STANDARD OPERATING PROCEDURES RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK

VERSION 3 JANUARY 2019

STANDARD OPERATING PROCEDURES RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK

Version 3 January 2019 Published by the World Health Organization (WHO) on behalf of the Global Polio Eradication Initiative (GPEI)

© World Health Organization 2019

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Cover photos credits (from left to right): Social mobilization in Nigeria, WHO; Travelling by boat to reach every last child, Nigeria, WHO; Vaccinating in Pakistan, WHO Laboratory staff investigating polio samples in Pakistan, WHO Printed by the WHO Document Production Services, Geneva, Switzerland Editing and design by Inis Communication – www.iniscommunication.com Contents

Acronyms and abbreviations iv Vaccine management and reporting 34 Routine immunization: Recovery and 1 Overview 5 strengthening 34

2 Strategic response framework 7 8 Surveillance following investigation 35 3 Poliovirus events and outbreaks 8 Surveillance enhancement 35 Environmental surveillance 36 Definitions 8 Strategies for special populations Classification of vaccine-derived polioviruses 8 and security-compromised areas 37 Event or outbreak 9 Defining “Day 0” for response monitoring 9 9 Communication and social mobilization 38 4 Detection, notification Strategic C4D framework for polio outbreak and investigation 12 response 38 Detection 12 Data gathering to guide C4D activities 39 Notification 12 Communication strategies 39 Investigation 12 Reaching special populations and conflict-affected areas 40 5 Risk assessment 17 10 GPEI support 41 Initial risk assessment 17 Coordination 42 Type 2 poliovirus 17 Budgets and financing 42 Including sentinel events in the risk assessment 18 Human resource surge 42 Ongoing risk assessment 18 GPEI performance standards 43

6 Response standards – overview 19 11 Monitoring and evaluation of response 44 Minimum response standards for poliovirus events and outbreaks 19 Monitoring quality of SIAs 45 Outbreak grading 21 Monitoring surveillance enhancement 46 Standard timelines for outbreak response 22 Outbreak response assessments (OBRAs) 46 Is the outbreak over? 47 7 Vaccination response 23 International Health Regulations (IHR) Timing and scale of immunization activities 23 Emergency Committee 48 High-quality campaigns 31 Documenting lessons learned 49 Planning for mobile, hard-to-reach and special populations 32 Bibliography 50 Concurrent circulation of different Annexes 52 poliovirus types 32 Annex 1. Risk assessment overview: Summary of Integration with other health interventions 32 elements for systematic risk assessment Inactivated polio vaccine (IPV) 33 of a new VDPV, WPV or SL2 isolation 53 Requesting vaccine 33 Annex 2. Timeline and responsibility for outbreak response activities from Day 0 to outbreak closure 55 Acronyms and abbreviations

AFP acute flaccid paralysis C4D Communication for Development EOC emergency operations centre EOMG Eradication and Outbreak Management Group ES environmental surveillance fIPV fractional dose inactivated polio vaccine GIS geographic information system GPEI Global Polio Eradication Initiative GPLN Global Polio Laboratory Network IDSR Integrated Disease Surveillance and Response IHR International Health Regulations (2005) IM independent monitoring IPV inactivated polio vaccine LQAS lot quality assurance sampling NGO nongovernmental organization NPAFP non-polio acute flaccid paralysis NPENT non-polio enterovirus OBRA outbreak response assessment OPRTT Outbreak Preparedness and Response Task Team OPV oral polio-containing vaccine bOPV bivalent OPV (contains Sabin types 1 and 3) tOPV trivalent OPV (contains Sabin types 1, 2 and 3) mOPV2 mOPV2 monovalent OPV (contains Sabin type 2) RED Reaching Every District RI routine immunization RR rapid response SAGE Strategic Advisory Group of Experts on Immunization SIA supplementary immunization activities SIAD short interval additional dose SOPs standard operating procedures SR surge response STOP Stop Transmission of Polio UNDSS United Nations Department of Safety and Security UNICEF United Nations Children’s Fund VDPV vaccine-derived polio virus aVDPV ambiguous vaccine-derived polio virus cVDPV circulating vaccine-derived polio virus iVDPV immunodeficiency related vaccine-derived polio virus WHE WHO Health Emergencies WHO World Health Organization WPV wild poliovirus WPV1 type 1 wild poliovirus WPV2 type 2 wild poliovirus WPV3 type 3 wild poliovirus

iv RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK 1 Overview

Background Scope As of July 2018, three countries remain endemic for These Global Polio Eradication Initiative (GPEI) type 1 wild poliovirus (WPV1): Afghanistan, Nigeria SOPs establish response standards and timelines and Pakistan. In 2015, type 2 WPV (WPV2) was for actions to stop transmission when WPV spreads declared eradicated, and type 3 WPV (WPV3) was to a non-endemic country, or when VDPV events last reported in November 2012. In 2016, type 2 and/or outbreaks of any type (VDPV1, VDPV2 or oral polio-containing vaccine was withdrawn from VDPV3) are detected in any context, whether a new all routine immunization programmes worldwide, emergence or previously undetected circulating replacing trivalent oral polio vaccine (tOPV) vaccine-derived poliovirus (cVDPV). containing attenuated poliovirus vaccine serotypes 1, 2 and 3 with bivalent oral polio vaccine (bOPV) This document updates the most recent version containing only types 1 and 3. of the polio outbreak SOPs published November 2017. This version 3.0 of the SOPs incorporates While efforts to eradicate WPV1 continue in endemic lessons learned from previous outbreak response countries, the world needs to be prepared for the efforts since the tOPV–bOPV switch in April and international spread of WPV, and for vaccine-derived May of 2016. The SOPs summarize the roles and poliovirus (VDPV) of serotypes 1, 2 or 3, which responsibilities of countries and GPEI partners can also still emerge in different contexts. Poliovirus during a polio outbreak or event. Since WPV2 is events or outbreaks may arise due to a number of now considered an eradicated pathogen, specific possible factors, including low population immunity, measures are outlined for responding to type 2 importation of virus, or a containment breach from events and outbreaks, including how to request laboratory or vaccine manufacturing facilities. and account for monovalent oral type 2 polio vaccine (mOPV2) from the global emergency vaccine stockpile. Purpose The purpose of these standard operating procedures Guidance in these SOPs relies on scientific evidence (SOPs) is to offer policy guidance and to provide and expert consensus, while remaining grounded performance standards on how to respond to any in operational realities and the context of waning type of poliovirus outbreak or event in a timely global immunity to type 2 poliovirus. Critical and effective manner, and specifically, to stop an aspects of the SOPs result from broad consultation outbreak within 120 days. of expert advisory groups, including the World Health Organization (WHO) Strategic Advisory This guide is for national governments and public Group of Experts (SAGE) on immunization, and health decision-makers who coordinate responses to endorsement by the GPEI Eradication and Outbreak poliovirus events and outbreaks, and their global, Management Group. regional and country-level partners.

RESPONDING TO A POLIOVIRUS 5 EVENT OR OUTBREAK These SOPs do not cover: WPV1 case response due to Supporting documents local transmission in an endemic context, field-level operational guidance or tools for planning high- Resources referenced in these SOPs are available quality supplemental immunization activities (SIAs), on the GPEI website (http://polioeradication.org/ or detailed methods for enhanced surveillance. tools-and-library/resources-for-polio-eradicators/ gpei-tools-protocols-and-guidelines/) and/or are listed in the bibliography. What’s new in this version Version 3.0 of the SOPs for poliovirus outbreak and event response offers technical updates, focuses on practical guidance, and guides response for all poliovirus types in a single document. Guidance covers all aspects of outbreak response: investigation, risk assessment and grading, coordination and management, vaccination, surveillance enhancement, communication for development (C4D), social mobilization, and other elements.

6 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Strategic response 2 framework

This framework guides national responses to All countries must plan for the eventuality of poliovirus events or outbreaks, providing the basis a poliovirus importation or local detection, for coordination and collaboration among partners, particularly those with low immunization coverage to ensure that national polio response activities are and those at risk of importation, or those with fully supported. facilities that handle the poliovirus (e.g. laboratory, research, vaccine manufacturing facilities). A Below are the essential elements to a successful preparedness plan should be developed and tested response to a polio event or outbreak: in a polio outbreak simulation exercise to ensure that public health personnel and emergency systems i) Fully engaged national and subnational are prepared to react quickly and effectively if any governments poliovirus isolate is detected. Countries with high- ii) Rapid detection, notification, investigation and risk populations and/or facing conflict, insecurity risk assessment or access challenges must consider how to prioritize iii) Strong advocacy, communication and social these populations and areas, adapting strategies to mobilization the local context. iv) A robust immunization response, where indicated v) High-quality and enhanced surveillance.

RESPONDING TO A POLIOVIRUS 7 EVENT OR OUTBREAK Poliovirus events 3 and outbreaks

Definitions VDPVs are identified based on their degree of genetic divergence from the parent OPV virus strain. Poliovirus isolates detected in persons or in the Viruses that are >1% divergent (i.e. ≥ 10 nucleotide environment can fall into three major categories: changes, for types 1 and 3) or >0.6% divergent wild, Sabin and Sabin-like, or vaccine-derived. New (i.e. ≥ 6 nucleotide changes, for type 2) from the detection of a poliovirus isolate may constitute an corresponding OPV virus strain, are labelled as emergency, which can be categorized as an event VDPV.b or an outbreak, depending on characteristics of the isolate and the context in which it appears (see below). Classification of vaccine-derived 1. Wild polioviruses. At this stage of the polioviruses eradication programme, each case or isolate VDPVs are classified into three categories: of wild poliovirus requires rigorous review as it may represent an importation, a local i) Circulating vaccine-derived poliovirus containment breach, or ongoing transmission (cVDPV) is a VDPV demonstrating person-to- in endemic countries. person transmission in the community, based 2. Sabin virus. Sabin virus is the live attenuated on evidence from human and/or environmental poliovirus in oral polio vaccine (OPV). This detections of related viruses. category also includes Sabin-like polioviruses, ii) Immunodeficiency-related vaccine-derived which are those genetically very closely related poliovirus (iVDPV) is a VDPV isolated to the strains in OPV but that have not yet from an individual with evidence of primary diverged sufficiently to meet the definition immunodeficiency. Unlike immunocompetent of a vaccine-derived virus (see below). Sabin persons, who excrete the vaccine virus for a and Sabin-like viruses are commonly detected limited period, in rare cases immunodeficient following vaccination with OPV.a persons may excrete a genetically diverged vaccine virus for an extended period of time 3. Vaccine-derived polioviruses (VDPVs). In after receiving OPV. under-immunized populations, if Sabin-like viruses continue to be transmitted from iii) Ambiguous vaccine-derived poliovirus person-to-person they can continue to diverge (aVDPV) is a classification of exclusion when genetically and eventually in rare instances the investigation does not support classification become VDPVs, which may evolve and can as cVDPV or iVDPV. Isolates may be from eventually regain the ability to cause paralysis. persons with no known immunodeficiency or from an environmental sample, without evidence of circulation.

a Type 2 Sabin and Sabin-like virus should no longer be detected except where mOPV2 has recently been used for response. Any Sabin or Sabin-like type 2 virus outside this circumstance warrants urgent investigation. b See “Classification and reporting of vaccine-derived polioviruses (VDPV)”. Geneva: Global Polio Eradication Initiative; 2016 (http://polioeradication.org/ wp-content/uploads/2016/09/Reporting-and-Classification-of-VDPVs_Aug2016_EN.pdf, accessed 8 November 2018).

8 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK These definitions are relevant to isolates of all Defining “Day 0” for response poliovirus serotypes (i.e. 1, 2 or 3). monitoring The GPEI guidelines, Classification and reporting of All poliovirus events and outbreaks will trigger the vaccine-derived polioviruses,c provide definitions and same set of response actions including; investigation, describes the laboratory and field epidemiological risk assessment, surveillance enhancement, strategic investigation needed to classify an isolate. advocacy, and communication, with or without a Occasionally, investigation and genetic sequencing of vaccination response. a VDPV may take some time. A new isolate unrelated to any known VDPV is referred to as a VDPV “pending For the purpose of performance monitoring, a “Day 0” classification” and may require response measures. A is defined so that progress of all response actions can previously classified virus may also be re-classified be monitored against the standards set in these SOPs. based on new information. Day 0 is the day of receipt of the genetic sequencing laboratory result by WHO headquarters. Event or outbreak Previously isolated VDPVs, classified as ambiguous Table 1 categorizes new or continuing poliovirus or pending classification, may be reclassified as isolation as an event or outbreak to help describe circulating (i.e. an outbreak) if another related the extent of person-to-person transmission and poliovirus is detected indicating evidence determine an appropriate response. The term of transmission. “outbreak” is reserved for situations with clear evidence of person-to-person transmission. For outbreaks or medium to high-risk events (deemed to require a vaccination response), Day 0 remains Events may evolve into outbreaks. the same for the purpose of operational response monitoring, even if new information confirming transmission becomes available.

In the case of a low-risk event without vaccination response, genetic sequencing information for new isolates may subsequently confirm transmission. In this case, consideration may be given by GPEI to adjust Day 0 to the date the new sequencing information is received.

c See “Classification and reporting of vaccine-derived polioviruses (VDPV)”. Geneva: Global Polio Eradication Initiative; 2016 (http://polioeradication.org/ wp-content/uploads/2016/09/Reporting-and-Classification-of-VDPVs_Aug2016_EN.pdf, accessed 8 November 2018).

RESPONDING TO A POLIOVIRUS 9 EVENT OR OUTBREAK Table 1: Definition of poliovirus events and outbreaks

Typology Definition Event Human (no Detection of: evidence of transmission) • VDPV in: -- single acute flaccid paralysis (AFP) case or asymptomatic person (e.g. contact), or -- one or more persons,1 with no evidence of further community-level circulation (iVDPV or aVDPV isolates) OR • Type 2 Sabin or Sabin-like isolate from individual sample(s) more than four months after use of any type 2 containing OPV (i.e. mOPV2 or tOPV) OR • WPV1, WPV2 or WPV3 infected individual with suspected or documented type-specific virus exposure in a laboratory or vaccine production facility. Environmental Detection of: • WPV single environmental sample without follow-up evidence of virus excretion;2 OR • VDPV without evidence of further transmission, such as: -- a single environmental sample without evidence of prolonged circulation; or -- an aVDPV. OR • Type 2 Sabin or Sabin-like isolate from environmental sample(s) more than four months after use of any type 2 containing OPV (i.e. mOPV2 or tOPV).

Outbreak Human (evidence of Detection of: transmission) • any WPV-infected individual(s)1 (i.e. outside endemic areas and without documented exposure to WPV in a laboratory or vaccine production facility); OR • any cVDPV infected individual(s).1 Environmental Detection of: • two or more separate3 environmental samples positive for WPV with genetic sequencing information indicating sustained local transmission; OR • a single environmental sample positive for WPV with follow-up evidence of virus excretion2 (and no documented exposure in a laboratory or vaccine production facility); OR • any cVDPV positive environmental sample(s).

1 Infected person can be an AFP case, or an asymptomatic/healthy person. 2 Evidence of virus excretion as identified during follow-up community investigation. 3 Separate means that samples were collected at more than one distinct environmental surveillance collection site (i.e. no overlapping of catchment areas), OR samples were collected from one site, but collection was more than two months apart.

10 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK END OF OUTBREAK notifi cation notifi Time from lab result lab result Time from WPV human cVDPV human WPV environment cVDPV environment OUTBREAK WPV with genetic sequencing that suggests local local WPV with genetic sequencing that suggests transmission of virus excretion evidence follow-up • for positive samples environmental ≥2 separate • WPV with for positive sample environmental 1 single

OUTBREAK OR HIGH-RISK EVENT WPV human iVDPV aVDPV aVDPV vaccine production facility) production vaccine WPV environment With possible or documented wild or documented With possible poliovirus exposure (laboratory or (laboratory exposure poliovirus EVENT WPV VDPV VDPV human Type 2 Type human or Sabin like Sabin like environment environment Poliovirus type 1, 3 or 2 DAY 0: DAY cation notifi Lab result Figure 1: SOPs at a glance: Events and Outbreaks Events at a glance: 1: SOPs Figure

RESPONDING TO A POLIOVIRUS 11 EVENT OR OUTBREAK Detection, notification 4 and investigation

Detection Investigation Samples collected from human (biological) or The country must investigate any poliovirus isolate environment sources during routine surveillance notifiable under IHR, whether the isolate is from AFP or an event or outbreak investigation are sent to a cases, AFP contacts or environmental surveillance. laboratory of the Global Polio Laboratory Network The GPEI will support the country as needed. (GPLN) to determine the presence of poliovirus. The virus can be identified through culture, intra-typic Local health authorities should initiate the differentiation and genetic sequencing. investigation within 24 hours of a poliovirus isolate report. The most effective approach is a joint epidemiological and social investigation with Notification support from the national level of any case and As soon as poliovirus is identified, the GPLN will affected community, as well as the gathering of inform the health authorities of the affected country relevant national data. Whether a known poliovirus and WHO at the country, regional and headquarters strain is isolated in a previously infected area or a levels. Under the International Health Regulations previously uninfected area, or a new poliovirus (2005) (IHR),d all notifiable polioviruses (see Box strain is detected, all require a comprehensive 1) must also be immediately reported by national detailed investigation. authorities to the IHR focal point at the respective Information from the GPLN and the epidemiological WHO regional office. and social investigation are used to describe the WHO headquarters will inform GPEI partners characteristics of the virus and determine if there when this information is received and validated. is evidence of person-to-person transmission. This Additional details, including any links to other will inform the risk assessment and classification. polioviruses, will be shared by the GPLN and WHO As investigation and classification can take headquarters as soon as available. days or weeks; it is critical to appreciate that response activities are often required before final Notification to WHO may lead to publication of a virus classification. disease outbreak news report on the WHO website, as appropriate, based on virus type, risk assessment and outbreak status.

