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March 5, 2015

Pakistan faces three-month extension in global travel restrictions

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March 5, 2015

ISLAMABAD: The Emergency Committee of the International Health Regulations (IHR) 2005 has called for a three-month extension in the temporary international travel restrictions clamped on Pakistan last year on May 15.
A decision to this effect was taken at the fourth meeting of the committee, which was convened on the call of the Director General World Health Organization (WHO) on February 17, 2015, to analyze the implementation of temporary recommendations by Pakistan, Cameroon, Equatorial Guinea, and the Syrian Arab Republic.
The documentation of a new exportation from Pakistan into Afghanistan after its last meeting held on November 13, 2014 has been seen by the committee as evidence that “the principle factors underpinning the international spread of wild poliovirus from Pakistan have not yet changed sufficiently.”
Barring a solo case of exportation from Pakistan, there has been no other documented international spread of wild poliovirus since March 2014. The committee has found that the spread of polio still constitutes a Public Health Emergency of International Concern (PHEIC), necessitating extension of international travel recommendations for another three months.
The committee observed that “although there is seasonal decline in the number of reported cases in Pakistan, transmission is ongoing in each of the four provinces and the Federally Administered Tribal Areas.”
It appreciated that Pakistan had prepared a new robust ‘low season’ vaccination plan, established national and provincial emergency operations centres and resumed campaigns in South and North Waziristan. Yet, its inability to sufficiently change the factors supporting the international spread of wild poliovirus has led to an extension in the international travel recommendations.
The recommendations require Pakistan to maintain the emergency status of poliovirus transmission being a national public health emergency; to ensure that all residents and long-term

visitors (i.e. 4 weeks) receive a dose of OPV or inactivated poliovirus vaccine (IPV) between 4 weeks and 12 months prior to international travel; to ensure that those undertaking urgent travel (i.e. within 4 weeks), who have not received a dose of OPV or IPV in the previous 4 weeks to 12 months, receive a dose of polio vaccine at least by the time of departure; to ensure that such travelers are provided with an International Certificate of Vaccination as proof of vaccination; and to intensify cross-border coordination to enhance surveillance for prompt detection of poliovirus and substantially increase vaccination coverage among refugees, travelers and cross-border populations.
Pakistan has additionally been asked to restrict, at the point of departure, the international travel of any resident lacking documentation of polio vaccination; and to continue to provide to the WHO Director General, a report on the implementation by month of the temporary recommendations on international travel, including the number of residents whose travel was restricted and the number of travelers who were vaccinated and provided appropriate documentation at the point of departure.
“Recognizing that the movement of people across the border with Afghanistan continues to facilitate exportation of wild poliovirus, Pakistan should intensify cross-border efforts by improving coordination with Afghanistan to substantially increase vaccination coverage of travelers crossing the border and of high-risk cross-border populations,” the Committee has further recommended.
Pakistan is required to maintain these measures until at least 6 months have passed without new exportations, and until it is able to provide documentation of full application of high-quality eradication activities in all infected and high-risk areas.
“In the absence of such documentation, these measures should be maintained until at least 12 months have passed without new exportations,” the Committee has recommended.
While the committee has appreciated the efforts that all countries have made in response to the temporary recommendations, it has also expressed concern that implementation of the temporary recommendations is incomplete in all affected countries, many of whom are affected by regional conflicts.
“Although the risk of new international spread from the nine other infected member states appears to have declined, the possibility of international spread still remains a global threat worsened by the expansion of conflict-affected areas, particularly in the Middle East and Central Africa. Furthermore, countries affected by conflict inevitably experience a decline in health service delivery that leads to deterioration of immunization systems in a number of such at-risk countries,” the committee has observed.
The committee has also recommended that the countries where there is significant cross-border population movement should apply a regional approach and develop joint immunisation strategies with neighbouring countries.
The committee considered these factors in reaching this conclusion: the continued international spread of wild poliovirus through 2014; the risk and consequent costs of failure to globally eradicate polio; the continued necessity of a coordinated international response to stop the international spread of wild poliovirus and to prevent new spread with the onset of the high transmission season in May-June 2015; the serious consequences of further international spread for the increasing number of countries in which immunization systems have been disrupted by armed conflict; and the importance of a regional approach and cooperation as much international spread of polio occurs over land borders.
Meanwhile, the director-general of WHO has requested the committee to reassess the situation within the next three months, particularly the committee’s advice whether the Temporary Recommendations should continue beyond the World Health Assembly in 2015 or Standing Recommendations would be required to more effectively reduce the risk of international spread of polio at that time.

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