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Medical Product Alert N°5/2020 – 7 May 2020
Falsified and contaminated Defibrotide identified in WHO regions of Western Pacific, Europe and Eastern Mediterranean

This alert relates to falsified DEFIBROTIDE 200MG VIALS OF 2.5ML (80MG/ML) CONCENTRATE FOR SOLUTION FOR INFUSION identified in Australia, Latvia and Saudi Arabia. This product is sold under the brand name Defitelio.

On 13 March 2020, the WHO Global Surveillance and Monitoring System on Substandard and Falsified (SF) Medical Products was informed that falsified DEFIBROTIDE 200MG vials were identified at patient level in Australia, displaying batch number 0286 (see Table 1 below for full details).

Following enquiries with stakeholders, on 8 April 2020, WHO was informed that falsified DEFIBROTIDE 200MG vials had also been supplied to Saudi Arabia, displaying batch number 0286 and 0126 (see Table 1 below for full details).

Following enquiries with stakeholders, on 9 April 2020, WHO was informed that falsified DEFIBROTIDE 200MG vials, displaying batch number 0126, had also been identified in Australia and Latvia.

DEFIBROTIDE is used to treat hepatic veno-occlusive disease, in which the blood vessels in the liver become damaged and obstructed by blood clots. This can be caused by treatments prior to a stem cell transplantation.

Laboratory analyses, conducted by national medicines regulatory authorities and the manufacturer of the genuine product, established that these falsified products do not contain any of the expected active ingredient. The solution in the vials is also contaminated with mould (Cladosporium sp. and Aspergillus niger).

Information available to WHO indicates that both batches of falsified DEFIBROTIDE 200MG vials were present within the regulated supply chain in Latvia as early as January 2020 and were also handled by medicine wholesalers in the United Kingdom in February 2020. It is important to note that widespread vigilance is required from all countries, regardless of where the product was originally identified.

Table 1: falsified defibrotide subject of WHO Alert n°5/2020, identified in Australia, Latvia and Saudi Arabia

The two products listed in Table 1 are confirmed falsified, on the basis that there is deliberate misrepresentation of their identity, composition and source.

The genuine manufacturer of Defibrotide, GENTIUM S.R.L has also confirmed to WHO that:
- They did not manufacture the above products.
- Authentic DEFIBROTIDE 200MG VIALS with batch number 0286 were supplied to Argentina, Hong Kong, Malaysia, Singapore and Turkey.
- Authentic DEFIBROTIDE 200MG VIALS with batch number 0126 were supplied to Australia, Jordan, Kuwait, Lebanon, New Zealand, Qatar, Singapore, Turkey and the United Arab Emirates.
  For guidance and photographs, please refer to page 2 of this Alert n°5/2020.
Photos of Falsified DEFIBROTIDE Batch number: 0286, with expiry date: 09/2021

Sample from Latvia Sample from Latvia

Photos of Falsified DEFIBROTIDE Batch number: 0126, with expiry date: 08/2021

Sample from Australia Sample from Australia

WHO requests increased vigilance within the supply chains of countries likely to be affected by these falsified products. Increased vigilance should include hospitals, clinics, health centres, wholesalers, distributors, pharmacies and any other suppliers of medical products.

If you are in possession of the above products, please do not use them. If you have used these falsified products, or if you suffer an adverse reaction/event having used these products, you are advised to seek immediate medical advice from a qualified healthcare professional, and to report the incident to the National Regulatory Authorities/National Pharmacovigilance Centre.

All medical products must be obtained from licensed, authorized and reliable sources. Their authenticity and condition should be carefully checked. Seek advice from a healthcare professional in case of doubt.

National regulatory/health authorities are advised to immediately notify WHO if these falsified products are identified in their country(ies). If you have any information concerning the manufacture, distribution, or supply of these products, please contact rapidalert@who.int.

WHO Global Surveillance and Monitoring System for Substandard and Falsified Medical Products

For further information, please visit our website: https://www.who.int/medicines/regulation/ssffc/en/

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May 9, 2020
Compendium of research projects at the interface of tuberculosis and COVID-19

As the world comes together to tackle the COVID-19 pandemic, it is important to ensure that tuberculosis (TB) prevention and care approaches are adapting appropriately to ensure continuous and safe delivery of high-quality TB services. Considering the overlaps in TB and COVID-19 in disease presentation and transmission, the pandemic presents many questions for the TB field that may require learning through research and innovation.

To better understand challenges and opportunities in this space, the World Health Organization Global TB Programme is collating information on ongoing research at the interface of TB and COVID-19 (i.e. research which would improve TB prevention and care approaches in the context of the COVID-19 pandemic). We are developing a living compendium (listing), which will be updated periodically to make ongoing research projects and publications visible on its website. With your consent we would like to include any study you have in this compendium.

To fulfill these objectives, we need the cooperation of organizations and individuals engaged in TB/COVID-19 research to complete this one page template before 20 May 2020. We encourage you to please share this in your network, so we can reach all stakeholders widely.

We thank you in advance for your cooperation, and please do not hesitate to contact us if you have any questions.

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May 9, 2020
Statement on the third meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of coronavirus disease (COVID-19)
The third meeting of the Emergency Committee convened by the WHO Director-General under the International Health Regulations (2005) (IHR) regarding the coronavirus disease (COVID-19), took place on Thursday, 30 April 2020, from 12:00 to 17:45 Geneva
time (CEST).

Proceedings of the meeting

Members and advisors of the Emergency Committee were convened by teleconference. Membership of the Emergency Committee was expanded
to reflect the nature of the pandemic and the need to include additional areas of expertise.

The Director-General welcomed the Committee, thanked them for their commitment to enhancing global public health, and provided an overview of the major achievements in the COVID-19 response since the last Emergency Committee meeting on 30 January 2020.
Representatives of the legal department and the Department of Compliance, Risk Management, and Ethics (CRE) briefed the members on their roles and responsibilities.

The Ethics Officer from CRE provided the members and advisers with an overview of the WHO Declaration of Interest process. The members and advisers were made aware of their individual responsibility to disclose to WHO, in a timely manner, any interests
of a personal, professional, financial, intellectual or commercial nature that may give rise to a perceived or direct conflict of interest. They were additionally reminded of their duty to maintain the confidentiality of the meeting discussions and
the work of the committee. Only those committee members and advisers who were not considered to have any perceived or direct conflict of interest participated in the meeting.

The Secretariat turned the meeting over to the Chair, Professor Houssin. He also welcomed the Committee and reviewed the objectives and agenda of the meeting.

The WHO Regional Emergency Directors and the Executive Director of the WHO Health Emergencies Programme (WHE) provided regional and the global situation overview. After ensuing discussion, the Committee unanimously agreed that the outbreak still constitutes
a public health emergency of international concern (PHEIC) and offered advice to the Director-General.

The Director-General declared that the outbreak of COVID-19 continues to constitute a PHEIC. He accepted the advice of the Committee to WHO and issued the Committee’s advice to States Parties as Temporary Recommendations under the IHR.

The Emergency Committee will be reconvened within three months or earlier, at the discretion of the Director-General. The Director-General thanked the Committee for its work.