Box 1. International Health Regulations 2005 (IHR) and the obligation to notify The IHR 2005 requires that detection of any WPV, any VDPV (type 1, 2, or 3), or Sabin type 2 virus more than four months after use of mOPV2, must be assessed within 48 hours and then notified by the IHR focal point to WHO within 24 hours, regardless of the source (i.e. case, environmental sample or other source), and without waiting for final classification. Sabin virus types 1 and 3 are not currently notifiable under IHR.

d See “International Health Regulations” (2005), 2nd Edition. Geneva: World Health Organization; 2008 (http://www.who.int/ihr/ publications/9789241596664/en, accessed 8 November 2018).

12 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Table 2 outlines the scope and objectives of an investigation.

Table 2: Investigation of poliovirus isolates from AFP cases, contacts or environmental surveillance

Investigation components Objectives Part A: 1. Detailed case investigation for a poliovirus • Gather information to confirm the event/ Investigating isolate from an AFP case or a positive outbreak the case or contact • Identify possible source of infection/ environmental 2. Investigating the site of an isolate from causes of the event/outbreak isolate and environmental surveillance • Determine the number and characteristics local context 3. Describing the community context of any of cases, the context for environmental detected isolate, regardless of source: isolates • Population immunity • Recent SIA performance • Population characteristics, movement and migration routes • Community social mapping. Part B: 4. Community search for additional cases of • Determine the geographic extent and Determining AFP and evidence of virus transmission: assess the risk of further transmission the • Contact sampling geographic • Targeted healthy children stool surveys extent of • Community household search for AFP transmission • Local health facility search for AFP • Other community outreach.

Part A: Investigating the case or An urgent epidemiological (i.e. person, place and time) and social investigation of the AFP case and environmental isolate and local close contacts is required. It is important to collect context detailed information on travel history, socioeconomic and community context, distance to health facility 1. Detailed case investigation of an isolate or other barriers to vaccination, and other relevant from an AFP case or contact information. The GPEI form, Detailed epidemiologic e For any poliovirus isolated from a child or adult case investigation form, provides a guiding template f (AFP case or contact), conduct a detailed clinical for a joint epidemiological and social investigation. and neurological examination. Collect a detailed history of treatment, injections and vaccination 2. Investigating the site of an isolate from (including all routine and SIA doses of any polio environmental surveillance vaccine, date of last vaccination, and reasons for Describe the catchment area of the infected sampling any missed doses). Clinical and family history site and other collection sites in the area, including should include any signs or symptoms of primary information on population demographics (especially immunodeficiency, and a test for quantitative high-risk groups), population movement, and immunoglobulins where indicated. relevant institutions (e.g. health facilities, schools and bus parks or other transportation centres).

e See “Detailed epidemiologic case investigation form”. GPEI guidance. Geneva: Global Polio Eradication Initiative; 2011 (see document within GPEI library http://polioeradication.org/tools-and-library/resources-for-polio-eradicators/gpei-tools-protocols-and-guidelines/, accessed 8 November 2018). f Country-specific tools required to investigate a poliovirus detection should be developed during outbreak preparedness and response planning. A national team to conduct the investigation should be trained as core capacity development for implementation of IHR or Integrated Disease Surveillance and Response (IDSR).

RESPONDING TO A POLIOVIRUS 13 EVENT OR OUTBREAK Describe the sewage or drainage system into the Collect epidemiologic evidence of any past collection site, complemented by geographic poliovirus detections (WPV or VDPV) in the affected information system (GIS) imagery where possible or surrounding communities. Review documented (e.g. elevation profile, links with other sites, and communicable disease incidence and transmission density of dwellings). Document the history of the patterns, including vaccine-preventable diseases, site, collection schedule, timeliness and completeness while paying special attention to diseases with of collection, and proportion of samples positive faecal–oral transmission such as cholera and acute for non-polio enteroviruses (NPENT). Record any bloody diarrhoea. poliovirus detected, including Sabin virus. Recent SIA performance. Use immunization For Sabin 2 virus isolation, investigate immediately coverage, independent monitoring (IM), and lot using the field guide and investigation template quality assurance sampling (LQAS) indicators from available (unless within four months of a mOPV2 recent SIAs to define the following: i) number and response in the immediate area). characteristics of missed children; ii) reasons for missing them; and iii) any interventions that worked Investigation of a WPV isolate in a non-endemic to successfully reach missed children. country must consider possible release from a laboratory or other facility,g or importation (e.g. by For any type 2 poliovirus, in addition to information an incoming traveller), particularly when genetic on any post-switch detection of Sabin 2 or previous sequencing to ascertain origin is still pending. VDPV2, collect additional details regarding last known use of tOPV or mOPV2, quality of mOPV2 3. Describing the community context of any vaccine management, and steps taken to search for detected isolate, regardless of source any remaining tOPV or mOPV2 vials. The information outlined below should be collected Population characteristics, movement and following detection of poliovirus in a previously migration routes. Obtain a general overview of uninfected community. For any subsequent detection the affected population, including information on in the same area, focus on significant updates to the population density, social structure and networks, general information previously collected. presence of minority or non-local residents, and community awareness of polio and immunization. Population immunity. Develop an immunity profile Highlight any security and access constraints. based on available information such as type-specific Take note of major population movements due to vaccination status of non-polio AFP cases, routine economic, seasonal or nomadic migration, religious and SIA vaccination coverage data, and community pilgrimage, insecurity, or natural disaster. immunization surveys. Determine the characteristics of unvaccinated and partially vaccinated children, Community social mapping. Use formal or high-risk or special populations, and seek details of informal sources to gain an appreciation of health-seeking behaviour. immunization practice and vaccine acceptance in the community. Gather general information on For type 2 isolates, distinguish carefully between media reach, community influencers, and relevant immunity to type 2 compared to types 1 and 3 social groups. polioviruses, and pay special attention to birth cohorts born since the switch or since last use of mOPV2. Estimate the population naive to oral polio vaccine or protected only by inactivated polio vaccine (IPV) for type 2 poliovirus.

g See “Public Health Management of Facility-Related Exposure to Live Polioviruses: Interim guidance in managing exposed persons for countries hosting facilities that maintain live polioviruses” on GPEI website library, http://polioeradication.org/tools-and-library/resources-for-polio-eradicators/ gpei-tools-protocols-and-guidelines/).

14 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Part B: Determining the geographic situation, one stool specimen for poliovirus testing extent of transmission is collected from each of three direct contacts, preferably un- or under-vaccinated children living in the same house or nearby to the AFP case. Close 4. Community search for additional cases of contact sampling can be conducted for up to two AFP and evidence of virus transmission months after onset of paralysis for cases that are Once a poliovirus has been detected from any found late, such as through retrospective search. source, additional steps are required to ascertain the geographic extent of possible transmission. Generally, contact stool sampling is not recom- These activities can include a review of surveillance mended if adequate stools can be collected from data, investigation of AFP contacts, others in the an AFP case. community, and health facilities using strategies that are often part of routine poliovirus surveillance, However, after poliovirus has been confirmed as but also useful in specific circumstances after a the cause of paralysis for an index VDPV case, poliovirus has been confirmed (see also Section 8 the field investigation should also include stool on enhanced routine surveillance). sampling from three close contacts to determine if there is other ongoing community circulation that Surveillance data. Conduct an in-depth review would thus warrant classification of the VDPV as a for polio across the country to analyse risk and cVDPV. This strategy may even be considered for determine the quality and sensitivity of the current areas outside of the community where the AFP case surveillance system. Include a review of AFP was detected, to include sampling of close contacts indicators at lowest applicable administrative level, where an infected child travelled from or to during including AFP detection, stool adequacy, NPENT his/her potentially infectious period (i.e. from two isolation rates and the non-polio AFP (NPAFP) days before to 60 days after onset of paralysis). immunization profile for the last five to 10 years at least. Also consider evidence of implementation Targeted healthy children stool surveys. Also of recommendations for surveillance strengthening known as community sampling or asymptomatic from recent programme or surveillance reviews. children stool sampling, a targeted healthy children stool survey is the collection and testing of stool Further investigation in the community and health specimens from asymptomatic children (i.e. children facilities are time- and resource-intensive, and without paralysis, who may have other illnesses). so require close coordination with the relevant In addition to any contact sampling, targeted stool poliovirus laboratory to prepare for any surge surveys should include collection of a stool sample requirements. Unless otherwise indicated, the from 20 children under five years of age (with strategies below should only be implemented as preference for those less than two years) chosen part of the field investigation following detection randomly from the same community (for a case) of a new unclassified VDPV case or newly positive or catchment area (for an environmental sample). environmental sample (VDPV or WPV) in an area that has not had documented transmission within During the initial investigation of a new event or the past 12 months (i.e. an index case or sample). outbreak, or when an outbreak has spread to a new, distant geographic area, targeted stool surveys of Possibly relevant investigation strategies include: asymptomatic children may be conducted to detect poliovirus transmission in the community. Priority Contact sampling. Since polioviruses are typically should be given to un/under-vaccinated children. transmitted to close contacts or may circulate more Do not include family or close contacts in the survey widely in the community, even if a paralysed child except when case contact sampling is indicated, as is not positive for poliovirus, contact sampling is outlined previously. a strategy used in routine poliovirus surveillance when an AFP case cannot produce an adequate stool within 14 days of the onset of paralysis. In this

RESPONDING TO A POLIOVIRUS 15 EVENT OR OUTBREAK Community household search. For any area with a Local health facility search. Conduct retrospective newly detected VDPV or environmental surveillance case search in health facilities (formal and informal) (ES) sample, a house-to-house search to identify any and document findings. Include at least six-month person with sudden onset of weakness or paralysis record reviews for undetected/unreported AFP cases. in one or more limbs in the past 60 days can help Assess clinicians’ knowledge of AFP surveillance and to determine if there is any additional community polio immunization performance and capabilities. transmission. The number of households to visit will Complete a search for vials of tOPV or mOPV2 depend on local population density and other risk where relevant. factors but should cover at least 200 households. National authorities and/or GPEI technical expert Other community outreach. As part of the advisory bodies can provide further guidance. search for any cases of paralysis, including during household search, investigators should engage local leaders and influencers in the community and sensitize them to the case definition of AFP and the importance of early reporting of paralysis.

16 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK 5 Risk assessment

Initial risk assessment A detailed summary of elements to help countries prepare a robust risk assessment is provided, along Isolation of a poliovirus in a previously non-infected with additional resources and tools (see Annex 1: area represents an event or outbreak that requires Risk assessment overview for detailed guidance). national authorities to complete an immediate risk assessment to inform the type and scale of response. The purpose of the risk assessment is to Type 2 poliovirus review virologic and epidemiologic characteristics All type 2 virus isolations require special attention of the newly detected virus, event or outbreak when conducting a risk assessment and determining and determine the level of risk for further local or the type and scale of response. Following the global international spread as high, medium or low. withdrawal of type 2 containing OPV from routine The risk assessment is presented by national immunization programmes in April and May of authorities and/or WHO national or regional offices 2016, there is increasing risk of very rapid virus to GPEI partners within 72 hours of receipt of a spread associated with declining mucosal immunity genetic sequencing result, or outbreak confirmation. in children. The assessment reviews critical factors that will For type 2 poliovirus (VDPV2 or WPV2) detection, influence the type and scale of response and allows consultation with GPEI partners is systematic and GPEI to recommend appropriate action. will often result in a discussion with the mOPV2 A risk assessment addresses three risk elements: Advisory Group to review the risk assessment and virologic, contextual, and risk of international assess the need for a potential vaccination response transmission (see Table 3). with monovalent type 2 oral polio vaccine (mOPV2).

Table 3: Elements to assess risk for further poliovirus transmission that will influence type and scale of response

Risk element Sample of risk factors considered (not exhaustive)

Virologic risk1 High degree of genetic deviation from parent Sabin, number and nature of nucleotide changes, and expert interpretation by virologists, etc.

Contextual risk Recent poliovirus detection or other sentinel events, sensitivity of AFP surveillance system, high population density, low immunization coverage and population immunity, geographic access, conflict, inaccessible or hard-to-reach populations, and population movements, etc.

Risk of international Border area with high population mobility, nomadic or refugee populations, cross- transmission border conflict, and international travel routes, etc.

1 Virologic risk is considered high for any WPV or cVDPV.

RESPONDING TO A POLIOVIRUS 17 EVENT OR OUTBREAK A detection of type 2 Sabin or Sabin-like virus in Ongoing risk assessment an area where mOPV2 has not been used in the previous four months is notifiable under IHR. Such Following initial investigation and risk assessment, a finding may reflect ongoing and/or unauthorized national authorities must continue to collect use of tOPV or mOPV2, as children vaccinated with detailed information to update the situation analysis OPV continue to shed Sabin virus for approximately and risk assessment (i.e. results from laboratory three months. For this reason, detection of type investigations, or detailed information on affected 2 Sabin or Sabin-like virus from any source four communities, etc.). Neighbouring countries/regions months or more after last mOPV2 use requires an must also continue to update their risk assessment investigation, risk assessment and IHR notification with support from WHO regional offices. to WHO. Relevant risk factors to include in the ongoing risk assessment include: Including sentinel events in the risk • detailed quantitative and qualitative analysis and assessment mapping of population movement (e.g. trade, migration, displacement, and travel and migration A sentinel event is information or an occurrence routes such as roads, lakes and rivers); of any nature, related or unrelated to polio, which • quantification of special high-risk or hard-to- suggests that the community or general geographic reach populations (e.g. geographic or cultural area may be at risk for a polio outbreak. Sentinel inaccessibility, areas of insecurity, vaccine refusals events can include: and sentinel events); 1. Appearance of vaccine-preventable disease • modelling of population immunity to relevant (e.g. measles, diphtheria, and/or VDPV of any outbreak/event poliovirus type(s); type) that suggests low routine immunization • detailed assessment of all surveillance indicators performance in general (e.g. measles) or at subnational level; polio-specific transmission risk due to mode of • mapping with geographic information system person-to-person spread (e.g. cholera); (GIS), with emphasis on high-risk populations, urban areas, border areas and regions difficult to 2. Rapid displacement or ongoing movement of access for any reason. under-immunized communities; 3. Detection of type 2 Sabin virus from a Ongoing analysis should use information from all biological or environmental source in the possible sources, including data beyond standard absence of mOPV2 use; polio programme information. Entities such as the International Organization for Migration, the United 4. Finding vials of tOPV or mOPV2 in Nations Office for the Coordination of Humanitarian the community. Affairs, and the WHO Health Emergencies Programme can provide critical information on Communities or administrative areas with sentinel population migration and insecurity. events should be included in the investigation and risk assessment.

18 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Response standards – 6 overview

The scope of response to a detected event or outbreak Scope of vaccination. The scope of vaccination will be determined by the type and classification of campaigns will vary with the type of poliovirus event the poliovirus and the risk assessment. The key to or outbreak, the source of detection and the context. a successful response and interrupting transmission All outbreaks (VDPV or WPV) require a vaccination lies in adapting strategies as the situation evolves, response with an appropriate type-specific OPV over the course of the investigation and response. within 14 days of laboratory notification. In some circumstances, events in high-risk contexts may also warrant vaccination response, based on the Minimum response standards for risk assessment and discussion with country health poliovirus events and outbreaks authorities and GPEI technical experts. This includes Notification of a new poliovirus, or the spread of VDPVs pending classification or ambiguous VDPVs poliovirus to a new geographic area or population, (aVDPVs). requires national authorities and GPEI partners Isolation of an iVDPV requires careful assessment to be strongly engaged and rapidly initiate the to ensure that all household members and close following elements: community contacts are immunized with IPV. Larger- 1. Detailed investigation and risk assessment scale SIAs are not required unless circulation in the (see chapters 4 and 5) community is established. An iVDPV carrier should receive appropriate therapy for their underlying 2. Enhanced surveillance to increase sensitivity immune deficiency syndrome and be offered optimal and confidence that any ongoing person- anti-poliovirus treatment where available. to-person transmission of poliovirus will be rapidly detected (see investigation in chapters Figure 2. Core and enabling functions for 5 and 8) quality outbreak response 3. Planning of a vaccination response.

