Progress Toward Poliomyelitis Eradication - Afghanistan, January 2018-May 2019 - CDC stacks
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Morbidity and Mortality Weekly Report
Progress Toward Poliomyelitis Eradication —
Afghanistan, January 2018–May 2019
Maureen Martinez, MPH1; Hemant Shukla, MD2; Joanna Nikulin, MD2; Chukwuma Mbaeyi, DDS1; Jaume Jorba, PhD3; Derek Ehrhardt, MPH1
Since October 2016, Afghanistan and Pakistan have been activities (SIAs)* (i.e., zero-dose children) was 1% nationally in
the only countries with reported cases of wild poliovirus 2018; the largest percentages of these children were from the
type 1 (WPV1) (1). In Afghanistan, although the number of southern provinces of Kandahar (26%) and Helmand (15%).
cases had declined during 2013–2016, the polio eradication Coverage with injectable inactivated poliovirus vaccine (IPV),
program experienced challenges during 2017–2019. This which was introduced into all OPV-using countries in 2016
report describes polio eradication activities and progress in in conjunction with the global, synchronized switch from
Afghanistan during January 2018–May 2019 and updates trivalent OPV (containing vaccine virus types 1, 2, and 3) to
previous reports (2,3). During May–December 2018, insurgent bivalent OPV (bOPV, containing types 1 and 3), was estimated
groups (antigovernment elements) banned house-to-house vac- at 66% in 2018.
cination in most southern and southeastern provinces, leaving During January 2018–May 2019, SIAs targeted children
approximately 1 million children inaccessible to oral poliovirus agedMorbidity and Mortality Weekly Report (2.9%) who were accessible but missed because of campaign Environmental surveillance. Supplementary poliovirus quality issues. surveillance in Afghanistan is conducted monthly through Lot quality assurance sampling§ surveys are used to assess sampling of sewage at 20 sites in nine provinces. WPV1 was the quality of SIAs in areas where postcampaign monitoring is detected in two of 184 (1%) specimens tested in 2016, 42 permitted. Depending on the number of unvaccinated persons of 316 (13%) specimens tested in 2017, 83 of 336 (25%) in the survey sample, districts were marked as either passed at specimens tested in 2018, and 25 of 128 specimens (23%) 90% (estimated coverage ≥90%), passed at 80% (estimated collected in 2019 (as of May 31); all detections of poliovirus coverage 80%–90%), or failed at
Morbidity and Mortality Weekly Report
TABLE. Acute flaccid paralysis (AFP) surveillance indicators and reported cases of wild poliovirus (WPV), by region and period — Afghanistan,
January 2018–May 2019*
AFP surveillance indicators (2018) No. of WPV cases reported
No. of Nonpolio % of AFP cases with adequate
Region of Afghanistan AFP cases AFP rate† stool specimens§ Jan–May 2018 Jun–Dec 2018 Jan–May 2019
All regions 3,357 17 94 8 13 10
Badakhshan 68 11 96 0 0 0
Central 615 13 97 0 0 0
Eastern 400 20 94 3 3 1
Northeastern 436 19 94 0 0 0
Northern 355 14 93 0 0 0
Southeastern 299 15 96 0 0 0
Southern 592 17 87 5 10 9
Western 592 21 96 0 0 0
* Data current as of May 31, 2019.
† Cases per 100,000 persons agedMorbidity and Mortality Weekly Report
FIGURE 2. Cases of wild poliovirus type 1 (WPV1),* by province — Afghanistan, January 2018–May 2019
January–May 2018 June–December 2018
Jawzjan Jawzjan
Kunduz Badakhshan Kunduz Badakhshan
Balkh Takhar Balkh Takhar
Samangan Panjsher Samangan Panjsher
Faryab Baghlan Faryab Baghlan
Saripul Saripul
Badghis Nuristan Badghis Nuristan
Parwan Kunar Parwan Kunar
Bamyan Bamyan
Hirat Wardak Kabul Laghman Hirat Wardak Kabul Laghman
Ghor Logar Nangarhar Ghor Logar Nangarhar
Paktya Kapisa Paktya Kapisa
Ghazni Ghazni
Urozgan Khost Urozgan Khost
Farah Paktika Farah Paktika
Zabul Zabul
Kandahar Kandahar
Helmand Helmand
Nimroz Nimroz
January–May 2019
Jawzjan
Kunduz Badakhshan
Balkh Takhar Province
Samangan Panjsher
Faryab Baghlan
Saripul WPV1
Badghis Nuristan
Parwan Kunar
Bamyan
Hirat Wardak Kabul Laghman
Ghor Logar Nangarhar
Paktya Kapisa
Ghazni
Urozgan Khost
Farah Paktika
Zabul
Kandahar
Helmand
Nimroz
* Each dot represents one case. Location of dot on map does not represent actual location of case.
