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I hope the following rationale helps explain the recommendation to change the

1. Ghana still has wild virus circulation.

2. The latest surveillance data I have (11 Jan 2000) shows that in 1999 Ghana
had 3 confirmed wild virus cases and 32 clinically compatable cases. The non-
polio AFP rate is 0.9, but only 51% had adequate stools. Your email implies that
the quality of surveillance is variable by district, with some districts performing
better than others.

3. We know that doing SNIDs in districts with known wild virus/poor surveillance
will help control the spread of polio, however, there is a growing body of
experience that shows that this strategy isn't sufficient to interrupt virus

4. When house-to-house/child-to-child (H2H/C2C) strategies have been used,
even in high performing countries, there are typically 10-30% more children
found than originally estimated based on past performance during NIDs. These
are the children who are missed during both routine EPI and NIDs. Increasingly,
we are learning that very young or sick children are not being brought to fixed
sites. When mobile teams "call out" for children, (rather than actually entering
the houses and asking for children) it is the same group of children who are
missed (sleeping infants, sick children). Other groups who are frequently missed
during NIDs/SNIDs include religious and ethnic minorities, children living in high-
rise buildings, children who accompany their caregiver to the workplace, children
in transit/refugee/mobile population, and children of elites and the people who
work for them (gardeners, housekeepers children). (see attached Tip Sheets)

5. These susceptible children, coupled with the new birth cohort, are enough to
maintain transmission at low levels for several years. This is the example from
Brazil, Colombia, Egypt, Iraq, China and Myanmar -- countries that have had
good routine EPI, very good NIDs and good surveillance. Virus transmission
persists or is imported because these same groups of children are consistently
missed. A few cases are reported each year or every 2-3 years.

6. While focusing SNIDs on geographic areas where wild virus has been
documented is a good strategy, there are several examples of when this
approach was insufficient (e.g. Turkey and Cambodia.) The net must be cast
wider. In areas with known wildvirus transmission, it is likely that many children
have been exposed to the wild virus (remember only 1 in 200 has paralysis) and
are asymptomatic. Doing SNIDs or outbreak response in these areas may be
politicially correct, but it is the larger ring of districts around the cases (the
"firewall" so to speak) that actually helps interrupt transmission. FYI, USAID is
funding PHR to document the cost effectiveness of various supplemental
immunizaton strategies -- there is lots of evidence to show that in the long run it
would have been cheaper and epidemiologically more effective to have
conducted H2H/C2C activities rather than several years of NIDs/SNIDs.

7. I would be careful about interpreting the ARCH studies. As explained above,
reaching 90% coverage is an amazing achievement, but the 10% that are missed
are turning out to be very significant, even if they are not found in large pockets.
While H2H/C2C strategies may still not reach 100% it will be much closer. If
Ghana is like other countries where H2H/C2C has been used and 10-30% more
children are found, it means that the orginal coverage estimates were way off.

8. Increasing the SNIDs to 50 districts may help, but I agree with you that unless
something "new" is done the same children will be missed as before. The gets to
your question about quality. The attached tip sheets help address some of the
gaps in quality that I've observed during 8 NIDs/SNIDs/H2H-C2C over the past
15 months. I've highlighted common mistakes in the microplanning and
supervision. I've noticed that many of the mistakes are ones of the "small kind"
but they add up. The best way to insure quality is to have early and detailed
microplanning at the district level and to assure that the common mistakes are
avoided. WHO a/o UNICEF can send an 'expert' to review the microplans for the
high risk areas to see if the steps that are planned are sufficient; see if the
training is detailed enough to address previous gaps; and to see if supervisors
are receiving special guidance. AFRO may need a request from the country to
spark some action. Social mobilization also needs refinement based on the
strategies and understanding of who is missed and why.

(FYI, in the countries I've been in where the H2H/C2C teams really did go to
every house/dwelling/tarp/high rise etc their level of motivation was very high.
They didn't believe that they had missed so many children before -- they had
believed their own data! I also heard anecdotes about health workers being
excited to find so many pregnant women and planned to hold more TT sessions
and/or find ways to get to these women.)

9. Ghana will have to keep immunity high as long as there is a risk of
importation. Latin America continues to conduct polio NIDs even though
transmission ceased in 1991 and the region was certified polio-free in 1994. The
countries in EURO (no case in over a year) and WPRO (last indigenous case in
1997; importation in 1999) continue to conduct NIDs. NIDs will probably need to
continue at a minimum until regional certification and most likely until global
certification. The decision about when to recommend stopping polio
immunization will be a factor of surveillance, laboratory containment and level of
caution the international community wants to assume (e.g. should there be a
period of a few years with IPV? as yet this is not decided.)
10. Ghana does NOT want to wait until other countries in the region are closer to
eradication before intensifying efforts. You want to avoid a build up of
susceptibles and re-establishing virus reservoirs. Keeping immunity at the
highest possible levels is good not only for the children, but because it shrinks
the number virus reservoirs and limits the genetic diversity of the virus. The
biggest question you should raise at this time is the availability of OPV should an
intensified strategy be adopted. There is a shortage of OPV at the moment so
planning is critical and the need for this year must be decided very soon. OPV
needs for next year should be decided pretty quickly too, so that manufacturers
have enough time to produce necessary stocks.

11. Ghana could help insure faster regional cetification by putting political
pressure on its neighbors to intensify efforts, by offering to provide short-term
teams to work in neighboring countries.

12. Loose management of funds is an issue in many countries. Outsourcing the
finances has been tried in some countries with good success. Other countries
are trying to require expenditure forms/results to be handed in prior to the next
release of funds. Perhaps Mary can find out from Okwo what more AFRO is
doing to improve financial accountability. Likewise, Mary knows more about
AFRO's overall financial situation than I do. Recently the UN Foundation and
Gates Foundation have made substantial contributions for polio eradication. A
coalition of Rotary, UNICEF, UNF and WHO have initiated a fundraising task
force to raise the estimated $500 million shortfall for the global program between
now and 2005.

13. Your role on the ICC is critical. These are exactly the issues that should be
raised -- please keep doing it. It would help us intervene on your behalf if you
could circulate the ICC meeting minutes and questions/outstanding actions to
Mary and me. Mary can forward them to AFRO and I can forward them to
UNICEF and ask about the follow-up.

I hope this helps.


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