Guidance for the response and management of a poliovirus event or outbreak in Canada

August 2023

Acronyms
Goals and objectives
1. Introduction
2. Definition of a poliovirus event or outbreak
3. Importance of rapid detection, notification, and investigation
4. Federal/provincial/territorial roles and responsibilities
5. Case classifications
6. Detection
7. Notification
8. Investigation
9. Management of cases and contacts
- 9.1 Management of cases
- 9.2 Management of contacts
10. Risk assessment
11. Public health response to a poliovirus event or outbreak in Canada
Acknowledgements
Resources
Annexes
Selected references

Acronyms

AFP: Acute Flaccid Paralysis
bOPV: Bivalent Oral Poliovirus Vaccine
CCDR: Canada Communicable Disease Report
CDC: Centers for Disease Control and Prevention
CPS: Canadian Paediatric Society
CPSP: Canadian Paediatric Surveillance Program
CNPHI: Canadian Network for Public Health Intelligence
GAP: Global Action Plan (for poliovirus containment)
GPEI: Global Polio Eradication Initiative
HPTA: Human Pathogens and Toxins Act
IHR: International Health Regulations (2005)
IPV: Inactivated Poliovirus Vaccine
NAC: National Authority for Containment (of Poliovirus)
NACI: National Advisory Committee on Immunization
nOPV: Novel Oral Poliovirus Vaccine
NML: National Microbiology Laboratory
OPV: Oral Poliovirus Vaccine
PHEIC: Public Health Emergency of International Concern
PAHO: Pan American Health Organization
PEF: Poliovirus Essential Facility
PHAC: Public Health Agency of Canada
PIM: Potentially Infectious Material (poliovirus)
PT: Provinces and Territories or Provincial/Territorial
PID: Primary Immunodeficiency Disorder
SOP: Standard Operating Procedure(s)
VAPP: Vaccine-Associated Paralytic Poliomyelitis
cVDPV: Circulating Vaccine-Derived Poliovirus
VDPV: Vaccine-Derived Poliovirus
WHO: World Health Organization
WPV: Wild Poliovirus

Goals and objectives

The Guidance for the Response and Management of a Poliovirus Event or Outbreak in Canada provides best practices to help prepare for, detect, and control poliovirus and defines roles and responsibilities for a coordinated response across the country. The objectives of the actions described in the Guidance are:

Enhance rapid and early detection, notification, and investigation to support timely implementation of public health controls to limit spread and support global polio eradication
Reduce the health impact of poliovirus on the people of Canada
Ensure public health responses based on best practices, scientific evidence, and expert input

1. Introduction

1.1 Polio

Polio (poliomyelitis) is a highly infectious viral disease that can infect the central nervous system and damage the nerve cells that activate muscles. While most people infected with poliovirus show no symptoms, others will become symptomatic, including a small proportion who can develop serious symptoms such as paralysis. In countries with low childhood immunization coverage, poliovirus infections are more common in children less than five years of age; however, any person who is not immune to poliovirus, regardless of age, can become infected. Transmission of poliovirus occurs predominantly through the fecal-oral route, particularly in areas with poor sanitation (that is, where excreted virus can contaminate food or water, or spread directly from one person to the other). Spread via the respiratory route is also possible but is less frequent.

The international spread of poliovirus has been identified as a public health emergency of international concern (PHEIC) by the World Health Organization (WHO) Director-General since 2014. The PHEIC introduced temporary recommendations to reduce the international spread to support polio eradication and prevent reintroduction of poliovirus in regions that have achieved elimination.^{Reference 1}

Three serotypes of wild poliovirus (WPV) exist – type 1, type 2, and type 3. Due to the efforts of the Global Polio Eradication Initiative (GPEI), WPV type 2 was declared eradicated in September 2015, with the last case detected in India in 1999.^{Reference 2} WPV type 3 was declared eradicated in October 2019, with the last case detected in Nigeria in 2012.^{Reference 3} As of March 2023, WPV type 1 remains endemic in Pakistan and Afghanistan.

There is no specific medication for polio and care is supportive in nature. The disease can be prevented through vaccination. There are two types of polio vaccines in use globally, the inactivated poliovirus vaccine (IPV) and the oral poliovirus vaccine (OPV). IPV, or Salk vaccine, consists of inactivated (killed) poliovirus strains for serotypes 1, 2, and 3 that are not capable of replicating and is administered by injection. IPV does not induce immunity in the gut and, therefore, if someone who has been vaccinated with IPV gets exposed to poliovirus, they can still transmit poliovirus by shedding the virus in their stool. OPV, or Sabin vaccine, contains live weakened virus that is administered orally. It replicates in the intestine to stimulate a protective immune response and is effective at interrupting transmission of the virus. Both IPV and OPV are safe, highly effective in preventing paralytic disease, and have been a critical part of global eradication efforts. In Canada, only IPV has been used since 1995/1996.

Following OPV administration, the vaccine virus is excreted in the stool and can spread from person to person via the fecal-oral route. Therefore, Sabin or Sabin-like vaccine viruses can be found in environmental sewage samples in regions where OPV is used or in an area to which someone who recently received OPV travels.

Along with wild poliovirus, vaccine-derived poliovirus (VDPV) is another form of poliovirus present globally. VDPV can develop in communities with low vaccination coverage when the live OPV virus mutates by spreading from one under-vaccinated individual to another over a long period of time (~12-18 months) or in rare cases, replicating for a prolonged time in a host who is immunocompromised. In this way, OPV strains can lose their attenuated (weakened) properties and revert to a virulent form, resulting in VDPV which behaves similar to the wild-type virus and can be just as pathogenic and transmissible. By definition, a strain will be classified as VDPV if the viral capsid (VP1) genomic region is > 1% divergent (meaning >=10 nucleotide changes) from the serotype 1 and 3 OPV strains or > 0.6% divergent (meaning >=6 nucleotide changes) from the serotype 2 OPV strain. A viral strain that is < 1% (type 1 or 3) or < 0.6% divergent (type 2) to the vaccine strain is classified as Sabin-like or vaccine-like.^{Reference 4}

When there is evidence of person-to-person transmission of VDPV in a community, VDPVs are defined as circulating, or cVDPVs. People who are fully immunized against polio (either with IPV or OPV) will be protected against paralysis caused by both wild-type poliovirus and VDPV.

Vaccine-associated paralytic poliomyelitis (VAPP) is different from vaccine-derived poliovirus (VDPV). VAPP is a rare adverse event from OPV vaccination occurring when one of the attenuated, or weakened, viruses in the OPV causes paralytic polio in someone who has received OPV or their close contacts. In Canada, IPV is used exclusively for vaccination and carries no risk of VAPP. All provinces and territories (PTs) publicly fund IPV as part of routine immunization programs.^{Reference 5}

The WHO recommends that all children are vaccinated against polio. As WPV type 2 was eradicated in 2015 and most cVDPVs detected around the world are type 2, the type 2 component of OPV was removed in favour of a bivalent (types 1 and 3) OPV (bOPV) in 2016.^{Reference 6} As of April 2019, all countries continuing to use bOPV have incorporated at least one dose of IPV into routine immunization programs.^{Reference 7} The WHO provides immunization schedule recommendations for countries using a combination of IPV and OPV through position papers on polio vaccines.^{Reference 8}

As of November 2020, the WHO authorized under emergency use a new vaccine, the novel OPV type 2 (nOPV2), in certain situations to respond to outbreaks of cVDPV2.^{Reference 9} nOPV2 is a modified version of the monovalent OPV2 that provides comparable protection but is more genetically stable and less likely to be associated with the emergence of VDPV.^{Reference 10} As nOPV2 is being used under the WHO’s Emergency Use Listing, countries need to meet specified criteria prior to use and it is being closely monitored for effectiveness and safety, including assessing if it has any ability to revert to a more virulent form that behaves similar to wild-type poliovirus.^{Reference 11} nOPV2 is being assessed for full vaccine licensure and novel OPVs targeting types 1 and 3 are also in development.^{Reference 12}

1.2 Canadian context

Polio has been nationally notifiable since 1924 and is included in the Canadian Notifiable Disease Surveillance System CNDSS. In addition, to ensure Canada maintains its polio free status in accordance with the WHO, the Public Health Agency of Canada (PHAC), in conjunction with the Canadian Paediatric Society (CPS), conducts surveillance of Acute Flaccid Paralysis (AFP) in children less than 15 years of age. AFP is a possible outcome of poliovirus infection that involves the acute onset of paralysis in one or more limbs but can also be caused by a number of other viruses, as well as other causes. By actively seeking out cases of AFP in Canada and ruling out polio, Canada is able to provide ongoing evidence that the country remains polio free. Canada reports AFP cases to the Pan American Health Organization (PAHO) twice yearly. The performance of AFP surveillance is evaluated based on three key indicators established by the WHO:

Detect at least one case of non-polio AFP annually per 100 000 population aged less than 15 years.
All AFP cases should have a full clinical and virological investigation with at least 80% of AFP cases having ‘adequate’ stool specimens collected.
At least 80% of AFP cases should have a follow-up examination for residual paralysis at 60 days after the onset of paralysis.

Canada, and many other countries who have achieved polio elimination, do not consistently meet the key AFP surveillance indicators for reasons including the availability of rapid diagnostics that confirm an alternative diagnosis, retrospective reporting of AFP cases, and lack of clinician knowledge about stool testing requirements.^{Reference 13} Although AFP surveillance in Canada does not conform to the WHO indicators, the Canadian AFP Surveillance System continues to be a sensitive and active surveillance system for the prompt and appropriate investigation of AFP cases to detect polio.

No endemic cases of wild poliovirus have been found in Canada since 1979 and Canada was certified polio free by the WHO in 1994.^{Reference 14} Cases of wild poliovirus in Canada reported since that time have been associated with importations from countries where the virus was still circulating. Canada has not detected wild poliovirus since 1996. Since 2004, there have been four detections of Sabin-like poliovirus in non-paralytic cases and one likely case of VAPP reported in Canada, all of which were imported from locations outside of Canada where OPV was used.^{Reference 15} Until polio eradication has been achieved globally and OPV is no longer used, there remains a small risk of importation of poliovirus (wild-type, Sabin or Sabin-like, or vaccine-derived poliovirus) into Canada.

Under the 71st World Health Assembly (2018) resolution, Canada has made international commitments on poliovirus biocontainment. The WHO’s Global Action Plan 4th edition (GAPIV) for poliovirus biocontainment identifies facility-related containment breaches (such as a laboratory or vaccine production facility) as a major risk for polio re-emergence in a post-eradication world.^{Reference 16} In Canada, eradicated polioviruses are stored only in certified Poliovirus Essential Facilities (PEFs) which are audited by the National Authority for Containment (NAC) within the Centre for Biosecurity, PHAC.