The core and enabling functions are illustrated in

Figure 2. Notify, investigate, Robust coordination, planning, budgeting, assess risk community engagement, and monitoring are Enhance surveillance enabling functions central to successful response. Enhance Assign surveillance Risk communication and social mobilization efforts grade and should be tailored to the event or outbreak context deploy Plan, support Vaccinate: budget and and support surveillance enhancement, vaccination reach every mobilize child response activities and routine immunization. For resources all outbreak and event responses, it is necessary A s to monitor and report all interventions and dvocat munitie e, communicate and mobilize com enhancements for surveillance, vaccination and communication (see Chapter 11). M ty onitor, evaluate and ensure quali

RESPONDING TO A POLIOVIRUS 19 EVENT OR OUTBREAK PLUS community non-household contact infected contact for household members for until two consecutive until two samples are negative are samples Clinical management Clinical with cVDPV response appropriate for primary for appropriate Examine monthly samples Examine monthly Immune disorder = iVDPV Immune disorder immunodefi ciency condition ciency immunodefi IPV Treat as cVDPV and continue Treat and close community contacts community and close Low

2 Investigate Assess risk Assess No linked VDPV; No linked Further fi eld and fi Further sequencing results vaccination response vaccination no immune def. = aVDPV no immune def. Depends on local situation. Depends on local re-classifi ed and/or require require ed and/or re-classifi High and detections, virus may be and detections, Based on further assessment Based on further assessment “New” unclassified VDPV unclassified “New” scenario with linked with linked unlinked VDPVs VDPVs unlinked = high risk event Additional cases Additional cases VDPV = cVDPV or VDPV several clustered clustered several or other high risk ) 3 OR High risk VDPV event 1 Investigate Investigate Assess risk Assess assessment Outbreak response response Outbreak within 8 weeks of day 0) within 8 weeks within 4-6 weeks of day 0) within 4-6 weeks OPV vaccination response OPV vaccination Continue w/ SIA 3+ if necessary Mop up (within 12 weeks of day 0) Mop up (within 12 weeks cVDPV Outbreak Large scale SIA1 (1-2 million children SIA1 (1-2 million children scale Large SIA2 (1-2 million children scale Large children < 5 years of age, within 14 days < 5 years children Rapid response round (200 000 to 500 000 (200 000 to round Rapid response genetically linked to known cVDPV or previous aVDPV genetically linked to known cVDPV or previous surveillance (ES) sample or single human/acute flaccid paralysis (AFP) case not linked to known aVDPV by WHO HQ of VDPV2 genetic sequencing results Day 0, the day of receipt from all times are 2 3 Figure 3: Response strategies following detection of an isolate of vaccine-derived poliovirus of vaccine-derived of an isolate detection following strategies 3: Response Figure 1

20 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Response strategies following detection of an isolate The purpose of the grading is to: of vaccine-derived poliovirus are illustrated in • inform all partners of the nature of the event or Figure 3. outbreak, the response required and the need for Defining and planning high-quality outbreak mobilization of internal and external resources; response. A comprehensive outbreak response • activate GPEI response mechanisms; includes investigation, surveillance and vaccination, • prompt local government and GPEI partners at all all supported by communication and social levels to mobilize resources for support, including mobilization activities, including cross-border immediate human resources. coordination between countries. Coordinated and WHO will assign an outbreak Grade 1, 2 or 3 within high-quality activities will ensure confidence in the 72 hours of Day 0. A grade is valid for three to country’s ability to detect rapidly any poliovirus six months, through the first phase of outbreak circulation and to interrupt transmission through response, and should be reviewed with new vaccination. For surveillance, it is necessary to information and/or as response activities progress. monitor carefully both process (e.g. AFP reporting rates, lab performance) and outcomes (e.g. early The criteria used to grade outbreaks include: 1) the detection of virus through all surveillance strategies potential for transmission within the country and in high-risk special populations). beyond national borders based on the risk assessment (virologic, contextual, risk of international spread); Outbreak grading and 2) the strength of the country’s ability to respond to and contain the outbreak, including All outbreaks, and in some instances, events in high- vaccine management capacity. Depending on risk contexts, will be graded by WHO as per the circumstances, the risk assessment may include Health Emergency Response Framework.h discussion of the urgency and complexity of the event and the reputational risk it may generate. Grading is a procedure that triggers outbreak Country capacity is a subjective assessment based on response policies in WHO and the affected country health infrastructure and current security or access or countries. The grading will indicate risk level and challenges. Figure 4 presents a general risk matrix determine actions needed to manage the poliovirus for grading an event or outbreak. event or outbreak in the country context. See Chapter 10 for outbreak response scale-up and detailed information on GPEI support according to grading.

Figure 4: General risk matrix for grading an event or outbreak

Country capacity to respond Risk of local or international Strong Moderate Weak transmission Low Grade 1 Grade 1 Grade 2 Medium Grade 1 Grade 2 Grade 3 High Grade 2 Grade 3 Grade 3

h See “Emergency Response Framework (ERF)”. World Health Organization; 2017 (https://www.who.int/hac/about/erf/en, pg. 28, accessed 8 November 2018).

RESPONDING TO A POLIOVIRUS 21 EVENT OR OUTBREAK Standard timelines for outbreak countries and GPEI partners at all levels. This may response include multilevel calls with sub-regional outbreak coordination offices, regional offices and global Table 4 outlines key actions and timelines for event partners. Following initial consultation, operations and outbreak response (see Annex 2 for a detailed are supported by the GPEI Outbreak Preparedness list from Day 0 to close of outbreak). It is essential to and Response Task Team (OPRTT) to manage rapidly establish coordination mechanisms between coordination with all partners.

Table 4. Major steps and timelines for critical components of event and outbreak response

Timeline Response actions for all isolates Within 24 hours Initiate investigation Country and each partner agency to initiate internal consultations Within 48 hours Initiate partner coordination via OPRTT1 Within 72 hours Country to notify WHO through IHR Risk assessment and grading mOPV2 Advisory Group and vaccine request (if applicable) Country to declare national public health emergency 72 hours to initiate Develop response plan for surveillance,2 vaccination and social mobilization OPRTT to coordinate and deploy RR team as required Within 14 days Rapid response vaccination (Round Zero) Within 90 days First large-scale, second large-scale, and a mop-up round Independent monitoring and LQAS results to Assess immunization quality: be shared within 14 days of each campaign • Independent monitoring required3 • LQAS4 to start as soon as possible Outbreak response assessments (OBRAs) 1. First assessment within three months of lab notification (Day 0) 2. Follow-up quarterly assessments 3. Final assessment after at least six months without poliovirus detection

1 OPRTT = Outbreak Preparedness and Response Task Team 2 See chapter 4 (Determining the geographic extent of transmission) and chapter 8 (Surveillance following investigation) 3 Independent monitoring does not replace, nor equal supervision 4 LQAS = lot quality assurance sampling

22 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK 7 Vaccination response

The primary objective of vaccination response is to A rapid response (RR) vaccination campaign rapidly interrupt person-to-person transmission of For an outbreak or high-risk event, a RR vaccination poliovirus. Both the timing and the quality of the campaign is the first vaccination response within vaccination response are critically important. To 14 days of receipt of a laboratory sequencing result accomplish virus interruption, a prompt vaccination (Day 0). It targets the immediate area of the virus response is required in a sufficiently large population isolation, to stop further transmission rapidly (even and geographic scope. High-quality vaccination will if the source remains unknown). protect individuals from poliovirus infection and prevent future outbreaks if importation occurs. SIA 1 and SIA 2 The oral polio vaccine appropriate to the poliovirus Two high-quality large-scale vaccination campaigns strain induces intestinal mucosal immunity (>90% of children vaccinated) should be completed and remains the vaccine of choice to interrupt within eight weeks of laboratory sequencing result transmission rapidly and stop polio outbreaks. The (Day 0). The response will be tailored to the most appropriate vaccine is selected with technical virus type and local context. The duration of the support from WHO and GPEI partners.i campaign for SIA1 and SIA2 can be extended, or effort intensified in other ways, such as deployment of additional personnel and supervisors, to complete Timing and scale of immunization the campaign and reach missed children in areas of activities poor performance, as identified by intra-campaign monitoring or supervisor observations. A four-step vaccination strategy has been endorsed by GPEI for outbreaks and events in high-risk Mop-up round or additional SIAs contexts for all poliovirus types (types 1, 2 and 3) (see Figure 5). The response consists of rapid response, A mop-up round is required as an additional step SIA1, SIA2, and a mandatory targeted mop-up wherever monitoring suggests children have been round, with the option for further SIAs if justified missed in certain health districts or areas, to ensure by breakthrough isolates, cases or other evidence of interruption of transmission (even in the absence ongoing transmission. of new poliovirus detections). Information to guide the selection of districts for full mop-up can The aim of this strategy is to ensure: 1) a timely include: intra-campaign monitoring, independent response; 2) two high-quality large-scale rounds; monitoring, eyewitness accounts and spot checks, 3) re-vaccination of all areas where quality was LQAS, post-campaign surveys, or new events insufficient; and 4) removal of all mOPV2 from the such as population movements, and breakthrough field as soon as possible (for type 2 response only). cases. A mop-up round should be included in the initial outbreak response plan, appropriately scaled and implemented after SIA2, and only cancelled if ALL health areas demonstrated high-quality implementation and vaccination coverage.

i See “15th Meeting of the Strategic Advisory Group of Experts (SAGE)” Polio Working Group, April 2018 – Conclusions and recommendations, Note for the Record. Geneva: World Health Organization; 2018 (http://www.who.int/immunization/sage/meetings/2018/april/2_WHO_Polio_SAGE_Apr2018. pdf?ua=1, accessed 8 November 2018).

RESPONDING TO A POLIOVIRUS 23 EVENT OR OUTBREAK Figure 5. Visual representation of timing and scale of immunization activities required

Rapid Mop-up Response SIA 1 SIA 2 Round

Intensifi cation or extension of campaign activities before the end of SIA 1 and SIA 2 to sweep or “mop up” areas of poor performance as identifi ed during the campaign.

Where quality is clearly inadequate in a large Target age-group geographic area, break-through isolates are For SIAs are children less than five years of age. identified, or the outbreak continues to spread An expanded age group (up to 10 or 15 years, or to unvaccinated areas, additional SIAs should be the whole population depending on local context) considered and planned. should be considered if there is evidence of virus Two campaigns must be completed after the last circulation among older age groups. detected virus. A high-quality mop-up round may be considered as one of these campaigns, if the area Short-interval campaigns of the detected virus was covered twice. The interval between SIA rounds can be as short as one week. This applies regardless of the type Target population of OPV used. For example, an mOPV2 campaign For the first RR (or Round Zero) can be 200 000 could be followed one week later with an additional to 500 000 children, and approximately 2 million round of mOPV2 or bOPV where needed. A short for subsequent larger scale rounds. It is possible to interval additional dose (SIAD) strategy may be consider increasing the scope further, in densely used in special circumstances when there are populated areas, or if there is evidence of, or multiple circulating polioviruses and/or when short potential for, extensive circulation (e.g. outbreak windows of access or opportunity to vaccinate arise population well connected to a major urban area). (e.g. mobile or hard-to-access children). Response The geographic scope for response is assessed strategies recommended for OPV using countries for case-by-case through a detailed risk assessment, each type of poliovirus type are outlined in Table 5 informed by discussion with technical experts (i.e. (events) and Table 6 (outbreaks). epidemiologists, virologists and country experts), to ensure that all high-risk zones are reached. The target population must be within the capacity of the programme to attain high coverage. Depending on the local context and capacity, phasing of campaigns may be considered to ensure quality in each geographic and demographic region covered.

24 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Routine immunization Type 2 poliovirus response Strengthening routine immunization (RI) remains a For type 2 events or outbreaks, when the use of central pillar of polio eradication. Vaccination with mOPV2 is necessary to protect children from bOPV/IPV and other antigens must continue as usual paralysis and stop transmission, it is even more and be further strengthened, even if immunization critical to respond quickly, and then ensure high sessions are conducted on the same day as, or within quality in larger scale and mop-up rounds. As Rapid Mop-up days of, an outbreak response. Strategies to mitigate type 2-containing OPV is no longer used in RI, Response SIA 1 SIA 2 Round any negative impact of outbreak response on the mOPV2 mop-up rounds are a final opportunity to conduct of RI should be planned in advance (e.g. ensure mucosal protection against type 2 poliovirus. if staff are diverted for the SIA efforts, immediate rescheduling of RI sessions). Intensifi cation or extension of campaign activities before the end of SIA 1 and SIA 2 to sweep or “mop up” areas of poor performance as identifi ed during the campaign.

Box 2. • Type 2 poliovirus now spreads rapidly due to waning type 2 immunity. In WPV1 endemic countries, response to cVDPV2 must be immediate. • During concurrent outbreaks of cVDPV2 and cVDPV1 or cVDPV3, immediate cVDPV2 response also takes precedence • Co-administration of mOPV2 and bOPV is not recommended during campaigns for operational reasons • A polio event or outbreak in a country that has been using only IPV in the RI programme requires immediate consultation with WHO, as for any polio event or outbreak anywhere • Regardless of outbreak response plans, routine bOPV and IPV immunization must continue without a break

RESPONDING TO A POLIOVIRUS 25 EVENT OR OUTBREAK In high-risk RR scenario: within 14 days. is Timeliness critical cVDPV2 to Refer 6 on Table outbreak table response In high-risk First scenario: SIA within followed 14 days by successive high coverage campaigns Time frame Intravenous immunoglobulin for case (+ monoclonal case for immunoglobulin Intravenous if available) antibodies or anti-virals community and close members household IPV for contacts Target age 0–5 years Target mOPV2 vaccine 200 000–500 000 children approx. RR targeting 1–2 million children approx. SIAs 1 and 2 targeting as required target Mop-up round WHO Director-General to request Vaccine Target age 0–5 years Target mOPV2 vaccine 1–2 million children approx. Targeting WHO Director-General to request Vaccine ------SIAs are not required SIAs are SIAs plan and implementation depends on the local depends on the local SIAs plan and implementation situation (RR), response rapid plan for In high-risk scenario, high quality SIA1, SIA2 and mop-up round SIAs plan and implementation depends on local depends on local SIAs plan and implementation situation, as advised by WHO and GPEI partners depends on the local SIAs plan and implementation situation plan for high risk. In high-risk scenario, No SIAs unless high quality SIA rounds two Immunization response Epidemiological and social investigation Epidemiological Epidemiological and social investigation Epidemiological and evidence cases for Community search of virus transmission population immunity Assess surveillance Enhance risk GPEI advises on virological immunization IPV routine Strengthen if SIAs assessment response Event conducted Community search for cases and evidence and evidence cases for Community search of virus transmission population immunity Assess surveillance Enhance if SIAs assessment response Event conducted and evidence cases for Community search of virus transmission population immunity Assess surveillance Enhance if SIAs assessment response Event conducted • • • • • • • • • • • • • • • • General response General Human Human or Environment Environment (with Environment of no evidence individual excreting virus) Source iVDPV2 VDPV aVDPV2 or VDPV2 (pending - classifica tion) WPV WPV 1 or 3 WPV 2 Isolate Table 5. Event response strategies by poliovirus type by poliovirus strategies response 5. Event Table

26 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Time frame SIAs may be considered SIAs may be considered SIAs may not required SIAs are be high risk deemed to unless not required SIAs are scenario Immunization response Epidemiological and social investigation Epidemiological and evidence cases for Community search of virus transmission population immunity Assess surveillance Enhance if SIAs Assessment Response Event conducted and social investigation Epidemiological and evidence cases for Community search of virus transmission population immunity Assess surveillance Enhance if SIAs Assessment Response Event conducted and social investigation Epidemiological and social investigation Epidemiological population immunity Assess surveillance Enhance • • • • • • • • • • • • • • General response General Human or Environment Human or Environment Human Human or Environment months four (over mOPV2 last since in response area) immediate Source VDPV1 or 3 (pending - classifica tion) aVDPV1 or 3 iVDPV1 or 3 Sabin 2 Sabin-like Isolate

RESPONDING TO A POLIOVIRUS 27 EVENT OR OUTBREAK Within 6–8 weeks Within 6–8 weeks Within 28 days Within 28 days Within 14 days is critical Timeliness months within three Mop-up round of initial virus sequencing (90 days) in all health zones not results, meeting quality standards Within 14 days is critical Timeliness Campaign timing from Day 0 Day Campaign timing from (lab sequencing result) mOPV2 bOPV mOPV2 bOPV mOPV2 WHO to Request General Director- mOPV2 through Advisory Group mOPV2 bOPV Vaccine Vaccine 0–5 years 0–5 years 0–5 years 0–5 years (or expanded if age group warranted) 0–5 years 0–5 years 0–5 years Age group At least 1–2 At least million children, all consider zones at risk 2 million children, all consider zones at risk At least 1–2 At least million children, all consider zones at risk 2 million children, all consider zones at risk Approximately. Approximately. 200 000 to 500 000 children As required Approximately 200 000 to 500 000 children Ongoing GPEI and mOPV2 Advisory Group consultation to review strategy and scope strategy review to consultation Ongoing GPEI and mOPV2 Advisory Group Campaign scope 3 1 1 2 Mop-up round SIA 2 With further quality improvements SIA 2 With further quality improvements SIA 1 High quality microplanning or expanded mop-up round targeted Further within 120 days not stopped SIAs if outbreak SIAs completed SIA3/SIA4 as needed until two detection poliovirus the last after SIA 1 High quality microplanning Rapid response (RR) response Rapid Small geographic immediate risk zone immediate Small geographic epicentre) (outbreak zones not meeting in all areas/health Required < 90%, failed e.g. coverage quality standards: in SIA1/2 children missed LQAS, risk zone immediate Small geographic epicentre) (outbreak Rapid response (RR) response Rapid Campaign strategy cVDPV cVDPV2 Human or environment cVDPV1 or 3 Human or environment Outbreak virus type Outbreak Table 6. Outbreak response vaccination by poliovirus type for OPV-using countries type for by poliovirus vaccination response 6. Outbreak Table

28 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Within 14 days is critical Timeliness Mop-up round within three months within three Mop-up round of initial virus sequencing (90 days) in all health zones not results, meeting quality standards Within 14 days is critical Timeliness within 3 months Mop-up round of initial virus sequencing (90 days) in all health zones not results, meeting quality standards Within 28 days Within 6–8 weeks Campaign timing from Day 0 Day Campaign timing from (lab sequencing result) mOPV2 WHO to Request General Director- mOPV2 through Advisory Group bOPV bOPV bOPV bOPV bOPV Vaccine Vaccine 0–5 years 0–5 years 0–5 years 0–5 years 0–5 years 0–5 years Age group

Approximately Approximately 200 000 to 500 000 children As required As required Minimum 500 000 children As required Ongoing GPEI consultation to review strategy and scope strategy review to Ongoing GPEI consultation Minimum 2 million children, allconsider zones at risk Minimum 2 million children, allconsider zones at risk and scope strategy review to consultation Ongoing GPEI and mOPV2 Advisory Group Campaign scope 3 3 Small geographic Small geographic 1 1 2 2 Further targeted mop-up round or expanded or expanded mop-up round targeted Further within 120 days not stopped SIAs if outbreak SIAs completed SIA3/SIA4 as needed until two detection poliovirus the last after SIA 1 High quality micro-planning or expanded mop-up round targeted Further within 120 days not stopped SIAs if outbreak SIAs completed SIA3/SIA4 as needed until two detection poliovirus the last after SIA 2 With further quality improvements Mop-up round Mop-up round immediate risk zone (outbreak epicentre) risk zone (outbreak immediate Required in all areas / health zones not meeting in all areas Required < 90%, failed e.g. coverage quality standards: in SIA1/2 children missed LQAS, risk zone immediate Small geographic epicentre) (outbreak / health zones not meeting in all areas Required < 90%, failed e.g. coverage quality standards: in SIA1/2 children missed LQAS, Rapid response (RR) response Rapid (RR) response Rapid Campaign strategy WPV WPV 1 or 3 Human or environmental WPV 2 Human Depends situation on local and whether a breach containment is identified or of re-emergence source unknown Outbreak virus type Outbreak

