Progress Toward Poliomyelitis Eradication -- Egypt, 1993

Since 1990, the Ministry of Health in Egypt has directed efforts toward achieving poliomyelitis eradication by the end of 1994. To achieve this goal, the Egyptian Expanded Program on Immunization (EPI) has progressively implemented each of four World Health Organization (WHO)-recommended strategies: 1) increasing and sustaining routine coverage with oral poliovirus vaccine (OPV); 2) conducting National Immunization Days (NIDs); 3) developing surveillance for acute flaccid paralysis (AFP), including laboratory confirmation of cases; and 4) instituting "mopping-up" vaccination (i.e., house-to-house administration of two doses of OPV at an interval of 4-6 weeks to all children aged less than 3 years who reside in areas where risk for wild poliovirus transmission is highest). This report summarizes the poliomyelitis eradication effort in Egypt based on a program review conducted during November 20-30, 1993, by the Egyptian Ministry of Health; Cairo University; the High Institute for Public Health in Alexandria, Egypt; WHO; Rotary International; and CDC.

Routine vaccination coverage with all EPI target disease vaccines (bacille Calmette-Guerin {BCG}, diphtheria and tetanus toxoids and pertussis vaccine {DTP}, measles, and OPV) increased substantially following the acceleration of activities in 1984, and coverage has remained high. The routine OPV vaccination schedule consists of doses at ages 2, 4, 6, 9, and 18 months. Reported vaccination coverage with three doses of OPV in children aged less than 1 year increased from 67% in 1984 to 90% in 1989 and has ranged from 87% to 89% during 1990-1993 (Figure_1). From 1984 to 1990, routine vaccination coverage with the other EPI target disease vaccines also increased (BCG: 53% to 89%; three doses of DTP: 57% to 87%; and measles vaccine: 41% to 87%), and since 1990, coverage with these vaccines has remained high.

In addition to the routine vaccination program, supplemental vaccination activities have been used to achieve poliomyelitis eradication goals. NIDs have been conducted intermittently since 1976, and the level of activity increased from 1990-1991, when a single dose of OPV was administered annually to approximately 8.5- 8.7 million children aged less than 5 years, to January-February 1993, when 17 million doses were administered in two separate rounds to approximately 8.4-8.6 million children (Figure_1). Mopping-up vaccination activities also have been used since 1991 (Figure_1). High-risk districts are designated on the basis of low vaccination coverage and confirmed poliomyelitis cases during the preceding 5 years. During 1991-1992, 6 million doses of OPV were administered during more than 100 districtwide mopping-up operations.

AFP surveillance was initiated in August 1990, and a policy of regular zero reporting (i.e., reporting even if no cases occurred) from all reporting sites was instituted in January 1992. In April 1992, AFP case investigation was intensified with emphasis on proper collection of two stool specimens for virus isolation. Despite increased surveillance, the reported number of cases of confirmed poliomyelitis decreased from 619 cases in 1991 to 115 cases in 1993 (Figure_1) and (Figure_2). In 1993, the seasonal variation in AFP incidence, which reflects the occurrence of poliomyelitis and usually peaks in Egypt during August-October, decreased substantially (Figure_2).

The geographic distribution of confirmed poliomyelitis cases remained widespread in 1992, with cases reported from 24 of 26 governorates. However, during 1993, poliomyelitis was focally distributed and reported in 17 of 26 governorates.

Reported by: Expanded Program on Immunization, Ministry of Health, Cairo. Eastern Mediterranean Regional Office, World Health Organization, Alexandria, Egypt; Expanded Program on Immunization, World Health Organization, Geneva. International Health Program Office; Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; Polio Eradication Activity, National Immunization Program, CDC.

Editorial Note

Editorial Note: Because of its location between the emerging poliomyelitis-free zones of the Mahgreb Union and Arab states of the Persian Gulf, Egypt is particularly important to the goal of global eradication of poliomyelitis by the year 2000 (1). As a result of the implementation of large-scale supplementary vaccination activities and efforts to strengthen the poliomyelitis disease surveillance system, Egypt has made substantial progress toward eradicating poliomyelitis by the end of 1994. The incidence of poliomyelitis has decreased despite improvements in the poliomyelitis surveillance system. In addition, supplemental vaccination activities with OPV have not adversely affected the routine vaccination program or coverage levels with vaccines for the other EPI target diseases (i.e., diphtheria, measles, pertussis, tetanus, and tuberculosis).

Since 1991, the epidemiologic pattern of poliomyelitis in Egypt has changed from widespread endemic disease to a problem of more limited focal distribution. This change may be attributed to the combination of NIDs and focused mopping-up vaccination in high-risk districts. The Ministry of Health in Egypt plans to continue two rounds of NIDs each in 1994 and 1995 to ensure interruption of transmission of wild poliovirus. Decisions to conduct additional NIDs will be made following reassessment of the epidemiologic situation during 1995.

Reference

1. World Health Assembly. Global eradication of poliomyelitis by the year 2000. Geneva: World Health Organization, 1988. (Resolution WHA41.28).

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