The risk of polio in Canada is minimal due to best biosecurity practices, good sanitation, and high polio vaccine coverage. High IPV coverage prevents paralysis should there be any circulation of the virus. In 2019, 91.9% of 2-year-olds in Canada received the recommended three or more doses of polio vaccine.^{Reference 17} However, national coverage estimates from 2019 are from before the COVID-19 pandemic, and there continue to be communities within Canada with low immunization coverage. Recent updates from PTs indicate that there have been disruptions, delays, and gaps in immunization activities. National data to understand the impact of the COVID-19 pandemic on childhood vaccination coverage are not yet available.

1.3 Guidance development

The Guidance developed for use during a poliovirus event or outbreak in Canada and builds on the following: Protocol for the investigation of AFP and suspected paralytic poliomyelitis (1998 CCDR article) and GPEI SOP: Responding to Poliovirus event or outbreak (Version 4, March 2022)

The Guidance should be used in conjunction with the Federal/Provincial/Territorial Public Health Response Plan for Biological Events.

2. Definition of a poliovirus event or outbreak

The Guidance outlines the response and management to a poliovirus (wild-type poliovirus [(WPV]), vaccine-derived poliovirus [(VDPV]), or Sabin/Sabin-like) event or outbreak. A poliovirus event is intended to capture detections of poliovirus from human, environmental (wastewater), or facility-related sources that do not indicate local circulation. A poliovirus outbreak are detections that suggest community level transmission.

The definitions below are adapted from the GPEI SOP: Responding to Poliovirus event or outbreak (Version 4, March 2022).

The criteria to confirm paralytic poliomyelitis or nonparalytic poliovirus infection in a person is outlined below in Section 5: Case Classifications.

A poliovirus event is defined as:

Detection in a person:
- Detection of confirmed paralytic poliomyelitis (wild-type or VDPV/cVDPV) in a person with a travel history to an area with poliovirus circulating within 35 days before onset of paralysis, and no evidence of local community transmission in Canada ;or
- Detection of laboratory-confirmed nonparalytic poliovirus infection with a travel history to an area with poliovirus circulating within 6 weeks before poliovirus detection^{Reference a} in the person, and no evidence of local community transmission in Canada; or
- Vaccine-associated paralytic poliomyelitis (VAPP):
  - VAPP in a recipient of OPV who received the OPV in the 7 to 35 days before onset of paralysis; or
  - VAPP in a close contact of a recipient of OPV, where the exposure in the close contact occurred within the communicable period of the OPV recipient (within up to 6 weeks after receipt of OPV).
Environmental detection:
- Single environmental (wastewater) laboratory-confirmed (by Canada’s National Microbiology Laboratory [NML]) detection of WPV, VDPV, or Sabin/Sabin-like; or
- Multiple environmental (wastewater) NML-confirmed detections of Sabin/Sabin-like type 1 or 3.
- Multiple environmental (wastewater) NML-confirmed detections if they do not meet the criteria for an outbreak below (for example the detections are from one site within 2 months and no evidence of ongoing viral replication).
Facility-related^{Reference b}: Confirmed type-specific poliovirus exposure, spill, or breach in a laboratory or vaccine production facility that handles poliovirus.

A poliovirus outbreak is defined as:

Detection of confirmed poliovirus infection (paralytic or nonparalytic) in a person (unless defined as a “poliovirus event” above); or
Two separate NML-confirmed detections from the environment (WPV, VDPV, Sabin/Sabin-like type 2), where “separate” means the samples were collected from two different sites with no overlapping catchment areas or from the same site but at least two months apart; or
Any newly detected cVDPV^{Reference c}, whether in a person or environmental sample; that is, when a VDPV isolated either in human stool or the environment can immediately be genetically linked to another VDPV in the community, thereby confirming circulation in the areas of detection.

3. Importance of rapid detection, notification, and investigation

Rapid identification of poliovirus is critical for identifying possible transmission. Early detection and subsequent investigation support the timely implementation of public health measures to limit the spread of polioviruses and maintain the elimination status achieved by Canada in 1994. Early identification and investigation are necessary for Canada to notify international partners to facilitate knowledge sharing and international public health cooperation. As such, all levels of the public health system play a role in rapid detection, notification, and investigation of a poliovirus event or outbreak.

4. Federal/provincial/territorial roles and responsibilities

Below is an overview of the roles and responsibilities of PHAC, the provincial/territorial and local/regional public health authorities, and the role of laboratories at all levels during a public health response to a poliovirus event or outbreak. Should the severity, scope, or significance require a coordinated federal, provincial, territorial response, please refer to the Federal, Provincial, Territorial Public Health Response Plan for Biological Events - Appendix C for a list of federal health portfolio and PT roles and responsibilities and consider activation of applicable operations centres.

4.1 PHAC

PHAC’s roles in a poliovirus event or outbreak, in collaboration with the PHAC’s National Microbiology Laboratory (NML) (whose specific roles are detailed below), include providing guidance and expert advice, coordinating inter-provincial/territorial and international collaboration and communication, and developing and coordinating PHAC’s risk assessments. PHAC may also play a supporting role in coordinating outbreak investigation committees with PTs in the case of multi-jurisdictional outbreaks, or outbreaks or events requiring national coordination and collaboration. PHAC will provide investigative support if requested by a province or territory. In its role as the National International Health Regulations (IHR) Focal Point for Canada, PHAC is also responsible for notifying the WHO of events that may constitute a public health emergency of international concern (PHEIC). PHAC, in collaboration with the affected PT(s), will share timely event information with other regions in Canada. In addition, Canada’s National Authority for Containment (NAC) of poliovirus is responsible for maintaining the national poliovirus inventory, and for auditing and inspecting Poliovirus Essential Facilities (PEFs) under the WHO’s Global Action Plan 4th edition (GAPIV) and the Canadian Human Pathogens and Toxins Act (HPTA) legislation. The National Advisory Committee on Immunization (NACI) and NACI Secretariat within PHAC provide guidance on the use of polio vaccines in situations where increased risk of exposure to poliovirus is anticipated.

4.2 Provincial/territorial and local/regional

PTs and local/regional levels are responsible for front-line diagnostics, sample collection of suspected cases, and provision of public health and health care services, including vaccination programs, to individuals within their jurisdictions. Local public health authorities are responsible for initiating investigations following the detection of poliovirus as well as case and contact management, and ensuring appropriate infection prevention and control practices are followed, where applicable. PT and local health authorities should provide information collected through public health investigation and share subject matter expertise with PHAC, to support a collaborative response associated with a poliovirus event or outbreak. PTs are also responsible for collaborating with PHAC to share timely event information with other regions in Canada and international partners. Health and public health authorities should also ensure that there are appropriate procedures in place to collect relevant epidemiologic and clinical information that accompany specimens from suspected polio cases, and that the specimens are transported to the testing laboratory safely and efficiently.

4.3 Laboratory

The NML is the only WHO Regional Reference Laboratory for poliovirus in Canada and is a designated PEF subject to the WHO’s GAPIV standard and containment certification scheme. The NML Poliovirus laboratory conducts virus isolation and molecular characterization by genome sequencing and is licensed for controlled activities with polioviruses under the HPTA and Human Pathogens and Toxins Regulations.

As such, all samples that screen positive for poliovirus (if tested) or samples collected from a suspected polio or suspected AFP case should be referred to the NML for poliovirus isolation and molecular characterization. Samples are typically referred to the NML from the provincial/territorial public health laboratory. However, they can also be sent directly to the NML from a hospital or community laboratory. If sending directly, centres are encouraged to report the suspected polio or AFP case to local and/or provincial/territorial public health authority to ensure compliance with PT notifiable disease and conditions reporting guidelines. Due to the possibility of a poliovirus being present, NML will further manipulate samples, as recommended in the WHO Global Action Plan for poliovirus containment.

5. Case classifications

At the time of Guidance development, the national poliovirus case definition was under review. As such, the Guidance refers to the adapted case classification to confirm cases in Table 1. For information about identifying suspected cases, see Section 8.1.1: Index of suspicion for poliomyelitis while awaiting laboratory confirmation.

**Table 1: Case classifications for confirmed paralytic poliomyelitis and nonparalytic poliovirus infection**
Case Classification	Confirmed case
Paralytic poliomyelitis	Clinical features^{table 1 note } compatible with paralytic poliomyelitis with laboratory confirmation of wild-type, vaccine-derived or Sabin/Sabin-like poliovirus detected in a clinical specimen or Clinical features^{table 1 note } compatible with paralytic poliomyelitis in a person who is epidemiologically linked to a laboratory-confirmed case
Nonparalytic poliovirus infection	Any person without symptoms of paralytic poliomyelitis with laboratory confirmation of wild-type, vaccine-derived or Sabin/Sabin-like poliovirus detected in a clinical specimen and Has not been vaccinated with OPV within 6 weeks prior to specimen collection date
Table 1 Notes Table 1 Note * Clinical features. The presence of some or all of these clinical features may suggest paralytic poliomyelitis: acute flaccid paralysis of one or more limbs decreased or absent deep tendon reflexes in the affected limb(s) weakness of facial, oropharyngeal or respiratory muscles no sensory or cognitive loss accompanies the paralysis no other apparent cause (including laboratory investigation to rule out other causes of a similar syndrome) Return to table 1 note * referrer

6. Detection

All samples suspected of containing poliovirus collected by provincial, territorial, and wastewater laboratories must be sent to the NML for testing to determine the presence of poliovirus. Due to the possibility of a poliovirus being present, respiratory, fecal, sewage concentrated samples and their derivatives that were collected at a time and place where poliovirus was in circulation, including samples that are stored under conditions that maintain virus viability^{Reference d} are considered poliovirus Potentially Infectious Materials (PIM). When working with and storing PIM, risk mitigation measures must be followed to prevent facility-related events, as outlined in the WHO PIM Guidance Document (2nd edition). See Annex C for details on PIM requirements.

For all cases compatible with the AFP case definition and all cases with suspicion of poliomyelitis, as outlined in Section 8.1.1: Index of suspicion for poliomyelitis while awaiting laboratory confirmation, ensure collection of at least two stool samples (taken at least 24 hours apart and minimum 2 grams per sample) within 14 days after symptom onset for viral studies (although samples can be collected up to 6 weeks after onset if it is not possible to collect earlier). In addition to stool testing, other diagnostic testing and investigations should be conducted, as appropriate, to help detect poliovirus infections or other conditions that may present similarly. These may include:

Collection of respiratory specimens (collected by two oropharyngeal or nasopharyngeal swabs) or cerebrospinal fluid
Neurological investigations, including nerve conduction studies and/or electromyography (EMG), magnetic resonance imaging (MRI), or computed tomography (CT) scan

Stool (two samples taken at least 24 hours apart) is the required clinical specimen for the laboratory investigation and diagnosis of poliovirus infections. A stool sample is preferred to a rectal swab because the diagnosis of poliovirus is more reliable. Stool samples are to be placed in a sterile leak proof container, frozen at ≤-20°C until sent for testing and shipped frozen on dry ice. No special medium is required. For information on specimen, collection, and other laboratory details for clinical samples, please refer to the NML’s Molecular Detection and Characterization. See more details on laboratory protocols in Annex C.