Advice to WHO

Coordination, planning, and monitoring
- Continue to lead and coordinate the global response to the COVID-19 pandemic in collaboration with countries, the United Nations (UN), and other partners.
- Work with fragile states and vulnerable countries that require additional technical, logistical and commodity support.
- Establish mechanisms to compile lessons learned from country and partner experiences and WHO missions and share the best practices and updated recommendations.
- Provide further guidance to countries about adjusting public health measures, taking into account the different epidemiological situations of the pandemic.
- Promote the inclusion of all interested countries, including low- and middle-income countries from all regions, in the Solidarity clinical trials for therapeutics and vaccines.
- Continue efforts with partners to obtain equitable access to personal protective equipment, diagnostics, and biomedical equipment essential to the pandemic COVID-19 response.
- Continue to coordinate global expert networks in epidemiology, laboratory, vaccines, clinical care, infection prevention and control, social sciences, and operational research; modelling; and other technical support.
One Health
- Work with the World Organisation for Animal Health (OIE), the Food and Agriculture Organization of the United Nations (FAO), and countries to identify the zoonotic source of the virus and the route of introduction to the human population, including
  the possible role of intermediate hosts. This should be accomplished through efforts such as scientific and collaborative field missions, which will enable targeted interventions and a research agenda to reduce the risk of similar events.
- Work closely with OIE and FAO to provide guidance on how to prevent SARS-CoV-2 infections in animals and humans and prevent the establishment of new zoonotic reservoirs.
- Work with partner organizations and countries to strengthen the global food supply chain, protect food workers, properly manage food markets, and mitigate possible disruptions to the food supply.
Essential Health Services
- Support countries to assess and manage the unintended consequences of public health measures implemented to control the COVID-19 pandemic, including gender-based violence and child neglect.
- Support countries to monitor their ability to provide and strengthen essential health services throughout a likely extended COVID-19 response. This should include, but is not limited to, essential prevention for communicable diseases, particularly
  vaccination; services related to reproductive health, including care during pregnancy and childbirth; care of vulnerable populations, such as young infants and older adults; provision of medications and supplies for the ongoing management of chronic
  diseases, including mental health conditions; continuity of critical inpatient therapies; management of emergency health conditions and common acute presentations that require time-sensitive intervention; and auxiliary services, such as basic
  diagnostic imaging, laboratory services, and blood bank services.
- Support countries to address shortages of essential medicines and health products, personal protective equipment, and other medical supplies and to establish sustainable risk management practices to prevent future shortages.
Risk communication and community engagement
- Continue risk communications and community engagement activities through the WHO Information Network for Epidemics (EPI-WIN) and other platforms to counter rumours and misinformation.
- Continue to regularly communicate clear messages, guidance, and advice about the evolution of the COVID-19 pandemic, how to reduce transmission, and save lives.
- Work with partners and countries to articulate potential long-term consequences of COVID-19 pandemic, emphasizing the need for strengthened cross-sectoral preparedness, transparency and global coordination.
Surveillance
- Clarify the testing strategy, support countries to increase testing capacity, and aim to provide equitable access to diagnostic tests and supplies in light of market failures and global shortages.
- Continue to provide guidance on monitoring disease trends using Severe Acute Respiratory Infections (SARI) and Influenza Like Illness (ILI) surveillance systems in anticipation of the co-circulation of influenza viruses.
- Develop qualitative and quantitative indicators that countries can use to assess and monitor SARS-CoV-2 transmission at all levels of public health response.
- Continue to support countries and partners by providing technical and operational guidance, training platforms, and tools such as Go.Data,to enhance case identification and contact tracing capacity, strengthen the public health workforce, and engage
  communities for contact tracing.
- Provide clear qualitative and quantitative indicators to monitor SARS-CoV-2 transmission to inform the adjustment of public health and social measures.
Travel and Trade
- Continue working with countries and partners to enable essential travel needed for pandemic response, humanitarian relief, repatriation, and cargo operations.
- Develop strategic guidance with partners for the gradual return to normal operations of passenger travel in a coordinated manner that provides appropriate protection when physical distancing is not feasible.
- Update recommendations on appropriate travel measures and analyze their effects on international transmission of COVID-19, with consideration of the balance between benefits and unintended consequences, including entry and exit screening, education
  of travelers on responsible travel behaviour, case finding, contact tracing, isolation, and quarantine, by incorporating evidence on the potential role of pre-symptomatic and asymptomatic transmission.
To all States Parties

Coordination and Collaboration
- Support WHO leadership and continue to collaborate with WHO at all levels of the organization and with other countries to enable effective global COVID-19 pandemic preparedness and response.
- Participate in global solidarity efforts to enable access to essential supplies for all.
- Document and share lessons learned from efforts to control the pandemic, including the timing, pace, and sequencing of the application and lifting of public health measures.
Preparedness
- Strengthen preparedness for health emergencies, and build resilient health systems, incorporating lessons learned during different stages of the pandemic, and sharing experiences with other countries.
Surveillance
- Work with WHO and multisectoral partners to interrupt transmission by maintaining robust surveillance systems; enhancing capacities for case detection, testing, isolation of cases, contact tracing, quarantine of contacts, and rapid response; strengthening
  the public health workforce; and actively engaging communities for contact tracing, with a particular focus on high risk areas.
- In settings where testing a large proportion of suspected cases is not possible, monitor overall trends; undertake early detection through laboratory confirmation of a limited number of cases with a focus on health workers; and rapidly implement
  public health measures.
- Share with WHO all data necessary to conduct global risk assessments through data platforms, such as the Global Influenza Surveillance and Response System and the IHR mechanism. These data should include SARI and ILI where available.
- Use the WHO qualitative and quantitative indicators to assess and monitor SARS-CoV-2 transmission at all levels of public health response.
Additional Health Measures
- Avoid restrictions on international transport of food, medical and other essential supplies and permit the safe movement of essential personnel required for an effective pandemic response.
- Implement appropriate travel measures with consideration of their public health benefits, including entry and exit screening, education of travelers on responsible travel behaviour, case finding, contact tracing, isolation, and quarantine, by
  incorporating evidence on the potential role of pre-symptomatic and asymptomatic transmission.
- Implement and monitor case finding and contact tracing of travellers, using digital tools where appropriate.
- Continue to review travel and trade measures based on regular risk assessments, transmission patterns at origin and destination, cost-benefit analysis, evolution of the pandemic, and new knowledge of COVID-19.
- Engage in global efforts to respond to the challenges of COVID-19 in managing maritime vessels.
- Do not implement trade restrictions beyond those considered to be of public health importance in accordance with relevant international agreements.
- Continue to provide appropriate public health rationale to WHO for additional health measures in accordance with IHR.
Health Workers
- Prioritize the protection of the health workforce through access to training and provision of personal protective equipment, infection prevention and control measures, improved working conditions, application of WHO recommended testing strategies,
  and prevention of stigma and attacks on health workers.
Food Security
- Work with WHO and partners to strengthen the global food supply chain, protect food workers, properly manage food markets, and mitigate possible disruptions to the food supply, especially for vulnerable populations.
One Health
- Promote sound practices to manage risks of trade of live animals in food markets and regulate trade of exotic wildlife.
Risk Communications and Community Engagement
- Continue to engage communities to address rumours and misinformation and keep the public informed, with a focus on vulnerable populations.
Research and development
- Address research gaps such as: routes of transmission, including the role of asymptomatic and pre-symptomatic infection droplet, contact, fomite and aerosol transmission; and viral shedding; and animal source and intermediate hosts, in collaboration
  with partners.
- Continue to support and conduct COVID-19 research, in line with the WHO Research and Development Blueprint, and the road map for COVID-19 vaccines, diagnostics, and therapeutics.
- Continue sharing full genome sequences to increase global understanding of virus evolution and phylogenetics and their application to public health practices.
Essential Health Services
- Maintain essential health services throughout a likely extended COVID-19 response. This should include essential prevention for communicable diseases, particularly vaccination; services related to reproductive health, including care during pregnancy
  and childbirth; care of vulnerable populations, such as young infants and older adults; provision of medications and supplies for the ongoing management of chronic diseases, including mental health conditions; continuity of critical inpatient
  therapies; management of emergency health conditions and common acute presentations that require time-sensitive intervention; and auxiliary services, such as basic diagnostic imaging, laboratory services, and blood bank services.
- Continue to track and document the impact of COVID-19 on essential health services.
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May 9, 2020
New estimates highlight need to step up the response to hepatitis D