RESPONDING TO A POLIOVIRUS 29 EVENT OR OUTBREAK isolate. investigated. Within 6–8 weeks Within 28 days Mop-up round within three months within three Mop-up round of initial virus sequencing (90 days) in all health zones not results, meeting quality standards Campaign timing from Day 0 Day Campaign timing from (lab sequencing result) mOPV2 mOPV2 mOPV2 Vaccine Vaccine 0–5 years 0–5 years 0–5 years Age group At least 1–2 At least million children, all consider zones at risk At least 1–2 At least million children, all consider zones at risk As required As required Ongoing GPEI and mOPV2 Advisory Group consultation to review strategy and scope strategy review to consultation Ongoing GPEI and mOPV2 Advisory Group Campaign scope Consult with WHO, GPEI partners and mOPV2 Advisory Group Consult with WHO, GPEI partners and mOPV2 Advisory Group Consult with WHO, GPEI partners 3 2 Mop-up round SIA 2 With further quality improvements Further targeted mop-up round or expanded or expanded mop-up round targeted Further within 120 days not stopped SIAs if outbreak SIAs completed SIA3/SIA4 as needed until two detection poliovirus the last after SIA 1 High quality microplanning Required in all areas/health zones not meeting in all areas/health Required < 90%, failed e.g. coverage quality standards: in SIA1/2 children missed LQAS, Campaign strategy WPV infection or AFP case: check immunization or AFP case: WPV infection person/ exposed OPV/IPV to and give status; contacts and close family, case, response broader options for Review with emphasis on possible Investigate depends on response breech; containment many factors

j A rapid response (RR) round is also sometimes referred to as Round Zero to emphasize that speed is the first priority. to as Round Zero is also sometimes referred (RR) round A rapid response newly groups, by purposeful independent monitoring in hard-to-reach (e.g. as revealed persistently missed children if evidence of less than 90% coverage, failed LQAS (90% threshold), is required A mop-up round Anecdotal information suggesting vaccination gaps must be fully or quality. or any other evidence suggesting inadequate campaign reach refusals) villages, or chronic discovered area of the last detected poliovirus the if the latter covered round may suffice For example, in specific situations, an SIA and a mandatory mop-up The scale and scope of SIAs will depend on local circumstances. to Live Polioviruses: Interim guidance in managing exposed persons for countries hosting facilities that maintain live polioviruses” on GPEI website library; See “Public Health Management of Facility-Related Exposure http://polioeradication.org/tools-and-library/resources-for-polio-eradicators/gpei-tools-protocols-and-guidelines/. WPV2 breach Containment Consult guidance public health for management of facility-related live to exposure polioviruses Outbreak virus type Outbreak WPV 2 Environment 2 3 1 j

30 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK High-quality campaigns no prior SIAs, inaccessible or mobile populations). See Microplanning Guidelinesk and Best Practices Consistent with the performance targets of the in Microplanning for Polio Eradicationl to guide SOPs, all polio outbreaks and any type 2 polio development of micro plans. event at high risk of rapid expansion require RR vaccination within 14 days of notification, followed Preparedness monitoring. A preparedness by implementation of high-quality vaccination dashboard and/or a checklist and timeline are campaigns (i.e. SIAs). In implementing the four- required to track country readiness to launch SIAs step vaccination strategy for outbreak response, a and support quality implementation. Detailed tension exists between achieving a timely response pre-campaign readiness and intra-campaign (i.e. within 14 days) and achieving the desired quality monitoring are expected for all vaccination vaccination coverage (>90%). In settings where responses. Resources to support preparedness poliovirus is detected, the RR (Round 0) may not monitoring are available. meet all quality expectations (e.g. situations with security or access challenges, operational difficulties, Campaign monitoring. A high-quality campaign hard-to-reach subpopulations and/or vaccine must aim for coverage of >90% for SIA1 and SIA2 hesitancy, or simply lack of adequate time to plan). with no persistently missed children. Intra- and This is acceptable as long as the response is timely. post-campaign monitoring is essential to ensure quality of SIAs in all phases. All sources of intra- However, quality campaigns are essential to and post-campaign data must be reviewed and interrupt transmission of poliovirus from child to triangulated to assess the quality of the campaign, child. Therefore, it is critical to ensure that the first including but not limited to: and second large-scale vaccination rounds (SIA1 and SIA2) reach every child. Reaching every child • administrative coverage is particularly important when using mOPV2 due • rapid intra-campaign monitoring, convenience to rapidly declining type 2 mucosal immunity surveys and spot checks everywhere since withdrawal of tOPV. • Independent monitoring: house-to-house and out-of-house (market surveys) monitoring Quality microplanning, preparedness monitoring, • clustered LQAS and intra- and post-campaign monitoring are • overall consistency of data sources essential strategies to prepare and achieve high- • ongoing and new population movements quality campaigns. • vaccine management, monitoring and reporting of vaccine wastage, doses remaining, number of Quality microplanning. Preparation of macro- vials unaccounted for (especially for mOPV2) level plans and budgets based on the target • observations of campaign personnel, supervisors, population, local conditions and operational monitors, and observers in the field. costs allows stakeholders to discuss strategies and secure resources. Such top-down planning must For any areas or populations where suboptimal rapidly be accompanied with effective bottom-up campaign planning and implementation are microplanning (i.e. developing and validating plans identified (e.g. coverage <90%, persistently missed at the community level). Training and supportive children, vaccine hesitancy/refusal), mop-up supervision help ensure that micro plans are of vaccination must be rapidly carried out. Further high quality. Innovations such as GIS imagery are details of monitoring approaches are provided in useful to validate plans in challenging or hard-to- Best Practices for Monitoring the Quality of Polio reach contexts (e.g. densely populated urban areas, Eradication Campaign Performancem and below remote settlements with weak documentation or in chapter 11.

k See “Microplanning Guidelines”. GPEI guidance. Geneva: Global Polio Eradication Initiative; 2011 (see document within GPEI library http:// polioeradication.org/tools-and-library/resources-for-polio-eradicators/gpei-tools-protocols-and-guidelines/, accessed 8 November 2018). l See “Best practices in microplanning for polio eradication”. GPEI guidelines. Geneva: Global Polio Eradication Initiative; 2018 (http://polioeradication. org/wp-content/uploads/2018/08/best-practices-20180810-03.pdf, accessed 8 November 2018). m See “Best Practices for Monitoring the Quality of Polio Eradication Campaign Performance”, GPEI guidelines. Geneva: Global Polio Eradication Initiative; 2018 (http://polioeradication.org/wp-content/uploads/2018/08/best-practices-20180810Ð03.pdf, accessed 8 November 2018).

RESPONDING TO A POLIOVIRUS 31 EVENT OR OUTBREAK Planning for mobile, hard-to-reach Examples include: and special populations i) A type 2 poliovirus event or outbreak with concurrent endemic WPV1 transmission. Special populations are groups that are underserved Both bOPV and mOPV2 are required. The or not served by the regular health system for two campaigns may take place separately two reasons such as insecurity, inadequate infrastructure, weeks apart (or less if operationally feasible). and/or access barriers. Population groups may be For example, one mOPV2 SIA could be followed mobile (e.g. economic migrants, internally displaced 10 to 14 days later by one bOPV SIA. Use of persons, refugees, nomadic populations) or mOPV1 may exceptionally be considered. stationary (e.g. remote, hard-to-reach communities, such as fisherman or islanders, or urban hard- ii) Ongoing transmission of two cVDPVs, to-reach populations, such as those who live in such as cVDPV1 or cVDPV3 with cVDPV2. informal settlements, religious communities, or Response to cVDPV2 takes priority. Rounds of who are members of marginalized groups). All mOPV2 and bOPV might be staggered based on aspects of outbreak response, including surveillance, operational feasibility. immunization and communication strategies, must Response strategy decisions will be made based on be tailored to reach special populations. careful review of the epidemiology, the geographical Strategies for special populations should be areas affected, the capacity for robust response, and developed in conjunction with community leaders, vaccine availability. communication and social mobilization experts, and personnel knowledgeable of the context, as Integration with other health well as service providers with special expertise (e.g. non-governmental organizations (NGOs), interventions public services, women’s groups, faith-based During outbreak response planning, consideration organizations). Appropriate strategies to vaccinate can be given to integrating with other health every child may require creative thinking, and interventions (e.g. measles campaign already planned, could include tactics such as transit posts, hit-and- vitamin A, etc.) in the following circumstances: run teams, market vaccinations, and/or combined • Full discussion with all partners takes place at outreach with veterinary or animal vaccinations or country and other relevant levels. other special strategies. • Following types 1 and/or 3 outbreak response: RR, All strategies and tactics must be well documented SIA1 and SIA2 rounds were successfully to ensure that data on the number of children implemented. Subsequent risk mitigation vaccinated, appropriate vaccine management, and rounds could consider integration as a cost- other relevant information is collected. saving measure. • During type 2 outbreak response: Additional opportunity available to offer bOPV in the Concurrent circulation of different midst of a type 2 outbreak, appropriate if bOPV poliovirus types campaign would otherwise be deferred, so as not to allow the type 2 response activities to compete If polioviruses of different types circulate with bOPV risk mitigation and generate types 1 concurrently, the response to type 2 poliovirus and 3 immunity gap. takes precedence, as type 2 immunity is waning • Plans are in place to secure high quality globally. Detailed response plans should be reviewed intervention for all antigens considered. on a case-by-case basis in consultation with GPEI • Monitoring mechanisms are agreed upon technical experts. in advance.

32 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Inactivated polio vaccine (IPV) the WHO Director-General can authorize release of mOPV2 from the global vaccine stockpile, or use Given the continuing IPV supply constraints, of in-country remaining mOPV2 stocks, upon the the Strategic Advisory Group of Experts on recommendation of the Advisory Group. immunization has not endorsed use of IPV for outbreak response and IPV should be reserved for For any outbreak or high-risk event that may require routine immunization in countries at risk for VDPV2 a vaccination response, the country must submit a emergence and spread. vaccine request for mOPV2, signed by the national authorities, within 72 hours of the type 2 poliovirus IPV does not induce mucosal immunity in sequencing result (Day 0). The Advisory Group persons without prior OPV immunization for the will rapidly review the risk assessment and vaccine corresponding serotype. In a child infected with request and recommend a course of action to the poliovirus without previous OPV vaccination, IPV WHO Director-General. does not stop onward transmission of the virus. Conversely, IPV may boost immunity in those with Upon approval, the mOPV2 vaccine stock with the prior OPV exposure. shortest shelf life will be released by UNICEF from the global stockpile for immediate use. (See vaccine In specific instances, such as co-circulation of request form and template for approval of import, VDPV2 and WPV1, or in areas where mOPV2 on the GPEI websitep). was previously used, IPV may boost humoral and mucosal immunity in OPV-vaccinated children. IPV requests Where IPV campaigns are deemed to be of benefit, fractional-dose IPV (fIPV) should be implemented. Any country considering use of IPV in SIAs should Similarly, for maximum benefit, an IPV SIA should fully justify this in the risk assessment and response be after at least two high-quality mOPV2 or bOPV plan and complete an IPV vaccine request form. The rounds. Health worker training materials for fIPV country can also request supplies for intradermal administration are available.n administration of fIPV (e.g. BCG syringes and adaptors). See IPV request form on the GPEI website.q Approvals will be on an exceptional basis Requesting vaccine only, in line with local circumstances. A request for intradermal fractional dosing will be considered. bOPV requests Vaccine requests for bOPV follow usual procurement procedures through the United Nations Children’s Fund (UNICEF). mOPV2 requests In line with the World Health Assembly resolution,o specific procedures are in place to access or use mOPV2. Countries must present a risk assessment and vaccine request for consultation by the Advisory Group on mOPV2 Provision(Advisory Group). Only

n See “Use of fractional-dose inactivated polio vaccine (fIPV) in supplementary-immunization activities (SIAs)”. GPEI Aide Mémoire, 2017 (http:// polioeradication.org/wp-content/uploads/2017/11/polio-fipv-in-sias-aide-memoire-01092017-en.pdf, accessed 8 November 2018). o See “Resolution WHA68. Poliomyelitis. In: Sixty-eighth World Health Assembly”, pg. 10. Geneva: World Health Organization, 26 May 2015. (http://apps. who.int/gb/ebwha/pdf_files/WHA68-REC1/A68_R1_REC1-en.pdf#page=1, accessed 8 November 2018). p See “mOPV2 Vaccine Request Form”. (Document within GPEI library (http://polioeradication.org/tools-and-library/resources-for-polio-eradicators/gpei- tools-protocols-and-guidelines/, accessed 8 November 2018) q See “IPV Request Form”. (Document within GPEI library (http://polioeradication.org/tools-and-library/resources-for-polio-eradicators/gpei-tools- protocols-and-guidelines/, accessed 8 November 2018)

RESPONDING TO A POLIOVIRUS 33 EVENT OR OUTBREAK Vaccine management and reporting Routine immunization: Recovery Vaccine management is integral to ensuring a high- and strengthening quality vaccination campaign and of paramount The backbone of polio eradication and outbreak importance at all levels and at all stages of the response remains routine immunization (RI) response. The movement of any vaccine used in against polio in line with the national childhood outbreak response must be monitored. All vaccine immunization schedule. In general, cVDPV received, distributed, and administered must be outbreaks occur in areas with sub-optimal recorded, through for example, stock management routine immunization coverage. Although tools and/or vaccine utilization records. All vials and priority must be given to achieving high-quality doses used, partially used or unused, must be fully response, polio surge resources can be tasked recorded (whether due to partial use, contamination, with supporting RI recovery as soon as possible. or vaccine vial monitor changes) and vials returned Immunization recovery should begin during the must be fully accounted for each SIA. outbreak response period, maximizing use of surge capacity to strengthen programme management, A reverse logistics and vial disposal plan must be microplanning, community mobilization and integrated with the outbreak response plan outlining: performance monitoring. It is also critical to build a) that health facilities and district vaccine stores on the political attention resulting from the cVDPV will be left with a one-month supply (except for to ensure accountability for routine immunization all mOPV2, which is immediately withdrawn); service delivery. The Emergency Operations Centre b) how excess unused vaccine will be returned to (EOC) in collaboration with EPI should effectively central or regional storage in a reverse cold chain; maximize the benefit of time-limited support to c) (for mOPV2 only), how all vials will be returned RI, through a thorough analysis of the reasons for to safe disposal sites (used, partially used, low immunization coverage in the outbreak areas unused, vials discarded due to vaccine vial followed by selected short and medium-term monitor changes or contamination). immunization systems strengthening actions in line with the operational components of the Reaching For all mOPV2 campaigns and mop-up rounds, Every District (RED)s approach, namely: it is of critical importance that every vial and dose of unused vaccine is accounted for and 1. Optimization of immunization services withdrawn to central storage in a safe and secure (focus on expansion and re-establishment manner. Reporting on the status of vaccine used, of outreach) retrieved and in storage is required after each 2. Supportive supervision for immunization and every SIA, including the immediate RR. All quality assurance lost and missing vials must be reported.r 3. Linking immunization services with communities 4. Monitoring and use of data for action 5. Effective planning and management of immunization resources.

r See: Technical Guidance for mOPV2 vaccine management, monitoring, removal and validation. Geneva: Global Polio Eradication Initiative; 2016 (http:// polioeradication.org/wp-content/uploads/2016/11/Technical-guidance-mOPV2-management-monitoring-removal-and-validation_Oct2016_EN.pdf, accessed 8 November 2018). s See “Reaching Every District (RED), 2017 revision”. Brazzaville: World Health Organization. 2017 (http://apps.who.int/iris/bitstream/han dle/10665/260112/9789290233954-eng.pdf?sequence=1&isAllowed=y, accessed 8 November 2018).

34 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Surveillance following 8 investigation

Guidelines for routine poliovirus surveillance, A key objective of AFP surveillance, following including AFP and environmental surveillance, are identification of an event in a high-risk area or outlined in other GPEI documents, including; Best any outbreak, is to achieve an annualized rate of Practices in Active Surveillance for Polio Eradicationt, greater than three non-polio AFP cases per 100 000 and the Global Polio Surveillance Action Planu. (While children, younger than 15 years of age, in every Chapter 4 (above) outlines the initial surveillance subnational division equivalent to a district, for at steps required as part of a thorough investigation, the least 12 months after the last case or isolate. While current chapter focuses on surveillance enhancement districts with fewer than 50 000 children under following initial investigation. 15 years of age may not detect AFP every year, the quality of AFP surveillance should be checked for any silent district regardless of population size. Surveillance enhancement Following the initial investigation of any polio event Countries are to undertake the following activities or outbreak, it is critical to assess and enhance to enhance AFP surveillance: poliovirus surveillance. Vigorous effort is required to • Immediately notify all national and subnational put the surveillance system on high alert and improve surveillance units about the poliovirus event/ sensitivity to identify promptly any new virus, AFP outbreak. cases, or ongoing transmission, even outside the • Rigorously sensitize all health care workers to immediate outbreak zone. The outbreak response AFP surveillance and notification requirements, plan must include surveillance initiatives from Day including zero-reporting. 0 of the event/outbreak, continue surveillance in • Review and reclassify reporting sites (if required) parallel with other aspects of the response, and in the AFP active surveillance network within the maintain selected supplemental strategies for six immediate outbreak zone and of neighbouring months or more after the last detected poliovirus.

Box 3. The goal of surveillance during a poliovirus high-risk event or outbreak is to increase sensitivity to detect any poliovirus. To achieve this it is also necessary to ensure proper data management and to meticulously document activity and performance indicators.

An outbreak surveillance plan should include steps for the ongoing review of timeliness and completeness of reporting sites in the AFP surveillance network (both AFP and ES), monitoring active case search, mapping populations not covered by the surveillance network, and raising awareness of surveillance needs among health care providers and the community. All national and international resource requirements (human, financial and logistical) should be included in the plan.

t See “Best practices in Active Surveillance for Polio Eradication”, 2018. GPEI guidelines. Geneva: Global Polio Eradication Initiative; 2018 (http:// polioeradication.org/wp-content/uploads/2018/08/best-practices-20180810-01.pdf, accessed 8 November 2018). u See “The Global Polio Surveillance Action Plan (2019Ð2020)” 2019. GPEI guidelines. Geneva: Global Polio Eradication Initiative (http://polioeradication. org/tools-and-library/resources-for-polio-eradicators/gpei-tools-protocols-and-guidelines/).