For environmental wastewater samples suspected of containing poliovirus, samples should be packaged by the collecting lab and sent to the NML, as per the guidance described in the NML’s Molecular Detection of SARS-CoV-2 from Wastewater. See more details on submission of wastewater samples for laboratory testing in Annex C.

7. Notification

7.1 Reporting within a province or territory

Any poliovirus event or outbreak (as defined in Section 2: Definition of a poliovirus event or outbreak) should be reported immediately to the local/regional public health authority and the provincial/territorial public health authorities and laboratories. Health authorities should also be notified for cases pending laboratory confirmation with suspicion of poliomyelitis, as outlined in Section 8.1.1: Index of suspicion for poliomyelitis while awaiting laboratory confirmation.

Cases compatible with the AFP case definition must be reported to the local public health authority, if legislatively required within the jurisdiction.

7.2 Reporting between PT authorities and PHAC

Polio is a nationally notifiable disease in Canada. Further, to support compliance with the International Health Regulations (IHR), all PTs are to notify PHAC authorities (email: vpd-mev@phac-aspc.gc.ca and hpoc-cops@phac-aspc.gc.ca) within 24 hours of PT detection of poliovirus for any poliovirus event or outbreak (as defined in Section 2: Definition of a poliovirus event or outbreak).

When reporting a case to PHAC, indicate if the case meets the case classification noted in Section 5: Case classifications. In addition to confirmed cases, consider reporting cases under investigation to PHAC that are compatible with the list of clinical features and have a higher index of suspicion for poliomyelitis, as outlined in Section 8.1.1: Index of suspicion for poliomyelitis while awaiting laboratory confirmation.

For a confirmed environmental detection or a facility-related incident, there are additional notification obligations. The appropriate local and PT public health officials and PHAC must be notified of all environmental samples that are confirmed of containing poliovirus by the NML within 24 hours. In the event of a facility-related event involving poliovirus, the HPTA-regulated PEF must notify the Centre for Biosecurity through the secure Biosecurity Portal (Laboratory Incident Notification Canada) in accordance with the HPTA 12(1) and HPTA 13.

A Canadian Network for Public Health Intelligence (CNPHI) Public Health Alert should be considered to allow for the timely notification and/or dissemination of information between local/regional, PT and national public health stakeholders. PHAC/NML can collaborate with local/regional and PT authorities to issue an alert, where necessary.

7.3 Reporting by PHAC to WHO

Day “0” for international reporting (to the WHO) is defined as the day the NML confirms a positive laboratory result for poliovirus by genetic sequencing (VDPV, WPV, Sabin/Sabin-like) from either human or environmental wastewater samples.

Under the IHR, Canada has an obligation to report, through an Article 6 Notification, all events which may constitute a public health emergency of international concern within its territory^{Reference 18}. The relevant technical teams at PHAC have 48 hours to conduct an assessment (from Day 0) using the IHR Annex 2 “decision instrument for the assessment and notification of events that may constitute a public health emergency of international concern” (Annex D), by working in collaboration with the reporting province/territory and the National IHR Focal Point Office.

If, by using the decision instrument, it is determined that the event meets the criteria for Article 6 (Notification) or Article 7 (Information sharing during unexpected or unusual public health events), Canada must alert WHO within 24 hours of assessment. Reporting an Article 6 or Article 7 requires a description of the event with the available details and the written assessment using the IHR Annex 2. The WHO headquarters will inform relevant Global Polio Eradication Initiative (GPEI) partners.

As indicated in the IHR case definitions for diseases requiring notification, all detections of paralytic poliomyelitis due to wild-type poliovirus requires immediate Article 6 Notification in all circumstances. PHAC must send the notification to the respective WHO regional office within 24 hours of NML sequencing a notifiable poliovirus (Day 0) through the National IHR Focal point (hpoc-cops@phac-aspc.gc.ca with a Cc: to ihr-rsi@phac-aspc.gc.ca). Note that in these instances there is no 48-hour period to complete the IHR Annex 2 assessment.

In addition to laboratory confirmed cases of paralytic poliomyelitis due to wild-type poliovirus, the isolation of the following must generally also be reported to the WHO^{Reference 19} as an Article 6 or Article 7, as determined by the public health authorities completing the assessment using the IHR Annex 2:

Wild poliovirus isolation from a case of nonparalytic poliovirus infection
Wild poliovirus isolation from a non-human source (environmental detection)
Vaccine-derived poliovirus (types 1, 2, 3) isolation from human or non-human sources
Sabin/Sabin-like type 2 isolation from human or non-human sources if they were detected from an area where Sabin OPV2 has not been used in the previous four months

For poliovirus events that do not meet the Article 6 Notification or Article 7 criteria, other reporting and information-sharing requirements to the WHO and other National IHR Focal Points may still apply under the Regulations to support transparency and public health response.

Note: Notification to PAHO/WHO may lead to the publication of a Disease Outbreak News or Epidemiological Alert report on the PAHO/WHO public websites, as appropriate, based on virus type, risk assessment and outbreak status as well as on the WHO Event Information Site, which is only accessible to National IHR Focal Points. Further, based on data sharing requirements from the GPEI and the Global Polio Laboratory Network, Canada has the responsibility to share specific geolocation of a poliovirus sample or case testing positive for poliovirus. The location data will be published on a secure site available to the National IHR Focal Points and members of the GPEI.

If an outbreak is declared, consult the Temporary Recommendations issued by the WHO Director-General upon the advice of the IHR Emergency Committee on the international spread of poliovirus. Visit World Health Organization’s website for past statements from the IHR.

Annex A contains figures to illustrate the key initial steps and notification requirements for detecting polio.

8. Investigation

8.1 Investigation of a case

8.1.1 Index of suspicion for poliomyelitis while awaiting laboratory confirmation

If a case with AFP is awaiting laboratory confirmation and is epidemiologically linked to a laboratory confirmed polio case, proceed to Section 8.1.2: Epidemiologic characteristics of poliovirus relevant to investigation and case/contact management, as this meets the case classification for confirmed paralytic poliomyelitis.

For other cases awaiting laboratory results of cases presenting with AFP, the following are high risk factors that raise the index of suspicion regarding poliovirus and would warrant managing the AFP case as a poliomyelitis case:

If the person with AFP received OPV within the previous 35 days
If the person with AFP had exposure to someone who received OPV within the 6 weeks prior to the exposure
If the person with AFP was a contact of someone being investigated for paralysis or poliomyelitis

The management for these higher risk cases awaiting laboratory confirmation include:

Isolating and managing case, as per the considerations in Table 3
Considering initiating contact identification and management, as per the considerations in Table 2, Table 4, and Table 5

Other factors may also increase suspicion that a person with AFP may have poliomyelitis and may warrant beginning early public health management:

Recent travel to area where there is poliovirus
Contact with a recent traveller from an area where there is poliovirus
Comes from or visited a community with a large unimmunized population or where poliovirus has been circulating
Unvaccinated or under-vaccinated (<4 doses of IPV or trivalent OPV, in any combination)

The management for these cases awaiting laboratory confirmation could include the considerations for case and contact management in Tables 2 to 5.

If poliovirus is confirmed, management guidance is provided in Section 8.1.3: Investigation of poliovirus infection (with or without paralysis).

8.1.2 Epidemiologic characteristics of poliovirus relevant to investigation and case/contact management

Period of communicability

Poliovirus can be identified from throat secretions as early as 36 hours after exposure and from stool as early as 72 hours after exposure. The virus persists in the throat for approximately 1 week and in the stool for 3 to 6 weeks. Cases are most infectious in the days before and after onset of first symptoms (which could be non-specific symptoms).

Incubation period

The incubation period is 3 to 6 days for onset of non-specific symptoms. In those that progress to paralysis, this occurs in 7 to 21 days from exposure (can range up to 35 days).

Assumptions for this document

Communicability starts very soon after acquisition of the poliovirus, so in some circumstances for this document, communicability will be considered to start at the time of acquisition of the virus. Therefore, for those with paralytic polio, 35 days (5 weeks) before onset of paralysis is the outer limit of the time of acquisition and approximately the start of the period of communicability. For those with nonparalytic poliovirus infection with poliovirus detected in their stool, 6 weeks before time of detection in stool is the outer limit of the time of acquisition and approximately the start of the period of communicability. For simplicity, 6 weeks will be used in some circumstances as the longest incubation period and start of the period of communicability for those with confirmed poliovirus infection (with or without paralysis) in some places in this document. Circumstances of a particular case or contact could further limit these periods, such as the specific date of return from travel.

Note that in some instances the incubation period and/or period of communicability can be longer. As an example, individuals with primary immunodeficiency disorder can excrete poliovirus for prolonged periods, thereby extending the period of communicability, and meaning the time of acquisition could be considerably earlier than 6 weeks.

In the sections of this document that follows, “detection” refers to either the date of onset of paralysis or date of stool sample collection that was positive for poliovirus (for those with nonparalytic poliovirus infection).

8.1.3 Investigation of poliovirus infection (with or without paralysis)

If poliovirus is detected, public health authorities should initiate investigation within 24 hours after PT or NML detection (do not wait for sequencing or final classification of the virus by the NML). The information collected from investigations will be important to inform risk assessments and international notification obligations to the WHO. PTs and local/regional leads will collaborate to conduct investigations, with support from PHAC where applicable.

In absence of a case investigation form in the corresponding jurisdiction, PHAC recommends using the PAHO polio case investigation form (all sections except Section VII) as a guide to inform public health investigations. The following minimum data requirements should be collected and included in the investigation for each case:

Date of birth and sex
Polio immunization status including total number of doses of OPV and/or IPV received, as well as the date(s) of administration
Exposure to someone who received the OPV, where the exposure occurred within the communicable period (up to 6 weeks after receipt of OPV)
History of travel to/from or residing in another country where there is a risk of poliovirus or OPV exposure within 6 weeks prior to onset of paralysis or collection of positive stool sample (for those without paralytic polio); Details of travel history, including travel dates and locations
Exposure to someone with a travel history to/residing in another country where there is a risk of poliovirus or OPV exposure, where the exposure occurred within the potential communicable period (up to 6 weeks after the traveller returned home) and onset of paralysis or collection of positive stool sample (for those without paralytic polio) occurred within approximately 6 weeks afterward; Details of travel history, including travel dates and locations
Summary of the clinical presentation, course of illness, and final diagnosis (if known)
Results of stool testing (if not available for testing, this should also be indicated in the report)
Results of other appropriate testing/investigations (including oropharyngeal and/or nasopharyngeal swabs, cerebrospinal fluid, nerve conduction studies and/or EMG, MRI, or CT scan), if available (also indicate if tests were not done)
Relevant medical history including immunocompromised status or abnormal neurological history
Whether a member of a group/community that is known to be unvaccinated or under-vaccinated
Final outcome obtained after 60 days after onset of illness

The following data elements should be collected to inform case and contact management:

Information on how to reach the case (phone, email, text, address)
Occupation/school or child care centre attendance
List and information on how to reach household members and close contacts, including if the case lives in a group living arrangement (such as dormitories, shelters, detention centres, group homes, settlement houses) and other contacts as outlined in Table 2, as appropriate
Preparation of meals for others during the period of communicability, with names, dates and information on how to reach them
Possible sources of exposure in the incubation period, if the acquisition source is not clear (such as food shopping stores, imported food consumed, restaurants, meals prepared by others, bathrooms used)

8.1.4 Contact tracing

Follow-up of close contacts is important to identify a potential source of infection if it is not readily apparent (acquisition source) and also to determine those who may have been infected by the case (transmission risk) to prevent further onward spread. Certain contacts may require exclusions (see Section 9.2: Management of contacts) and should thereby be identified without delay. Contact tracing for acquisition is only required if the source is not apparent and possible sources of acquisition are still being investigated (meaning it would not be required if the case had an obvious source of acquisition such as recent travel to a country where poliovirus transmission is occurring or a facility-related exposure). Potential contacts are outlined in Table 2.