Lyon, France, 29 April 2020 – In a study published in the Journal of Hepatology,¹ Professor Anna Maria Geretti and Dr Alexander Stockdale from the University of Liverpool (United Kingdom), in collaboration with researchers
from the World Health Organization (WHO) and the International Agency for Research on Cancer (IARC), estimate that worldwide, hepatitis D virus (HDV) affects nearly 5% of people who have a chronic infection with hepatitis B virus (HBV) and that HDV
co-infection could explain about 1 in 5 cases of liver disease and liver cancer in people with HBV infection..

To map the epidemiology of HDV infection in the world, Professor Geretti and Dr Stockdale joined forces with the WHO Global Hepatitis Programme and IARC, alongside investigators in Germany, Malawi, and the United Kingdom. “Infection with HDV occurs
in about 1 in 22 cases of chronic HBV infection in the world,” Dr Stockdale says. “More high-quality data are needed, but we have identified several geographical hotspots of high prevalence of HDV infection: in Mongolia, the Republic of
Moldova, and countries in Western and Middle Africa.”

“Although it is less common than hepatitis B, hepatitis D is a serious disease that often affects underprivileged and vulnerable populations,” says Dr Meg Doherty, Director of the WHO Global Hepatitis Programme. Those who are more likely to
have HBV and HDV co-infection include people who inject drugs and people with hepatitis C virus or HIV infection. The risk of co-infection also appears to be higher in recipients of haemodialysis, men who have sex with men, and commercial sex workers.
Dr Doherty points out, “This information helps in identifying the groups with HBV among whom we should be looking for HDV.”

HDV (formerly known as the Delta agent) is a small virus – one of the smallest that is known to cause disease in humans – and can replicate only in the presence of HBV, from which HDV borrows some of its structures. Compared with people with
HBV infection alone, those who have a chronic infection with both HBV and HDV have a much higher risk of developing disease in the form of cirrhosis and liver cancer. “HDV is a significant contributor to severe liver disease and liver cancer,”
says IARC scientist Dr Catherine de Martel. “The findings from this study inform our work on the association between viral infections and cancer, which is focused on developing improved prevention strategies.”

Professor Geretti concludes, “HDV has long been neglected, because for decades the prevalence of infection remained uncertain and effective treatment was lacking. Mapping the epidemiology of the infection is just the first step. More efforts are
needed to reduce the global burden of chronic hepatitis B and develop medicines that are safe and effective against hepatitis D and are affordable enough to be deployed on a large scale to those who are most in need.”

¹ Stockdale AJ, Kreuels B, Henrion MYR, Giorgi E, Kyomuhangi I, de Martel C, Hutin Y, Geretti AM (2020). The global prevalence of hepatitis D virus infection: systematic review and meta-analysis. J Hepatol. Published online 23 April 2020;
https://doi.org/10.1016/j.jhep.2020.04.008

For more information, please contact

Véronique Terrasse, Communications Group, at +33 (0)6 45 28 49 52 or terrassev@iarc.fr or IARC Communications, at com@iarc.fr

The International Agency for Research on Cancer (IARC) is part of the World Health Organization. Its mission is to coordinate and conduct research on the causes of human cancer, the mechanisms of carcinogenesis, and to develop scientific strategies for
cancer control. The Agency is involved in both epidemiological and laboratory research and disseminates scientific information through publications, meetings, courses, and fellowships. If you wish your name to be removed from our press release emailing
list, please write to com@iarc.fr.

About University of Liverpool

Founded in 1881 as the original ‘red brick’, the University of Liverpool is one of the UK’s leading research-intensive higher education institutions. Consistently ranked in the top 200 universities worldwide, we are a member of the prestigious
Russell Group and have a global reach and influence that reflects our academic heritage as one of the country’s largest civic institutions. For more information please visit us at www.liverpool.ac.uk

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May 9, 2020
WHO calls for healthy, safe and decent working conditions for all health workers, amidst COVID-19 pandemic
On World Day for Safety and Health at Work, the World Health Organization calls upon all governments, employers and workers organizations and the global community to take urgent measures for strengthen countries’ capacities to protect occupational health and safety of health workers and emergency responders respect their rights to decent working conditions, and develop national programmes for occupational health of health workers and to provide them with occupational health services. Amidst the COVID-19 pandemic, ILO has dedicated World Day for Safety and Health at Work 2020 in addressing the outbreak of infectious diseases at work, in particular, on the COVID-19 pandemic.

Health workers are at the front line of the COVID-19 outbreak response and as such are exposed to hazards that put them at risk of infection. Hazards include pathogen exposure, long working hours, psychological distress, fatigue, occupational burnout, stigma, and physical and psychological violence.

Infections with COVID-19, insufficient measures for infection prevention and control, occupational safety and health, mental health and psychosocial support for health workers result in high rates of absenteeism and deplete the health workforce – the most precision resources for stopping the COVID outbreak.

Key Messages and Facts

COVID-19 infections among health workers:
- As of 21 April 2020 countries reported to WHO that over 35, 000 health workers were infected with COVID19. This number is significantly higher because of underreporting.
- The major occupational risks for COVID19 infection among health workers are: late recognition or suspicion of COVID-19 in patients, working in a higher-risk department, longer duty hours, sub-optimal adherence to infection prevention and control measures, such as hand hygiene practices, and lack of or improper use of personal protective equipment (PPE). Other factors have also been documented, such as inadequate or insufficient IPC training for respiratory pathogens, including the COVID-19 virus, as well as long exposure in areas in healthcare facilities where large numbers of COVID-19 patients were being cared for.
- The prevention of infections requires the use of appropriate infection prevention and control measures by all health workers, with a special focus on the adherence to hand hygiene and personal protective equipment when caring for COVID-19 patients, as well as a combination of environmental and administrative controls
- Health workers infected with COVID-19 following exposure in the workplace should have the right to employment injury benefits for occupational disease, including compensation, rehabilitation, and curative services.
Violence and stigma against health workers:
- Health workers are at high risk of violence all over the world. Between 8% and 38% of health workers suffer physical violence at some point in their careers. Many more are threatened or exposed to verbal aggression and social stigma because of their work.
- In the COVID19 crisis, shortage of staff and resources and increasing social tensions result in increased level of violence against health workers and even attacks against health care facilities. Doctors, nurses, security personnel and those who are assisting in testing, tracing contacts and enforcing physical distancing measures to stop COVID-19 experience threats and aggression.
- WHO calls upon governments, employers and workers organizations to institute measures for zero-tolerance to violence against health workers at the workplace and at the way to and from their workplace, and for intensifying social support and respect for health workers and their families.
Long working hours and psychosocial hazards for health workers:
- Many health workers have to work longer or irregular hours because of the increasing demand for health services. In addition, many countries experience shortage of health workers, or junior staff are working in demanding new roles.
- Health workers face psychosocial hazards, which are exacerbated during emergencies where demands increase and they have to experience risk of infection witness higher suffering or mortality.
- Long working hours, shift work, high workload and other psychosocial hazards can lead to fatigue, occupational burnout, increased psychological distress or declining mental health – affecting the health of health workers, and the quality and safety of care delivered.
- WHO calls for adequate staffing levels and clinical rotation in healthcare facilities, measures to minimize psychosocial hazards, and provision of access to mental health and psychosocial support for health workers.
The annual World Day for Safety and Health at Work on 28 April promotes the prevention of occupational accidents and diseases globally. It is an awareness-raising campaign intended to focus international attention on the magnitude of the problem and on how promoting and creating a safety and health culture can help reduce the number of work-related deaths and injuries.