RESPONDING TO A POLIOVIRUS 35 EVENT OR OUTBREAK districts (high-risk areas) and ensure that Environmental surveillance secondary and tertiary health facilities are fully involved in AFP surveillance. Environmental surveillance (ES) serves as a • Ensure that supplemental AFP case-finding complement to AFP surveillance, but never as a strategies are in place in the outbreak zone substitute. It is the monitoring of wastewater or and high-risk areas, including ad hoc active sewage from designated locations to detect the search during campaigns by vaccination teams, presence of poliovirus. In the context of events independent monitors, and LQAS survey teams. and outbreaks, ES can provide information on • Monitor and document that at least 90% of all the geographic extent and duration of poliovirus planned active surveillance visits are conducted. circulation, as well as the excretion of polio vaccine • Consider supplemental strategies, such virus following vaccination. as enhancing environmental surveillance, At the outset of a new event or outbreak, the in consultation with national and GPEI following actions should be put in place surveillance experts. • Ensure the national laboratory is involved • Assess the performance of all existing ES sites in in outbreak planning and that capacity is the area. strengthened to handle additional workload and • Increase the frequency of specimen collection to maintain rapid specimen handling. every two weeks, where feasible, for a minimum of six months following the most recent isolate detected or the most recent use of mOPV2, whichever is later. • Consider new collection sites within and outside the outbreak or event area, where technically appropriate and laboratory capacity allows. • Assess nearby urban areas with a population of 100 000 or more as candidates for new or enhanced environmental sampling.

Figure 6. Decision process for enhancement of environmental surveillance following a new VDPV2 isolation

Yes No Change in # Sites, Frequency Yes Adequate? No • Increase sample collection frequency to every two weeks immediately and/or, • Consider an increase in the number of sites following assessment by the New VDPV ES In Regional Office (RO) and partners Isolation place? I. Immediate: Assess feasibility and need of ES deployment (Within 2 weeks of type-2 poliovirus Isolation), by RO and partners.

II. If feasibility/need is confirmed, conduct ES screening from No at least 3 different sites biweekly (Ideally within 2–4 weeks of every response) and continue for ≥ 6 months after last mOPV2 vaccination campaign

III. Use a method of sampling depending on assessment of local factors, feasibility of sample shipment, reference laboratory capacity, and epidemiologic situation

Source: Polio Environmental Surveillance Enhancement Following Detection of Vaccine-Related Type-2 Poliovirus. 9 May 2018

36 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Any proposal to scale up ES must consider laboratory 4. Selectively use other supplemental strategies capacity to support the effort, and not jeopardize that are usually only part of an initial field AFP surveillance. Detailed guidelines on polio investigation. Given the relatively low yield environmental surveillance enhancement following and high resource needs of these strategies detection of vaccine-related type 2 poliovirus is when used in the long term, they should available, from which Figure 6 is drawnv. only be considered in consultation with GPEI partners and laboratory counterparts. Strategies for special populations • Contact sampling in high-risk, security- compromised or hard-to-reach populations and security-compromised areas may exceptionally be advised for every AFP Supplemental surveillance strategies may be required case for a limited time only, such as, for in circumstances involving highly vulnerable example, in recently accessed areas. As an populations (e.g. nomads or other populations ongoing surveillance strategy, ongoing contact who do not routinely access health services) and/or sampling can be maintained for no longer inaccessible areas beyond the routine reach of even than six months. enhanced health or surveillance services. Activities • Once transmission has been demonstrated in will need to be tailored to the specific situation, but an area, healthy children surveys are no longer consider the following approaches: necessary and not recommended. However, such surveys may occasionally help assess 1. If not already in place, identify community possible outbreak expansion (e.g. into other leaders or healers, including women, as focal geographic areas where poliovirus may be points and provide the training and tools to circulating undetected by AFP surveillance, facilitate access to and reporting of suspect or along transit routes of mobile groups). In AFP cases. exceptional situations, a stool survey may 2. Increase community sensitization to polio be a screening tool for groups moving from and AFP surveillance, using culturally an event/outbreak area to a new area (e.g. appropriate tools. internally displaced populations, refugees). 3. Leverage innovative partnership with other 5. If poliovirus is found in a high-risk mobile groups or services with access to special population (e.g. internally displaced populations (e.g. other government ministries populations, refugees, or nomads), or in an or departments, other United Nations area frequented by populations on the move, organizations, NGOs, civil society groups, then immediately assess surveillance sites veterinarians, etc.). along known migration routes to seek evidence of transmission.

v See "Polio Environmental Surveillance Enhancement Following Detection of Vaccine-Related Type-2 Poliovirus." 2018. Geneva: Global Polio Eradication Initiative (http://polioeradication.org/tools-and-library/resources-for-polio-eradicators/gpei-tools-protocols-and-guidelines).

RESPONDING TO A POLIOVIRUS 37 EVENT OR OUTBREAK Communication and 9 social mobilization

Communication for Development (C4D) is a Strategic C4D framework for polio systematic, planned and evidence-informed strategy to promote positive and measurable behaviour outbreak response and social change. Effective social mobilization, Immediate C4D outbreak response communication with emphasis on high-risk populations, is a key is initiated as soon as an outbreak is declared and component of polio outbreak response. The polio should be integrated in all aspects of planning and C4D outbreak response approach is designed to responding to an outbreak or high-risk event. The redress perceptions and social norms that deter outcome of the joint epidemiological and social caregivers from vaccinating their children, and investigation of the infected case/area is critical rebuild commitment to vaccination, including to understand the social environment for areas or routine immunization. groups affected by the virus. Interventions should be based on understanding of all relevant social barriers A strong communication strategy will strengthen and promote vaccination. (See Strategic Framework performance of all response activities, increase within the Communication for Development uptake of vaccination in all population groups, Guidelines for Responding to Polio Events and and support robust surveillance with early Outbreaks for detailed guidancew). notification of AFP. At this phase, the focus is on building (or Critical C4D steps include: rebuilding) caregivers’ critical awareness about • raising awareness of campaign dates polio, OPV and the fact that there is an outbreak • strengthening community perception of in the community that puts children at risk. The vaccination through building trust in health primary goal is to raise awareness of the outbreak to worker capacity, vaccine safety and efficacy at least 90%. Communication approaches should be • elevating perception of polio risk straightforward, clear and elicit an urgent response • addressing bottlenecks in the decision to vaccinate. from parents and the community at large.

In the context of vaccine-derived poliovirus, Plans for subsequent campaigns, including SIA1, communication of risk is particularly challenging, SIA2 and a mop-up round, should include C4D especially when the virus is detected only in the interventions to reach missed children and reduce environment. While the C4D outbreak response for refusals. Activities should continue to elevate public VDPVs follows the same principles as for WPV, it is risk perception of the outbreak and its impact, important to reinforce vaccine safety messaging and especially for non-compliant groups or communities. address any context-specific fears or misconceptions For campaigns using the SIAD approach, locally around vaccines. For VDPV found only from appropriate messaging is important, so that families environmental sources, it is critical to explain that understand the process and why children may be low immunity is the root cause. vaccinated more than one time in short intervals.

w See “Communication for development guidelines for responding to polio events and outbreaks, post switch”. 2016. Geneva: Global Polio Eradication Initiative (http://polioeradication.org/wp-content/uploads/2016/12/C4DGuidelines_OutbreakPostSwitch_Nov2016_EN.pdf, accessed 8 November 2018).

38 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Protracted outbreak response. Where an communications interventions address the different outbreak is ongoing for more than four months needs, challenges, preferences and perceptions of (120 days), there may be one or more underlying everyone in the community. This review should be communication barriers. As the target audience may done before initiating the response and to guide the include acceptors, vulnerable acceptors, transient development of C4D interventions. groups or even rejecters, conducting a root cause analysis is effective to identify such barriers, After each campaign, IM/LQAS data and or other whether social, or related to access or quality of sources should be analysed in a timely way, the service. Reasons for missed children should be especially regarding the core indicators for C4D, well investigated and analysed to adjust strategies in order to amend communication strategies as for issues such as fatigue of repeated campaigns, or required. Core indicators include: overall percentage mistrust in vaccine or frontline workers. of missed children; percentage of missed children for different reasons (grouped into social, operational In a protracted outbreak, the barriers to acceptance and absences); percentage of refusals; percentage of are specific to each community, culture and region, refusals by reason; percentage of absence by reason; and may be unique and complex. It is important percentage of parents aware of the campaign prior to monitor systematically and understand patterns to vaccinator’s visit; and percentage reached through of reported reasons for missed children before different communication channels. This data must designing communication solutions. The objective is be sex-disaggregated and analysed accordingly. to maintain or increase the percentage of awareness to 90% or more and keep total refusals below 2%. At the end of the outbreak, it is important to assess community acceptance of, and commitment to, Maintaining gains and strengthening routine vaccination, for example, through small-scale immunization. Regardless of how the outbreak surveys or secondary data analysis, and to document evolves, the focus of C4D strategies should shift the outcome of C4D activities. towards supporting routine immunization as soon as possible, and also as the outbreak draws to a close. Outbreak response plans should indicate how Communication strategies routine immunization services will be promoted, Deploying a variety of strategies ensures that especially for low coverage areas. The outbreak communities and decision-makers at local, national, coordination should also develop preparedness and regional levels are engaged in promoting plans to mitigate the risk of future outbreaks. vaccination. The C4D interventions must always The final outbreak response assessment (OBRA) precede the conduct of campaigns to achieve the reviews country improvement plans for routine desired awareness and acceptance of vaccination. immunization and longer-term preparedness. Immediately creating or reinvigorating a national Achievements and lessons learned from social communication or social mobilization committee mobilization, advocacy and media and partnership is critical. The role of the committee is to plan, activities at the national, provincial, and district coordinate and ensure the successful implementation levels should be documented. of media and C4D interventions.

In many contexts, political advocacy is urgent to Data gathering to guide C4D garner the attention needed to support response activities efforts and strengthen public trust in vaccination. At the beginning of an outbreak, it is important At the beginning of the outbreak, media advocacy to review existing data sources for knowledge, is also critical to ensure that information is clear attitudes, practices and behaviour, or if not and managed. The Ministry of Health and WHO, available, to conduct a rapid social assessment of generally the first to announce an outbreak, should norms that may affect vaccination. Gender issues take the lead in this area. As part of the C4D/ should be integrated into data analysis to ensure communication strategy it is recommended to that gender roles and norms are considered, and

RESPONDING TO A POLIOVIRUS 39 EVENT OR OUTBREAK Box 4. Details of C4D and communication activities, including social mapping, training of social mobilizers, engagement with influencers, tracked refusals, etc. should all be included as part of the operational micro plans. establish immediately which agency is leading the Reaching special populations and media response. This leadership role will depend conflict-affected areas on capacity in each country, noting that UNICEF usually leads C4D and supports the media response. Special populations that are hard-to-reach or in conflict areas can be particularly vulnerable to polio Mass and social media play a critical role for outbreaks. The design of strategic C4D interventions reaching a large audience very quickly, especially and messages for these populations should always where interpersonal communication networks are be based on social profiling of polio-confirmed and less strong. In conflict areas, radios are an excellent zero-dose non-polio AFP cases or contact cases, channelling tool. as well as any other available social research for those groups. Engagement with religious and community leaders, health providers, parliamentarians, women’s and Community mobilizers should be selected from youth groups, or other influencers in the social target communities and efforts should be made to network is an important strategy to build strong include women. To build community trust, (s)he public consensus about the urgency of the outbreak should be trained on key messages and be part of and the need to take collectively the decision the vaccination team. to vaccinate. Community influencers/groups should be consulted Training of frontline workers and community and engaged in the planning phase of the campaign mobilizers is critical for high-quality response, with continuation through to the end of the outbreak. especially when the C4D strategy relies on These influencers can be a clan leader, mayor, interpersonal communication. Global training grandmother, school teacher, or a community elder. standards are available for training of vaccinators It would be important to sensitize communities to and other volunteers.x AFP and encourage reporting, including through community networks if applicable.

Geographic, security or demographic challenges could limit access. The use of non-traditional means such as mobile texting, awareness around water points, days when a population moves from one place to the other, printing messages about polio on food bags, or inserting messages in bread packages and other innovations, may augment standard communication strategies.

x See Polio training manual for health worker supervisors. Geneva: Global Polio Eradication Initiative (https://poliok.it/library/Polio%20Training%20 Manual%20For%20Health%20Worker%20Supervisors, accessed 8 November 2018).

40 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK 10 GPEI support

National authorities have the ultimate ownership –– surveillance enhancement and accountability for a robust and comprehensive –– security and access response to poliovirus outbreaks and the • finance and logistics, including coordinated maintenance of leadership throughout. The GPEI resource mobilization partners support key functions for an outbreak • outbreak response assessment. response including: • outbreak preparedness Table 7 offers a summary of the nature of support • risk assessment and event/outbreak response that GPEI is expected to provide, according to planning the grade of the outbreak as assigned by WHO or • advocacy and coordination amended for GPEI surge support. Each outbreak • technical and human resources, including: is unique, and so are the support needs. Those –– information management responsible for outbreak coordination nationally, –– communication, social mobilization and regionally and globally, will need to reassess support behaviour change needs on a continuing basis to ensure effective and –– vaccination activities timely response.

Table 7. Outbreak response scale-up and support according to grade

Type of Grade 1 Grade 2 Grade 3 Support Response National coordinator GPEI-nominated coordinator GPEI-nominated coordinator and leadership high-level advocacy as needed Technical Polio expert mission from Deployment of a Deployment of a multidisciplinary liaison the GPEI partners to support multidisciplinary rapid response rapid response team outbreak response plan team development Surge Stop Transmission of Polio • Deployment of surge support • Deployment of surge support (STOP) programme support team:1 multidisciplinary team:1 multidisciplinary if needed consultant team for minimum consultant team for minimum six six-month deployment -month deployment • STOP support • STOP support Financial Standard financing ‘No-regrets’ financing policy ‘No-regrets’ financing policy for outbreak response (an advance of up to $500 000) Financial support for security immunization activities prior to completion of response measures, if required (an advance of up to budget US$500 000)2 Security and Coordination with United Coordination with United Deployment of field security officer(s) access Nations and humanitarian Nations and humanitarian where necessary agencies in the field agencies in the field Coordination with United Nations and humanitarian agencies in the field

1 Composition of team and number of experts deployed for rapid response and surge support teams will be scaled up to meet the needs of the country. 2 Standard financing is subject to re-payment conditions, as determined on a case-by-case basis.

RESPONDING TO A POLIOVIRUS 41 EVENT OR OUTBREAK Coordination work plan and budget shared with all levels involved will aid in mobilizing funds from donors to secure Coordination mechanisms for polio are triggered by financing for response activities. a laboratory notification (Day 0) of a new outbreak or high-risk event. The country, region and global WHO headquarters will provide specific guidance levels will coordinate to support the investigation, and timelines on outbreak budgeting. rapid risk assessment and determination of next steps. “No-regrets” financing policy The OPRTT will lead outbreak coordination with The “no-regrets” financing policy (an advance of national authorities, WHO and UNICEF regional up to $500 000) helps ensure a timely, barrier-free offices, and all GPEI partners. The OPRTT will release of funds to countries to support outbreak conduct a coordination call within 48 to 72 hours response, even if it is later realized that a smaller with partners to address the needs of the country, contribution may have sufficed. This policy affirms monitor the immediate provision of no-regrets that it is better to over-resource critical functions funding, and plan the required resources and initial than to risk failure by delays in resources. The response support interventions. The OPRTT will release of funds by GPEI partners may pre-date include all necessary skill sets to coordinate outbreak outbreak grading by WHO, based on the initial response, including a resource mobilization focal risk assessment and discussion between national, point. Regular updates will be provided from regional and global levels. Whereas funds will OPRTT to the GPEI Eradication and Outbreak usually be released by WHO, either UNICEF or Management Group. another GPEI partner may on occasion provide the funding. For grade 2 and 3 outbreaks (and high-risk events), WHO and UNICEF regional offices, in consultation with OPRTT, will nominate an outbreak coordinator Human resource surge for deployment to the country level within 14 days The objectives of GPEI surge support are to: of Day 0. The GPEI outbreak coordinator will be i) rapidly activate deployment of skilled deployed as additional support for in-country professionals, especially for grade 2 and grade authorities, supplementary to existing senior 3 outbreaks, to support the national response GPEI staff, to ensure comprehensive and timely team for key outbreak response functions; and coordination and outbreak management at national ii) ensure smooth transition to longer-term staffing. and subnational levels. It is important to ensure the balanced recruitment of women and men into technical and operational Budgets and financing roles at all levels. The earliest activation is deployment within 72 Coordinated approach hours of laboratory result notification (Day 0) The goal of outbreak response financing is to ensure through a partner-wide interregional mechanism for that cash flow challenges do not interfere with the deploying staff and engaging qualified consultants. roll-out of response activities, based on a “budget– mobilize–finance–replenish” model. National The OPRTT coordinates surge support and technical authorities should rapidly prepare a comprehensive assistance in the following areas: budget, in collaboration with WHO, UNICEF • Identifying key roles, according to outbreak grade and other partners. The budget should include a and assessed needs of the country. Expertise comprehensive estimate of costs for all activities offered includes both technical (communication, (i.e. coordination, vaccination, surveillance, immunization, surveillance, data management), communication and social mobilization) and and operational (coordination, finance, human enabling functions (i.e. laboratory operations, resources) skill sets. training and transport). A joint comprehensive

42 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK • Team composition scaled according to need, GPEI performance standards for example, outbreak coordinator, operations manager, communications officer, and technical The GPEI partners will undertake a range of activities experts for immunization and surveillance. to support a country-led response. Outbreak • Personnel with specialized expertise may also response performance standards describe the be available to provide support to innovative expected outputs from each level of GPEI partners strategies to improve the quality of response, such in key outbreak response functions. The actions as for GIS mapping of the outbreak zone. and deliverables expected of countries and GPEI • The Rapid Response Team involves deployment partners by specific timeline (within hours, days and from respective GPEI agencies, including weeks of virus sequencing report) are outlined in regional offices. Recruitment for active support Annex 2). may extend beyond outbreak teams within These performance standards apply to polio each agency. The period of deployment is from outbreaks of all grades. The time frame for the outbreak notification until the rapid response expected response is counted forward from the date SIA, where indicated. of the initial laboratory sequencing results. These • The Surge Support Team is an interagency standards are not exhaustive and may be modified on-call roster for longer-term deployment as required to fit the context specific to the country using a central platform for ease of visibility and the outbreak. and reporting. The Surge Support Team should be in place within three weeks of outbreak The OPRTT will provide support to coordinate and confirmation. The expected period of deployment monitor the outbreak response. is from the rapid response SIA until the end of the outbreak. Response teams will aim for at least one week of overlap between the work of the Rapid Response Team and that of the Surge Support Team to ensure complete and detailed handover. • Identifying needs and advocating for specialized support and innovation when warranted by context (e.g. GIS-informed microplanning, detailed enumeration, administration, and finance).

