Update: Mass Vaccination with Oral Poliovirus Vaccine -- Asia and Europe, 1996

In 1995, a group of 18 geographically contiguous countries in Europe, Central and South Asia, and the Middle East cooperated in conducting coordinated National Immunization Days (NIDs) * with oral poliovirus vaccine (OPV) (1). The World Health Organization (WHO) had designated this effort "Operation MECACAR" (MEditerranean, CAucasus, and Central Asian Republics) **. Operation MECACAR was repeated in 1996 with the addition of the Russian Federation (Figure_1). This report describes OPV coverage achieved during the mass vaccination campaign in 1996 and summarizes the impact of the NIDs on poliomyelitis incidence during 1995 and the first 6 months of 1996.

To maximize the geographic area covered and the number of children targeted simultaneously for mass vaccination campaigns with OPV, adjoining countries in Europe (Armenia, Azerbaijan, Bulgaria [1995 only], Georgia, Russia [starting in 1996], and Turkey), Central Asia (Kazakstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan), South Asia (Afghanistan, Iran, and Pakistan), and the Middle East (Iraq, Jordan, Lebanon, Syria, and West Bank and Gaza) conducted synchronized NIDs during 1995 and 1996 and are planning to conduct NIDs in 1997. Based on the desirability of scheduling mass vaccination campaigns during the low polio incidence season, all rounds of NIDs were scheduled during March-May. The only exception was Pakistan, which conducted NIDs in December 1995 and January 1996 to synchronize efforts with India (2) and China (3).

A total of 62 million children were targeted to receive two doses each of OPV, including 16 million children aged less than 4 years in Europe and Central Asia (the European Region of WHO [EURO]) and 46 million children aged less than 5 years in South Asia and the Middle East (the Eastern Mediterranean Region of WHO [EMRO]). Reported coverage was 92%-99% for each round in EURO and 84%-100% in EMRO (Table_1).

The mass vaccination efforts were followed by declines among participating countries in the incidence of polio reported to EURO and EMRO. In EURO, 50 cases of polio were reported in 1995, compared with 201 cases in 1994. For the first 6 months of 1996, a total of 13 cases of polio were reported from participating countries in EURO (all from Russia and Turkey). In EMRO, 647 cases of polio were reported from participating countries in 1995, compared with 691 cases in 1994. For the first 6 months of 1996, a total of 60 cases of polio were reported from these countries in South Asia and the Middle East (Table_1).

Reported by: Regional Office for Europe, Copenhagen; Regional Office for Eastern Mediterranean Region, Alexandria; Global Programme for Vaccines and Immunization, World Health Organization, Geneva, Switzerland. Respiratory and Enterovirus Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; Polio Eradication Activity, National Immunization Program, CDC.

Editorial Note

Editorial Note: In 1988, the World Health Assembly, the governing body of WHO, resolved to eradicate polio from the world by the year 2000 (4); efforts to achieve this goal have progressed rapidly in many regions. For example, in 1994, the Western Hemisphere was certified as free of wild poliovirus (5), and substantial progress has been achieved in the rest of the world (6). These successful efforts have been associated with the implementation of recommended strategies for polio eradication, which include 1) achieving and maintaining high routine vaccination coverage with OPV; 2) instituting sensitive surveillance systems for polio; 3) introducing NIDs; and 4) conducting other supplemental vaccination activities (e.g., mopping-up operations). In 1995, approximately 300 million children aged less than 5 years (an estimated one half of the world's children in this age group) received OPV administered during NIDs (6). By the end of 1996, all polio-endemic countries of Europe and Asia will have conducted NIDs, and 29 countries in the African Region of WHO will implement NIDs (n=26) or Sub-National Immunization Days (SNIDs) (n=three) (6).

The collaboration among the 18 countries in EURO and EMRO for polio eradication has included countries characterized by different political systems and economies and racial/ethnic and religious diversity. In 1996, as a result of a large polio outbreak in Chechnya in 1995 (7) and suboptimal routine vaccination coverage in some states, Russia joined the coalition of countries comprising Operation MECACAR. Bulgaria conducted successful NIDs in 1995 and increased coverage especially among Gypsy populations, but did not participate in Operation MECACAR in 1996. In Albania, NIDs were conducted during April and May 1996. In the fall of 1996, NIDs will be conducted in Moldova and Ukraine, while Romania and Serbia and Montenegro will conduct SNIDs.

