EFTA01103569.pdf

Special Theme — Polio Eradication Eradication of poliomyelitis in countries affected by conflict R.H. Tangermann,1 H.F. Hull,1 H. Jafari,2 B. Nkowane,1 H. Everts,3 & R.B. Aylward' The global initiative to eradicate poliomyelitis is focusing on a small number of countries in Africa (Angola, Democratic Republic of the Congo, Liberia, Sierra Leone, Somalia, Sudan) and Asia (Afghanistan, Tajikistan), where progress has been hindered by armed conflict. In these countries the disintegration of health systems and difficulties of access are major obstacles to the immunization and surveillance strategies necessary for polio eradication. In such circumstances, eradication requires special endeavours, such as the negotiation of ceasefires and truces and the winning of increased direct involvement by communities. Transmission of poliovirus was interrupted during conflicts in Cambodia, Colombia, El Salvador, Peru, the Philippines, and Sri Lanka. Efforts to achieve eradication in areas of conflict have led to extra health benefits: equity in access to immunization, brought about because every child has to be reached; the revitalization and strengthening of routine immunization services through additional externally provided resources; and the establishment of disease surveillance systems. The goal of polio eradication by the end of 2000 remains attainable if supplementary immunization and surveillance can be accelerated in countries affected by conflict. Keywords: child welfare; delivery of health care; epidemiological surveillance; immunization programmes; poliomyelitis, prevention and control; war. Voltpage 335 le resume en francals. En la pigMa 336 figura an resumen en espeol Introduction Tajikistan has become one of the greatest challenges to polio eradication (9). In addition, smaller conflicts The global initiative for polio eradication has been in other parts of the world, as in the border areas extraordinarily successful in interrupting the trans- between Iraq, Syrian Arab Republic, and Turkey (10), mission of the disease in many areas and countries and between Eritrea and Ethiopia, continue making it (1), and work is continuing in all the countries where difficult to reach and immunize populations at it is still endemic. The Region of the Americas was highest risk for polio and other vaccine-preventable certified as polio-free in 1994 (2). Endemic wild diseases. poliovirus has not been reported since March 1997 Since the end of the Second World War there from the Western Pacific Region, which includes have been more than ISO major conflicts, mostly civil China (3).The European Region (4) (including all the wars, in developing countries. Civilians have been countries of the former Soviet Union), large parts of increasingly targeted and millions have become the Eastern Mediterranean Region (5) and increasing refugees and displaced persons, often in their own areas in northern and southern Africa (6) were polio- countries. Children are especially vulnerable in such free by late 1999. situations, and thousands are killed or maimed ever• At the end of 1999 the eradication effort was year by bombs, bullets and landmines (11). Many focused on a limited number of countries on the more children are victims of a war-related upsurge in Asian subcontinent and in sub-Saharan Africa in malnutrition and vaccine-preventable diseases which polio was endemic. These countries were (12, 13). Infectious diseases increase nutritional either major poliovirus reservoirs (Bangladesh, demands and decrease the absorption of nutrients, Democratic Republic of the Congo, India (7), Nigeria thus aggravating underlying nutritional deficiencies, (8), Pakistan) or were affected by armed conflict which in turn reduce the effectiveness of the immune (Fig. 1). Current or recent armed conflict in system and consequently increase morbidity and Afghanistan, Angola, the Democratic Republic of mortality associated with these diseases. the Congo, Liberia, Sierra Leone,Somalia, Sudan, and In this situation, getting vaccines to children is an urgent priority•. The global Polio Eradication Initiative presents an opportunity to mobilize coun- Medical Officer, Vaccines and Biologicals, Wool Health tries and donors to carry• out vaccination and provide Organization, 1211 Geneva 27, Snitzerland. Correspondence should be addressed to Dr Tangerrnann. basic health services for the children in greatest need. 2 Medical Officer, World Health Organization Regional Office for the The present article provides an update on the current Eastern Meciterranean, Alexandria, Egypt. status of polio eradication in five countries where polio 3 Technical Officer, Vaccines and Biologicals, World Health is still endemic and where conflict is taking place: Organization. Geneva , SvAtzeiland. Afghanistan, Angola, the Democratic Republic of the Ref. No. 99-0268 Congo, Somalia, and Sudan. 