RESPONDING TO A POLIOVIRUS 43 EVENT OR OUTBREAK Monitoring and 11 evaluation of response

Quality assurance for outbreak response is critical Table 8 outlines suggested, but not comprehensive, and should include both quantitative and qualitative approaches and indicators for monitoring. Electronic methods for all core aspects of response. Countries data capture using mobile-enabled devices and real- are encouraged to develop tools and indicators time secure data upload is recommended wherever tailored to best monitor all stages and components feasible to support timely and comprehensive of outbreak investigation and response See GPEI reporting for all response activities (surveillance, library for tools and guidance documents. y vaccination, social indicators). The use of electronic data capture methods requires effective training, data cleaning and analysis, and continual quality checks.

Table 8. Assessing quality of response: factors to consider before, during and after implementation

Surveillance Vaccination Communication and social mobilization Planning and preparation • Rapid review of available • Preparedness dashboard • Evidence of engagement with surveillance data indicators >90% community, women’s groups and • Increase ES sampling • Evidence of training for all religious leaders frequency to every two personnel • Engagement of national government weeks • Accurate bottom-up microplans with active support for response • Initiate new ES if with detailed mapping, • Targeted strategies detailed and appropriate complemented by innovations updated for special populations • Validate AFP cases and ES such as GIS imagery and cross- • In-depth social investigation of case(s) sewage sample collection validation where feasible and/or community to identify special populations or under-vaccinated children Implementation • AFP annualized rate • Intra-campaign independent • Targeted strategies used to optimize >3 cases/100 000 children monitoring >90% coverage response activities in special under 15 years of age • Spot checks and surveys >90% populations in outbreak zone and coverage (e.g. at markets, • Evidence of overall increased immediate risk area transit hubs) community sensitization to AFP and • Impact of surveillance • Use of strategies to ensure importance of vaccination enhancement (e.g. source that borders are covered (e.g. • Active support from community and number of AFP cases “handshake” hand-off between including women’s groups and religious reported, active search) teams) leaders active during vaccination • ES process and campaigns 1 performance indicators • No block vaccination refusals

y See GPEI tools, protocols and guidelines (website). Geneva: Global Polio Eradication Initiative (http://polioeradication.org/tools-and-library/resources-for- polio-eradicators/gpei-tools-protocols-and-guidelines/, accessed 8 November 2018).

44 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Surveillance Vaccination Communication and social mobilization Post-campaign follow-up • AFP surveillance >3/100 • Post-campaign independent • Evidence that campaign awareness 000 for at least 12 months monitoring >90% coverage; and was>90% of all households (IM and/or after last poliovirus >80% LQAS lots passed at 90% LQAS) detection threshold • Special populations >90% coverage • Specific analysis of AFP • No evidence of persistently • Analysis of disaggregated data for rate for all high-risk missed children or missed high-risk populations and gender for populations geographic areas missed children or refusals, to guide • Evidence of impact of • Robust and timely reporting, interventions surveillance in hard-to- using innovations such as reach, inaccessible, and mobile-data collection and/or high-risk populations global positioning system (GPS) coordinates for coverage where feasible

1 For detailed guidance see Global Polio Surveillance Action Plan and Polio Environmental Surveillance Enhancement Following Detection of Vaccine-Related Type-2 Poliovirus in GPEI library (http://polioeradication.org/tools-and-library/).

Monitoring quality of SIAs Intra- and post-campaign monitoring. Intra and post-campaign monitoring employ survey The primary indicator for the rapid response SIA methods with purposeful sampling in areas where is the time in days from outbreak notification (Day coverage is expected to be insufficient and should 0) to the first day of vaccination (Target <14 days). be implemented according to protocol. The goal of Campaign monitoring may be carried out if capacity intra-campaign monitoring is to ensure corrective allows but should not detract resources from high- action in a timely manner (e.g. the same day or the quality microplanning for large-scale SIA1 and SIA2. next day, including re-visit strategies) to improve SIA 1 and SIA 2 must be fully monitored, and implementation performance. Post-campaign results communicated to GPEI partners within 14 monitoring allows in-depth and rigorous analysis days of each campaign. The purpose of monitoring for areas missed or not meeting coverage targets, is to identify all areas or sub-populations with <90% and an examination of the reasons for missed or coverage or persistently missed children so that unvaccinated children. corrective action may be taken. Under-performing Clustered LQAS surveys undertaken with sampling areas must be comprehensively discussed to proportional to population size are recommended determine special strategies, additional effort (e.g. for all areas covered by outbreak response. For extending the campaign, additional communications results to be valid, care must be taken to plan and and/or vaccination teams, or a mop-up round implement according to protocol. Specific guidance with an adjusted communications strategy), and is available.z resources needed. Spot checks, convenience surveys and verbal Strategies required to monitor campaigns for all SIAs reports by monitors, supervisors, and independent (SIA1, SIA2), all mop-up activities, and additional campaign observers (e.g. international GPEI large-scale SIAs – include, at a minimum, IM and personnel or third-party agency personnel) are a clustered-LQAS. very useful adjunct for SIA monitoring, and should be welcomed and used liberally to confirm or question coverage reporting.

z See “Assessing vaccination coverage levels using clustered lot quality assurance sampling: field manual”. 2012. Geneva, Global Polio Eradication Manual (http://polioeradication.org/wp-content/uploads/2016/09/Assessing-Vaccination-Coverage-Levels-Using-Clustered-LQAS_Apr2012_EN.pdf, accessed 8 November 2018).

RESPONDING TO A POLIOVIRUS 45 EVENT OR OUTBREAK Selection and training of monitors is important. The laboratory should also routinely summarize any Clear terms of reference outlining independence capacity challenges they face and proposed solutions. of the monitors from immunization activities are helpful for all monitors. Ideally, monitors should be recruited and trained for each SIA round. Deploying Outbreak response assessments the same personnel for successive campaigns is (OBRAs) discouraged. Sources for recruitment of monitors The purpose of OBRAs is to assess whether include universities and colleges (e.g. nursing or vaccination and surveillance response is robust medical students), community NGOs or service enough to detect and stop poliovirus transmission agencies (e.g. health workers not directly involved and to determine what is needed to address gaps. in the response) and should be selected to fit the Polio OBRAs should be timely, effective, practical local context. and independent.

Timeliness of reporting monitoring results is The OBRAs are conducted approximately every three important to ensure accountability, rapid issue months, or as appropriate to the circumstances. An identification, and course correction where external team of experts will assess the quality of warranted. Monitoring results must be communicated response, the evidence of poliovirus transmission to GPEI partners at national, regional and global and the quality of surveillance. Specifically, the levels within 14 days of campaign completion. objectives are to: 1. assess and strengthen efforts to increase Monitoring surveillance population immunity; enhancement 2. assess progress towards interrupting Countries should monitor weekly surveillance poliovirus transmission; indicators and reporting from all subnational 3. assess and strengthen surveillance sensitivity. reporting units with emphasis on high-risk sub- populations and the outcome and impact of For any response with mOPV2, the OBRA team will all enhancements. recommend management options for the vaccine remaining after all campaigns are completed. For In addition to routine AFP surveillance indicators high-risk events for which vaccination was carried with detail to subnational reporting level, regular out, an event response assessment or external desk updates on process indicators should be provided, review may also be undertaken. including timeliness of investigation, sample collection, and receipt at laboratory. The OBRA team leader will conduct a debriefing before departing and submit a report to the Reporting should be adequate to allow authorities country team, OPRTT chair, WHO regional office, to identify issues early, generate appropriate and the Director of the WHO polio programme. solutions to improve performance, and bolster The WHO regional office will confirm the end confidence that the performance is good enough of the outbreak based on the assessment report to detect ongoing virus transmission. For example, and recommendations. findings from retrospective and ad hoc active case searches in community and health facilities should The country must provide a post-OBRA action plan be comprehensively summarized and reported in a within one month of the end of the OBRA. timely manner. Detailed guidance, tools and materials for outbreak response assessments and vaccine management are available.aa

aa See “Polio Outbreak Response Assessment (OBRA): Aide Mémoire”. 2018 (http://polioeradication.org/tools-and-library/resources-for-polio-eradicators/ gpei-tools-protocols-and-guidelines/).

46 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Is the outbreak over? The criteria to determine if a poliovirus outbreak has ended are outlined below in table 9.

Table 9. Criteria to determine if a poliovirus outbreak is over

Criteria to determine if a poliovirus outbreak is over 1 No poliovirus of the outbreak serotype detected from any source (AFP, contact, environmental) for at least six months since virus last detected. AND 2 Surveillance criteria over previous 12 months met in outbreak and high-risk areas, and other areas at risk, including cross-border outbreaks1: i) NPAFP ≥3 per 100 000 population <15 years of age (or national objective, whichever is higher). ii) ≥80% stool adequacy of all AFP case stool collected. AND 3 Convincing evidence that areas at high risk or with conflict, displacement, difficult to access and small populations, have been identified and planned for, and that adapted strategies2 have been successfully implemented to: i) interrupt transmission of poliovirus; ii) detect any ongoing poliovirus transmission. After comprehensive review of indicators, data quality and qualitative information in the local context, the OBRA team has the responsibility to give the best possible opinion as to whether: i) an outbreak appears to be over, even if not all criteria are strictly met; or ii) an outbreak cannot be considered over, even in the absence of detectable virus isolation.

1 Criteria to be met at first administrative level, or second administrative level for populous countries (e.g. India, Nigeria, Pakistan), and other high-risk areas, as determined by the OBRA team. 2 Strategies include: innovative vaccination outreach activities, active case search, community surveillance, estimate of population, as yet unreached by vaccination, by surveillance

The OBRAs should continue until the end of • Repeat OBRA after 3–4 months. outbreak criteria are met. When criteria are met and/or the OBRA team is If the ‘end of outbreak’ criteria are not met in a satisfiedthat outbreak response has been sufficient, country or zone, the OBRA team will recommend in following the decision tree below (Figure 7), the the next steps: OBRA team recommends that the outbreak can • At 6 months with no poliovirus detected, be closed. strengthen internal and external support for response and continue OBRAs and/or external The WHO regional office considers the OBRA desk reviews as appropriate. findings in consultation with the OPRTT, shares the report with the national and regional certification • At 9 to 12 months without virus detected, put in commissions, and may confirm the outbreak place an additional 3- month emergency plan for: is over and can be ‘closed’. The country is a) surveillance, e.g. intense active case search in informed accordingly. outbreak area or other enhancements Figure 7 illustrates a decision tree for determining b) supplemental immunization, e.g. innovative if an outbreak has ended. strategies to reach every child in mobile or high-risk populations c) routine immunization, e.g. proven strategies to reach every district (RED approach);

RESPONDING TO A POLIOVIRUS 47 EVENT OR OUTBREAK Figure 7. Outbreak response assessment decision tree

Poliovirus outbreak

OBRA at 3-month intervals No poliovirus detected from any source for at least 6 months

OBRA after 6 months without poliovirus detection Good evidence of: Insuffi cient evidence of: • high-quality effective immunization response • high-quality immunization • sensitive AFP surveillance • sensitive AFP surveillance

Outbreak Outbreak may not likely ended have ended Response continues

OBRA continues at 3-month intervals or as appropriate • three-month additional emergency surveillance action plan implemented, and 12 months -- plus one month to complete laboratory testing and report -- from time of last poliovirus isolate, and • test results available for all samples collected.

Outbreak likely ended

International Health Regulations The criteria of the IHR Emergency Committee (IHR) Emergency Committee outlines when a country may be determined as infected or not infected. The IHR Emergency As polio has been declared a public health emergency Committee criteria may differ from those used of international concern, the IHR Emergency operationally to assess if an outbreak is over. Committee reviews the status of all poliovirus- The quarterly IHR review statements are available.ab infected and at-risk countries every three months.

ab See IHR statements [website] Geneva: World Health Organization (http://www.who.int/mediacentre/news/statements/2018/16th-ihr-polio/en/, accessed 8 November 2018).

48 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Documenting lessons learned Typically, best practice in emergency response includes a formal after-action review. The lessons learned There is great value for countries to review the are useful in improving emergency preparedness performance of the outbreak or event response planning and can inform response to future events and document lessons learned. The outbreak or outbreaks. documentation should, among other things, include: a) a detailed outbreak investigation and risk Outbreak documentation should also outline assessment lessons learned and best practices highlighted by b) descriptive epidemiology (including index the OBRAs as strategic to successful interruption of case investigation) polio outbreaks. Several relevant documents on best ac c) surveillance response to monitor the evolution practice have recently been published . Support is up to the end available for countries to document lessons learned d) immunization response outlining the key from polio eradication. milestones for quality assurance and innovations (micro-planning, training, preparedness monitoring, logistics management, community engagement and monitoring/supervision) e) coordination of the outbreak response, including timing and effectiveness of surge of efforts.

ac See Capturing and sharing lessons learned [website] Geneva: Global Polio Eradication Initiative (http://polioeradication.org/polio-today/preparing-for-a- polio-free-world/transition-planning/lessons-learned-from-polio-eradication/, accessed 8 November).

RESPONDING TO A POLIOVIRUS 49 EVENT OR OUTBREAK Bibliography

For additional information, users of this document are requested to consult the following:

AGORA. UNICEF’s Global Hub for Learning and Development (https://agora.unicef.org/index.php, accessed on 4 December 2018). Assessing immunization coverage with clustered lot quality assurance sampling (clustered-LQAS). Field Manual. Geneva: Global Polio Eradication Initiative; 2012 (http://polioeradication.org/wp-content/uploads/2016/09/Assessing- Vaccination-Coverage-Levels-Using-Clustered-LQAS_Apr2012_EN.pdf, accessed 8 November 2018).

Best Practices for Monitoring the Quality of Polio Eradication Campaign Performance. GPEI guidelines. Geneva: Global Polio Eradication Initiative; 2018 (http://polioeradication.org/wp-content/uploads/2018/08/best-practices-20180810-03.pdf, accessed 8 November 2018).

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50 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Polio eradication and endgame strategic plan 2013–2018 [website]. Geneva: Global Polio Eradication Initiative; 2013 (http:// www.polioeradication.org/resourcelibrary/strategyandwork.aspx, accessed 8 November 2018).

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Public Health Management of Facility-Related Exposure to Live Polioviruses: Interim guidance in managing exposed persons for countries hosting facilities that maintain live polioviruses, GPEI website library (http://polioeradication.org/tools-and-library/ resources-for-polio-eradicators/gpei-tools-protocols-and-guidelines/, accessed on 4 December 2018).

Reaching Every District (RED), 2017 revision. Brazzaville: World Health Organization. 2017 (http://apps.who.int/iris/bitstream/ handle/10665/260112/9789290233954-eng.pdf?sequence=1&isAllowed=y, accessed 8 November 2018).

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RESPONDING TO A POLIOVIRUS 51 EVENT OR OUTBREAK Annexes

Annex 1. Risk assessment overview: Summary of elements for systematic risk assessment of a new VDPV, WPV or SL2 isolation.

Annex 2. Timeline and responsibility for outbreak response activities from Day 0 to outbreak closure

52 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Annex 1. Risk assessment overview: Summary of elements for systematic risk assessment of a new VDPV, WPV or SL2 isolation

Risk Category High risk Low risk Remarks Virology cVDPV Automatically defined as high-risk situation Virologic factors • Genetic deviation from parent Sabin (nucleotide Substantial Not Seek expert changes) Substantial virologist • Relatedness, if any, to past isolations Related assessment • Virologist characterization / interpretation Yes Not related • Co-circulation with WPV Yes No • Detection of other (un-related) VDPVs in region Yes No No Human source • Co-isolation with other Sabin or enterovirus Yes • Evidence of primary immunodeficiency No No Yes Environmental source • Number / density of virus in samples High • Mix of poliovirus, Sabin virus, and other enteric Yes Medium/low virus in sample No Context Case Characteristics Review and discussion by • Member of known “high risk”/underserved Yes No technical experts, population (slum, minority, refugee, mobile, between country, internally displaced, etc.) region and global • 0 dose or “under”-vaccinated Yes No levels • Aged above 5 years Yes No Coverage data ”Population Immunity” for type 2 • RI coverage (IPV if available-otherwise diptheria- Poor Good/high polioviruses, should tetanus-pertussis (DPT3) in infected Admin 1 level factor time since • Quality of prior SIAs (>5% missed children by IM Poor Fair/good switch and use of data) IPV to estimate type 2 naïve population Surveillance quality

• Surveillance gaps (e.g. sub-standard AFP Evident Fair/good indicators, infrequent or absent ES, orphan virus) in infected Admin 1 level • Other recent poliovirus detection Yes No

RESPONDING TO A POLIOVIRUS 53 EVENT OR OUTBREAK 30+

Risk Category High risk Low risk Remarks Admin level 1 context 15–30

• Large, densely populated area Yes No 14

• Known high risk populations (e.g. mobile, refugee, Yes No 13 trade, pilgrimage, displacement) • Insecure and/or inaccessible area affecting Yes No 12 surveillance and/or immunization 11 • Any type of sentinel events suggesting higher risk Yes No

of rapid spread 10

• Evidence of containment breach Yes No 9 • Finding tOPV/mOPV2 in a sweep of the vaccine Yes No

distribution chain 8 • Environmental conditions associated with high Poor water and Fair/good 7 levels of fecal-oral transmission sanitation water and

sanitation 6 International Spread 5 Linkages with International Border Local case investigation / based 4 • Contiguous or direct transport link to int’l border Yes No on available data (especially if other area is known high risk) 3 Review and

• Links between site or person with poliovirus to Yes No discussion by GPEI 2 other countries (e.g. markets, transport routes) technical experts, • Travel history of poliovirus case or household (e.g. Yes No in consultation with 1 refugee, nomadic, pilgrimage, stateless persons) country, regional 0 • History of any other sentinel event shared across Yes No levels sequencing results post Days borders • Prior history of polio transmission patterns and Yes No outbreaks between countries

Population mobility-migration • Common service points between infected area and Yes No neighbouring areas like markets, pilgrim sites, watering points for nomads • Evidence of high levels of migration (from Yes No sequencing data, available cell phone data, prior migration patterns, etc.)

