LETTERS

Address for correspondence: Jamal A. Ahmed, differentiation at the Regional genotype, which was circulating in KEMRI Compound, Mbagathi Rd, PO Box Reference Laboratory for Polio, Angola and Democratic Republic of 606-00621 Nairobi, Kenya; email: JAhmed@ Institut Pasteur de Bangui, using Congo at that time (Figure). ke.cdc.gov World Health Organization (WHO) Of 163 AFP cases from 2009, standard procedures (5). Isolated 14 in Ouham-Pende district were WPV strains were sent to the Centers laboratory confirmed as WPV3; this for Disease Control and Prevention cluster was designated D2B2B1. (Atlanta, Georgia, USA) or the Sequencing results showed that the National Institute for Communicable virus in this cluster belonged to Wild Poliovirus Diseases (Johannesburg, South West Africa B genotype, which was Africa) for sequencing according to circulating in Nigeria and southern Importation, WHO guidelines (6–8). Cases were Chad at that time (Figure). Central African classified as laboratory confirmed or Of 142 AFP cases from 2011, Republic1 polio-compatible according to WHO four in Ouham district were laboratory recommendations; a polio-compatible confirmed as WPV1; this cluster was To the Editor: Since the case was defined as AFP for which designated I6C2B4C1A2. Sequencing Global Polio Eradication Initiative stool samples were not adequate or a results showed that the virus in this was launched in 1988, indigenous situation in which the patient was lost cluster belonged to West Africa transmission of wild poliovirus to follow up or had residual paralysis B genotype, which was circulating (WPV) has been interrupted in 60 days after testing. in south Chad and Nigeria at the all countries except Afghanistan, Of 141 AFP cases from 2008, time (Figure). Pakistan, and Nigeria (1). However, three, from Bangui, Ouham, and Ouaka The importation of wild poliovirus during 2003–2011, outbreaks resulting districts, were laboratory confirmed as strains into CAR appeared to follow from importation of WPV occurred WPV1; this cluster was designated 3 different routes. In 2008, WPV1 in 29 previously polio-free countries B2D1B (Figure). Sequencing results originated from Democratic Republic in Africa, including Central African showed that the virus in this cluster of Congo and was first detected in the Republic (CAR) (1–3). In 2011, 350 belonged to the South Asia A (Indian) capital, Bangui, which is located in WPV cases were reported from 12 countries in Africa, a 47% decrease from the 657 cases reported by 12 countries in Africa in 2010 (1). In CAR, the last case of poliomyelitis caused by indigenous transmission of wild poliovirus was reported in 2000, but importation of WPV type 1 has been reported (4). We describe the importation of WPV1 and WPV3 into CAR during successive events in 2008, 2009, and 2011. To investigate importation of WPV into CAR, we conducted a study using fecal samples collected from patients in CAR who had acute flaccid paralysis (AFP) during 2008– 2011. The samples were analyzed for virus isolation, typing, and intratypic

1Data from this report were presented to the Global Polio Laboratory Network, Geneva, Figure. Clusters of polio cases caused by wild poliovirus importations, Central African Switzerland, and at the First International Republic, 2008–2011. Each circle represents 1 case of acute flaccid paralysis confirmed as polio. Black circles, cluster B2D1B, 2008 poliovirus (PV) type 1 SOAS importation from Conference of the African Society of Democratic Republic of Congo (DR Congo); white circles, cluster D2B2B1, 2009 PV3 Laboratory Medicine, 2012 Dec 1–7, Cape WEAF-B importation from Nigeria and southern Chad; gray circles, cluster I6C2B4C1A2, Town, South Africa. 2011 PV1 WEAF-B importation from southern Chad.