Table 2: Potential contacts of a case infected with poliovirus and the possible acquisition and/or transmission risk

Higher risk contacts include: household contacts and those who stayed overnight in the same household as the case; sexual contacts; contacts in group living settings who shared a bathroom with the case or had close interactions with the case (for example, dormitories, shelters, detention centres, group homes, settlement houses); children who attended child care with the case and the child care workers; and those who had contact with the feces of the case (excluding health care providers who used appropriate infection prevention and control practices). Other contacts are generally considered lower risk. The transmission risk for a contact is dependent on the timing and nature of the exposure with the case and is not influenced by the contact’s vaccination status, since those vaccinated with IPV can still become infected and spread infection to others.

Table 2: Potential contacts of a case infected with poliovirus and the possible acquisition and/or transmission risk
Potential contact or exposure source (generally listed from highest to lowest transmission risk)	To determine acquisition source (only relevant if a source of acquisition is not apparent)	To determine transmission risk	Transmission risk level
Household and other close contacts: including those who stayed overnight in the same household as the case, sexual contacts, and contacts in group living settings who shared a bathroom with the case or had close interactions with the case (such as dormitories, shelters, detention centres, group homes, settlement houses), if applicable	If exposure occurred in the case’s incubation period (could include up to 6 weeks before detection)	If exposure occurred while the case was communicable (could include up to 6 weeks before detection until the case was recognized and proper infection prevention and control measures were initiated)	Higher risk contact – See Table 4 for management considerations
Child care contacts: including staff and children in the group/class with the case and groups/classes who had regular interactions with or routinely shared a bathroom with the case’s group/class at the child care centre	If exposure occurred in the case’s incubation period (could include up to 6 weeks before detection)	If exposure occurred while the case was communicable (could include up to 6 weeks before detection until the case was recognized and excluded from the child care setting)	Higher risk contact – See Table 4 for management considerations
Known contact with feces (including changing diapers and assisting with toileting) See last row for health care and laboratory workers handling specimens from the case	If exposure occurred in the case’s incubation period (could include up to 6 weeks before detection)	If exposure occurred while the case was communicable (could include up to 6 weeks before detection until the case was recognized and proper infection prevention and control measures were initiated)	Higher risk contact – See Table 4 for management considerations
Toilet exposure (such as using a common bathroom in a workplace)	If exposure occurred in the case’s incubation period (could include up to 6 weeks before detection)	Those who frequently shared toilets with the case if exposure occurred while the case was communicable (could include up to 6 weeks before detection up until the toilet was appropriately cleaned, disinfected, and not used again by the case)	Generally lower risk contact– See Table 5 for management considerations
Food exposure / handling	Food shopping stores, imported food consumed, restaurants, meals prepared by others in the case’s incubation period (could include up to 6 weeks before detection)	If the case prepared food for others while the case was communicable (could include up to 6 weeks before detection until proper infection prevention and control instituted, particularly if the food was not cooked after handling by the case)	Generally lower risk contact– See Table 5 for management considerations
Health care workers who provided care for the case and laboratory workers who handled specimens from the case	NA	If exposure occurred while the case was communicable (could include up to 6 weeks before detection)	Generally lower risk contact– See Table 5 for management considerations. If the health care worker is determined to not have used adequate personal protective equipment^{table 2 note } and infection prevention and control practices in addition to having substantial close contact or contact with the case’s feces, they could be considered higher risk - See Table 4 for management considerations If the health care worker / laboratory worker is determined to have used adequate personal protective equipment^{table 2 note } and infection prevention and control practices, they could be considered not a contact.
Table 2 Notes Table 2 Note * For information on adequate personal protective equipment for poliovirus, please refer to PHAC’s Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings (2016) - page 83 Return to table 2 note * referrer

The following minimum data requirements should be collected from household members or other higher risk contacts. Collection of some or all of this information on lower risk contacts may also be relevant depending on the circumstances:

Information on how to reach the contact (phone, email, text, address)
Date of birth and sex
Polio immunization status including total number of doses of OPV and/or IPV received, as well as the date(s) of administration
Travel history within 12 weeks before the onset of illness in the case and details of travel history, including dates and locations if the acquisition sources is unclear and the contact could be a possible acquisition source
Whether the contact is experiencing any symptoms, including details of the symptoms and their onset
Whether the contact is a member of a group/community that is known to be unvaccinated or under-vaccinated
Relevant medical history including immunocompromised status or abnormal neurological history
Occupation/school or child care centre attendance
Group living arrangements (for example, dormitories, shelters, detention centres, group homes, settlement houses)
If not a household contact, determine dates, times, and locations of exposure to the case, in the 6 weeks before the case was detected and up until proper infection prevention and control was used. Include if and when the contact prepared food for the case (if the acquisition source of the case is not apparent) or the case prepared food for the contact
For health care workers who provided care for the case and laboratory workers who handled specimens from the case while the case was communicable, determine the dates and types of exposure, and if appropriate, personal protective equipment (see ^{table 2 note *} note above in Table 2 for further information) and infection prevention and control practices were used

In addition to the case and contact investigation, collecting information about the local population, such as vaccination coverage and socio-demographic characteristics of unvaccinated and under-vaccinated individuals in the area, may be warranted to inform risk assessments to assess the potential for transmission.

8.2 Investigation of a detection from environmental wastewater sampling

If a poliovirus of concern (WPV, VDPV, or Sabin/Sabin-like 2) is confirmed in an environmental wastewater sample by NML, local/regional health authorities should initiate investigation within 24 hours of confirmation. Best efforts should be made to gather the following information specific to the sampling site catchment area and neighbouring sites:

Population characteristics (for example, population size included in catchment area, demographics of affected population, polio vaccination coverage, presence of unvaccinated and under-vaccinated groups, vaccine acceptance)
Population movement (for example, migration and travel patterns, cultural/travel links with other affected areas)
Description of the catchment area (for example, location, links with other sites, closed or converging sewer network, density of dwellings)
Relevant institutions (for example, health facilities, schools, poliovirus essential facility (PEF) like a poliovirus vaccine manufacturer or laboratory, transportation centres such as airports, settlement houses for newcomers)
Collection schedule, number and frequency of samples collected, timeliness and completeness of collection

More data elements for consideration are outlined in the GPEI SOP: Responding to Poliovirus event or outbreak (Version 4, March 2022) - Chapter 3

8.3 Investigation of a facility-related event involving poliovirus

The PEF performs investigations of facility-related events with poliovirus in the facility and the NAC would provide containment guidance and oversee the investigation of root causes leading to an event. The contact tracing recommendations included in Section 8.1.4: Contact tracing and other public health follow-up may still be required, and as such, local/regional and PT health authorities should be notified as per Section 7.1: Reporting within a province or territory.

9. Management of cases and contacts

Detecting a poliomyelitis case or non-paralytic poliovirus infection in Canada is likely to be very rare. However, in the event of a case detection, immediate public health precautions should be initiated to prevent transmission. Transmission of poliovirus can put people in Canada who are unvaccinated or under-vaccinated at risk and could endanger Canada’s polio free status. As such, the recommendations regarding case and contact management provided below are restrictive in nature to minimize the risk of transmission. The management recommendations are outlined to support PT decision making and are not intended to supersede existing guidelines or protocols within a jurisdiction.

9.1 Management of cases

General recommendations:

Notify local public health for all cases with suspicion of poliomyelitis, as outlined in the Section 8.1.1: Index of suspicion for poliomyelitis while awaiting laboratory confirmation.
Investigate all cases to help maintain Canada’s polio elimination status, to determine the source of infection, and prevent further cases. Information that should be obtained from the case is outlined above in Section 8.1.3: Investigation of poliovirus infection (with or without paralysis).
Follow all appropriate infection prevention and control measures. Hospitalization is recommended for cases where clinically indicated. For hospitalized patients, admit the patient to a private room with routine practices and contact precautions. Cases that do not require hospitalization are permitted to isolate at home with appropriate infection prevention and control measures. An overview of possible case management recommendations and considerations are outlined in Table 3.
Handle secretions, feces, and contaminated articles using routine practices and contact precautions. In areas where there is modern sewage disposal, feces and urine can be discharged directly into the sewers. Collect and incinerate waste if sanitary sewage is not connected to a municipal wastewater management system.
Report cases compatible with the AFP case definition to the Canadian Paediatric Surveillance Program (CPSP) using the CPSP case questionnaire, in addition to local public health if legislatively required within the jurisdiction.
For cases meeting the AFP case definition, conduct a follow-up assessment of the outcome of paralysis 60 days after onset of paralysis. A follow-up report should be submitted when the information is available.
- Note: the initial report should not be delayed because of incomplete information; however, all relevant case information should be sent in a follow-up report as soon as it is available.

Table 3: Overview of possible polio (with or without paralysis) case management recommendations and considerations

Notes:

The following applies to confirmed cases. Some aspects may also apply to suspect cases while awaiting laboratory results, depending on the level of suspicion that the case has poliomyelitis (such as if the case has paralysis and received OPV within the previous 35 days or is a member of a community with an ongoing outbreak).

Some of the following possible recommendations/considerations are relevant until the case is deemed to be no longer infectious (marked with a *). A case can be considered no longer infectious based on three consecutive negative stool samples each collected at least 24 hours apart. All stool sample testing must be conducted by the NML. The turnaround time for poliovirus isolation in cell culture at the NML is 14 days (See Annex C for details).

Poliovirus in the stool is usually cleared within 3 to 6 weeks in an immunocompetent person. For cases that do not clear the infection in this time frame, such as individuals with primary immunodeficiency disorder, public health management and stool testing will be determined on a case-by-case basis in consultation with public health and infectious disease specialists. Further recommendations can be found in the GPEI's Guidelines for Implementing Poliovirus Surveillance among Patients with Primary Immunodeficiency Disorders (PIDs). The recommendations/considerations below also reflect that there may be unrecognized cases in the household, as the contact investigations may still be ongoing.