Context of neighboring areas • Evidence of surveillance gaps or other high- Yes No risk factors in neighboring areas susceptible to importation from affected area • Population immunity in neighbouring countries Low Good/high • Conflict Present None Timeline and responsibility for actions in the first month following poliovirus detection poliovirus month following actions in the first for Timeline and responsibility Actions Notification regional office, and WHO at country country health authorities of the affected GPLN informs levels and headquarters office Polio Global relevant informs health authorities, WHO headquarters Country informs (GPEI) partners Initiative Eradication point notifies WHO IHR focal Investigation investigation epidemiological/social initiates Country team Coordination and headquarters, offices mechanisms at regional response event/outbreak Establish GPEI partner coordination for including the OPRTT as soon available and deploy surge response rapid Activate as soon available support and deploy surge Activate plan and response Risk assessment (Advisory GPEI partners to proposal and response risk assessment presents Country team - EOMG) Management Group and Outbreak mOPV2 (AD G) /Eradication for Group mOPV2 (if applicable) for request vaccine submits Country team team country to recommendations (AD G/EOMG) meet and provide GPEI partners (WHE) Headquarters, by WHO Health Emergencies be graded to Outbreak as per the ERF Framework plan and budget response finalize and submit outbreak to Country team management Vaccine (if applicable) stockpile of mOPV2 from authorizes release WHO Director-General (if applicable) country shipped to and syringes mOPV2 vaccine (if applicable) field sent to mOPV2 vaccine activities Response fund initial to office regional/country to $500 000) released funding (up to No regrets activities response a National Public Health Emergency polio outbreak Declare plan and communication a national advocacy and implement Develop activities enhancement surveillance Initiate 0” “Round Implement the country to and funds release budget endorsed response Outbreak SIA 1, 2 and mop-up rounds Implement Annex 2A : Annex

54 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK 30+ 15–30 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 Days post sequencing results sequencing results post Days Timeline and responsibility for actions in the first month following poliovirus detection poliovirus month following actions in the first for Timeline and responsibility Actions Notification regional office, and WHO at country country health authorities of the affected GPLN informs levels and headquarters office Polio Global relevant informs health authorities, WHO headquarters Country informs (GPEI) partners Initiative Eradication point notifies WHO IHR focal Investigation investigation epidemiological/social initiates Country team Coordination and headquarters, offices mechanisms at regional response event/outbreak Establish GPEI partner coordination for including the OPRTT as soon available and deploy surge response rapid Activate as soon available support and deploy surge Activate plan and response Risk assessment (Advisory GPEI partners to proposal and response risk assessment presents Country team - EOMG) Management Group and Outbreak mOPV2 (AD G) /Eradication for Group mOPV2 (if applicable) for request vaccine submits Country team team country to recommendations (AD G/EOMG) meet and provide GPEI partners (WHE) Headquarters, by WHO Health Emergencies be graded to Outbreak as per the ERF Framework plan and budget response finalize and submit outbreak to Country team management Vaccine (if applicable) stockpile of mOPV2 from authorizes release WHO Director-General (if applicable) country shipped to and syringes mOPV2 vaccine (if applicable) field sent to mOPV2 vaccine activities Response fund initial to office regional/country to $500 000) released funding (up to No regrets activities response a National Public Health Emergency polio outbreak Declare plan and communication a national advocacy and implement Develop activities enhancement surveillance Initiate 0” “Round Implement the country to and funds release budget endorsed response Outbreak SIA 1, 2 and mop-up rounds Implement Annex 2A : Annex

RESPONDING TO A POLIOVIRUS 55 EVENT OR OUTBREAK With support from WHO and UNICEF With support from and headquarters office regional GPEI inform to WHO headquarters EOMG, Strategy (OPRTT, partners - SC) Committee to GPEI partners With support from the national health authorities ensure to information the necessary have with country effectively communicate stakeholders. WHO and UNICEF regional offices/ WHO and UNICEF regional required provide rapidly to headquarters documents WHO and UNICEF regional offices and offices WHO and UNICEF regional headquarters Regional/Global Regional/Global Responsibility National health authorities, with support offices WHO and UNICEF country from National health authorities, with support offices WHO and UNICEF country from National health authorities National health authorities, with support offices WHO and UNICEF country from National health authorities, with support offices WHO and UNICEF country from National health authorities, with support offices WHO and UNICEF country from National health authorities, with support offices WHO and UNICEF country from Country Brief Minister of Health, Head of Government/State and of Health, Head Government/State Brief Minister for required officials on the specific steps other relevant the outbreak: stop to response an urgent polio a National Public Health Emergency 1. Declare or advise the of outbreak in case within 72 hours if the virus is an emergency declare need to potential as an outbreak. reclassified center operating a national emergency 2. Establish is structure coordination emergency if an existing (EOC) official by a senior government led in place, not already point and supported focal outbreak as the designated communication, strategic administration, for by staff management and finance. supply logistics, operations, Inform national authorities and other relevant partners. national authorities and other relevant Inform Part B: Determine geographic extent of transmission (i.e of transmission extent geographic B: Determine Part etc.). search sampling, active contact the stop to operations response the required 3.Implement SOPs, response as per the outbreak virus transmission 7). (see Chapter virus type and classification Establish an outbreak management team with management team an outbreak Establish agencies. all relevant from representation Find national polio outbreak preparedness and response and response preparedness Find national polio outbreak in National Certification in Annex be found plan (can report). (NCC) Committee Identify trained or experienced polio outbreak response response polio outbreak or experienced Identify trained in country/region. persons Read any reports or documents of previous outbreak outbreak of previous or documents any reports Read activities. response documents guidance has technical team country Ensure SOPs, (outbreak and response support investigation to etc.). template, risk assessment template, investigation Initiate joint epidemiological and social investigation and social investigation joint epidemiological Initiate guidance): for 4 and template (see Chapter context and local isolate case/ES A: Investigate Part Activities Outbreak Outbreak coordination and advocacy Communication Function Outbreak Outbreak coordination Resources Resources Resources Resources Resources Resources Resources Investigation Timeline and responsibility for outbreak response activities from Day 0 to close of outbreak close 0 to Day activities from response outbreak for Timeline and responsibility Within of 24 hours notification Notification Notification of virus from - laboratory 0 Day Within of 24 hours notification Timeline Annex 2B : Annex

56 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK With support from WHO and UNICEF With support from and headquarters office regional GPEI inform to WHO headquarters EOMG, Strategy (OPRTT, partners - SC) Committee to GPEI partners With support from the national health authorities ensure to information the necessary have with country effectively communicate stakeholders. WHO and UNICEF headquarters GPEI partners and chair calls initiative to OPRTT regional WHO/UNICEF from support With and headquarters office WHO and UNICEF regional offices/ WHO and UNICEF regional required provide to headquarters rapidly documents coordinate to OPRTT regional WHO/UNICEF from support With and headquarters office WHO and UNICEF regional offices/ WHO and UNICEF regional required provide rapidly to headquarters documents WHO and UNICEF regional offices and offices WHO and UNICEF regional headquarters Regional/Global Regional/Global Regional/Global Responsibility Responsibility National health authorities, with support offices WHO and UNICEF country from National health authorities, with support offices WHO and UNICEF country from National health authorities WHO and UNICEF to participate WHO and UNICEF to National health authorities, WHO and UNICEF offices country National health authorities with support from offices WHO and UNICEF country National health authorities WHO and UNICEF country offices to make make to offices WHO and UNICEF country arrangements in-country National health authorities with support from offices WHO and UNICEF country National health authorities, WHO and UNICEF and nominate agree to offices country National health authorities, with support offices WHO and UNICEF country from National health authorities, with support offices WHO and UNICEF country from National health authorities, with support offices WHO and UNICEF country from National health authorities, with support offices WHO and UNICEF country from Country Country Conduct a press briefing/media release briefing/media release Conduct a press Conduct a media landscape analysis Conduct a media landscape media monitoring. Initiate Brief Minister of Health, Head of Government/State and of Health, Head Government/State Brief Minister for required officials on the specific steps other relevant the outbreak: stop to response an urgent polio a National Public Health Emergency 1. Declare or advise the of outbreak in case within 72 hours if the virus is an emergency declare need to potential as an outbreak. reclassified center operating a national emergency 2. Establish is structure coordination emergency if an existing (EOC) official by a senior government led in place, not already point and supported focal outbreak as the designated communication, strategic administration, for by staff management and finance. supply logistics, operations, Inform national authorities and other relevant partners. national authorities and other relevant Inform Part B: Determine geographic extent of transmission (i.e of transmission extent geographic B: Determine Part etc.). search sampling, active contact the stop to operations response the required 3.Implement SOPs, response as per the outbreak virus transmission 7). (see Chapter virus type and classification mechanism at all levels monitoring systematic 4. Ensure progress monitor to and district) (national, regional up actions and follow of planning, implementation activities. response throughout of of the progress reporting and regular 5. Timely the head of government/ activities to response outbreak and GPEI partners. state division if type 2 poliovirus UNICEF supply Alert to: counterparts and government with partners Work • • • Initiate event/outbreak response mechanisms at regional mechanisms at regional response event/outbreak Initiate any available Share levels. and headquarters office risk assessment, (draft team with country information security coverage, historical assessments, surveillance etc.). high-risk groups, assessments, to (OPRTT) Team and Preparedness Response Outbreak WHO, UNICEF between calls conference weekly establish and GPEI partners. of the national HR capacity the on-the-ground Assess WHO, UNICEF and other in-country health system, operations. response implement to partners Request expedited procedures for visas at the port of for procedures expedited Request responders. outbreak any international entry for Activate surge support processes; deploy as soon deploy support processes; surge Activate 21 Target Response; - Rapid 72 hours (Target available. Support). - Surge days for with proposal template risk assessment Initiate and (see template strategy immunization response 7). chapter the for and spokesperson person Identify a media focal outbreak. Establish an outbreak management team with management team an outbreak Establish agencies. all relevant from representation Find national polio outbreak preparedness and response and response preparedness Find national polio outbreak in National Certification in Annex be found plan (can report). (NCC) Committee Identify trained or experienced polio outbreak response response polio outbreak or experienced Identify trained in country/region. persons Read any reports or documents of previous outbreak outbreak of previous or documents any reports Read activities. response documents guidance has technical team country Ensure SOPs, (outbreak and response support investigation to etc.). template, risk assessment template, investigation Initiate joint epidemiological and social investigation and social investigation joint epidemiological Initiate guidance): for 4 and template (see Chapter context and local isolate case/ES A: Investigate Part Activities Activities Outbreak Outbreak coordination and advocacy Communication Communication Outbreak Outbreak coordination Outbreak coordination HR surge support HR surge HR surge support HR surge HR surge support Risk and assessment response Communication Communication Function Function Outbreak Outbreak coordination Resources Resources Resources Resources Resources Resources Resources Investigation Timeline and responsibility for outbreak response activities from Day 0 to close of outbreak close 0 to Day activities from response outbreak for Timeline and responsibility Within of 24 hours notification Within of 24 hours notification Within of 24 hours notification Notification Notification of virus from - laboratory 0 Day Within of 24 hours notification Timeline Timeline Annex 2B : Annex

RESPONDING TO A POLIOVIRUS 57 EVENT OR OUTBREAK

Regional/Global Regional/Global WHO headquarters to coordinate and coordinate to WHO headquarters release Division UNICEF Supply mOPV2 Advisory Group secretariat to review review to secretariat mOPV2 Advisory Group Division UNICEF Supply and send to WHE coordinate, to WHO headquarters with in consultation grade to Headquarters office regional WHO Headquarters to support to WHO Headquarters WHO regional office and headquarters and headquarters office WHO regional support as required security advisors and office WHO/UNICEF regional support with OPRTT Headquarters support to UNICEF Headquarters Responsibility Country UNICEF country office office UNICEF country National Health Authorities point National IHR focal with national offices WHO and UNICEF country health authorities WHO country office WHO country WHO and UNICEF representatives with national in collaboration UNDSS, authorities National Health Authorities with support from offices WHO and UNICEF country National Health Authorities with support from offices WHO and UNICEF country National Health Authorities with support from offices WHO and UNICEF country Release “no regret” funding (up to $500 000) to regional/ $500 000) to funding (up to “no regret” Release activities. fund initial response to office country as per vaccine response shipment of bundled Initiate proposal. response Declare polio a National Public Health Emergency. Declare be WHO; a summary may to Submit IHR notification as a Disease on the WHO website publicly reported (DON). Notification Outbreak grading for call in WHO 3-level and participate Prepare office regional headquarters, by WHE, WHO Polio Response as per the Emergency office, and country Framework. proposal, and response 1) Finalize risk assessment including from information, with all available neighbouring countries OPRTT/ to and proposal risk assessment 2) Present or mOPV2 3 poliovirus) 1 or Type EOMG (Type and feedback for 2 poliovirus) (Type Advisory Group recommendations. forecasts, plan including: vaccine a logistics Complete utilization distribution, warehousing, storage, cold and disposal (see accountability, vaccine monitoring, management guidance. vaccine authorization of for form request Submit mOPV2 vaccine by WHO Director-General. realease vaccine Coordinate with the United Nations Department of Safety Nations Department of Safety with the United Coordinate missions. on field and Security (UNDSS) of the virus in the area the security and access Assess security advisor Request areas. and surrounding isolate assessment. level a field conduct to Inform the United Nations Resident Coordinator and the Coordinator Nations Resident the United Inform Country Team. Humanitarian Activities Finance Logistics IHR notification Grading Function Logistics Logistics planning request Vaccine Risk assessment and response planning Complex Complex emergency settings (if applicable) Outbreak response Within 72 hours of (3 days) notification Timeline

58 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Regional/Global Regional/Global OPRTT to facilitate review and review facilitate to OPRTT GPEI partners from recommendations WHO and UNICEF regional offices to to offices WHO and UNICEF regional support offices/ WHO and UNICEF regional support to headquarters Responsibility Country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country Background and risk for further transmission and risk for Background timing, etc.) of SIAs (scope, strategy Proposed activities enhancement Surveillance and social mobilization communication Advocacy, activities and partnerships Coordination assessment Human resources response and outbreak evaluation Monitoring, (OBRA) assessments Budget Pre-campaign awareness sessions targeting high-risk targeting sessions awareness Pre-campaign populations and hard-to-reach and ensuring communities communication Proactive of the the dangers sensitized to are health workers of the vaccine disease and benefits Engagement of key influencers and key stakeholders stakeholders and key influencers Engagement of key leaders, community religious, (including political, hard-to-reach to access provide to celebrities) communities plan to of a special crisis communication Development vaccination to of resistance in case rumours address following events adverse actions to respond and rapid vaccination. Activities Communicate preliminary plan to all provinces and all provinces plan to preliminary Communicate activities. in response involved districts plan (see response of the outbreak development Initiate guidance). detailed for template • • • • • • • • subnational teams and input from Seek feedback Activate the national emergency operating center (EOC) (EOC) center operating the national emergency Activate out roll to structure coordination emergency or existing immunization response the first for activities required plan. response and subsequent activities in the outbreak and of a national advocacy development Initiate on community plan focusing communication information engagement, social mobilization and general response the outbreak across strategies dissemination Include: guidance.) detailed 9 for period. (See Chapter • • • • Function Function Outbreak Outbreak response Advocacy and Advocacy communication Advocacy and Advocacy communication Timeline Within 72 hours of (3 days) notification Within 72 hours of (3 days) notification

