Progress Toward Global Eradication of Poliomyelitis, 1988-1991

The report of the last case of smallpox from Somalia in 1977 demonstrated that an infectious disease could be eradicated globally. Because polioviruses have no animal reservoir and do not survive for long periods of time in the environment, and because lifelong immunity to paralytic poliomyelitis is conferred by existing, effective vaccines, poliomyelitis has been considered a candidate for eradication (1). In 1985, the Pan American Health Organization (PAHO) initiated a regional poliomyelitis eradication program. Based on the success of this program and high vaccination levels achieved worldwide by the Expanded Program on Immunization (EPI), in May 1988, the World Health Assembly of the World Health Organization (WHO) adopted a resolution to eradicate poliomyelitis globally by the year 2000. This report summarizes progress of the global poliomyelitis eradication initiative from 1988 through 1991 *.

Global. Reported global vaccination coverage with three doses of oral poliovirus vaccine (OPV3) by age 1 year increased from 67% in 1988 to 84% in 1991 (Figure 1). During the same period, reported cases of poliomyelitis decreased 56%, from 32,286 to 14,176 (Figure 1). From 1988 through 1991, there were substantial decreases in the number of countries/territories reporting poliomyelitis cases (88 {45%} of 196 and 70 {34%} of 208, respectively) and the number of countries reporting more than 10 cases per year (56 {29%} and 38 {18%}, respectively) (Figure 2). In addition, the number of countries reporting zero endemic cases increased from 107 (55%) to 129 (61%) **.

African Region. Reported coverage with OPV3 increased from 44% to 57%, while reported cases of poliomyelitis decreased from 4546 to 2623; the number of countries in the region reporting poliomyelitis cases decreased from 37 (79%) of 47 to 25 (53%) of 47. In 1991, the African Region reported 19% of the global total of poliomyelitis cases.

Region of the Americas. Reported coverage with OPV3 increased from 82% to 89%, while reported cases of poliomyelitis decreased from 340 to nine; the number of countries in the region reporting poliomyelitis cases decreased from 13 (28%) of 47 to two (4%) of 47. This region has reported no confirmed cases of poliomyelitis since September 1991 in Peru.

Eastern Mediterranean Region. Reported coverage with OPV3 increased from 69% to 80%, while reported cases of poliomyelitis decreased from 2332 to 2035; the number of countries in the region reporting poliomyelitis cases decreased from 17 (71%) of 24 to 15 (65%) of 23. In 1991, the Eastern Mediterranean Region reported 14% of the global total of poliomyelitis cases; 87% of the regional total were reported from Pakistan and Egypt. Despite OPV3 coverage of greater than 85%, small outbreaks also occurred in Oman (1988- 1989) and Jordan (1991-1992); 51% of 118 persons with acute poliomyelitis in Oman and 53% of 32 persons with acute poliomyelitis in Jordan had received OPV3.

European Region. Reported coverage with OPV3 decreased from 86% to 82%, while reported cases of poliomyelitis increased from 206 to 313; the number of countries in the region reporting poliomyelitis cases increased from seven (23%) of 31 to 15 (33%) of 45. In 1991, the European Region reported 2% of the global total of poliomyelitis cases; 68% of the regional total was from republics of the former Soviet Union.

Southeast Asian Region. Reported coverage with OPV3 increased from 57% to 93%, while reported cases of poliomyelitis decreased from 22,814 to 6581; the number of countries in the region reporting poliomyelitis cases (nine {82%} of 11) was unchanged. In 1991, the Southeast Asian Region reported 46% of the global total of poliomyelitis cases; 91% of the regional total was from India.

Western Pacific Region. Reported coverage with OPV3 increased from 89% to 95%, while reported cases of poliomyelitis increased from 2079 to 2615; the number of countries in the region reporting poliomyelitis cases decreased from six (17%) of 35 to five (14%) of 35. In 1991, the Western Pacific Region reported 18% of the global total of poliomyelitis cases; 98% of the regional total was from the People's Republic of China and Vietnam.

Reported by: Expanded Program on Immunization, World Health Organization, Geneva. Surveillance, Investigations, and Research Br, National Immunization Program; Respiratory and Enterovirus Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Since 1988, all six WHO regions have reported substantial progress toward poliomyelitis eradication, and poliomyelitis has apparently been completely eliminated from one region. *** In the Region of the Americas, three major strategies were used to eliminate poliomyelitis: 1) achievement of high vaccination coverage; 2) maintenance of sensitive systems of clinical and laboratory surveillance; and 3) implementation of supplementary vaccination activities, including national vaccination days biannually for all children below a specified age (usually age 5 years, regardless of prior vaccination status) and door-to-door vaccination campaigns in areas with a high incidence of poliomyelitis cases and/or low vaccination coverage (3).