house-to-house vaccination in the past, but over many periods, As long as the ban on vaccination campaigns continues,
local access was permitted after discussions with local lead- routine immunization services provide the most critical oppor-
ers. Antigovernment elements in the eastern provinces have tunity for polio vaccination in the country, but these services
imposed intermittent bans on house-to-house activities since are extremely limited in many parts of the country. Enhanced
2016. To date, efforts to resume house-to-house campaigns efforts by national and international immunization partners
after the nationwide ban have been unsuccessful; however, can facilitate systematic provision of routine immunization
resumption of these campaigns is vital to achieving popula- activities through fixed, mobile, and outreach approaches,
tion immunity high enough to interrupt virus transmission, particularly in the most needed areas.
particularly in the southern and eastern provinces.
732 MMWR / August 23, 2019 / Vol. 68 / No. 33 US Department of Health and Human Services/Centers for Disease Control and PreventionMorbidity and Mortality Weekly Report
Corresponding author: Maureen Martinez, ivx2@cdc.gov, 404-996-7381.
Summary
1Global Immunization Division, Center for Global Health, CDC; 2Polio
What is already known about this topic?
Eradication Department, World Health Organization, Geneva, Switzerland;
Wild poliovirus circulation continues in Afghanistan. 3Division of Viral Diseases, National Center for Immunization and Respiratory
Diseases, CDC.
What is added by this report?
With bans on house-to-house vaccination campaigns in many All authors have completed and submitted the International
provinces since May 2018 and a nationwide ban since April Committee of Medical Journal Editors form for disclosure of potential
2019, wild poliovirus circulation has increased during conflicts of interest. No potential conflicts of interest were disclosed.
2018–2019.
References
What are the implications for public health practice?
1. Greene SA, Ahmed J, Datta SD, et al. Progress toward polio eradication—
Routine immunization systems, which are critically weak in the
worldwide, January 2017–March 2019. MMWR Morb Mortal Wkly
provinces where wild poliovirus is currently circulating, are vital Rep 2019;68:458–62. https://doi.org/10.15585/mmwr.mm6820a3
to polio eradication efforts, particularly until bans on campaigns 2. Martinez M, Shukla H, Ahmadzai M, et al. Progress toward poliomyelitis
are lifted. Successful discussions with local leaders have facilitated eradication—Afghanistan, January 2017–May 2018. MMWR Morb
house-to-house campaigns in the past, and such campaigns are Mortal Wkly Rep 2018;67:833–7. https://doi.org/10.15585/mmwr.
essential to interrupting wild poliovirus virus transmission. mm6730a6
3. Martinez M, Shukla H, Nikulin J, et al. Progress toward poliomyelitis
eradication—Afghanistan, January 2016–June 2017. MMWR Morb
Solutions for improving immunization coverage and provid- Mortal Wkly Rep 2017;66:854–8. https://doi.org/10.15585/mmwr.
ing basic health services, including in areas held by antigov- mm6632a5
4. World Health Organization. WHO vaccine-preventable diseases:
ernment elements, are necessary to make substantial progress monitoring system. 2019 global summary. Geneva, Switzerland: World
toward polio eradication in Afghanistan. These solutions will Health Organization; 2019. https://apps.who.int/immunization_
require close partnership from the highest levels of government monitoring/globalsummary/countries?countrycriteria%5Bcountry%5D
and all international partners. %5B%5D=AFG
Acknowledgments
Steven Wassilak, Wasan Al-Tamimi, Global Immunization
Division, Center for Global Health, CDC; Sumangala Chaudhury,
Polio Eradication Programme, World Health Organization, Kabul,
Afghanistan; Salmaan Sharif, Department of Virology, National
Institute of Health, Islamabad, Pakistan; Erica Adams Lehnert,
Division of Toxicology and Human Health Sciences/Geospatial
Research, Analysis and Services Program, CDC/Agency for Toxic
Substances and Disease Registry.
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