Europe’s journal on infectious disease epidemiology, prevention and control Special edition: Polio October 2014 Featuring • The polio eradication end game: what it means for Europe • Molecular epidemiology of silent introduction and sustained transmission of wild poliovirus type 1, Israel, 2013 • The 2010 outbreak of poliomyelitis in Tajikistan: epidemiology and lessons learnt www.eurosurveillance.org Editorial team Editorial advisors Based at the European Centre for Albania: Alban Ylli, Tirana Disease Prevention and Control (ECDC), Austria: Reinhild Strauss, Vienna 171 83 Stockholm, Sweden Belgium: Koen De Schrijver, Antwerp Telephone number Belgium: Sophie Quoilin, Brussels +46 (0)8 58 60 11 38 Bosnia and Herzogovina: Nina Rodić Vukmir, Banja Luka E-mail Bulgaria: Mira Kojouharova, Sofia [email protected] Croatia: Sanja Musić Milanović, Zagreb Cyprus: to be nominated Editor-in-chief Czech Republic: Bohumir Križ, Prague Ines Steffens Denmark: Peter Henrik Andersen, Copenhagen Senior editor Estonia: Kuulo Kutsar, Tallinn Kathrin Hagmaier Finland: Outi Lyytikäinen, Helsinki France: Judith Benrekassa, Paris Scientific editors Germany: Jamela Seedat, Berlin Karen Wilson Greece: Rengina Vorou, Athens Williamina Wilson Hungary: Ágnes Csohán, Budapest Assistant editors Iceland: Haraldur Briem, Reykjavik Alina Buzdugan Ireland: Lelia Thornton, Dublin Ingela Söderlund Italy: Paola De Castro, Rome Associate editors Kosovo under UN Security Council Resolution 1244: Lul Raka, Pristina Andrea Ammon, Stockholm, Sweden Latvia: Jurijs Perevoščikovs, Riga Tommi Asikainen, Frankfurt, Germany Lithuania: Milda Zygutiene, Vilnius Mike Catchpole, London, United Kingdom Luxembourg: Thérèse Staub, Luxembourg Denis Coulombier, Stockholm, Sweden The former Yugoslav Republic of Macedonia: Elisaveta Stikova, Skopje Natasha Crowcroft, Toronto, Canada Malta: Tanya Melillo Fenech, Valletta Christian Drosten, Bonn, Germany Montenegro: Dragan Laušević, Podgorica Karl Ekdahl, Stockholm, Sweden Netherlands: Paul Bijkerk, Bilthoven Johan Giesecke, Stockholm, Sweden Norway: Hilde Klovstad, Oslo Herman Goossens, Antwerp, Belgium Poland: Malgorzata Sadkowska-Todys, Warsaw David Heymann, London, United Kingdom Portugal: Isabel Marinho Falcão, Lisbon Heath Kelly, Melbourne, Australia Romania: Daniela Pitigoi, Bucharest Irena Klavs, Ljubljana, Slovenia Serbia: Tatjana Pekmezovic, Belgrade Karl Kristinsson, Reykjavik, Iceland Slovakia: Lukáš Murajda, Martin Daniel Lévy-Bruhl, Paris, France Slovenia: Alenka Kraigher, Ljubljana Richard Pebody, London, United Kingdom Spain: Elena Rodríguez Valín, Madrid Panayotis T. Tassios, Athens, Greece Sweden: Christer Janson, Stockholm Hélène Therre, Paris, France Turkey: Fehmaniz Temel, Ankara Henriette de Valk, Paris, France United Kingdom: Norman MacDonald, Glasgow Sylvie van der Werf, Paris, France European Commission: Paolo Guglielmetti, Luxembourg World Health Organization Regional Office for Europe: Nedret Design / Layout Emiroglu, Copenhagen Fabrice Donguy / Arne Haeger Online submission system http://www.editorialmanager.com/eurosurveillance/ www.eurosurveillance.org © Eurosurveillance, 2014 Contents Polio EDITORIALS The polio eradication end game: what it means for Europe 2 D Heymann et al. SURVEILLANCE AND OUTBREAK REPORTS Intensified environmental surveillance supporting the response to wild poliovirus type 1 silent circulation in Israel, 2013 5 Y Manor et al. The 2010 outbreak of poliomyelitis in Tajikistan: epidemiology and lessons learnt 15 ML Yakovenko et al. RESEARCH ARTICLES Development and validation of a real time quantitative reverse transcription-polymerase chain reaction (qRT-PCR) assay for investigation of wild poliovirus type 1-South Asian (SOAS) strain reintroduced into Israel, 2013 to 2014 28 MY Hindiyeh et al. Molecular epidemiology of silent introduction and sustained transmission of wild poliovirus type 1, Israel, 2013 35 LM Shulman et al. Immunity against poliomyelitis in the Netherlands, assessed in 2006 to 2007: the importance of completing a vaccination series 43 NA van der Maas et al. PERSPECTIVES Silent reintroduction of wild-type poliovirus to Israel, 2013 – risk communication challenges in an argumentative atmosphere 53 E Kaliner et al. © Eurosurveillance Illustration of polio viruses, phylogenic tree www.eurosurveillance.org 1 Editorials The polio eradication end game: what it means for Europe D Heymann ([email protected])1,2, Q Ahmed3 1. London School of Hygiene and Tropical Medicine, London, United Kingdom 2. Chatham House Centre on Global Health Security, London United Kingdom 3. State University of New York (SUNY) at Stony Brook, New York, United States Citation style for this article: Heymann D, Ahmed Q. The polio eradication end game: what it means for Europe. Euro Surveill. 