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May 9, 2020
Maternal infections in health facilities

A clearer picture of the global impact

New research from the Global Maternal Sepsis Study (GLOSS), a major WHO/HRP initiative, shows that infection has a much larger impact on global maternal mortality and morbidity than previously thought.

The
results from GLOSS, published in The Lancet Global Health, are the first to provide data on frequency of maternal infections and
sepsis across the pregnancy and post-pregnancy period, in a large number of health facilities around the world.

Around 11 women per 1000 live births had an infection which resulted in or contributed to what is known as a severe maternal outcome – either they died or nearly died – during their hospitalization.

Urgent improvement is needed to manage this life-threatening risk faced by all pregnant and recently pregnant women, wherever they are in the world.

What is maternal sepsis and how does it lead to maternal death?

Maternal sepsis is a life-threatening condition that arises when the body’s response to infection causes injury to its own tissues and organs during pregnancy, child-birth, post-abortion or the postpartum period.

The latest global estimates place sepsis due to obstetric infections as the third most common cause of maternal mortality. However, this only includes infections as a direct result of pregnancy, such as endometritis or post-caesarean wound infections.

Few
previous studies include post-abortion infections. Neither do they address indirect infections such as respiratory and meningitis, which are aggravated by pregnancy but not directly caused by it.

A better understanding of maternal infection

GLOSS was a massive facility-based data collection effort led by WHO, accompanied by a ‘STOP SEPSIS!’ campaign to increase awareness among healthcare providers.

The study gathered data on women who were admitted with suspected or confirmed infection during pregnancy or post-pregnancy over a one-week period in 2017. More than 2800 women participated in the study in 52 countries.

GLOSS included healthcare facilities that care for women during pregnancy, childbirth or at the end of pregnancy, as well as facilities without maternity service but where women could be hospitalized during or after pregnancy, and data on infections
which are not usually recorded as maternal sepsis, including post-abortion and indirect infections.

The result is a more complete understanding of the frequency and impact of maternal infections in health facilities.

GLOSS calls attention not only to the wider range of risks faced by pregnant women but also to the long period of time during which they are at risk.

Putting global numbers on maternal infection and sepsis

Overall, around 70 pregnant or recently-pregnant women per 1000 live births were found to have a maternal infection needing hospital management.

Across the study, 11 women with either direct or indirect infection per 1000 live births developed a severe maternal outcome, but in low- and middle-income countries up to 15 women per 1000 births were affected.

Infections were the underlying cause of most of the deaths recorded during the study, primarily post-abortion infection and indirect infections. Infections were also present in about a third of deaths attributed to other causes, such as postpartum
haemorrhage.

This suggests that the contribution of infection to global maternal mortality and morbidity may be larger than current reports of maternal sepsis mortality suggest.

Preventing, identifying and treating maternal infection and sepsis

Some of the most common maternal infections found in the study, such as urinary tract infections, post-caesarean and post-abortion infections, are largely preventable and treatable.

GLOSS results suggest that current levels of monitoring and clinical care across health facilities are not enough to prevent, identify and treat levels of maternal infection effectively.

For instance, a complete set of vital signs was not reported for a third of the women in the study, on the day their infection was suspected or diagnosed. Delays in antimicrobial therapy were frequent.

GLOSS also shows marked differences across countries, with the highest burden in low- and middle-income countries, compared with high-income countries.

This may reflect the impact of broader health determinants in different country contexts. Challenges of overcrowding, limited access to water and sanitation and constraints to safe births by skilled birth attendants can reduce the ability of healthcare
providers to manage the frequency and outcome of maternal infections.

An opportunity to implement evidence-based practice

GLOSS gives healthcare providers, policy-makers, and the public at large an opportunity: to mobilise around these data improve evidence-based practice, and save lives.

WHO has produced a number of resources which can support timely action to prevent, diagnose and treat maternal infection, as well as activities such as the upcoming SAVE LIVES: Clean Your Hands campaign
on 5 May which celebrates the central role played by nurses and midwives in clean health care.

In addition, WHO will publish a global sepsis epidemiology report around the 73rd World Health Assembly (WHA) in May, as requested in the
2017
WHA Resolution on Improving the prevention, diagnosis and clinical managementof sepsis.

Understanding why and how infection affects women is essential for equipping healthcare providers with life-saving knowledge and enabling health care systems to bring down global maternal mortality and morbidity.

Related publications

WHO recommendations for prevention and treatment of maternal peripartum infections

WHO Clinical practice handbook for safe abortion

Global guidelines on the prevention of surgical site infection

WHO statement on maternal sepsis

World Health Assembly resolution on Improving the prevention, diagnosis and clinical management of sepsis

Health Topics

Antimicrobial resistance

Infection Prevention and Control

Water Sanitation Hygiene

Other links

Global Maternal Sepsis Study

SAVE LIVES: Clean Your Hands 5 May 2020

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https://www.who.int/news-room/detail/27-04-2020-maternal-infections-in-health-facilities

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May 9, 2020
MIEA warns public to beware of property scams

KUALA LUMPUR: The Malaysian Institute of Estate Agents (MIEA) is advising the public to be cautious in buying and selling properties during the Movement Control Order (MCO) period to avoid falling prey to scams.

MIEA noted that amid the MCO, the majority of Malaysians who are keen to buy or sell property will be relying on online platforms.

“Be extra vigilant as there are still a high number of cases where the general public has fallen prey to these property pitfalls,” it said yesterday.

MIEA president Lim Boon Ping highlighted that registered estate agents (REA) and negotiators (REN) are recognised as professionals under Malaysian law and that there are firm requirements that need to be adhered to when publishing an advertisement in order to protect the public’s interest.

Among others, they are required to include their name, REN/REA number, contact number and the real estate firm they represent with its E registration number and the firm’s telephone number, which the public can verify on www.lppeh.gov.my.

“There will a sudden surge on online and offline advertisement by those illegal brokers who will take advantage on the Covid-19 rise in low priced property deals and these advertisements will not contain the before-mentioned authenticity information and the public should avoid calling them,“ warned Lim.

He reminded that if one sees an advertisement or a property deal that looks “too good to be true”, be extra cautious and do your research”.

“Always engage a registered estate agent or a certified negotiator to verify these potential property deals,“ added Lim. — Bernama

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https://www.thesundaily.my/local/miea-warns-public-to-beware-of-property-scams-AB2245651

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April 11, 2020
Medical Product Alert N°4/2020
This Medical Product Alert relates to a number of confirmed falsified chloroquine products circulating in the WHO region of Africa. Please note that this Medical Product Alert n°4/2020 will be updated as new reports of falsified chloroquine are received and validated by WHO.