330 • World Health Organization 2000 Bulletin of the World Health Organization, 2000, 78 (3) EFTA01103569  Eradication of poliomyelitis in countries affected by conflict Fig I. Polio eradication status in countries affected by conflict, 1990-99, and countries that are major reservoirs of poliovirus Cobrtia, laicise MN ItiE Cony iTynianoning Fa] Et-ado:113n during conllia Cooly main pollens fermi Background diseases. In Chechnya in the Russian Federation there were 150 cases of polio in 1995 following a Since 1985, conflicts have presented special chal- three-year disruption of immunization services (19). lenges, often delaying the final interruption of In Iraq there was an upsurge in polio cases in the poliovirus transmission in particular countries. aftermath of the Gulf War (2g. A new polio outbreak Following the negotiation of a formal ceasefire, that occurred in Iraq in 1999 (21) was linked to children in both government-held and rebel- continuing conflict in the north of the country and to controlled pares of El Salvador were reached by the long-term social and economic consequences of polio immunization campaigns between 1985 and the Gulf War. In Albania the disintegration of health 1991 (14). Eradication efforts in Guatemala were and social support services contributed to a large conducted in the face of similar difficulties until the polio outbreak in 1996, which spread to neighbouring country's last case of polio was reported in 1990, and Kosovo and Greece (22). Large outbreaks of polio civil disorder complicated the picture in Colombia have been reported from certain countries affected until the last case was reported there in 1991. In Peru by conflict, particularly in Africa (Angola (23) and (15) the last case of polio in the Americas occurred in Sudan (24)). Elsewhere, the mobility of refugee 1991 in a three-year-old boy who was unable to populations and internally displaced persons con- complete his polio immunization after the local tinues to hamper efforts to organize and follow up health centre had been destroyed as a result of both routine immunization and national immuniza- conflict. tion days, leaving many children only partially Paralytic polio is a major cause of long-term immunized and therefore unprotected. disability in countries affected by conflict. In 1996 a The delivery of health services, including the survey in Kandahar Province, one of the areas most implementation of polio eradication activities, re- heavily mined during the civil war in Afghanistan, mains a problem in all conflict situations. However, revealed that the commonest cause of disability the health impacts of conflicts and the opportunities among children under 15 years of age was not that may arise to deliver health services during landmines but residual paralysis associated with conflicts vary with the type of conflict situation. In poliomyelitis (16, 17): 0.5% were affected in this this connection it is worth distinguishing the patterns way. Surveys conducted in 1998 found that under of conflicts shown below. 15% of infants in Kandahar routinely received three • himarifrinlentationahrogliribehnen lancountries. This doses of oral poliovirus vaccine (OPV) (a). is not a principal pattern in any country where In a number of countries, war-related disrup- polio is endemic today, although several current tion of immunization services has triggered out- conflicts are becoming increasingly international- breaks of polio and other vaccine-preventable Bulletin of the World Health Organization, 2000, 78 (3) 331 EFTA01103570 Special Theme — Polio Eradication ized (e.g. in the Democratic Republic of the Table 1 compares key polio eradication parameters Congo). for 1997, 1998 and 1999 in each country. The quality • Primarily internal conflict (cad mu) inrolring two main of acute flaccid paralysis (AFP) surveillance is factions (i e. go:raiment trans main rebel firer or rebel indicated by the rates of non-polio AFP per alliance). This is the most prevalent conflict 100 000 population under 15 years of age (the target situation, found in Afghanistan, Angola, the is I case per 100 000). Democratic Republic of the Congo, and Sudan. • Primarily internal rat rt Oa bat nithosti a Afghanistan retognited antral somnolent and bunking mallifie Eradication activities in Afghanistan, although de- factions and gimps. This type of situation, an layed by the complex emergency induced by civil war, example of which is the conflict in Somalia, have progressed further than in other countries presents the greatest obstacle to the delivery• of