RESPONDING TO A POLIOVIRUS 59 EVENT OR OUTBREAK Regional/Global Regional/Global Regional/Global Regional/Global WHO/UNICEF regional office WHO/UNICEF regional WHO regional offices offices WHO regional GPEI partner review coordinate to OPRTT and budget and feedback WHO regional offices offices WHO regional With support from WHO/UNICEF regional WHO/UNICEF regional With support from and headquarters offices and headquarters office UNICEF regional support to UNICEF regional office and headquarters office UNICEF regional OPRTT to facilitate GPEI partner support facilitate to OPRTT support to GPEI partners and offices WHO/UNICEF regional OPRTT, Headquarters directors WHO/UNICEF regional UNICEF regional office and headquarters and headquarters office UNICEF regional support to and headquarters office UNICEF regional support with OPRTT Responsibility Responsibility Country Country National health authorities National health authorities, with WHO country office National health authorities, with support from offices WHO and UNICEF country facilitate to offices WHO and UNICEF country National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country National health authorities and UNICEF office country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country WHO country office office WHO country National health authorities with support from National health authorities with support from UNDSS National health authorities with UNICEF office country WHO and UNICEF country offices with offices WHO and UNICEF country and media donors in-country WHO and UNICEF country offices offices WHO and UNICEF country National health authorities with UNICEF office country Notify and sensitize health care workers at national workers Notify and sensitize health care about notification units and subnational surveillance requirements activities AFP case-finding supplemental Implement in the AFP active sites reporting and reclassify Review network surveillance in outbreak is involved the national laboratory Ensure is strengthened capacity ensure planning to sampling from of environmental frequency Increase and appropriate. feasible where sites, existing already Mapping community leaders, key players, players, key leaders, Mapping community and identify influencers stakeholders point vaccination permanent/transit Planning for areas inaccessible surrounding strategies to strategies vaccination opportunistic Planning for areas. populations in inaccessible reach Activities Activities Develop a preparedness dashboard to assess readiness readiness assess to dashboard a preparedness Develop example, of activities (for tracking Initiate 0”. “Round for guidance). for available dashboards activates enhancement surveillance Initiate guidance.): detailed 8 for (See Chapter • • • • • high-level secure plan to advocacy an external Develop and country the affected from commitment political efforts. advocacy in-country complement the to write to directors WHO and UNICEF regional and of Health highlighting the emergency Minister and representatives the full support of country and support. guidance for organizations Determine human resources surge requirements with requirements surge human resources Determine needs. and country based on grading OPRTT Conduct a follow up media briefing on plans and Conduct a follow the outbreak. to responding for proposals of long-term and list the C4D polio toolkit Share use immediately can office that the country agreements activities. response accelerate to and context of the case the social profiling Complete guide the to tools investigation using special country design of C4D interventions. Provide a briefing to the highest government authorities government the highest a briefing to Provide brief) and other key memo or presidential (e.g. cabinet response a successful needed for partners strategic political/religious/ parliamentarians, ministries, (relevant in the epicenter). partners health and NGO civic leaders, Initiate outbreak response plan activity monitoring to to plan activity monitoring response outbreak Initiate dashboard). (e.g. tracker, implementation track in the stakeholders meeting with key a weekly Establish of the implementation and monitor coordinate to country plan. response outbreak macro of the national operations development Initiate coordination strategy, 0” detailing “Round plan for human resources, logistics, vaccine, structure, and supervision, social mobilization, communication needs, etc. training subsequent SIA 1/SIA 2 and plan for macro Revise additional mop-up round. Finalize outbreak response plan and six-month budget response Finalize outbreak and timing); guidance for and budget SOPs (see template finalize within one week. to team country Initiate partner coordination with other United Nations with other United partner coordination Initiate agencies on the ground. and humanitarian Initiate development of an access plan, including: of an access development Initiate • • • Initiate weekly media briefing on the response plan and media briefing on the response weekly Initiate activities. of immunization and surveillance status Inform broader donor community of poliovirus of poliovirus donor community broader Inform activities, of polio response and status notification including immunization and surveillance. Finalize media protocol kit with key messages, produce produce messages, kit with key Finalize media protocol relevant products and other communication media briefs use. and regional/global local for the outbreak to Initiate the development of a joint WHO/UNICEF situation the development Initiate on weekly GPEI partners update (SITREP) to report planning and response of investigation, the progress guidance). for available activities (template Function Function Function Function Outbreak Outbreak plan response and budget Partner coordination Outbreak response plan operations Outbreak Outbreak plan response and budget Partner Partner coordination Communication Communication Communication Communication Outbreak Outbreak response Surveillance enhancement and Advocacy communication and Advocacy communication Communication Human resources support surge Communication Complex emergency settings (if applicable) Communication Communication C4D, social mobilization and communication Timeline Within of 7 days notification Timeline Within of 14 days notification Within of 7 days notification

60 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Regional/Global Regional/Global WHO/UNICEF regional office WHO/UNICEF regional WHO regional offices offices WHO regional GPEI partner review coordinate to OPRTT and budget and feedback WHO regional offices offices WHO regional With support from WHO/UNICEF regional WHO/UNICEF regional With support from and headquarters offices and headquarters office UNICEF regional support to Responsibility Country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country WHO country office office WHO country National health authorities with support from National health authorities with support from UNDSS National health authorities with UNICEF office country WHO and UNICEF country offices with offices WHO and UNICEF country and media donors in-country WHO and UNICEF country offices offices WHO and UNICEF country National health authorities with UNICEF office country Mapping community leaders, key players, players, key leaders, Mapping community and identify influencers stakeholders point vaccination permanent/transit Planning for areas inaccessible surrounding strategies to strategies vaccination opportunistic Planning for areas. populations in inaccessible reach Activities Initiate outbreak response plan activity monitoring to to plan activity monitoring response outbreak Initiate dashboard). (e.g. tracker, implementation track in the stakeholders meeting with key a weekly Establish of the implementation and monitor coordinate to country plan. response outbreak macro of the national operations development Initiate coordination strategy, 0” detailing “Round plan for human resources, logistics, vaccine, structure, and supervision, social mobilization, communication needs, etc. training subsequent SIA 1/SIA 2 and plan for macro Revise additional mop-up round. Finalize outbreak response plan and six-month budget response Finalize outbreak and timing); guidance for and budget SOPs (see template finalize within one week. to team country Initiate partner coordination with other United Nations with other United partner coordination Initiate agencies on the ground. and humanitarian Initiate development of an access plan, including: of an access development Initiate • • • Initiate weekly media briefing on the response plan and media briefing on the response weekly Initiate activities. of immunization and surveillance status Inform broader donor community of poliovirus of poliovirus donor community broader Inform activities, of polio response and status notification including immunization and surveillance. Finalize media protocol kit with key messages, produce produce messages, kit with key Finalize media protocol relevant products and other communication media briefs use. and regional/global local for the outbreak to Initiate the development of a joint WHO/UNICEF situation the development Initiate on weekly GPEI partners update (SITREP) to report planning and response of investigation, the progress guidance). for available activities (template Function Function Outbreak Outbreak plan response and budget Partner coordination Outbreak response plan operations Outbreak Outbreak plan response and budget Partner Partner coordination Communication Communication Communication Communication Communication Communication Communication Complex emergency settings (if applicable) Timeline Within of 14 days notification Within of 7 days notification

RESPONDING TO A POLIOVIRUS 61 EVENT OR OUTBREAK Regional/Global Regional/Global Regional/Global Regional/Global WHO/UNICEF regional offices offices WHO/UNICEF regional OPRTT to facilitate support from partners partners support from facilitate to OPRTT provide to office WHO/UNICEF regional support technical provide to WHO headquarters support office WHO regional WHO/UNICEF regional office WHO/UNICEF regional UNICEF regional office and headquarters office UNICEF regional UNICEF regional office and headquarters and headquarters office UNICEF regional support provide to OPRTT to facilitate support from GPEI support from facilitate to OPRTT partners to office/headquarters WHO regional support provide OPRTT to facilitate process process facilitate to OPRTT Responsibility Responsibility Country Country National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country National health authorities National health authorities, with support from offices WHO and UNICEF country National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with WHO and office UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country WHO and UNICEF country offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country Engage the community leaders and identified leaders Engage the community influencers and influencers players, key through access Negotiate stakeholders point vaccination a permanent/transit Implement areas inaccessible surrounding strategies to strategies vaccination opportunistic Implement areas. populations in inaccessible reach Supervision and post-campaign) (intra- Independent monitoring daily performance, meetings (team review Daily reporting) sampling (LQAS) Lot quality assurance related issues refusals, including vaccine SIA reviews, etc. mistrust, to Activities Activities Within 14 days, implement “Round 0” immunization “Round implement Within 14 days, response. Deploy a field security officer. a field Deploy listed of strategies plan (examples access Implement below): • • • • Implement the advocacy and communication plan to and communication the advocacy Implement at the national and stakeholders engage all relevant activities. response in outbreak subnational levels (SITREP) is that joint WHO/UNICEF situation report Ensure among partners. and circulated generated and positions in infected fill vacant to process Initiate high-risk areas. comprehensive ensure mOPV2 response For and monitoring management of all vials. Detailed and remaining retrieved, of vials deployed, reporting at the end of each immunization activity is for unaccounted management guidance.) (See vaccine required. Develop tools and training for development of micro of micro development for and training tools Develop coordination strategies, detailing 0”, “Round plans for human resources, logistics, vaccine, structure, and supervision, social mobilization, communication microplanning for practice (Best needs, etc. training guidance.) for available subsequent SIA 1/SIA 2 and plans for micro Revise additional mop-up round. Develop tools and training for development of micro of micro development for and training tools Develop structure, coordination strategies, plans detailing supervision, human resources, logistics, vaccine, needs and training social mobilization, communication for is available microplanning for practice (Best etc. guidance.) Establish campaign monitoring for SIAs: for monitoring campaign Establish • • • • • interventions. of communication monitoring Establish Develop SIAs preparedness monitoring dashboards dashboards monitoring SIAs preparedness Develop at national and SIAs readiness assess be used to to subnational levels. one week weeks, two assessments Conduct readiness inform to SIA implementation prior to days and three SIAs quality assurance. support for technical targeted and external of the internal the implementation Track interventions of successful note plans. Taking advocacy OPRTT. further needs to and communicating OPRTT and EOMG to provide endorsement of outbreak of outbreak endorsement provide and EOMG to OPRTT and initiate plan and budget (within 20 days) response funds funds. Within 28 days release mechanisms to in country. be available should Function Function Function Function Vaccine Vaccine management Communication Immunization C4D, social Micro plan Micro development mobilization and communication Complex emergency settings (If applicable) Micro plan Micro development Monitoring Monitoring immunization Monitoring communication Monitoring Monitoring preparedness Monitoring preparedness Monitoring advocacy Finances Within of 14 days notification Timeline Timeline until 14 days of completion immunization activities (75–90 days)

62 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Regional/Global Regional/Global UNICEF regional office and headquarters and headquarters office UNICEF regional support provide to OPRTT to facilitate support from GPEI support from facilitate to OPRTT partners to office/headquarters WHO regional support provide OPRTT to facilitate process process facilitate to OPRTT Responsibility Country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with WHO and office UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country Supervision and post-campaign) (intra- Independent monitoring daily performance, meetings (team review Daily reporting) sampling (LQAS) Lot quality assurance related issues refusals, including vaccine SIA reviews, etc. mistrust, to Activities Develop tools and training for development of micro of micro development for and training tools Develop structure, coordination strategies, plans detailing supervision, human resources, logistics, vaccine, needs and training social mobilization, communication for is available microplanning for practice (Best etc. guidance.) Establish campaign monitoring for SIAs: for monitoring campaign Establish • • • • • interventions. of communication monitoring Establish Develop SIAs preparedness monitoring dashboards dashboards monitoring SIAs preparedness Develop at national and SIAs readiness assess be used to to subnational levels. one week weeks, two assessments Conduct readiness inform to SIA implementation prior to days and three SIAs quality assurance. support for technical targeted and external of the internal the implementation Track interventions of successful note plans. Taking advocacy OPRTT. further needs to and communicating OPRTT and EOMG to provide endorsement of outbreak of outbreak endorsement provide and EOMG to OPRTT and initiate plan and budget (within 20 days) response funds funds. Within 28 days release mechanisms to in country. be available should Function Function Micro plan Micro development Monitoring Monitoring immunization Monitoring communication Monitoring Monitoring preparedness Monitoring preparedness Monitoring advocacy Finances Timeline until 14 days of completion immunization activities (75–90 days)

RESPONDING TO A POLIOVIRUS 63 EVENT OR OUTBREAK Regional/Global Regional/Global UNICEF regional office and headquarters to and headquarters office UNICEF regional support provide OPRTT, WHO/UNICEF regional offices and offices WHO/UNICEF regional OPRTT, headquarters WHO regional office WHO regional GPEI support from facilitate to OPRTT partners OPRTT to provide support provide to OPRTT Responsibility Country National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country Triangulation of data including: low performing areas, areas, performing including: low of data Triangulation or other observed children on refusals/missed social data etc. data surveillance social barriers, Conduct additional vaccinator and supervisor training and supervisor training Conduct additional vaccinator skills interpersonal for and regular supervision, monitoring Strengthen meetings during campaign review high-risk missed, reach to special strategies Initiate populations or mobile the quality of SIAs, improve Conduct activities to by GIS supported microplanning including detailed and feasible. appropriate mapping where Activities Conduct trainings of front-line workers (vaccinators, (vaccinators, workers of front-line Conduct trainings skills, on technical and social mobilizers) supervisors SIA 1 and 2 skills for and interpersonal communication areas. targeted management and vaccine capacity cold-chain Assess SIA 1. fill gaps prior to to steps urgent and take capabilities subsequent immunization activities (SIA 1,Implement plan. response as per outbreak SIA 2, mop-up round) the quality of SIAs with each improve Conduct activities to subsequent round: • • • • • Liaise with in-country data managers to identify and to managers data Liaise with in-country issues. and completeness format data resolve Conduct regular donor meetings and advocacy activities. donor meetings and advocacy Conduct regular Ensure in-depth discussion and alignment with other in-depth discussion Ensure additional interventions consider to health partners A and vitamin such as providing OPV, alongside type 1 for particularly feasible, where tablets, deworming should type 2 outbreaks for (Integration and 3 outbreaks. exceptionally.) be considered only Function Function Training Vaccine Vaccine management Immunization Information Information management Immunization Partner Partner coordination Partner Partner coordination Timeline until 14 days of completion immunization activities (75–90 days)

64 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK Regional/Global Regional/Global Regional/Global UNICEF regional office and headquarters to and headquarters office UNICEF regional support provide OPRTT, WHO/UNICEF regional offices and offices WHO/UNICEF regional OPRTT, headquarters UNICEF regional office and headquarters and headquarters office UNICEF regional support provide to GPEI support from facilitate to OPRTT partners UNICEF regional office and headquarters and headquarters office UNICEF regional support provide to OPRTT to provide recommendations recommendations provide to OPRTT WHO regional office WHO regional GPEI support from facilitate to OPRTT partners OPRTT to provide support provide to OPRTT Responsibility Responsibility Country Country National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities, with support from National health authorities, with support from and polio offices WHO and UNICEF country in country resources surge National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities with support from National health authorities with support from offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country Triangulation of data including: low performing areas, areas, performing including: low of data Triangulation or other observed children on refusals/missed social data etc. data surveillance social barriers, Conduct additional vaccinator and supervisor training and supervisor training Conduct additional vaccinator skills interpersonal for and regular supervision, monitoring Strengthen meetings during campaign review high-risk missed, reach to special strategies Initiate populations or mobile the quality of SIAs, improve Conduct activities to by GIS supported microplanning including detailed and feasible. appropriate mapping where Activities Activities Conduct trainings of front-line workers (vaccinators, (vaccinators, workers of front-line Conduct trainings skills, on technical and social mobilizers) supervisors SIA 1 and 2 skills for and interpersonal communication areas. targeted management and vaccine capacity cold-chain Assess SIA 1. fill gaps prior to to steps urgent and take capabilities subsequent immunization activities (SIA 1,Implement plan. response as per outbreak SIA 2, mop-up round) the quality of SIAs with each improve Conduct activities to subsequent round: • • • • • Extend support to immunization during the outbreak immunization during the outbreak support to Extend to capacity use of surge period, maximizing response management, microplanning, programme strengthen monitoring. mobilization and performance community the benefit of time- maximize effectively should The EOC actions in line selected RI, through support to limited Every of the Reaching components with the operational 7, and RED (See end of Chapter (RED)*approach. District guidance.) detailed for strategy Analyse and triangulate all data to assess population assess to all data and triangulate Analyse and progress sensitivity of surveillance immunity, transmission. interrupting towards Disposal of used, and partially used vaccine vials for vials for used vaccine Disposal of used, and partially Unopened vials should type 2 immunization response. control with access stores in strategic stored be securely (see closed is considered until the outbreak facilities management guidance). vaccine Ensure surveillance, SIA and monitoring data are are data SIA and monitoring surveillance, Ensure offices WHO and UNICEF regional and sent to completed timelines (within agreed to according and headquarters, AFP data). for all SIAs, and weekly for 14 days reports utilization and accountability vaccine Complete 0 (see vaccine including round each round, after management guidance). Review and adapt the outbreak response plan, including response and adapt the outbreak Review activities and communication immunization, surveillance made and/or progress subsequent phases. Track for gaps. any remaining close support needed to Liaise with in-country data managers to identify and to managers data Liaise with in-country issues. and completeness format data resolve Conduct regular donor meetings and advocacy activities. donor meetings and advocacy Conduct regular Ensure in-depth discussion and alignment with other in-depth discussion Ensure additional interventions consider to health partners A and vitamin such as providing OPV, alongside type 1 for particularly feasible, where tablets, deworming should type 2 outbreaks for (Integration and 3 outbreaks. exceptionally.) be considered only Function Function Function Routine Routine immunization: and recovery strengthening Data analysis Data Vaccine disposal Vaccine Information Information management Vaccine and reporting accountability Training Outbreak plan response Vaccine Vaccine management Immunization Information Information management Immunization Partner Partner coordination Partner Partner coordination Until close Until close of outbreak Timeline until 14 days of completion immunization activities (75–90 days) Timeline until 14 days of completion immunization activities (75–90 days)

RESPONDING TO A POLIOVIRUS 65 EVENT OR OUTBREAK Regional/Global Regional/Global OPRTT to coordinate to OPRTT WHE coordinate, to WHO headquarters with regional in consultation grade HQ to office Surveillance Task Team (STT) Team Task Surveillance coordinate to OPRTT Responsibility Country National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities, with support from National health authorities, with support from offices WHO and UNICEF country National health authorities, with support from offices WHO and UNICEF country population immunity Notify and sensitize health care workers at national workers Notify and sensitize health care about notification units and subnational surveillance requirements in the AFP active sites reporting and reclassify Review network. surveillance at national workers Notify and sensitize health care about notification units and subnational surveillance requirements in the AFP active sites reporting and reclassify Review network surveillance increase to efforts and strengthen 1. Assess sensitivity surveillance and strengthen 2. Assess transmission. interrupting towards progress 3. Assess Activities A review of the grading is conducted every three months; three every is conducted of the grading A review will be adapted changes, the response if the grade accordingly. learned. lessons and share Document the response Continue surveillance enhancement activities (see enhancement Continue surveillance guidance): detailed 8 for chapter • • assessment response Conduct an independent outbreak in OBRA Aide- available guidance (OBRA) (detailed activities enhancement Continue surveillance Mémoire). guidance): detailed 8 for (See chapter • • reports utilization and accountability vaccine Complete 0 (see vaccine including round each round, after management guidance). Function Function Grading review - review Grading 3 months learnt Lessons Surveillance Surveillance enhancement OBRA - 3 months OBRA - 6, 9, 12 months etc. Timeline Until close of outbreak

66 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK

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68 RESPONDING TO A POLIOVIRUS EVENT OR OUTBREAK