Between 31 March and 2 April 2020, the WHO global surveillance and monitoring system on substandard and falsified (SF) medical products received nine reports of confirmed falsified chloroquine products from three countries. All reported products were identified at patient level and all have been confirmed as falsified.

This WHO medical product alert N°4/2020 refers to nine different falsified chloroquine products, with different presentations (see Table 1). It is important to note that widespread vigilance is required from all countries, regardless of where the product was originally identified.

Table 1: List of identified falsified chloroquine products, subject of WHO Alert N°4/2020

All the products listed in Table 1 are confirmed as falsified, on the basis that they deliberately/fraudulently misrepresent their identity, composition or source. Indeed, it can be noted that:
- either: the products do not contain the correct amount of the active pharmaceutical ingredient, based on the results of preliminary or full compendial analysis;
- and/or: the products were not produced by the manufacturer whose name is stated on the product labels, and the variable data (batch number and dates) of the above products do not correspond to genuine manufacturing records;
- and/or: the manufacturer whose name is stated on the product labels does not exist.
Chloroquine phosphate or sulfate is referenced on the WHO Model List of Essential Medicines for the treatment of Plasmodium vivax infection (malaria). Large clinical trials are under way to generate the robust data needed to establish the efficacy and safety of chloroquine and hydroxychloroquine in the treatment of COVID-19. These medicines are currently authorized for malaria and certain autoimmune diseases and it is important that patients do not face shortages caused by stockpiling or use outside the authorized indications.
Both chloroquine and hydroxychloroquine can have serious side effects, especially at high doses or when combined with other medicines.

The SOLIDARITY trial, led by WHO, is reviewing potential treatments for COVID-19. Please refer to WHO medical product alert n°3/2020 for general information on falsified medical products in relation to the management
of COVID-19.

For photographs of products listed in Table 1, please refer to the WHO Medical Product Alert website, and
to the annex of this medical product alert n°4/2020 (see pages 3-7).

WHO requests increased vigilance within the supply chains of countries likely to be affected by these falsified products. Increased vigilance should include hospitals, clinics, health centres, wholesalers, distributors, pharmacies and any other suppliers of medical products.

If you are in possession of the above products, please do not use. If you have used these falsified products, or if you suffer an adverse reaction/event having used these products, you are advised to seek immediate medical advice from a qualified healthcare professional, and to report the incident to the National Regulatory Authorities/National Pharmacovigilance Centre.

All medical products must be obtained from licensed, authentic and reliable sources. Their authenticity and condition should be carefully checked. Seek advice from a healthcare professional in case of doubt.

National regulatory/health authorities are advised to immediately notify WHO if these falsified products are discovered in their country. If you have any information concerning the manufacture, distribution, or supply of these products, please contact: rapidalert@who.int.

WHO Global Surveillance and Monitoring System for Substandard and Falsified Medical Products
For more information, please visit: www.who.int/medicines/regulation/ssffc/en/

Annex: Photographs of falsified chloroquine products circulating in the WHO region of Africa, Medical Product Alert N°4/2020

CAMEROON

Photographs of confirmed falsified Chloroquine Phosphate (100mg)

Photographs of confirmed falsified Chloroquine Phosphate (250mg)

Photographs of confirmed falsified Chloroquine Phosphate 250mg

DEMOCRATIC REPUBLIC OF CONGO

Photographs of confirmed falsified CLOROQUINE 250MG

Photographs of confirmed falsified Chloroquine Phosphate 250mg

NIGER

Photographs of confirmed falsified Samquine 100 (100mg)

Photographs of confirmed falsified Chloroquine phosphate tablets B.P 100mg

Photographs of confirmed falsified Niruquine (100mg)

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https://www.who.int/news-room/detail/09-04-2020-medical-product-alert-n4-2020

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April 10, 2020
Glossary of Youth: Its Education, Regimen, and Hygiene, by G. Stanley Hall

GLOSSARY

AGAMIC. Unmarried; unmarriageable, sometimes non-sexed.

AGENIC. Lacking in reproductive power; sterile.

AMPHIMIXIS. That form of reproduction which involves the mingling of substance from two individuals so as to effect a mixture of hereditary characteristics. It includes the phenomena of conjugation and fertilization among both unicellular and multicellular organisms.

ANABOLISM. See METABOLISM.

ANAMNESIC. Pertaining to or aiding recollection.

ANEMIC. Deficient in blood; bloodless.

ANTHROPOMORPHISM. The attributing of human characteristics to natural, supernatural, or divine beings.

ANTHROPOMETRY. Science of measurement of the human body.

ARTIFACT. Any artificial product.

APHASIA. Impairment or lose of the ability to understand or use speech.

ASSOCIATIONISM. The psychological theory which regards the laws of association as the fundamental laws of mental action and development.

ATAVISTIC. Pertaining to reversion through the influence of heredity to remote ancestral characteristics.

ATAXIC. Pertaining to inability to coördinate voluntary movements; irregular.

CALAMO-PAPYRUS. Reed papyrus or pen-paper.

CATABOLISM. See METABOLISM.

CATHARSIS. Purgation or cleansing. Aristotle’s esthetic theory that little renders immune for much.

CEREBRATION. Brain action, conscious or unconscious.

CHOREA. St. Vitus’s dance; a nervous disease marked by irregular and involuntary movements of the limbs and face.

CHRESTOMATHY. A collection of extracts and choice pieces.

CHRISTENTHUM. The Christian belief; the spirit of Christianity.

COMMANDO EXERCISES. Gymnastic exercises whose order is dependent upon the spoken command of the director.

CORTEX. The gray matter of the brain, mostly on its surface.

CORTICAL. Pertaining to the cortex.

CRANIOMETRY. The measurement of skulls.

CRYPTOGAMOUS. Having an obscure mode of fertilization; or, of plants that do not blossom.

CULTUS. A system of religious belief and worship.

DEUTSCHENTHUM. The spirit of the German people.

DIATHESIS. A constitutional predisposition.

EPHEBIC. Pertaining to the Greek system of instruction given to young men to fit them for citizenship; adolescent.

EPIGONI. Successors; followers who only follow.

EPISTEMOLOGY. The theory of knowledge; that branch of logic which undertakes to explain how knowledge is possible and to define its limitations, meaning, and worth.

EUPEPTIC. Having good digestion.

EUPHORIA. The sense of well-being; of fullness of life.

EVIRATION. Emasculation; loss of manly characteristics.

FERAL. Wild by nature; untamed; undomesticated.

FORMICARY. An artificial ants’ nest.

GEMÜTH. Disposition; the entire affective soul and its habitual state.

HEBETUDE. Dullness; stupidity.

HEDONISTIC. Relating to hedonism, that form of Greek philosophy which taught that pleasure is the chief end of existence.

HETAERA. A Greek courtesan. This class was often highly trained in music and social art, and represented the highest grade of culture among Greek women.

HETEROGENY. (1) The spontaneous generation of animals and vegetables, low in the scale of organization, from inorganic elements. (2) That kind of generation in which the parent, whether plant or animal, produces offspring differing in structure or habit from itself, but in which after one or more generations the original form reappears.

HETERONOMOUS. Having a different name.

HOROLOGY. The science of measuring time and of constructing instruments for that purpose.

HYGEIA. The Greek goddess of health; health.

HYPERMETHODIC. Methodic to excess; overmethodic.

HYPERTROPHY. Excessive growth.

INDISCERPTIBLE. Incapable of being destroyed by separation of parts.