affected by conflict (25). With support from health services because of relative anarchy. UNICEF, WHO and nongovernmental organiza- tions, basic immunization services in Afghanistan Although most conflicts have elements of all three have been maintained at fixed sites in the majority of scenarios, the opportunities for implementing a districts during more than 20 years of conflict. health initiative such as polio eradication and of However, coverage of neonates does not exceed 30% using it to re-establish and strengthen other primary• overall and in many areas is much lower. Supple- health care services are greatest wherever negotiating mentary• polio immunization was first conducted and cooperating partners remain. However, even in during annual multi-antigen campaigns from 1994 to the absence of any recognized central government or 1996, although national coverage was relatively force, effective local partnerships have been formed limited. In 1997 the first national immunization days and used effectively, for instance in Somalia. (NIDs) only reached about 85% of children aged The implementation of polio eradication under 5 years with two doses of OPV. In 1998, NIDs activities has been particularly difficult in conflicts could not be conducted in northern Afghanistan for of comparatively recent origin, as in Angola and the political reasons, but coverage in the rest of the Democratic Republic of the Congo. The situation is country• was reportedly high. Over 4 million children easier in long-standing, complex emergencies, such were reached during each of four nationwide as that of Afghanistan, because often a relatively immunization rounds conducted in 1999 (Table 1). comprehensive system of alternative service provi- Special ceasefires and days of tranquillity for sion through UN agencies and nongovernmental immunization, negotiated between UN agencies organizations has been put in place. and all the parties in conflict, greatly helped the implementation of mass immunization campaigns. AFP surveillance for polio eradication was Country scenarios established in Afghanistan in 1997 and its level of performance is already higher than in many countries 13escnbed below is the current status of polio free of conflict where the disease is endemic eradication in five countries affected by conflict. (Table 1). AFP surveillance relies on trained health Table'. Performance of national immunization days (NIDs) and results of acute flaccid paralysis (AFP) surveillance in five countries affected by conflict, 1997-99 Afghanistan Angola Democratic Somalia Southern Republic Sudan' of the Congo Children immunized 1997 3.7 2.2 — 033 during NIDs in millions 1998 2.6 2.5 3.0 1A 0.8 b (round 1 only) 1999 4.1 2.6 8.2 1.2 Non-polio AFP rate 1997 0.1 0.24 -` C in children aged under 15 years 1998 0.66 0.1 0.1 0.2 1999d 0.95 1.2 0.2 0.79 0.75 Confirmed polio cases 1997 19 (7) 15 82 (3) 1 (0) (by wild virus isolation) 1998 59 (27) 7 (3) 10 (0) 12 (0) 6 1999 141 (62) 1 103 (53) 45 (2) 16 (0) 11 (1) 4 Estimated population b NIDs held up to November 1999. AFP surveillance system not yet established. d 1999 non.polioAFP rates are projected, based on data from January to November. 332 Bulletin of the World Health Organization, 2000, 78 (3) EFTA01103571  Eradication of poliomyelitis in countries affected by conflict workers receiving small monthly incentives who society is highly fragmented by disputes between make regular visits to large health facilities and other clans. The infrastructure has been largely destroyed. sites where cases of AFP are likely to occur. Stool Health care for the estimated population of 6 million specimens are shipped by UN plane to Islamabad, is delivered primarily through national and inter- Pakistan, where they are analysed in WHO's regional national nongovernmental organizations, supported poliovirus laboratory•. Wild poliovirus has been and coordinated by WHO and UNICEF. Cluster identified in many parts of Afghanistan, and surveys conducted in 1996 estimated routine OPV3 improved surveillance recently detected a polio coverage among infants in northern Somalia to be outbreak in the underimmunized north of the under 30%, while coverage in the south of the country•. Afghanistan is one of the first countries to country is likely to be even lower. include data on measles and neonatal tetanus in Since 1997, NIDs have been conducted in all weekly reports from its 84 AFP surveillance sites. parts of Somalia. the implementation of polio Polio eradication activities have triggered new eradication strategies has depended on partnerships attempts to improve the coverage of routine im- with local and international nongovernmental organi- munization services in Afghanistan. Since 