Table 3: Overview of possible polio (with or without paralysis) case management recommendations and considerations
Factor	Recommendations and considerations
Isolation and infection prevention and control in health care facilities^{table 3 note *}	The case should be isolated in a private room with a private bathroom. Staff should follow routine practices and contact precautions as per the recommendations of their facility. Only staff who are fully vaccinated^{table 3 note } against poliovirus and are not immunocompromised should provide care for a poliovirus patient. Fully vaccinated^{table 2 note } staff may be offered a single lifetime adult booster dose of IPV-containing vaccine if they have not had one at or after 18 years of age. See “General recommendations” above regarding the handling of sewage and other waste.
Isolation and infection prevention and control at home^{table 3 note *}	Although transmission within the household may already have occurred before the case was recognized, steps should be taken to limit any further transmission. Close contact with others in the household should be avoided as much as possible, including sleeping in a separate bedroom if possible. The case should use a separate bathroom that is not used by anyone else, if possible. If the bathroom must be used by others, it should be cleaned and disinfected after the case has a bowel movement. Use household bleach or 0.5% accelerated hydrogen peroxide for disinfection. In addition, clean and disinfect all bathrooms at least daily. Use household bleach or 0.5% accelerated hydrogen peroxide for disinfection. Reinforce proper hand hygiene with all household members including after using the bathroom, after changing diapers, after cleaning the bathroom, and before preparing, serving or eating food. The case should not share personal items with household members such as towels, bed linen, or unwashed eating utensils, dishes, or drinking glasses. Restrict contact with household members who are immunocompromised, unvaccinated, or under-vaccinated^{table 3 note ***} (such as young children). If the case must provide care or have direct contact with these individuals, the case should perform proper hand hygiene before any contact. See “General recommendations” above regarding the handling of sewage and other waste.
Stool testing^{table 3 note *}	Collect stool samples approximately weekly until the first negative result and then can be collected every day (at least 24 hours apart) until no longer considered infectious.^{table 3 note } For individuals with sustained positive stool samples, stool testing frequency can be determined on a case-by-case basis.^{table 3 note } Proper environmental cleaning and hand hygiene are required after collecting stool samples.
Food preparation^{table 3 note *}	The case should not prepare food for others.
Exclusions^{table 3 note *}	The case should isolate at home until they are no longer infectious (although they can go outside but should not use any bathrooms except in their house and should avoid close contact with others). Special allowances may be required for those who do not clear the infection after six weeks and will be determined on a case-by-case basis in consultation with public health and infectious disease specialists. In these instances, the following should still be avoided: Attendance or work in group childcare settings while the case remains infectious. Preparation of food for others outside of the household (and therefore, must not work as a food handler). Working as a health care provider. Contact with people who are immunocompromised, unvaccinated or under-vaccinated^{table 3 note ***} outside the household.
Visitors^{table 3 note *}	Visitors to the case’s house or room at their health care facility should be restricted to only those who are essential. Essential visitors should avoid the use of the bathrooms in use by the case and the bathrooms in the case’s house. They should not be served food or drinks. They should avoid any close contact with the case and minimize close contact with other household members. Children who may be unable to appropriately wash their hands (typically children younger than 8 years of age), visitors who are immunocompromised and visitors who are unvaccinated or under-vaccinated^{table 3 note ***} should not visit the case.
Clinical management	At this time, there are no specific pharmaceutical therapeutics/antiviral medication against polio, although there may be some investigational therapeutic options available. Clinical case management is at the direction of attending clinicians and includes supportive care directed towards addressing symptoms and complications of acute illness and paralysis. Consultation with an infectious disease specialist and neurologist are recommended, as is early rehabilitation therapy.
Monitoring	Public health officials should be in touch with the case on a regular basis, as appropriate, to ensure compliance with recommended measures and help to problem solve issues that arise. Conduct a follow-up assessment of outcome of paralysis 60 days after its onset, where applicable.
Vaccination	Once determined to no longer be infected with poliovirus based on three consecutive stool samples, unvaccinated or under-vaccinated^{table 3 note ***} cases should be offered polio vaccination (IPV) and other outstanding vaccinations as per the Canadian Immunization Guide.
Table 3 Notes Table 3 Note * These precautions should be in place until three consecutive negative samples are collected, each at least 24 hours apart. All stool sample testing must be conducted by the NML. The turnaround time for poliovirus isolation in cell culture at the NML is 14 days (See Annex C for details). Return to table 3 note * referrer Table 3 Note Fully vaccinated refers to individuals who have received at least four doses of IPV or trivalent OPV (in any combination). Return to table 3 note referrer Table 3 Note * Unvaccinated and under-vaccinated refers to individuals who have received less than four doses of IPV or trivalent OPV (in any combination). This includes children who are up to date for their age but have not received four doses. Return to table 3 note * referrer

9.2 Management of contacts

General recommendations:

A guide to identification of contacts can be found in Table 2 and information that should be obtained from contacts is outlined above in Section 8.1.4: Contact tracing.
A summary of contact management recommendations/considerations are outlined in Table 4 for household and other close and/or higher risk contacts and Table 5 for lower risk contacts.

Table 4: Higher risk contact management recommendations and considerations for poliovirus

Applies to: Household and other close and/or higher risk contacts, including those who stayed overnight in the same household as the case; sexual contacts; contacts in group living settings who shared a bathroom with the case or had close interactions with the case (such as dormitories, shelters, detention centres, group homes, settlement houses); children who attended child care with the case and the child care workers; and those who had contact with the feces of the case (excluding health care providers who used appropriate infection prevention and control practices).

Notes:

Some of the following recommendations/considerations are relevant until the contact is determined not to be infected (marked with a *), based on two consecutive negative stool samples taken at least 48 hours apart, with the first collected at least 4 days after the contact’s last exposure to the case before infection prevention and control measures were initiated. Note that this is a different procedure for stool sample testing compared to the process outlined in Table 3 for a polio case. All stool sample testing must be conducted by the NML. The turnaround time for poliovirus isolation in cell culture at the NML is 14 days (See Annex C for details).

Table 4: Higher risk contact management recommendations and considerations for poliovirus
Factor	Recommendations and considerations
Infection prevention at home^{table 4 note *}	If the contact lives in the same household as the case, the contact should: Avoid sharing personal items with household members such as towels, or unwashed eating utensils, dishes, or drinking glasses. Clean and disinfect the bathrooms at least daily. Use household bleach or 0.5% accelerated hydrogen peroxide for disinfection. Employ proper hand hygiene. Public health should reinforce the need for proper hand hygiene with the contact and all household members including after using the bathroom, after changing diapers, after cleaning the bathroom, and before preparing, serving or eating food. If the contact lives in a separate household from the case (meaning others in the contact’s household are not also contacts), the contact should: Minimize contact with others in their household including sleeping in a separate bedroom if possible. Use a separate bathroom that is not used by anyone else, if possible and clean and disinfect that bathroom at least daily. If the bathroom must be used by others, it should be cleaned and disinfected after the contact has a bowel movement as well as on a daily basis. Use household bleach or 0.5% accelerated hydrogen peroxide for disinfection. Avoid, if possible, contact with household members who are immunocompromised, unvaccinated or under-vaccinated^{table 4 note ***} (such as young children). If the contact must provide care or have direct contact with these individuals, the contact should perform proper hand hygiene before any contact.
Stool testing^{table 4 note *}	Collect the first stool sample at least 4 days after the contact’s last exposure to the case before infection prevention and control measures were initiated, and the second test at least 48 hours after the first stool sample.^{table 4 note *} Proper environmental cleaning and hand hygiene are required after collecting stool samples.
Food preparation^{table 4 note *}	The contact should not work as a food handler. The contact should also avoid preparing food for others who have not been identified as close contacts of the case. The contact should perform proper hand hygiene before any food preparation.
Exclusions^{table 4 note *}	The contact should not use a bathroom outside of the house or be in close contact with others outside of the household and therefore should not attend childcare, school or work outside of the home, or other indoor public settings.
Visitors^{table 4 note *}	Visitors to the contact’s house should be restricted to only those who are essential. Essential visitors should avoid use of the bathrooms in the house. If that is not possible, they should avoid the use of the bathroom used by the contact, perform good hand hygiene afterwards, and not use shared towels. They should not be served food or drinks. They should minimize any close contact with the contact and other household members. Children who may be unable to appropriately wash their hands (typically children younger than 8 years of age), visitors who are immunocompromised and visitors who are unvaccinated or under-vaccinated^{table 4 note ***} should not visit the contact’s house.
Monitoring	Contacts should be alert to any symptoms that could be compatible with poliovirus infection and should know how to contact public health officials immediately should these develop. Public health officials should be in touch with the contact on a regular basis to ensure compliance with recommended measures and help to problem solve issues that arise. Public health should inquire about any symptoms in the contact. Contacts should be referred to a health care provider if symptoms develop. The health care provider should be aware of the contact’s poliovirus exposure history and the proper precautions to take. The health care provider should be fully vaccinated^{table 4 note **} against poliovirus and not immunocompromised.
Vaccination	Once determined not to be infected with poliovirus, unvaccinated or under-vaccinated^{table 4 note *} contacts should be offered polio vaccination (IPV) and other outstanding vaccinations as per the Canadian Immunization Guide. Offer a single lifetime adult booster dose of IPV-containing vaccine for adult contacts who have not had one at or after age 18 years of age. If the contact lives in a household that is different than the case, ensure that the contact’s household members are fully vaccinated^{table 4 note } and consider offering a single lifetime adult booster dose of IPV-containing vaccine for adults who have not had one at or after age 18 years of age. Note: Vaccination is recommended to protect an individual against ongoing exposure and not intended as post-exposure immunoprophylaxis for contacts.
Table 4 Notes Table 4 Note * These precautions should be in place until two consecutive negative stools taken at least 48 hours apart, with the first at least 4 days after the contact’s last exposure to the case before infection prevention and control measures were initiated. Note that this is a different procedure for stool sample testing compared to the process outlined in Table 3 for a polio case. All stool sample testing must be conducted by the NML. The turnaround time for poliovirus isolation in cell culture at the NML is 14 days (See Annex C for details). Return to table 4 note * referrer Table 4 Note Fully vaccinated refers to individuals who have received at least four doses of IPV or trivalent OPV (in any combination). Return to table 4 note referrer Table 4 Note * Unvaccinated and under-vaccinated refers to individuals who have received less than four doses of IPV or trivalent OPV (in any combination). This includes children who are up to date for their age but have not received four doses. Return to table 4 note * referrer

Table 5: Lower risk contact management recommendations and considerations for poliovirus

Applies to: Those who shared toilets with the case; ate food prepared by the case; health care workers who provided care for the case or laboratory workers who handle specimens from the case (unless they are classified as higher risk or no risk, see Table 2).

Notes:

If contacts shared toilets with the case, ate food prepared by the case, or health care workers who provided care for the case or laboratory workers who handle specimens from the case are deemed, based on a risk assessment, to be at higher risk of contracting poliovirus from their exposure to the case, they should follow the recommendations in Table 4, otherwise they should follow the recommendations in Table 5. Health care workers / laboratory workers determined to have used adequate personal protective equipment and infection prevention and control practices could be considered not a contact.

