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Strategic Plan for Polio Outbreak Response in the Middle East

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The “WHO/UNICEF Strategic Plan for Polio Outbreak Response in the Middle East” outlines the specific actions that will need to be implemented across the Syrian Arab Republic, Iraq, Jordan, Lebanon, Turkey, Egypt and the West Bank and Gaza Strip in response to the circulation of wild poliovirus (WPV) following importation. Successful implementation of all activities will meet the stated objective of the plan: to stop this outbreak by the end of March 2014.

New innovations and outbreak response guidelines form the backbone of this plan, based on lessons learnt over the past 10 years and capitalizing on new tools and tactics proven to more rapidly stop outbreaks following reinfection. The plan was jointly finalized by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) in collaboration with the ministries of health and other humanitarian aid and United Nations (UN) partners.

On 28 October 2013, the Minister of Health of the Syrian Arab Republic announced that after a 15-year absence, polio had returned to the Middle East.

Thirteen cases due to wild poliovirus type 1 (WPV1) were confirmed from Deir Al Zour province. Genetic sequencing indicates that the virus has been in the region for nearly a year (linked to virus detected in environmental samples in Egypt in December 2012, with closely related strains also detected in environmental samples in Israel, and the West Bank and Gaza since February 2013). Since that time, four additional cases have been reported including from Aleppo and rural Damascus, confirming the initial assumption that WPV circulation was widespread. As of 26 November 2013, a total of 17 cases have been reported.

Given the current situation in the Syrian Arab Republic, frequent population movements across the region and the immunization level in key areas, the risk of further international spread of WPV1 across the region is considered to be high. Thus within 24 hours of confirmation that polio had returned to the Middle East, the ministers of health from across the Eastern Mediterranean declared this reinfection a public health emergency, calling for extraordinary joint action to combat this ancient scourge.

A comprehensive outbreak response will need to be implemented across the region, with seven countries and territories to conduct mass polio vaccination campaigns targeting more than 22 million children aged under 5 years. Depending on the area and based on the evolving epidemiology, the anticipated response will last at least six to eight months. Based on a comprehensive risk assessment, priority zones of intervention have been defined, and available resources will be allocated to these areas in order of priority.

The repeated, large-scale immunization campaigns will need to reach at least 90% of the identified target population, taking full advantage of the short interval additional dose approach, proven to more rapidly boost population immunity levels, in particular in difficult-to-access areas. A surveillance alert for the entire region has been issued, and efforts are ongoing to strengthen surveillance for acute flaccid paralysis (AFP). Extensive social mobilization activities are being scaled up, to further build on a history of strong community participation for immunization services across the region.

A critical challenge will be to access all children, including those living in areas difficult to reach due to conflict or insecurity. Outbreak response must therefore be conducted within the broader humanitarian response effort to the Syrian crisis, particularly in the Syrian Arab Republic and in refugee camps and host communities of neighbouring countries.

Effective coordination with international humanitarian organizations, UN agencies, national Red Crescent societies, nongovernmental organizations (NGOs) and broader civil society forms a critical aspect of the plan. The primary goal is to ensure that oral polio vaccine (OPV) is urgently delivered into all communities.

Achieving this goal will require financial support. It is estimated that the overall cost for the six-month response in all zones will be approximately US$ 39.6 million with US$ 13.3 million for 2013 and US$ 26.3 million for 2014. Donors are invited to fund the polio outbreak response efforts in the Middle East through Regional Response Plan #6 (RRP6) of the Office of the United Nations High Commissioner for Refugees (UNHCR), the Syrian Humanitarian Assistance Response Plan (SHARP) and other emergency funding mechanisms.

Specific funding projects for the polio outbreak and response efforts are being included in the RRP6 (surrounding countries) and in the SHARP (Syrian Arab Republic) to facilitate this process.
Bilateral funding from donor governments and humanitarian assistance agencies will also be necessary to cover any urgent gaps in funding for WHO and UNICEF budget lines not met by the humanitarian funding mechanisms, or to cover the costs of countries that cannot be included in the RRP6 and SHARP – for example, the West Bank and Gaza Strip.

WHO and UNICEF are committed to working with all organizations and agencies providing humanitarian assistance to Syrians affected by the conflict. This includes vaccinating all Syrian children no matter where they are, whether in government or contested areas, or indeed outside the Syrian Arab Republic.
Ultimately, however, successful implementation of the plan will require the full engagement of all political and civil society partners across the region, as well as the support of the international development community to ensure that the plan is fully implemented and that the threat of polio is eliminated once again from the Middle East.