1997, zations and on the hiring of Somali nationals in all parts annual supplemental campaigns have been conducted of the country. Negotiations for ceasefires were not to accelerate overall EPI coverage using diphtheria— possible at the national level. However, discussions on pertussis—tetanus vaccine and measles vaccine for security were held with local community and religious children and tetanus toxoid for women of childbearing leaders, when partners in each district developed plans age. The 1999 EN acceleration campaigns provided of action for NIDs. NIDs in Somalia were the first catch-up immunization to 82 000 children under 2 nationwide health activity implemented jointly be- years of age and to 206 000 women of reproductive tween nongovernmental organizations and Somali age in 14 urban areas. communities since the beginning of the civil war. Active AFP surveillance began at over 80 reporting Southern Sudan sites in nonhem Somalia during 1998 and is now being Much of southern Sudan, including large areas of the introduced in the south. Bahr al-Ghazal, Upper Nile and Equatoria zones, is not under the control of the central Sudanese Angola government. These areas have experienced conflict, Except for brief interruptions, civil war has affected periodic famine and population displacement for the health of children in Angola for many years. more than 15 years. Health services for the estimated Limited routine immunization services continue in population of 5.4 million are provided through the many pans of country•, and NIDs for polio southern sector of Operation Lifeline Sudan, a eradication have been conducted since 1996. How- consortium of UNICEF and several nongovern- ever, both routine immunization and NIDs have mental organizations, which delivers health supplies given unsatisfactory coverage because of the conflict. and personnel by air from Kenya. Large numbers of people continue to migrate within In 1998, NIDs covering all parts of southern the country and across borders to escape the conflict, Sudan were organized for the first time (26), in thus becoming either internally displaced persons or coordination with NIDs in all government- refugees. Children in these groups are at high risk of controlled parts of the country. Local plans of action remaining unimmunized. for NIDs were developed with the help of the Major movements of internally displaced network of nongovernmental organizations operat- persons, including thousands of children either not ing under Operation Lifeline Sudan and of trained, immunized or incompletely immunized with OPV, locally hired Sudanese health workers. Vaccines and occurred early in 1999 from areas of conflict to the other supplies were flown in from Kenya to more capital province of Luanda. A large outbreak of wild than 80 airstrips throughout southern Sudan. Vita- poliovirus type-3 poliomyelitis occurred in the min A supplements were given to children aged Luanda area between April and June 1999, mainly 6-59 months during the second of the NID rounds affecting unimmunized infants and young children of organized in 1998. internally displaced families (27). There were more In the training of over 5000 MD volunteers, than 1000 cases of polio and over 80 polio-related emphasis was placed on the opportunities offered by deaths. The outbreak focused attention on the need vaccine vial monitors (VVMs). The full potential of to accelerate polio eradication and AFP surveillance. VVMs to increase the period in which vaccine is handled and used outside refrigeration equipment Democratic Republic of the Congo was first achieved during NIDs in southern Sudan. This country, formerly Zaire, has the third-largest This "fast cold chain" approach is now employed population in Africa. Many years of economic decline routinely during OPV campaigns around the world. have compromised the transportation, communica- tion and health infrastructures. Immunization cover- Somalia age is inadequate. In 1996, only 36% of infants were Somalia has been in the grip of civil war since 1991. officially reported to be fully immunized against There is no recognized central government and polio, and measles vaccine coverage was reported as Bulletin of the World Health Organization., 2000, 78 (3) 333 EFTA01103572 Special Theme — Polio Eradication 41%. A polio outbreak involvingmore than 700 cases The need to protect children affected by armed occurred in 1995 (28) and several measles outbreaks conflict continues to be a major focus of activity of with high fatality rates have been reported in recent UNICEF (31, 32) and has been discussed repeatedly years. The country is probably experiencing the most at meetings of the UN General Assembly (33, 34 intense