1012 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 19, No. 6, June 2013 LETTERS the southern part of the country. Two CAR is one of the countries with References more cases were detected in 2 other the highest predicted risk for WPV 1. World Health Organization. Progress districts, in the north (Ouham) and circulation after importation (9). The towards global polio eradication–status of in the middle (Ouaka) of the country. 3 WPV importation events we report wild poliovirus circulation in Africa,2011. During that year, 2 AFP cases were demonstrate that current immunization Wkly Epidemiol Rec. 2012;87:109–15. classified as polio-compatible; these levels in this country are insufficient 2. World Health Organization. Resurgence of wild poliovirus types 1 and 3 in 15 African cases originated from Haute Kotto to guard against polio. High, sustained countries, January 2008–March 2009. and Ouham districts. In 2008, routine levels of routine OPV coverage in Wkly Epidemiol Rec. 2009;84:133–40. coverage of oral polio vaccine (OPV) every district, supplemented by high- 3. World Health Organization. Polio global was 45%, 33%, and 57% for Bangui and quality supplementary immunization eradication initiative. Annual report 2009. Geneva: The Organization; 2010. Sanitary Regions 3 and 4, respectively. activities, will help prevent future 4. Gouandjika-Vasilache I, Kipela J, (Sanitary regions are equivalent to outbreaks. Surveillance standards Daba RM, Mokwapi V, Nambozuina E, provinces and have several districts must also be maintained to ensure the Cabore J, et al. Wild poliovirus type 1, under their jurisdiction; Bangui rapid detection of WPV importation, Central African Republic. Emerg Infect Dis. 2005;11:1498–9. http://dx.doi. is considered a Sanitary Region thus enabling timely response and org/10.3201/eid1109.050517 containing 8 districts.) To interrupt containment. 5. World Health Organization. Supplement wild poliovirus circulation, health to the WHO polio laboratory manual. An alternative test algorithm for poliovirus authorities implemented 4 rounds of Acknowledgments isolation and characterization. Geneva: national immunization days, 2 using We thank Jean Fandema Yetimbi The Organization; 2007. monovalent OPV (mOPV) type 1 for the isolation and identification work, 6. Centers for Disease Control and and 2 using trivalent OPV; 1 local Jane Iber and Qi Chen for sequencing Prevention. Progress toward global polio immunization day using mOPV1 was poliovirus isolates, and Beth Henderson eradication–Africa, 2011. MMWR Morb Mortal Wkly Rep. 2012;61:190–4. also instituted. for assistance with geographic mapping. 7. Liu HM, Zheng DP, Zhang LB, In 2009, WPV3 was imported from All data on routine vaccine coverage and Oberste MS, Pallansch MA, Kew OM. southern Chad to the Ouham-Pende supplementary vaccine activities were Molecular evolution of a type 1 wild- district in CAR. This insecure district collected during discussion with the vaccine poliovirus recombinant during widespread circulation in China. J is difficult to access, but routine OPV president of the National Certification Virol. 2000;74:11153–61. http://dx.doi. coverage was reported as 61% for 2009, Committee, Gerard Gresenguet. org/10.1128/JVI.74.23.11153-11161.2000 compared with the country’s official 8. World Health Organization. Polio OPV coverage of 55%. The apparently This work was supported by a WHO laboratory manual, 4th edition. Geneva: higher coverage in areas of insecurity grant, Technical Service Agreement (TSA) The Organization; 2004. WHO/IVB/04.10. 2008, TSA 2009, and TSA 2011. 9. O’Reilly KM, Chauvin C, Aylward is likely the result of inaccurate target RB, Maher C, Okiror S, Wolff C, et al. population estimates. Five additional A statistical model of the international AFP cases were classified as polio- Ionela Gouandjika-Vasilache, spread of wild poliovirus in Africa used to predict and prevent outbreaks. PLoS compatible; these occurred in Ouham Arthur Mazitchi, Med. 2011;8:e1001109. http://dx.doi. (1), Ouham Pende (2), Mambere Kadei Nicksy Gumede, org/10.1371/journal.pmed.1001109 (1), and Mbomou (1) districts. To Alexandre Manirakiza, interrupt wild poliovirus circulation, 8 Casimir Manenegu, Address for correspondence: Ionela Goaundjika- supplementary immunization activities Thomas D’Aquin Koyazegbe, Vasilache, Institut Pasteur de Bangui, BP 923, were organized. and Cara Burns Bangui, Central African Republic; email: The 2011 polio outbreak occurred Author affiliations: Institut Pasteur, Bangui, [email protected] in the district of Ouham and was Central African Republic (I. Gouandjika- caused by WPV1 poliovirus imported Vasilache, A. Mazitchi, A. Manirakiza); from southern Chad (Figure). National Institute for Communicable Fourteen additional cases of AFP Diseases, Johannesburg, South Africa were classified as polio-compatible; (N. Gumede); World Health Organization, these occurred in Ouham-Pende (6), Bangui (C. Manenegu); Ministère de la Ouham (1), Ombela M’Poko (1), Santé, de la Population et de la lute contre Kemo (1), Ouaka (1), Haute Kotto (2), le SIDA, Bangui (T. D’Aquin Koyazegbe); and Mbomou (2) districts. Routine and Centers for Disease Control and OPV coverage for this insecure and Prevention, Atlanta, Georgia, USA difficult-to-access region was 55% for (C. Burns)

2010 and 58% for 2011. DOI: http://dx.doi.org/10.3201/eid1906.121821

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