For information on adequate personal protective equipment for poliovirus, please refer to PHAC’s Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings (2016) - page 83

Table 5: Lower risk contact management recommendations and considerations for poliovirus
Factor	Recommendations and considerations
Infection prevention and control	Reinforce proper hand hygiene with the contact and all household members including after using the bathroom, after changing diapers, after cleaning the bathroom and before preparing, serving or eating food.
Stool testing	Stool testing is generally not indicated for this group of contacts. Stool testing could be considered for contacts, who are a possible acquisition source for the case, by collecting two stool samples as soon as possible, 24 hours apart. Proper environmental cleaning and hand hygiene are required after collecting stool samples.
Monitoring	Contacts should be alert to any symptoms that could be compatible with poliovirus infection and should know how to contact public health officials immediately should these develop. Contacts should be referred to a health care provider if symptoms develop. The health care provider should be aware of the contact’s poliovirus exposure history and the proper precautions to take. The health care provider should be fully vaccinated^{table 5 note *} against poliovirus and not immunocompromised.
Vaccination	Unvaccinated or under-vaccinated^{table 5 note **} contacts should be offered polio vaccination (IPV) and other outstanding vaccinations as per the Canadian Immunization Guide. Consider offering a single lifetime adult booster dose of IPV-containing vaccine for adult health care providers, laboratory worker contacts, or other contacts who have not had one at or after age 18 years of age.
Table 5 Notes Table 5 Note * Fully vaccinated refers to individuals who have received at least four doses of IPV or trivalent OPV (in any combination). Return to table 5 note * referrer Table 5 Note Unvaccinated and under-vaccinated refers to individuals who have received less than four doses of IPV or trivalent OPV (in any combination). This includes children who are up to date for their age but have not received four doses. Return to table 5 note referrer

Further possible control measures for management of a person exposed to poliovirus material from a facility-related event are contained in Annex B.

10. Risk assessment

GPEI Initial risk assessment: Consider using the GPEI risk assessment tool Annex E in this document and Annex 1 of the GPEI SOP) in the early stages of the investigation for WPV, VDPV, and Sabin/Sabin-like type 2 detections. The initial risk assessment can be used as a guide to inform the type and scale of response, including a review of virologic risk and epidemiologic characteristics, and to determine the risk of further transmission in the area of the event or outbreak and internationally. The assessment can be completed by subject matter experts at PHAC and the affected PT.

An overview of the GPEI risk instrument is outlined in GPEI SOP: Responding to Poliovirus event or outbreak (Version 4, March 2022) - Chapter 4

Rapid risk assessment: A comprehensive Rapid Risk Assessment is an important tool to describe the risk to people in Canada and assess gaps in knowledge using a standard framework and method. Where applicable, based on established information, the RRA would be conducted by PHAC, with input from the investigating PT. This process is consistent with the Initial Assessment phase (3.2) of the Federal/Provincial/Territorial Public Health Response Plan for Biological Events.

11. Public health response to a poliovirus event or outbreak in Canada

Public health authorities in Canada manage responses to public health events in various ways such as surveillance and monitoring activities, public health measures and leveraging laboratory networks. Emergency management authorities facilitate and support coordination of responses to public health events, for example by providing logistical guidance and support, and using platforms and tools such as emergency operations centres for planning and coordination of integrated response activities. The Federal/Provincial/Territorial Public Health Response Plan for Biological Events describes how the two programs will work together using the governance structure and concept of operations of the plan, and that response activities and coordination required will vary depending on response objectives of the event.

The following activities should be considered in response to a poliovirus event or outbreak.

11.1 Enhanced case surveillance

The objective of enhanced case surveillance activities is to increase the probability of detecting cases and enrich quality of reporting. In the event of a WPV/VDPV case or environmental detection in Canada, enhancements to existing active surveillance networks are warranted to ensure sensitivity.

Further considerations include:

Enhanced communications to health professionals at all levels regarding the current situation and the importance of:
- Detecting cases presenting with symptoms compatible with AFP (at all ages)
- Monitoring for non-specific symptoms in those with poliovirus exposure
- Collecting stool samples within 14 days of symptom onset and sending to the laboratory for all AFP cases, and also when there is suspicion of poliovirus
- Reporting AFP with suspicion of poliovirus and confirmed cases to local public health
Expanding AFP surveillance to be PT notifiable in all jurisdictions
Inclusion of adolescents and adults in AFP reporting (the geographic area will be informed by the initial case investigation)

11.2 Expanded environmental wastewater sampling

In the event of a WPV/VDPV case or environmental detection in Canada or international detections presenting a risk of importation to Canada, expanded strategic environmental wastewater sampling (such as increased number of sites sampled or increased frequency of sampling) may be warranted to complement AFP surveillance. It is important to note that wastewater testing for poliovirus is different from that for other pathogens such as COVID-19. Poliovirus wastewater testing is not routinely or broadly recommended, and there are strict laboratory safety requirements. To ensure public health plans are in place to confirm, interpret and follow up on environmental detections, decisions to implement/expand environmental wastewater sampling in a region is the joint responsibility between local, PT and federal stakeholders. If wastewater sampling in a region is agreed upon, all samples at this time should be sent to the NML for testing.

If a case is identified, the case’s area of residence and other catchment areas (depending on identified epidemiological links) could be considered for environmental sampling to assess the geographic scope of detections, community transmission, and duration of poliovirus circulation. The identification of highest risk areas should be based on the location of populations considered at risk and behavioural characteristics that represent potential transmission risk including:

Known or suspected population immunity gaps, such as specific age cohorts that missed vaccination, and groups who are unvaccinated or under-vaccinated on religious, philosophical or other grounds
Known or suspected links to areas with circulating polioviruses
Areas with a large mobile population (for example, daily movement of population for work, migrants, nomads, refugees, informal settlements, undocumented guest workers)
Low coverage in routine poliovirus vaccination (<90%)

The sampling frequency is recommended to be every 2 weeks, but the minimum frequency is monthly. Sampling will cease after there have been no further WPV/VDPVs isolated in a six-month period.

For more information on enhancing environmental surveillance refer to GPEI SOP: Polio Environmental Surveillance Enhancement Following Investigation of a Poliovirus Event or Outbreak (Version 15, December 2020)

11.3 Community stool sampling

In some instances, consensual community stool sampling may be considered when trying to determine a possible source or the extent of transmission. This may be appropriate in closed groups such as child care centres, congregate living settings, or religious communities that are known to be unvaccinated or under-vaccinated. Sampling of routinely collected stool samples or samples from diapers in health care offices, health care facilities or child care centres could be considered, with parental/guardian consent.

11.4 Vaccination

Assessing immunization coverage and targeted IPV immunization campaigns are warranted in populations at high risk, such as communities near the detected event and/or communities with populations who are known or suspected to be unvaccinated or under-vaccinated. Given that delivery of immunization programs is a PT responsibility, vaccination activities will be led by the respective PT health authority and will be supported by PHAC where necessary. The National Advisory Committee on Immunization (NACI) may also be involved in providing specific vaccination recommendations and the Canadian Immunization Committee (CIC) may be involved in programmatic and operational discussions. Where applicable, engagement from trusted community members, such as faith leaders, may be included as part of vaccination campaign efforts.

The extent of further IPV immunization activities is dependent on the event or outbreak and determined based on factors related to the case/contacts, rapid risk assessment, and in consultation with public health and other partners, as appropriate. Further immunization activities could include:

Catch-up vaccines for unvaccinated or under-vaccinated people
Immunization with a single adult lifetime booster with IPV-containing vaccine for high risk adults if they have not previously had one at or after 18 years of age (such as close contacts, health care workers, adults at risk of exposure)
Outbreak vaccination among certain groups (for example, all children under 5 years of age regardless of vaccination status).

If PTs require additional vaccination supplies, PHAC may be involved to assist coordinating procurement. Federal and PT partners will need to be vigilant in disseminating public communication to ensure vaccinations are up to date, as per the Provincial and territorial routine and catch-up vaccination schedule for infants and children in Canada. Recommendations on routine immunization schedules, booster doses and immunization of travelers are available in the Canadian Immunization Guide: Poliomyelitis vaccine.

11.5 Communication

Consistent, clear, and coordinated communication is important following a poliovirus event or outbreak to support response activities, inform people in Canada about any risks and actions to protect their health, increase vaccination uptake and support robust surveillance with early notification of AFP and poliovirus.

During an event/outbreak, it is important to develop communication strategies and resources to:

Advise health professionals to consider polio in patients with polio-like symptoms (for clinical symptoms of polio, refer to Canadian Immunization Guide: Poliomyelitis vaccine), especially if the patient is unvaccinated or under-vaccinated and/or recently traveled or resided in a country where polio still occurs or was exposed to a person who traveled to these areas or was potentially exposed as part of a local event or outbreak.
Advise health professionals to ensure their patients are up to date on polio vaccinations as per recommendations in the Canadian Immunization Guide.
Raise awareness of the risks of polio to children, families, and communities.
Strengthen community confidence in vaccination and encourage vaccination uptake.

Communication considerations:

Coordinate and align communication approaches and messaging between FPT authorities, where appropriate.
Engage/leverage stakeholders to assist in reaching target audiences, where appropriate.
Employ targeted approaches and translation to communities that have been marginalized and remote populations, as needed.
Display openness, transparency, and timeliness with information and messaging that provides advice, acknowledges uncertainties, and explains next steps.
In addition to traditional media and social media, leverage existing platforms for communication such as professional networks, CNPHI public health alerts, and yellow fever and travel health clinics.

11.6 Surveillance evaluation and assessment following investigation

Following the initial investigation of any poliovirus event or outbreak, it is critical to assess and enhance AFP and poliovirus surveillance.

The current Canadian Acute Flaccid Paralysis Surveillance System should be evaluated and enhanced, where needed, to increase data management capacity to ensure all databases and analyses are up to date, ensure data harmonisation with the laboratory, and work with health professionals to increase case compliance of full clinical and virological investigation and follow-up of cases.

As per the recommendations of the GPEI, complete the following outbreak response assessments:

First assessment within 3 to 4 months of lab notification.
Follow-up quarterly assessments during the course of the outbreak.
Final assessment after at least 6 months without poliovirus detection.
Further desk reviews in prolonged outbreaks, as appropriate.

For more information on Surveillance following investigation refer to GPEI SOP: Responding to a poliovirus event or outbreak (Version 4, March 2022) - Chapter 7.

Acknowledgements

The Public Health Agency of Canada would like to express sincere gratitude to all individuals and organizations who contributed to the development of the Guidance for the Response and Management of a Poliovirus Event or Outbreak. The collaborative efforts from centres across the Agency as well as external partners were invaluable in shaping the robust and comprehensive framework.