transmission of polio in the world. It is The World Summit for Children emphasized that the imperative to interrupt wild poliovirus transmission, provision of basic needs and health care, including not only to protect children in the Democratic immunization, should not be postponed until Republic of the Congo but also to stop the spread of conflicts are resolved. Unfortunately, children in polioviruses to neighbouring countries. most countries affected by conflict are not receiving Before 1999, supplementary immunization basic routine care and preventive services. In such efforts did not cover the whole country. In 1997, countries, polio eradication activities may be the first subnational campaigns were held in 23 urban areas. health services offered during conflict The negotia- Children living in areas along the eastern border of tion of ceasefires or days of tranquillity may the country were immunized in early 1998. NIDs contribute to peace-building in war zones. planned in August 1998 were postponed because of NIDs provide a rationale for negotiating truces increased military activity. Subnational immunization or ceasefires by focusing the attention of warring days were held in five provinces under government factions on their children's health. The planning and control in the south and west of the country during conducting of NIDs may also open channels of December 1998 and January: 1999, reaching 3 million communication for further negotiations between the children (about 30% of the target population). parties on other issues of common interest. Working In August 1999, the Democratic Republic of together on common goals encourages cooperation the Congo became the last country with endemic and helps to build the trust necessary• for permanent polio to conduct nationwide NIDs (29). To accel- solutions. The creation of days of tranquillity• was an erate polio eradication, three NID rounds were important step on the road to such solutions in El conducted in August, September and October 1999. Salvador (33) and the Philippines (36). The re- The Director-General of WHO and the Executive establishment of immunization and other primary Director of UNICEF requested the assistance of the care services also promotes peace in the long term by Secretary-General of the United Nations in negotiat- rebuilding health infrastructures for entire popula- ing days of tranquillity during which NIDs were tions and thus tackling the inequality that is a root organized. More than 8 million children were given cause of war. OPV during each of the three rounds conducted in Polio eradication activities in areas of conflict 1999. However, access to some districts was are the first, and often the only, contact between impossible because of renewed fighting. Access and health services and the most underserved and coverage were greater during the second and third vulnerable population groups in the world. These rounds. activities can serve as a platform for strengthening Much remains to be done to eradicate polio in other immunization and preventive health services. this country•, including the establishment of AFP Critical elements of the polio eradication strategies — surveillance, which has only recently been initiated. political commitment, international partnerships, However, the success of the 1999 NIDs demon- capacity for surveillance, and integration of preven- strates that accelerated action to eradicate polio is tive services — can be used to strengthen routine possible even under very adverse circumstances. services. Vitamin A supplementation has now become pan ofmost NIDs (37, 38). The experience gained in reaching remote and inaccessible popula- Discussion tions during polio NIDs is now being used to develop alternative strategies for the delivery• of routine Mass immunization is not possible in zones of active immunization services to hard-to-reach populations combat. The concept of ceasefires for immunization in a sustainable way. was first enunciated in 1990 during the World Experience in countries engaged in polio Summit for Children, when 159 nations signed a eradication, particularly those affected by conflict, declaration and plan ofaction endorsing the need for shows that the immediate and long-term benefits of days of tranquillity and relief corridors (30). The the effort far outweigh any possible short-term World Declaration on the Survival, Protection and negative effects on health programmes (39). Polio Development of Children states: eradication promotes equity in health care for "The essential needs of children and families children, the most vulnerable population group, must be protected even in times of war and in particularly in war-affected countries. violence-ridden