2014;19(7):pii=20702. Available online: http://www. eurosurveillance.org/ViewArticle.aspx?ArticleId=20702 Article submitted on 5 February 2014 / published on 20 February 2014 This edition of Eurosurveillance provides a series of has often been weeks, not days, causing delays in articles related to polio that present a microcosm of response, more widespread transmission, and greater some of the issues that have plagued polio eradication and more costly containment efforts. Recently though, since the programme first began, and it also provides times from specimen collection to outbreak control many of the solutions. have decreased considerably by strengthening trans- port systems from the field to the laboratory, and Had these and other issues been clearly understood in modifying the testing protocol [4]. At the same time, 1988 when the World Health Assembly passed the res- there is active research and development of new test- olution that committed all countries to polio eradica- ing algorithms that can provide more rapid results tion by the year 2000, the decision to eradicate would [5]. Hindiyeh et al. have concluded that their qRT-PCR have been more difficult. But fortunately, buoyed by system could be a promising application for testing of the then recent success in the eradication of smallpox, RNA extracted directly from processed stool samples active debate on whether to use inactivated or live polio from children with acute flaccid paralysis (AFP), and it vaccines, awareness that many countries had already remains to be seen whether further study will be con- interrupted polio transmission, and unawareness of ducted along these lines [3]. the difficult eradication end game, the resolution was passed by consensus of the World Health Organization The article by Manor et al. [6] describes the discovery of (WHO)’s member states [1]. Although progress towards a silent introduction of wild poliovirus, in the absence eradication has been slower than anticipated in 1988, of detection of AFP in children (the standard surveil- paralytic polio has decreased from an estimated 1,000 lance methodology), by what they describe as an early children per day during 1988, to approximately 400 dur- warning system of sewage monitoring for poliovirus. ing 2013. Today there remain only three countries with They point out that this silent introduction occurred in endemic polio, Afghanistan, Nigeria and Pakistan, and a highly immune population in which inactivated polio the recent risk assessment from the European Centre vaccine (IPV) has been used exclusively since 2005, for Disease Prevention and Control (ECDC) reminds us and that AFP surveillance alone had not detected this that Europe must remain vigilant with strong surveil- introduction and circulation. The authors suggest that lance and sustained laboratory capacity [2]. there is a fundamental role for environmental surveil- lance in routine monitoring as an early warning system The series of polio articles in this edition begins with in polio-free countries, possibly more sensitive than the article by Hindiyeh et al. [3] describing direct sew- surveillance for AFP. Shulman et al. [7] add greater per- age testing for wild poliovirus antigen, using a multi- spective in their report on genetic sequencing of these plex quantitative reverse-transcription PCR (qRT-PCR) wild polioviruses. It suggests that they were linked to for rapid detection of the virus, directly on concen- strains that were circulating in South Asia and Egypt in trated sewage samples. When compared to cell culture 2012 and concludes that there had been one, or per- of the same sewage specimens, which is the initial pro- haps more than one, importation event. cess in the gold standard testing protocol for confirma- tion of polio, sensitivity and specificity of the multiplex Indeed, environmental monitoring in sewage has been system were shown to be high. Results were obtained used by many countries during the past decade, and in 24 to 48 hours, rather than the usual five to seven it has identified wild poliovirus imported in 2007 to days required for the culture-based protocol. Switzerland from Chad, and in 2013 to Egypt from Pakistan [8,9]. Environmental surveillance has been The time from collection of a stool sample to analy- a mainstay of polio eradication in several developing sis for polio virus in polio eradication programmes countries as well, for example in Egypt and India, and 2 www.eurosurveillance.org its wider role in the polio eradication end game contin- circulating on the world wide web, that the vaccine ues to be assessed [10]. was being used in a plot by some Western nations to permanently sterilise young Muslim girls, and in some Van der Maas et al. [11] and Yakovenko