We extend our appreciation to the following groups for their valuable contributions and expertise:

Canadian Immunization Committee
Provincial and Territorial partners
Special Advisory Committee / Pan-Canadian Public Health Network
Centre for Biosecurity, Public Health Agency of Canada
Centre for Border and Travel Health, Public Health Agency of Canada
Communications and Public Affairs Branch, Health Canada/Public Health Agency of Canada
Centre for Emergency Preparedness, Public Health Agency of Canada
Centre for Immunization Readiness, Public Health Agency of Canada
Centre for Immunization and Respiratory Infectious Diseases, Public Health Agency of Canada
Centre for Immunization Surveillance, Public Health Agency of Canada
National Microbiology Laboratory, Public Health Agency of Canada

Resources

Biosecurity

Case definitions

Case questionnaires

Lab processes

Reporting

SOPs and reference

Annexes

Annex A: Key initial steps and notification requirements

Key initial steps and notification requirements to be taken are illustrated in the case of a poliomyelitis case or nonparalytic poliovirus infection (Figure 1), positive environmental wastewater sample (Figure 2), or facility-related event involving poliovirus (Figure 3).

Figure 1. Text version below. — Figure 1. Key initial steps and notification requirements for paralytic poliomyelitis or nonparalytic poliovirus infection in a person, adapted from Protocol for the investigation of AFP and suspected paralytic poliomyelitis

Figure 2. Text version below. — **Figure 2. Key initial steps and notification requirements for a detection of poliovirus from environmental wastewater sampling**

Figure 3. Text version below. — **Figure 3. Key initial steps and notification requirements for a facility-related event involving poliovirus**

Annex B: Public health management of a facility-related event involving poliovirus

Public health risk assessment of a facility-related exposure event for poliovirus

Table: Public health risk assessment of a facility-related exposure event for poliovirus
Public Health Risk	Poliovirus Exposure Event
Very High Risk	Any exposure involving WPV2/VDPV2.
High Risk	Any exposure involving WPV1/VDPV1 or WPV3/VDPV3 Any exposure involving Sabin/Sabin-like type 2, in an area with inadequate vaccination coverage (<90% IPV coverage) and /or has lower access to basic safely managed sanitation.
Low Risk	Any exposure involving Sabin/Sabin-like type 2 with adequate vaccination coverage (>90% IPV coverage) AND high access to safely managed sanitation.
Minimal Risk	Consider any exposure involving Sabin/Sabin-like types 1 and 3 material minimal risk at this time. However, following the cessation of OPV use globally, this will be re-addressed in future revisions.

Note 1: Where a breach involves multiple polioviruses, assess the risk to the virus that poses the highest public health risk.

Note 2: When assessing public health risk, consider the immunization history/profile of the exposed persons close contacts and/or local community.

Viral shedding monitoring post exposure in a facility-related event: specimen collection and sampling schedule

Collect both throat swab in Universal Transport medium (UTM) and stool (2-8 g) samples on days 3/4 and days 7/8 post exposure. If sample(s) test negative for poliovirus by RT-PCR, the probable exposure has not led to measurable virus excretion. Discontinuing isolation of individual is possible.

If any sample(s) test positive for poliovirus, continue to collect stool samples daily until 3 consecutive samples collected 24 hours apart test negative for poliovirus.

Possible control measures for management of a potentially exposed person in a facility-related event by the type of poliovirus material

Table: Possible control measures for management of a potentially exposed person in a facility-related event by the type of poliovirus material
Activity	Sabin/Sabin-like type 1 or 3	Sabin/Sabin-like type 2 (with > 90% IPV coverage and access to safely managed sewage)	WPV/VDPV (any type) Sabin/Sabin-like type 2 - (< 90% IPV coverage and lower access to safely managed sewage)
Isolation	None	At home	At home, provided good compliance
Isolation Duration	N/A	Min. 7 days at home if all testing negative	Min. 7 days at home if all testing negative
Management of Stool	General Sewage; Disinfection of toilet following use	General Sewage. Dedicated (own use) toilet if possible.	General Sewage. Dedicated (own use) toilet or Collect and incinerate if toilet is not connected to municipal wastewater management system
Cleaning/ Disinfection	Household bleach/0.5% Accelerated Hydrogen Peroxide (AHP) containing disinfectant (i.e., PREempt RTU)	Household bleach/0.5% AHP containing disinfectant (i.e., PREempt RTU)	Household bleach/0.5% AHP containing disinfectant (i.e., PREempt RTU)
Food Handling (for other people)	Not Permitted	Not Permitted	Not Permitted
Close Contacts/Visitors	Should be limited to those with proven vaccination history and in good general health (i.e., not immunocompromised); should be educated on proper handwashing.	Should be limited to those with proven vaccination history and in good general health (i.e., not immunocompromised); should be educated proper handwashing.	Should be limited to those with proven vaccination history and in good general health (i.e., not immunocompromised); should be educated on proper handwashing.

For additional recommendations of control measures based on the public health risk posed by the exposure, refer Guidance in managing exposed persons for countries hosting facilities that maintain live polioviruses.

Relevant Canadian legislation: Human Pathogens and Toxins Act

Under the HPTA (12(1)): “Obligation to Inform Minister: Inadvertent release: 12(1) if a licence holder has reason to believe that a human pathogen or toxin has been released inadvertently from the facility in the course of an activity that is otherwise authorized by the licence, the licence holder shall, without delay, inform the Minister of the release and provide the Minister with the information referred to in subsection (3) that is under the licence holder’s control.”
- In the case of a poliovirus biocontainment incident that involves human disease: “Obligation to Inform Minister: Disease (13) if a licence holder has reason to believe that an incident involving a human pathogen or toxin that is in their possession has, or may have, caused disease in an individual, the licence holder shall, without delay, inform the Minister of the incident and provide the Minister with the following information that is under the licence holder’s control: (a) a description of the incident; (b) the name of the human pathogen or toxin; and (c) any other information relating to the incident that the Minister may require.”

Annex C: Laboratory protocols

Clinical specimen collection protocol

For diagnostics, ensure collection of at least two stool samples (taken at least 24 hours apart and minimum 2 grams per sample) within 14 days after symptom onset for viral studies.

Stool (two samples taken at least 24 hours apart) is the required clinical specimen for the laboratory investigation and diagnosis of poliovirus infections. Stool collected from diapers are acceptable samples. A stool sample is preferred to a rectal swab because the diagnosis of poliovirus is more reliable.

A case can be considered no longer infectious based on three consecutive negative stool samples each collected at least 24 hours apart.

A high risk contact subject to stool sampling can be determined not to be infected, based on two consecutive negative stool samples taken at least 48 hours apart, with the first collected at least 4 days after the contact’s last exposure to the case before infection prevention and control measures were initiated.

Table: Stool Specimen Requirements
Minimum Volume Required	2-8 g
Turnaround Time	Total turnaround time for the complete polio testing algorithm is 28 calendar days: PV Virus isolation in cell culture: 14 days PV Intratypic Differentiation and VDPV screening by real time PCR: 7 days PV VP1 Sequencing: 7 days
Collection, Storage, and Preservation of Specimen Prior to Shipping	At least two stool specimens collected at least 24 hours apart, ideally within 14 days after onset Samples can be collected up to 6 weeks after onset if it is not possible to collect earlier Place in sterile leak proof container Keep specimens frozen (≤ -20C) Do not add transport medium
Shipping Instructions	NML does not accept routine shipments on weekends or holidays. Please make sure packages arrive Monday – Friday. Ship specimens frozen on dry ice according to TDG regulations.

Table: Wastewater specimen collection protocol
Collection, Storage, and Preservation of Specimen Prior to Shipping	500 mL of composite or grab samples should be sent to PHAC NML Wastewater Surveillance Unit. Ideally the samples should be maintained at 4οC during collection and storage. The impact of common water/wastewater preservatives has not been assessed and submitters are discouraged from sending preserved samples. Please contact the NML (NMLWastewater.NMLWastewater@phac-aspc.gc.ca) before planning to ship samples to the NML for testing wastewater for poliovirus
Shipping Instructions	NML does not accept routine shipments on weekends or holidays. Please make sure packages arrive Monday – Friday. Please refer to Packaging wastewater samples for shipment protocol. Accompany each shipment with a sample requisition sheet available online. Fill the form to the best of your ability Indicate “poliovirus testing” in the sample comments Provide a unique sample number under “location/code”, label the bottle with the same unique code. Print and submit the sample requisition with your sample. Essential details: Samples should be sealed in a leak proof primary vessel (no glass) within a sealed secondary container (for example, a resealable bag). Secondary container packaging should contain proportional absorbent material in case of leak or spill. Pack bottles upright and in alignment with directional markings on overpack. Ship no-more than 4 L total per shipping container. Ship samples at 4oC with cold packs (no wet ice). Fill voids with packing paper to avoid movement of bottles during shipping. All samples bottles should be specifically marked and identified as wastewater samples. Ship samples within insulated packaging (Styrofoam or hard shell cooler), contained within appropriately sized and labelled cardboard overpack.

Working and storing potentially infectious materials (poliovirus)

When working with and storing PIM, risk mitigation measures must be followed to prevent facility-related events, as outlined in the WHO PIM Guidance Document (2nd edition). These requirements include:

Verification of polio vaccination of personnel handling the virus. If vaccination cannot be verified, they must receive a single lifetime adult booster of IPV-containing vaccine. Enhanced Biosecurity protocols - this includes storing the PIM in locked freezers, segregated from the general inventory, with access limited to trained personnel. Also, detailed inventories must be maintained and reported to PHAC’s Centre of Biosecurity as Canada’s National Authority of Containment (NAC) for Poliovirus. For additional information, containment questions can be directed to Canada’s NAC at polio@phac-aspc.gc.ca; use the subject line – “Poliovirus Containment Wastewater”; use the subject line – “Poliovirus Containment Wastewater”
Note: Although sewage/concentrates may not pose an immediate risk to vaccinated personnel (virus concentration is below the infectious dose), the intent of the guidelines is to ensure the facility identifies these materials so that no high risk activities (such as inoculation into polio permissive cells) are inadvertently performed.
Detailed biological risk assessments, which will inform best biosafety practices (such as measures to reduce aerosol exposure, what disinfectants and additional PPE are to be used) need to be on file.
If the presence of an eradicated poliovirus (type 2), or of any type or a VDPV/WPV, is confirmed, this material is subject to full containment requirements. For laboratories who are not officially designated by the NAC as PEFs, the PIM must be destroyed or inactivated using validated procedures. The Canadian NAC can be contacted for guidance on containment and disposition of PIM at polio@phac-aspc.gc.ca.
If the facility wishes to retain this material, the options are to:
- Transfer the PIM to a certified PEF (the NML), or,
- Apply to the NAC to become a PEF that is certified to meet the biosafety and biosecurity requirements outlined in the Global Action Plan for Poliovirus Containment (GAPIV) and Strategy for Poliovirus Containment.

Annex D: IHR reporting

Event description prompts

Insert event description, where possible including:

number of cases and deaths
case definitions
laboratory results
source and type of the risk
conditions affecting the spread of the disease and
public health measures employed

Note: if this information is not yet available at the time of reporting, then provide it to PAHO/WHO as soon as possible in a follow-up / update report

Annex E: GPEI initial risk assessment

Figure 4. Text version below. — **Figure 4. IHR decision Instrument**

Source: International Health Regulations (2005) (IHR) Annex 2

Note: The decision for each prompt, as well as a rationale, will need to be documented and submitted as part of the assessment.