areas. We ask that periods of Eradicating polio from countries affected by tranquillity and special relief corridors be conflict removes the threat of virus reimportation observed for the benefit of children where into polio-free areas. Polioviruses are highly infec- war and violence are still taking place." tious, and infected persons can quickly transport 334 Bulletin of the World Health Organization, 2000, 78 (3) EFTA01103573  Eradication of poliomyelitis in countries affected by conflict virus over long distances (40). Wild polioviruses Conclusion found in the Islamic Republic of Iran, the Nether- lands (41), and Albania (22) have been linked It is essential to give priority to polio eradication in epidemiologically to Afghanistan, Pakistan, Turkey, countries affected by conflict in order to achieve and Iraq. Genetic analyses of polioviruses isolated in global polio eradication by the target date. Poliovirus southern Africa (42) showed that they probably can be imported into polio-free areas from infected originated in what was then Zaire (now the areas. Countries affected by war which are lagging Democratic Republic of the Congo). During the behind in polio eradication therefore represent an initial phase of polio eradication in the Region of the increasing threat to those from which the disease has Americas, the cost of the initiative was largely borne been eradicated. by the countries themselves. External funds were Additional NID rounds, requiringconsiderable required for only 20% of the ant ofpolio eradication extra resources, are being conducted in most in Latin America, and for only 10% in China. countries affected by conflict because routine However, in countries affected by war almost the immunization services are absent or insufficient. It entire cost of polio eradication has to be borne by is essential to intensify efforts in the remaining areas external donors. Eradication activities in conflict of endemicity as the goal of global eradication draws areas are much more expensive than in countries at nearer. In this situation the cost per case prevented peace. In Cambodia the cost per immunized child rises steeply, making other health interventions during NIDs and the resources required for AFP appear to be more cost-effective. Because polio is surveillance have been higher than in most other highly infectious and spreads insidiously, immuniza- countries (43). In the absence of stable government tion must continue worldwide until eradication is in countries affected by conflict it has been relatively achieved in every country. difficult to secure sufficient external funding for Significant contributions towards achieving polio eradication. Nongovernmental organizations polio eradication in countries affected by conflict make a substantial contribution towards polio have been made by Rotary International, UNICEF, eradication activities in such circumstances. WHO, the Centers for Disease Control and Preven- Completely stopping disease transmission tion and USAID in the USA, the United Kingdom's requires that interventions reach all targeted indivi- Department for International Development (DFID), duals, including the population at highest risk. Equity the Danish International Development Agency, is thus achieved by delivering health interventions Australia's AusAID, Japan through JICA, and Nor- preferentially to those in greatest need rather than to way through NORAID. It is vital to assure the only the children who can be most easily reached. continuing availability of sufficient funds for eradica- Once global eradication is achieved, equity on an tion activities in countries affected by conflict. even broader and more enduring basis will result: The eradication of polio in conflict situations is polioviruses will no longer exist and it will be possible possible, as has been demonstrated in certain to stop immunization. Progress towards polio countries of Asia and Central America. However, eradication in countries with civil unrest, insecurity the accelerated campaigns currently under way can and low routine coverage with OPV is critical for the lead to fulfilment of the goal of global eradication in success of the global polio eradication initiative. It is 2000 only if all the partners, including governments urgently necessary to optimize coverage in all NID and local leaders in countries where the disease is rounds, as well as to achieve rapid development of endemic, as well as international donors, give AFP surveillance of high quality, eventually meeting unconditional and unprecedented support. ■ the criteria for certification of polio eradication. Recent successes in reaching large proportions of Acknowledgement target children during NIDs in