INHIBITION. Interference with the normal result of a nervous excitement by an opposing force.

IRRADIATION. The diffusion of nervous stimuli out of the path of normal discharge which, as a result of the excitation of a peripheral end organ may excite other central organs than those directly connected with it.

KINESOLOGICAL. Pertaining to the science of tests and measurements of bodily strength.

KINESOMETER. An instrument for measuring muscular strength.

MEDULLATION. The investment of nerve fibers with a protective covering or medullary sheath, consisting of white, fat-like matter.

MERISTIC. Pertaining to the levels or spinal and cerebral segments of the body.

METABOLISM. The act or process by which, on the one hand, dead food is built up into living matter—anabolism, and by which, on the other, the living matter is broken down into simpler products within a cell or organism—catabolism.

METAMORPHOSIS. Change of form or structure; transformation.

METEMPSYCHOSIS. The doctrine of the transmigration of the soul from one body to another.

MONOPHRASTIC. Pertaining to or consisting of a single phrase.

MONOTECHNIC. Pertaining to a single art or craft.

MORPHOLOGY. The science of form and structure of plants and animals without regard to function.

MYOLOGY. The scientific knowledge of the muscular system.

MYTHOPOEIC. Producing or having a tendency to produce myths.

NOETIC. Of, pertaining to, or conceived by, mind.

NUANCE. Slight shade; difference; distinction; degree.

ORTHOGENIC. Pertaining to right beginning and development.

ORTHOPEDIC. Relating to the art of curing deformities.

OSSUARY. A depository of dry bones.

PALEOPSYCHIC. Pertaining to the antiquity of the soul.

PANTHEISTIC. Relating to that doctrine which holds that the entire phenomenal universe, including man and nature, is the ever-changing manifestation of God, who rises to self-consciousness and personality only in man.

PATRISTICS. That department of study occupied with the doctrines and writings of the fathers of the Christian Church.

PHOBIA. Excessive or morbid fear of anything.

PHYLETICALLY. In accordance with the phylum or race; racially.

PHYLETIC. Pertaining to a race or clan.

PHYLOGENY. The history of the evolution of a species or group; tribal history; ancestral development as opposed to ontogeny or the development of the individual.

PHYLUM. A term introduced by Haeckel to designate the great branches of the animal and vegetable kingdoms. Each phylum may include several classes.

PICKELHAUBE. The spiked helmet of the German army.

PLANKTON. Sea animals and plants collectively; distinguished from coast or bottom forms and floating in a great mass.

POLYGAMIC (LOVE). Pertaining to the habit of having more than one mate of the opposite sex.

POLYPHRASTIC. Having many phrases; pertaining to rambling, incoherent speech.

POST-SIMIAN. Pertaining to an age later than that in which simian or monkey-like forms prevailed.

PRENUBILE. Pertaining to the age before sexual maturity or marriageability is reached.

PRIE DIEU. A praying desk.

PROPEDEUTIC. Preliminary; introductory.

PROPHYLACTIC. Any medicine or measure efficacious in preventing disease.

PSEUDOPHOBIAC. Pertaining to a morbid condition in which the subject is continually in fear of having said something not strictly true.

PSYCHOGENESIS. The origin and development of soul.

PSYCHONOMIC. Pertaining to the laws of mind.

PSYCHOSIS. Mental constitution or condition; any change in consciousness, especially if abnormal.

PUBERTY. The age of sexual maturity.

PUBESCENT. Relating to the dawning of puberty.

PYGMOID. Of pygmy size and form.

RABULIST. A chronic wrangler; one who argues about everything.

SCHEMA. A synopsis; a summary. In the Kantian sense, a general type.

SCHEMATISM. An outline of any systematic arrangement; an outline.

SUPERFOETATION. A second conception some time after a prior one, by which two foetuses of different age exist together in the same female. Often used figuratively.

TEMIBILITY. (From Italian temibile, to be feared.) The principle of adjustment of penalty to crime in just that degree necessary to prevent a repetition of the criminal act.

TIC. A nervous affection of the muscles; a twitching.

TRANSCENDENTAL. In the Kantian system having an a priori character, transcending experience, presupposed in and necessary to experience.

TRAUMATA. Wounds.

TRAUMATISM. A wound; any morbid condition produced by wounds or other external violence.

VERBIGERATION. The continual utterance of certain words or phrases at short intervals, without reference to their meaning, as seen in insane Gedankenflucht or rapid flight of thought.

Extract from Youth: Its Education, Regimen, and Hygiene, by G. Stanley Hall

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April 9, 2020
Statement of the Twenty-Fourth IHR Emergency Committee
The Twenty-fourth meeting of the Emergency Committee under the International Health Regulations (2005) (IHR) on the international spread of poliovirus was convened by the Director General on 26 March 2020 with committee members only attending
via teleconference, supported by the WHO Secretariat. In order to ease the burden on affected State Parties in the exceptional situation following the determination of the COVID-19 outbreak as a Public Health Emergency of International Concern
(PHEIC) on 30 January 2020, characterized as a pandemic on 11 March 2020, the invited State Parties were asked to present their reports electronically only instead of attending via teleconference. Reports were received from Afghanistan, Burkina
Faso, Central African Republic, Cote d’Ivoire, Democratic Republic of Congo (DR Congo), Ethiopia, Ghana, Pakistan, and Philippines.

The Emergency Committee reviewed the data on wild poliovirus (WPV1) and circulating vaccine derived polioviruses (cVDPV). The WHO Secretariat presented a report of progress for affected IHR States Parties subject to Temporary Recommendations.

Wild poliovirus

The Committee remains gravely concerned by the significant increase in WPV1 cases globally in 2019 and 2020, with 175 cases in 2019 compared to 33 in 2018, and already 32 cases as at 17 March 2020, compared to six for the same period in 2019, with no
significant success yet in reversing this trend.

In Pakistan transmission continues to be widespread, as indicated by both acute flaccid paralysis (AFP) surveillance and environmental sampling. While the issues of vaccine hesitancy and refusals by individuals and communities and problems with management
of the national polio program are being addressed, these are yet to have impact on the current worrying epidemiology. The added pressure on the program due to detection of cVDPV2 and ongoing spread in several provinces (see below) has continued
into 2020.

In Afghanistan, the security situation remains very challenging. Inaccessibility and missed children particularly in the Southern Region have led to a large cohort of susceptible children in this part of Afghanistan. The risk of a major upsurge
of cases is growing, with other parts of the country that have been free of WPV1 for some time now at risk of outbreaks. This would again increase the risk of international spread.

The Committee noted that based on sequencing of viruses, there were recent instances of international spread of viruses from Pakistan to Afghanistan and also from Afghanistan to Pakistan. The recent increased frequency of WPV1 international
spread between the two countries suggests that rising transmission in Pakistan and Afghanistan correlates with increasing risk of WPV1 exportation beyond the single epidemiological block formed by the two countries.

The Committee noted the continued cooperation and coordination between Afghanistan and Pakistan, particularly in reaching high risk mobile populations that frequently cross the international border and welcomed the all-age vaccination now being taken
at key border points between the two countries.

Vaccine derived poliovirus (VDPV)

The multiple cirulating VDPV (cVDPV) outbreaks in four WHO regions (African, Eastern Mediterranean, South-east Asian and Western Pacific Regions) are very concerning, with two new countries reporting outbreaks since the last meeting (Malaysia and Burkina
Faso). Unlike historical experience, cross border spread of cVDPV2 has become quite common, with recent spread from Angola to DR Congo and Zambia, and from Chad and CAR to Cameroon, and from Ghana to Burkina Faso. In addition, local emergences
attributable to mOPV2 use have recently occurred in Togo, Chad and Ethiopia.