Table: GPEI initial risk assessment
Risk category	High Risk	Low Risk	Remarks
Virology
cVDPV	Automatically defined as high risk situation	-	-
Virologic factors
Genetic deviation from parent vaccine virus (nucleotide changes)	Substantial	Not substantial	Seek expert virologist assessment
Relatedness, if any, to past isolations	Related	Not related
Virologist characterization / interpretation	Yes	No
Co-circulation with WPV	Yes	No
Detection of other (un-related) VDPVs in region	Yes	No
Human Source
Co-isolation with other Sabin or enterovirus	Yes	No
Evidence of primary immunodeficiency	No	Yes
Environmental Science
Number of virus isolates	High	Medium/low
Genetic diversity (number of genetic clusters)	High	Medium/low
Context
Case Characteristics
Member of known “high risk”/underserved population (slum, minority, refugee, mobile, internally displaced, etc.)	Yes	No	Review and discussion by technical experts, between country, region and global levels
0 dose or “under”-vaccinated	Yes	No
Aged above 5 years	Yes	No
Coverage data
RI coverage (IPV if available-otherwise diphtheria-tetanus-pertussis (DPT3) in infected Admin 1 level	Poor	Good/high	Population Immunity for type 2 polioviruses, should factor time since switch and use of IPV to estimate type 2 naïve population
Quality of prior (>5% missed children by IM data, >80% LQAS lots passed)	Poor	Fair/good
Surveillance quality
Surveillance quality (factors such as sub-standard AFP indicators, infrequent or absent environmental surveillance, orphan virus) in infected Admin 1 level	Evident	Fair/good	-
Other recent poliovirus detection	Yes	No	-
Admin level 1 context
Large, densely populated are	Yes	No	-
Known high risk populations (such as mobile, refugee, trade, pilgrimage, displacement)	Yes	No	-
Insecure and/or inaccessible area affecting surveillance and/or immunization	Yes	No	-
Any type of sentinel events suggesting higher risk of rapid spread	Yes	No	-
Evidence of containment breach	Yes	No	-
Finding tOPV/mOPV2/nOPV2 in a sweep of the vaccine distribution chain	Yes	No	-
Environmental conditions associated with high levels of fecal-oral transmission	Poor water and sanitation	Fair/good water and sanitation	-
International spread
Linkages with International Border
Contiguous or direct transport link to int’l border (especially if other area is known high risk)	Yes	No	Local case investigation / based on available data Review and discussion by GPEI technical experts, in consultation with country, regional levels
Links between site or person with poliovirus to other countries (such as markets, transport routes)	Yes	No
Travel history of poliovirus case or household (such as refugee, nomadic, pilgrimage, stateless persons) to the neighbouring (or any other) country	Yes	No
Prior history of polio transmission patterns and outbreaks between countries	Yes	No
Population mobility/migration
Common service points between infected area and neighbouring areas like markets, pilgrim sites, common trading sites etc.	Yes	No	-
Evidence of high levels of migration (from sequencing data, available cell phone data, prior migration patterns, etc.)	Yes	No	-
Context of neighbouring areas
Evidence of surveillance gaps or other high risk factors in neighbouring areas susceptible to importation from affected areas	Yes	No	-
Population immunity in neighbouring countries/areas	Low	Good/high	-
Conflict	Present	None	-

Source: GPEI SOP: Responding to a poliovirus event or outbreak

Selected references

Reference a

Detection meaning the date of stool sample collection that was positive for poliovirus for those with nonparalytic poliovirus infection.

Return to referrer a referrer

Reference b

See Annex B for details on facility-related events. For more details on laboratory and vaccine manufacturing related poliovirus events, refer to Public health management of facility-related exposure to live polioviruses: Guidance in managing exposed persons for countries hosting facilities that maintain live polioviruses.

Return to referrer b referrer

Reference c

The criteria for cVDPV classification can be found in the GPEI’s Classification and reporting vaccine-derived polioviruses (VDPV) - page 3.

Return to referrer c referrer

Reference d

Poliovirus in clinical and environmental samples survive indefinitely in the laboratory freezer (≤ -20° C), and for many months in the refrigerator.

Return to referrer d referrer

Reference 1

World Health Organization. Poliovirus IHR Emergency Committee Statements. 2023; Available at: https://www.who.int/groups/poliovirus-ihr-emergency-committee

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Reference 2

Global Polio Eradication Initiative. Global eradication of wild poliovirus type 2 declared. 2015; Available at: https://polioeradication.org/news-post/global-eradication-of-wild-poliovirus-type-2-declared

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Reference 3

Global Polio Eradication Initiative. Two out of three wild poliovirus strains eradicated. 2019; Available at: https://polioeradication.org/news-post/global-eradication-of-wild-poliovirus-type-2-declared

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Reference 4

Global Polio Eradication Initiative. Classification and reporting of vaccine-derived polioviruses (VDPV). 2016; Available at: https://polioeradication.org/wp-content/uploads/2016/09/Reporting-and-Classification-of-VDPVs_Aug2016_EN.pdf

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Reference 5

Public Health Agency of Canada. Provincial and territorial routine and catch-up vaccination schedule for infants and children in Canada. 2023; Available at: https://www.canada.ca/en/public-health/services/provincial-territorial-immunization-information/provincial-territorial-routine-vaccination-programs-infants-children.html

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Reference 6

Global Polio Eradication Initiative. OPV Cessation. 2023; Available at: https://polioeradication.org/polio-today/preparing-for-a-polio-free-world/opv-cessation/#:~:text=The%20switch,with%20significant%20public%20health%20benefitsalertalert

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Reference 7

Global Eradication Initiative. Inactivated polio vaccine now introduced worldwide. 2019; Available at: https://polioeradication.org/news-post/inactivated-polio-vaccine-now-introduced-worldwide/

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Reference 8

World Health Organization. Polio vaccines: WHO position paper - June 2022. Wkly Epidemiol Rec 2022 June 24;25(97):277-300

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Reference 9

World Health Organization. First ever vaccine listed under WHO emergency use. 2020; Available at: https://www.who.int/news/item/13-11-2020-first-ever-vaccine-listed-under-who-emergency-use

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Reference 10

Global Polio Eradication Initiative. nOPV2. 2023; Available at: https://polioeradication.org/nopv2

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Reference 11

Global Polio Eradication Initiative. Preparing for nOPV2 Use: An overview on requirements for countries. 2022; Available at: https://polioeradication.org/wp-content/uploads/2022/06/nOPV2-requirements-overview-for-countries-.pdf

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Reference 12

Macklin GR, Peak C, Eisenhawer M, Kurji F, Mach O, Konz J, et al. Enabling accelerated vaccine roll-out for Public Health Emergencies of International Concern (PHEICs): Novel Oral Polio Vaccine type 2 (nOPV2) experience. Vaccine 2023 April 06;41:A122-A127

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Reference 13

Desai S, Smith T, Thorley BR, Grenier D, Dickson N, Altpeter E, et al. Performance of acute flaccid paralysis surveillance compared with World Health Organization standards. J Paediatr Child Health 2014 July 14;51(2):209-214

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Reference 14

Public Health Agency of Canada. Polio: For health professionals. 2023; Available at: https://www.canada.ca/en/public-health/services/diseases/poliomyelitis-polio/health-professionals.html

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Reference 15

Booth TF, Grudeski E, McDermid A, Rotondo J. The polio eradication endgame: Why immunization and continued surveillance is critical. Can commun dis rep 2015 October 01;41:233

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Reference 16

World Health Organization. WHO Global Action Plan for Poliovirus Containment (GAPIV). 2022; https://polioeradication.org/wp-content/uploads/2022/07/WHO-Global-Action-Plan-for-Poliovirus-Containment-GAPIV.pdf

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Reference 17

Public Health Agency of Canada. Highlights from the 2019 Childhood Immunization Coverage Survey (cNICS). 2023; Available at: https://www.canada.ca/en/public-health/services/diseases/poliomyelitis-polio/health-professionals.html

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Reference 18

World Health Organization. International Health Regulations (2005), 3rd ed. 2016; Available at: https://apps.who.int/iris/handle/10665/246107

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Reference 19

World Health Organization. Case definitions for the four diseases requiring notification in all circumstances under the International Health Regulations. 2005; Available at: https://cdn.who.int/media/docs/default-source/documents/emergencies/case-definitions-ihr-four-diseases7f1ee707-3d13-4581-a1af-d5f44f86423a.pdf?sfvrsn=9c68df20_1&download=true

Return to referrer 19 referrer

Page details

Date modified:: 2023-08-04

Guidance for the response and management of a poliovirus event or outbreak in Canada

Table of contents

Acronyms

Goals and objectives

1. Introduction

1.1 Polio

1.2 Canadian context

1.3 Guidance development

2. Definition of a poliovirus event or outbreak

3. Importance of rapid detection, notification, and investigation

4. Federal/provincial/territorial roles and responsibilities

4.1 PHAC

4.2 Provincial/territorial and local/regional

4.3 Laboratory

5. Case classifications

Table 1 Notes

6. Detection

7. Notification

7.1 Reporting within a province or territory

7.2 Reporting between PT authorities and PHAC

7.3 Reporting by PHAC to WHO

8. Investigation

8.1 Investigation of a case

8.1.1 Index of suspicion for poliomyelitis while awaiting laboratory confirmation

8.1.2 Epidemiologic characteristics of poliovirus relevant to investigation and case/contact management

Period of communicability

Incubation period

Assumptions for this document

8.1.3 Investigation of poliovirus infection (with or without paralysis)

8.1.4 Contact tracing

Table 2 Notes

8.2 Investigation of a detection from environmental wastewater sampling

8.3 Investigation of a facility-related event involving poliovirus

9. Management of cases and contacts

9.1 Management of cases

Table 3 Notes

9.2 Management of contacts

Table 4 Notes

Table 5 Notes

10. Risk assessment

11. Public health response to a poliovirus event or outbreak in Canada

11.1 Enhanced case surveillance

11.2 Expanded environmental wastewater sampling

11.3 Community stool sampling

11.4 Vaccination

11.5 Communication

11.6 Surveillance evaluation and assessment following investigation

Acknowledgements

Resources

Biosecurity

Case definitions

Case questionnaires

Lab processes

Reporting

SOPs and reference

Annexes

Annex A: Key initial steps and notification requirements

Annex B: Public health management of a facility-related event involving poliovirus

Public health risk assessment of a facility-related exposure event for poliovirus

Viral shedding monitoring post exposure in a facility-related event: specimen collection and sampling schedule

Possible control measures for management of a potentially exposed person in a facility-related event by the type of poliovirus material

Relevant Canadian legislation: Human Pathogens and Toxins Act

Annex C: Laboratory protocols

Clinical specimen collection protocol

Working and storing potentially infectious materials (poliovirus)

Annex D: IHR reporting

Event description prompts

Annex E: GPEI initial risk assessment

Selected references

Page details