Afghanistan, the We dedicate this paper to the health workers who Democratic Republic of the Congo, Liberia, Somalia, perished while trying to deliver vaccine to children in and southern Sudan, and the ability to establish conflict situations in Ethiopia, Liberia, Peru, the functioning surveillance systems in these countries, Democratic Republic of the Congo, Sierra Leone, demonstrate that global polio eradication is feasible, Somalia, and southern Sudan. even in adverse circumstances. Résumé Eradication de la poliomyelite dans les pays touches par des conflits L'initiative mondiale pour reradication de la poliomyelite et Tadjikistan). Dans ce dernier groupe, les activites est axee sur un petit nombre de pays qui representent des d'eradication ont etc freinees par les conflits qui ont reservoirs majeurs de poliovirus (Bangladesh, Inde, provoque l'effondrement des systemes de sante. De plus, Nigeria, Pakistan et Republique democratique du Congo) des difficultes d'acces et des problemes de securite et/ou qui sont touches par des conflits alines en Afrique entravent thrieusement la mise en oeuvre des strategies (Angola, Liberia, Republique democratique du Congo, de vaccination et de surveillance qui s'imposent pour Sierra Leone, Somalie et Soudan) et en Asie (Afghanistan reradication de la poliomyelite. Dans les pays touches Bulletin of the World Health Organization, 2000, 78 (3) 335 EFTA01103574 Special Theme — Polio Eradication par un conflit, la poliomyélite paralytique reste une cause nationales de vaccination et de systèmes de surveillance majeure d'incapacités à long terme. Une enquête de la paralysie flasque aiguë. conduite en 1996 dans la province de Kandahar, en La transmission du poliovirus a pu être interrompue Afghanistan, a montré que les causes les plus fréquentes en période de conflit au Cambodge, en Colombie, en El d'incapacités chez les enfants n'étaient pas les mines Salvador, au Liban, aux Philippines, à Sri Lanka et ailleurs, terrestres mais des cas de paralysie résiduelle attribua- ce qui prouve que l'initiative en vue de l'éradication de la bles à la poliomyélite. Des poussées importantes de poliomyélite peut aboutir même dans des conditions poliomyélite se sont produites dans des pays dont les extrêmement difficiles. Par ailleurs, dans les zones en proie services de vaccination avaient été détruits par la guerre, à des conflits, les activités d'éradication ont apporté bien comme en Angola, en Tchétchénie, dans la Fédération de plus, dans le domaine de la santé, que la seule élimination Russie, en Irak et au Soudan. d'une maladie : égalité d'accès aux vaccinations puisque Il est impossible de procéder à des vaccinations de chaque enfant doit pouvoir être atteint; revitalisation et masse dans les zones de combats. L'organisation de renforcement des services de vaccination gràce à l'apport journées nationales de vaccination offre l'occasion de ressources extérieures ; introduction de la supplémen- d'appeler l'attention des belligérants sur la santé de tation en vitamine A; enfin, mise en place de systèmes de leurs enfants et de négocier des trêves ou des cessez-le- surveillance des maladies. Les poliovirus sont hautement feu. La préparation et l'exécution de ces journées ouvrent infectieux et les personnes contaminées peuvent les aussi aux parties en présence des possibilités de transporter rapidement sur de longues distances. L'éra- négociations sur d'autres questions d'intérêt commun. dication de la poliomyélite dans les pays en proie à des Ainsi, dans les pays en proie à des conflits, l'éradication conflits ôte la menace d'une réimportation du virus dans de la poliomyélite exige le recours à d'autres stratégies, des régions exemptes de poliomyélite. comme la négociation de trêves ou de cessez-le-feu et un Il est essentiel d'accorder une attention toute engagement direct accru de la communauté, ainsi que particulière à la lutte contre la poliomyélite dans les pays des ressources humaines et financières extérieures touchés par des conflits pour que soit réalisée dans les beaucoup plus considérables que dans les pays délais l'éradication mondiale de la maladie. Les campa- d'endémicité qui ne sont pas affectés par des conflits. gnes accélérées en cours ne permettront d'atteindre Le but à atteindre étant l'éradication mondiale de la l'objectif de l'éradication mondiale de la poliomyélite en poliomyélite d'ici la fin de l'an 2000, des efforts l'an 2000 que si tous les partenaires, y compris les particuliers sont faits dans tous les pays touchés par gouvernements et les responsables locaux des pays où la des conflits pour accélérer les progrès de l'éradication par maladie est endémique, leur apportent un soutien la mise en place de séries supplémentaires