The Committee noted that the GPEI has published a strategy to address cVDPV2 outbreaks but was extremely concerned that the monovalent OPV2 stockpile was still depleted. The Committee strongly supports the development and proposed Emergency Use
Listing of the novel OPV2 vaccine which should become available mid-2020, and which it is hoped will result in no or very little seeding of further outbreaks.

Impact of COVID-19

The Committee noted the very recent policy guidance of the GPEI:
- GPEI recommendations for countries during the COVID-19 pandemic. This document summarizes the recommendations from the Polio Oversight Board meeting on 24 March 2020 which calls for postponement of both preventive and outbreak response campaigns,
  while ensuring surveillance and nOPV2 development and roll out plans continue in full.
- The COVID-19 Polio programme continuity plan. The operational guide was developed in collaboration with the regional polio eradication teams and the GPEI Partners to ensure essential GPEI functions continue, polio programme personnel and staff are
  kept safe, and to plan for a fast and effective resumption of polio eradication activities including supplementary immunization activities as soon as the public health situation with COVID-19 allows.
The Committee is extremely concerned about the impact of the COVID-19 pandemic on the risk of heightened transmission of polio and consequently the potential for international spread and significant reversal of polio eradication.

Conclusion

The Committee unanimously agreed that the risk of international spread of poliovirus remains a Public Health Emergency of International Concern (PHEIC) and recommended the extension of Temporary Recommendations for a further three months. However
noting that some if not many international borders are closed to prevent international spread of COVID-19, State Parties may not currently be able to enforce the Temporary Recommendations in all places. The Committee strongly urges countries
subject to these recommendations to maintain a high state of readiness to implement them as soon as possible ensuring the continued safety of travelers as well as health professionals . The Committee recognizes the concerns regarding the lengthy
duration of the polio PHEIC, but concludes that the current situation is extraordinary, with clear ongoing risk of international spread and ongoing need for coordinated international response. The Committee considered the following factors in reaching
this conclusion:
- Rising risk of WPV1 international spread: The progress made in recent years appears to have reversed, with the Committee’s assessment that the risk of international spread is at the highest point
  since 2014 when the PHEIC was declared. This risk assessment is based on the following:
  - the WPV1 exportation in 2019 from Pakistan to Iran and to Afghanistan, and more recently spread from Afghanistan to Pakistan;
  - ongoing rise in the number of WPV1 cases and positive environmental samples in Pakistan, and to a lesser extent Afghanistan;
  - the quickly increasing cohort of unvaccinated children in Afghanistan, with the risk of a major outbreak imminent if nothing is done to access these children;
  - the urgent need to overhaul the leadership and strategy of the program in Pakistan, which although already commenced, is likely take some time to lead to more effective control of transmission
    and ultimately eradication;
  - increasing community and individual resistance to the polio program.
- Rising risk of cVDPV international spread: The clearly documented increased spread in recent months of cVDPV2 demonstrate the unusual nature of the current situation, as international spread of cVDPV
  in the past has been very infrequent. The number of new emergences of cVDPV2 in Africa raises further concern. The risk of new outbreaks in new countries is considered extremely high, even probable.
- COVID-19: This new and unprecedented pandemic is likely to substantially negatively impact the polio eradication program and outbreak control efforts. There is a risk of exportation of both
  WPV1 and cVDPV to known high risk countries, to which it may take a lot of time and effort to adequately respond.
- Falling PV2 immunity: Global population mucosal immunity to type 2 polioviruses (PV2) continues to fall, as the cohort of children born after OPV2 withdrawal grows, exacerbated by poor coverage
  with IPV particularly in some of the cVDPV infected countries.
- Multiple outbreaks: The evolving and unusual epidemiology resulting in rapid emergence and evolution of cVDPV2 strains is extraordinary and not yet fully understood and represents an additional risk
  that is yet to be quantified.
- Weak routine immunization: Many countries have weak immunization systems that can be further impacted by various humanitarian emergencies including COVID19, and the number of countries in which immunization
  systems have been weakened or disrupted by conflict and complex emergencies poses a growing risk, leaving populations in these fragile states vulnerable to outbreaks of polio.
- Surveillance gaps: The appearance of highly diverged VDPVs in the Philippines, Somalia and Indonesia are examples of inadequate polio surveillance, heightening concerns that transmission could be missed
  in various countries. Furthermore, the missed transmission in China for a year illustrates that even countries with generally good surveillance can miss VDPV transmission. COVID-19 is likely to have a negative impact on polio surveillance
  also.
- Lack of access: Inaccessibility continues to be a major risk, particularly in several countries currently infected with WPV or cVDPV, i.e. Afghanistan, Nigeria, Niger, Somalia and Myanmar, which all
  have sizable populations that have been unreached with polio vaccine for prolonged periods.
- Population movement: The risk is amplified by population movement, whether for family, social, economic or cultural reasons, or in the context of populations displaced by insecurity and returning refugees.
  There is a need for international coordination to address these risks. A regional approach and strong crossborder cooperation is required to respond to these risks, as much international spread of polio occurs over land borders.
Risk categories

The Committee provided the Director-General with the following advice aimed at reducing the risk of international spread of WPV1 and cVDPVs, based on the risk stratification as follows:
- States infected with WPV1, cVDPV1 or cVDPV3, with potential risk of international spread.
- States infected with cVDPV2, with potential risk of international spread.
- States no longer infected by WPV1 or cVDPV, but which remain vulnerable to re-infection by WPV or cVDPV.
Criteria to assess States as no longer infected by WPV1 or cVDPV:
- Poliovirus Case: 12 months after the onset date of the most recent case PLUS one month to account for case detection, investigation, laboratory testing and reporting period OR when all reported AFP cases with onset within 12 months of last case have been tested for polio and excluded for WPV1 or cVDPV, and environmental or other samples collected within 12 months of the last case have also tested negative, whichever is the longer.
- Environmental or other isolation of WPV1 or cVDPV (no poliovirus case): 12 months after collection of the most recent positive environmental or other sample (such as from a healthy child) PLUS one month to account for the laboratory testing and reporting period
- These criteria may be varied for the endemic countries, where more rigorous assessment is needed in reference to surveillance gaps (e.g. Borno State, Nigeria)
Once a country meets these criteria as no longer infected, the country will be considered vulnerable for a further 12 months. After this period, the country will no longer be subject to Temporary Recommendations, unless the Committee has concerns based on the final report.