The primary purpose of mass vaccination campaigns with OPV is to interrupt the transmission of wild poliovirus. These mass vaccination efforts have interrupted wild poliovirus transmission in many areas of Europe, as reflected by the rapid decrease in cases in EURO following the efforts conducted in 1995 and 1996; of the 50 countries in EURO, only four (Albania [8], Russia, Turkey, and Ukraine) have reported polio cases in 1996. Despite some dramatic successes in EMRO (Iran, Jordan, Lebanon, and West Bank and Gaza), other countries (Afghanistan, Iraq, Pakistan, and Syria) reported more limited progress in 1995. For example, Pakistan continued to report more than half (64%) of the regional total number of polio cases in EMRO, and Syria detected four polio cases associated with isolation of wild poliovirus. However, preliminary data for January-June 1996 suggest a substantial decline in the number of reported cases in both EURO and EMRO countries (Table_1).

The technical basis for achieving worldwide polio eradication already exists; however, insufficient political will, inadequate funding, and other barriers will need to be addressed to ensure that polio will be eradicated by the year 2000.

References

1. CDC. Mass vaccination with oral poliovirus vaccine -- Asia and Europe, 1995. MMWR 1995;44:234-6.

2. CDC. Progress toward poliomyelitis eradication -- India, December 1995 and January 1996. MMWR 1996;45:370-3.

3. CDC. Progress toward poliomyelitis eradication -- People's Republic of China, 1990-1994. MMWR 1994;43:857-9.

4. World Health Assembly. Global eradication of poliomyelitis by the year 2000. Geneva, Switzerland: World Health Organization, 1988 (Resolution WHA41.28).

5. CDC. Certification of poliomyelitis eradication -- the Americas, 1994. MMWR 1994;43:720-2.

6. CDC. Progress toward global eradication of poliomyelitis, 1995. MMWR 1996;45:565-8.

7. Oblapenko G, Sutter RW. Status of poliomyelitis eradication in Europe and the Central Asian Republics of the former Soviet Union. J Infect Dis (in press).

8. CDC. Poliomyelitis outbreak -- Albania, 1996. MMWR 1996;45:819-20.

* Mass campaigns over a short period (days to weeks) in which two doses of oral poliovirus vaccine are administered to all children aged less than 5 years, regardless of prior vaccination history, with an interval of 4 -- 6 weeks between doses.

** Operation MECACAR is supported by a coalition of organizations that include WHO, United Nations Children's Fund (UNICEF), other bilateral and multilateral organizations, and Rotary International.

TABLE 1. Percentage of oral poliovirus vaccine (OPV) coverage achieved during
National Immunization Days * in 1996, and reported poliomyelitis cases during
1994-June 1996, by World Health Organization (WHO) region and countries
participating in Operation MECACAR
===============================================================================
                          1996 %                      No. reported
                        Coverage                      polio cases
WHO region/        --------------------             ------------------
Country            Round 1     Round 2              1994  1995  1996 +
-------------------------------------------------------------------------------
EURO &

Armenia                99%         98%                 5     3     0
Azerbaijan             97%         98%                16     5     0
Georgia                92%         95%                 0     0     0
Kazakhstan             97%         99%                 4     1     0
Kyrgyzstan             98%         99%                 0     0     0
Russian
Federation             99%         99%                 5 @ 154 @   3
Tajikistan             95%         99%                26     0     0
Turkey                 93%         96%                27    32    10
Turkmenistan           99%         99%                 6     8     0
Uzbekistan             98%         98%               117     1     0
Total                                                201    50    13

EMRO **
Afghanistan            87%         84%                NR ++ NR    NR
Iran                   99%        100%                93   101    15 &&
Iraq                   98%         98%                63    34     3
Jordan @@            >100%       >100%                 4     0     0
Lebanon                99%         95%                 2     0     0
Pakistan @@          >100%       >100%               527   508    42
Syria @@             >100%       >100%                 2     4     0
West Bank and
Gaza @@              >100%       >100%                NR     0     0

Total                                                691   647    60
-------------------------------------------------------------------------------
*  Mass campaigns over a short period (days to weeks) in which two doses of OPV
   are administered to all children aged <5 years, regardless of prior
   vaccination history, with an interval of 4-6 weeks between doses.
+  January-June.
&  Comprising countries in Europe and Central Asia.
@  Russia joined Operation MECACAR in 1996; cases reported in 1994 and 1995 are
   excluded from the regional total.
** Comprising countries in South Asia and the Middle East.
++ Not reported.
&& January-May.
@@ Coverage levels above 100% result from vaccinating children outside the
   target age group (numerator problem) and uncertainties about the exact
   target age group (denominator problem).
===============================================================================

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