de journées inconditionnel et sans précédent. Resumen Erradicacion de la poliomielitis en los paises afectados por conflictos La iniciativa mundial de erradicaciOn de la poliomielitis se No es posible Ilevar a cabo una inmunizacién esta centrando en un pequerio nùmero de paises que son masiva en las zonas de combate activa. Los chas importantes reservorios mundiales de poliovirus — nacionales de inmunizace brindan una buena °cas& Bangladesh, la Repùblica Democràtica del Congo, la para negociar treguas o un alto el fuego, pues centran la India, Nigeria y el Pakistàn — y/0 estàn afectados por atenciôn de los beligerantes en la salud de sus niiios. conflictos armados en Africa — Angola, la Repùblica Ademàs, la planificacién y la organizacién de los dias Democràtica del Congo, Liberia, Sierra Leona, Somalia y nacionales de inmunizacién abre cauces de comunica- el Sudàn —y en Asia —el Afganistàn y Tayikistàn. En este cién para nuevas negociadones entre las partes sobre ùltimo grupo de paises, las actividades de erradicacién otros asuntos de interés comùn. La erradicaciôn de la han ido a la zaga porque los conflictos armados han poliomielitis en los paises afectados por conflictos exige desarticulado los sistemas de salud. Ademàs, las mas estrategias, como la negociacién de un alto el fuego dificultades de acceso y los problemas de seguridad y de treguas y mas participacién directa de la comunidad. representan obstàculos importantes para las estrategias Las tareas de erradicaciôn en las zonas afectadas por de inmunizadôn y vigilanda necesarias para erradicar la conflictos requieren asimismo recursos humanos y poliomielitis. La poliomielitis paralitica sigue siendo una finanderos externos muy superiores a los que se de las principales causas de discapacidad de larga necesitan en los paises endémicos donde no hay duraciôn en los paises afectados por conflictos. En 1996, conflictos. Con el fin de alcanzar la meta mundial de la una encuesta realizada en la provinda de Kandahar, en erradicaciôn de la poliomielitis para finales de 2000, se el Afganistàn, mostrô que la causa mas frecuente de estàn realizando grandes esfuerzos en todos los paises discapaddad entre los ninas no eran las minas terrestres afectados por conflictos para acelerar el ritmo de avance sino la paràhsis residual atribuible a la poliomielitis. Se mediante la organizacién de rondas suplementarias de han producido grandes brotes de la enfermedad en dias nacionales de inmunizacién y la ràpida implantaciôn paises cuyos servidos de inmunizaciôn se han visto de sistemas de vigilancia de la paràlisis flàccida aguda. perturbados por la querra, como Angola, Chechenia en En Camboya, Colombia, El Salvador, Filipinas, el la Federaciôn de Rusia, el Iraq y el Sudàn. Liban, Sri Lanka y otros lugares, se ha interrumpido la 336 Bulletin of the World Health Organization, 2000, 78 (3) EFTA01103575  Eradication of poliomyelitis in countries affected by conflict transmision del poliovirus durante bs conflictos, lo que distancia. La erradicacion de la poliomielitis en los paises demuestra que la inidativa de erradicadon puede tener afectados por conflictos elimina la amenaza de que el exit° incluso en circunstancias muy dificiles. Las virus sea reimportado en zonas exentas de la actividades de erradicadon en las zonas de conflict° enfermedad. han aportado otros beneficios sanitarios, ademas de la Es vital prestar una atencion especial a la elimination de una enfermedad: la equidad en el acceso erradicadon de la poliomielitis en bs paises afectados a la inmunizaci6n, ya que todos los nirios deben ser por conflictos para conseguir la erradicadon mundial en vacunados; la revitalizacion y el reforzamiento de bs el plazo previsto. La aceleracion de las campaiias servicios habituales de inmunizadon gracias a los emprendidas solo puede conducir al logro de la recursos adicionales procedentes del exterior; la inclu- erradicadon mundial en 2000 si todos los asociados, sion de suplementos de vitamin A; y el establecimiento en particular los gobiernos y los dirigentes locales en los de sistemas de vigilanda de las enfermedades. El paises donde la enfermedad es endemica, asi como los poliovirus es altamente infeccioso y las personas donantes intemacionales, prestan un apoyo incondicio- contagiadas pueden transportarlo rapidamente a gran nal y sin precedentes. References 1. Progress tanardsglcbal poliomyelitis eradication. as of May1999. 20. Aylward B. Polio eradication nitiative in Iraq. Lancet 1996, Wee% EpirkmiologialReoord 1959, 74 (21): 165-170. 307 (9002): 695. 2. Ma Report of the Third Aleetingof the international Commission 21. Polio outbreak, Iraq, 1999. Week*tjakkiniologicalliecord. 1999. for theCertification°,Fradkationof Polionoeli