TEMPORARY RECOMMENDATIONS

States infected with WPV1, cVDPV1 or cVDPV3 with potential risk of international spread

WPV1

Afghanistan                               (most recent detection 25 February 2020)

Pakistan                                                (most recent detection 2 March 2020)

Nigeria                                      (most recent detection 27 Sept 2016)

cVDPV1

Malaysia                                     (most recent detection 26 October 2019)

Myanmar                                   (most recent detection 9 August 2019)

Philippines                                 (most recent detection 28 October 2019)

These countries should:
- Officially declare, if not already done, at the level of head of state or government, that the interruption of poliovirus transmission is a national public health emergency and implement all required measures to support polio eradication; where such declaration has already been made, this emergency status should be maintained as long as the response is required.
- Ensure that all residents and longterm visitors (i.e. > four weeks) of all ages, receive a dose of bivalent oral poliovirus vaccine (bOPV) or inactivated poliovirus vaccine (IPV) between four weeks and 12 months prior to international travel.
- Ensure that those undertaking urgent travel (i.e. within four weeks), who have not received a dose of bOPV or IPV in the previous four weeks to 12 months, receive a dose of polio vaccine at least by the time of departure as this will still provide benefit, particularly for frequent travelers.
- Ensure that such travelers are provided with an International Certificate of Vaccination or Prophylaxis in the form specified in Annex 6 of the IHR to record their polio vaccination and serve as proof of vaccination.
- Restrict at the point of departure the international travel of any resident lacking documentation of appropriate polio vaccination. These recommendations apply to international travelers from all points of departure, irrespective of the means of conveyance (e.g. road, air, sea).
- Further intensify crossborder efforts by significantly improving coordination at the national, regional and local levels to substantially increase vaccination coverage of travelers crossing the border and of high risk crossborder populations. Improved coordination of crossborder efforts should include closer supervision and monitoring of the quality of vaccination at border transit points, as well as tracking of the proportion of travelers that are identified as unvaccinated after they have crossed the border.
- Further intensify efforts to increase routine immunization coverage, including sharing coverage data, as high routine immunization coverage is an essential element of the polio eradication strategy, particularly as the world moves closer to eradication.
- Maintain these measures until the following criteria have been met: (i) at least six months have passed without new infections and (ii) there is 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 the state meets the above assessment criteria for being no longer infected.
- Provide to the Director-General a regular report on the implementation of the Temporary Recommendations on international travel.
States infected with cVDPV2s, with potential or demonstrated risk of international spread

Afghanistan           (most recent detection 8 January 2020)

Angola                      (most recent detection 9 February 2020)

Benin                        (most recent detection 9 December 2020)

Burkina Faso          (most recent detection 11 January 2020)

Cameroon              (most recent detection 30 January 2020)

CAR                           (most recent detection 5 February 2020)

Chad                         (most recent detection 5 February 2020)

Cote d’Ivoire          (most recent detection 11 February 2020)

China                        (most recent detection 25 April 2019)

DR Congo                 (most recent detection 22 January 2020)

Ethiopia                (most recent detection 21 February 2020)

Ghana                      (most recent detection 28 January 2020)

Malaysia                 (most recent detection 18 January 2020)

Niger                         (most recent detection 3 April 2019)

Nigeria                  (most recent detection1 January 2020)

Pakistan                   (most recent detection 12 February 2020)

Philippines              (most recent detection 16 January 2020)

Somalia                    (most recent detection 4 February 2020)

Togo                          (most recent detection 10 January 2020)

Zambia                     (most recent detection 25 November 2019)

These countries should:
- Officially declare, if not already done, at the level of head of state or government, that the interruption of poliovirus transmission is a national public health emergency and implement all required measures to support polio eradication; where such declaration has already been made, this emergency status should be maintained.
- Noting the existence of a separate mechanism for responding to type 2 poliovirus infections, consider requesting vaccines from the global mOPV2 stockpile based on the recommendations of the Advisory Group on mOPV2.
- Encourage residents and longterm visitors to receive a dose of IPV four weeks to 12 months prior to international travel; those undertaking urgent travel (i.e. within four weeks) should be encouraged to receive a dose at least by the time of departure.
- Ensure that travelers who receive such vaccination have access to an appropriate document to record their polio vaccination status.
- Intensify regional cooperation and crossborder coordination to enhance surveillance for prompt detection of poliovirus, and vaccinate refugees, travelers and crossborder populations, according to the advice of the Advisory Group.
- Further intensify efforts to increase routine immunization coverage, including sharing coverage data, as high routine immunization coverage is an essential element of the polio eradication strategy, particularly as the world moves closer to eradication.
- Maintain these measures until the following criteria have been met: (i) at least six months have passed without the detection of circulation of VDPV2 in the country from any source, and (ii) there is 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 the state meets the criteria of a ‘state no longer infected’.
- At the end of 12 months without evidence of transmission, provide a report to the Director-General on measures taken to implement the Temporary Recommendations.
States no longer infected by WPV1 or cVDPV, but which remain vulnerable to re-infection by WPV or cVDPV

WPV1
- none
  cVDPV
  - Kenya cVDPV2 (last env positive specimen 21 March 2018)
  - Mozambique cVDPV2 (last virus detected 17 December 2018)
  - PNG cVDPV1 (last environmental positive specimen 6 November 2018)
  - Indonesia cVDPV1 (last virus detected 13 February 2019)
These countries should:
- Urgently strengthen routine immunization to boost population immunity.
- Enhance surveillance quality, including considering introducing supplementary methods such as environmental surveillance, to reduce the risk of undetected WPV1 and cVDPV transmission, particularly among high risk mobile and vulnerable populations.
- Intensify efforts to ensure vaccination of mobile and crossborder populations, Internally Displaced Persons, refugees and other vulnerable groups.
- Enhance regional cooperation and cross border coordination to ensure prompt detection of WPV1 and cVDPV, and vaccination of high risk population groups.
- Maintain these measures with documentation of full application of high quality surveillance and vaccination activities.
- At the end of 12 months without evidence of reintroduction of WPV1 or new emergence and circulation of cVDPV, provide a report to the Director-General on measures taken to implement the Temporary Recommendations.
Additional considerations

Impact of COVID-19 on the polio program:
- The committee urges all countries, but particularly those at high risk of polio, to maintain a high level of polio surveillance throughout the pandemic period, noting that the postponement of polio immunization campaigns whether preventive or in response to outbreaks may lead to an increase in polio transmission including international spread. Maintainenance of access to laboratory diagnosis in the face of widespread transport and shipping disruption is critical.
- Secondly, countries affected by campaign postponement should strive to maintain a high degree of operational readiness in order that immunization activities, including border vaccination, can resume quickly adhering to principles of good hygiene and safety for the vaccinee as well as for the health professionals to prevent COVID-19 spread. This includes ensuring teams have access to appropriate personal protective equipment.
- Given the risk of international spread, countries need to ensure that they are ready to use appropriate vaccines, as recommended by the Strategic Advisory Group of Experts on Immunization, in response to new outbreaks.
- The committee urged countries to maximize the use of polio assets to synergistically address the COVID19 pandemic, noting that polio affected countries may be vulnerable to poorer outcomes in the pandemic due to health care system fragility and poorer health status of the population generally.
- Lastly the pandemic should serve as a reminder to high risk countries with poor immunization coverage that infectious disease outbreaks can lead to social and economic disruption as well as straining the health care system, and countries can increase their population resilience and recovery through prioiritising robust immunization programmes. This is relevant not only to polio, but to all other vaccine preventable diseases particularly measles.
Based on the current situation regarding WPV1 and cVDPV, and the reports provided by affected countries, the Director-General accepted the Committee’s assessment and on 7 April 2020 determined that the situation relating to poliovirus continues to constitute a PHEIC, with respect to WPV1 and cVDPV. The Director-General endorsed the Committee’s recommendations for countries meeting the definition for ‘States infected with WPV1, cVDPV1 or cVDPV3 with potential risk for international spread’, ‘States infected with cVDPV2 with potential risk for international spread’ and for ‘States no longer infected by WPV1 or cVDPV, but which remain vulnerable to re-infection by WPV or cVDPV’ and extended the Temporary Recommendations under the IHR to reduce the risk of the international spread of poliovirus, effective 7 April 2020.

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April 9, 2020