on measures taken to implement the Temporary Recommendations.
States no longer infected by WPV1 or cVDPV, but which remain vulnerable to re-infection by WPV or cVDPV
WPV1
Cameroon (last case 9 Jul 2014)
Niger (last case 15 Nov 2012)
Chad (last case 14 Jun 2012)
Central African Republic (last case 8 Dec 2011)
cVDPV
Ukraine (last case 7th July 2015)
Madagascar (last case 22nd August 2015)
Myanmar (last case 5th October 2015)
Guinea (last case 14th December 2015)
Lao PDR (last case 11th January 2016)
These countries should:
Urgently strengthen routine immunization to boost population immunity.
Enhance surveillance quality to reduce the risk of undetected WPV1 and cVDPV transmission, particularly among high risk mobile and vulnerable populations.
Intensify efforts to ensure vaccination of mobile and crossborder populations, Internally Displaced Persons, refugees and other vulnerable groups.
Enhance regional cooperation and cross border coordination to ensure prompt detection of WPV1 and cVDPV, and vaccination of high risk population groups.
Maintain these measures with documentation of full application of high quality surveillance and vaccination activities.
At the end of 12 months* without evidence of reintroduction of WPV1 or new emergence and circulation of cVDPV, provide a report to the Director General on measures taken to implement the Temporary Recommendations.
*For the Lake Chad countries, this will be 12 months after the last case of WPV1 or cVDPV2, whichever is the latest, in the sub-region. Based on the last cases (above) in Ukraine the report will be due August 2017, for Myanmar in November 2017, for Madagascar in September 2017, for Guinea in January 2017, and in Lao PDR February 2018).
Additional considerations
The committee advised WHO to carefully review the event in the Netherlands, and also to review all applicable existing guidance to prevent and respond to such accidental release, and develop further guidance as necessary.
The committee noted that the VDPV in the Russian Federation was still unclassified, and that the event would be given further consideration at the European Regional Certification Commission in June and is still under review by the Advisory Committee for the release of mOPV2 vaccine.
The Committee strongly urged global partners in polio eradication to provide optimal support to all infected and vulnerable countries at this critical time in the polio eradication programme for implementation of the Temporary Recommendations under the IHR, as well as providing ongoing support to all countries that were previously subject to Temporary Recommendations (Somalia, Ethiopia, Syria, Iraq and Israel).
The Committee noted a detailed analysis of the public health benefits and costs of implementing temporary recommendations was completed and was currently undergoing peer review prior to publication.
The Committee urged all countries to avoid complacency which could easily lead to a polio resurgence. Surveillance particularly needs careful attention to quickly detect any resurgent transmission, and careful assessment of where insecurity and inaccessibility impact on surveillance. Similarly, there needs to be tracking of populations where there are high proportions of unvaccinated children due to inaccessibility.
Based on the advice concerning WPV1 and cVDPV, and the reports made by Afghanistan, Pakistan, Nigeria, and Equatorial Guinea, the Director General accepted the Committee’s assessment and on 2 May 2017 determined that the events relating to poliovirus continue to constitute a PHEIC, with respect to WPV1 and cVDPV. The Director General endorsed the Committee’s recommendations for countries falling into the definition for ‘States infected with WPV1, cVDPV1 or cVDPV3 with potential risk for international spread’, ‘States infected with cVDPV2’ and for ‘States no longer infected by WPV1 or cVDPV, but which remain vulnerable to re-infection by WPV or cVDPV’ and extended the Temporary Recommendations as revised by the Committee under the IHR to reduce the risk of international spread of poliovirus, effective 2 May 2017.
The Director General thanked the Committee Members and Advisors for their advice.