In regions other than the Americas, vaccination strategies for poliomyelitis control have consisted primarily of routine vaccination. However, recent poliomyelitis outbreaks in highly vaccinated populations (4,5) and studies indicating suboptimal seroconversion to poliovirus types 1 and 3 following three doses of oral poliovirus vaccine in many tropical and subtropical regions suggest that routine vaccination alone may be insufficient to eliminate wild poliovirus infections and that supplementary activities, including national vaccination days, are necessary in countries where poliomyelitis is endemic (6).

In addition to the strategies used in the Region of the Americas, current global poliomyelitis eradication strategies include establishing and expanding polio-free zones and focusing additional resources on countries that are major exporters of wild poliovirus (7). The Global Poliomyelitis Eradication Plan of Action, endorsed by the EPI Global Advisory Group, emphasizes achieving effective surveillance of acute flaccid paralysis in all countries, initiating supplementary vaccination activities in all countries, and establishing a fully operational laboratory network in all WHO regions by 1995 with the goal of eliminating wild poliovirus transmission globally by the year 2000 (7).

Despite progress in increasing vaccination coverage and decreasing the incidence of poliomyelitis worldwide, there are at least five major barriers to global poliomyelitis eradication: 1) the presence of populations with suboptimal vaccination coverage, including unvaccinated subpopulations; 2) the failure of some countries and regions to identify poliomyelitis eradication as a priority activity (including the implementation of national vaccination days); 3) inadequate managerial skills to implement surveillance and vaccination programs effectively in certain countries; 4) suboptimal immunogenicity of oral poliovirus vaccine in many tropical and subtropical regions; and 5) inadequate commitment of financial resources at national and international levels (3).

The success of efforts to eradicate poliomyelitis in the Region of the Americas was based on the financial support of a broad coalition of national governments, international donor agencies (e.g., Rotary International, the United Nations Children's Fund, the Inter-American Development Bank, the Canadian Public Health Association, and the United States Agency for International Development), the Pan American Health Organization, and nongovernment community organizations. The creation of such coalitions -- both regionally and globally -- is of paramount importance in future efforts. In addition, success in global disease eradication requires that unaffected countries provide necessary assistance to geographic areas lacking adequate resources (1). The success of the global poliomyelitis eradication initiative will entail finding solutions to these financial, political, and technical challenges.

References

1. CDC. International Task Force for Disease Eradication. MMWR 1990;39:209-12,217.

2. CDC. Isolation of wild poliovirus type 3 among members of a religious community objecting to vaccination -- Alberta, Canada, 1993. MMWR 1993;42:337-9.

3. de Quadros CA, Andrus JK, Olive JM, de Macedo CG, Henderson DA. Polio eradication from the Western Hemisphere. Annu Rev Public Health 1992;13:239-52.

4. Reichler MR, Abbas A, Alexander J, et al. Outbreak of poliomyelitis in a highly immunized population in Jordan {Abstract}. In: Program and abstracts of the 32nd Interscience Conference on Antimicrobial Agents and Chemotherapy. Washington, DC: American Society for Microbiology, 1992.

5. Sutter RW, Patriarca PA, Brogan S, et al. Outbreak of paralytic poliomyelitis in Oman: evidence for widespread transmission among fully vaccinated children. Lancet 1991;338:715-20.

6. Patriarca PA, Wright PS, John TJ. Factors affecting immunogenicity of oral poliovirus vaccine in developing countries: review. Rev Infect Dis 1991;13:926-39.

7. World Health Organization. Expanded Programme on Immunization Global Advisory Group, part II. Wkly Epidemiol Rec 1993;68:11-6.

• Based on surveillance data submitted to the EPI; because 1992 figures are provisional, 1991 data were used for global and regional disease incidence. ** The difference between the number of countries reporting poliomyelitis cases or zero cases and the total number of countries reflects those not submitting reports. *** In April 1993, Canada reported isolation of wild poliovirus type 3 from asymptomatic members of a religious group that objects to vaccination. This virus was likely imported because it was identical to a wild poliovirus type 3 that caused an outbreak among persons of a religious community objecting to vaccination in the Netherlands in 1992-1993 (2).

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