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1.  Support for children identified with acute flaccid paralysis under the global polio eradication programme in Uttar Pradesh, India: a qualitative study 
BMC Public Health  2012;12:229.
Cases of polio in India declined after the implementation of the polio eradication programme especially in these recent years. The programme includes surveillance of acute flaccid paralysis (AFP) to detect and diagnose cases of polio at early stage. Under this surveillance, over 40,000 cases of AFP are reported annually since 2007 regardless of the number of actual polio cases. Yet, not much is known about these children. We conducted a qualitative research to explore care and support for children with AFP after their diagnosis.
The research was conducted in a district of western Uttar Pradesh classified as high-risk area for polio. In-depth interviews with parents of children with polio (17), with non-polio AFP (9), healthcare providers (40), and key informants from community including international and government officers, religious leaders, community leaders, journalists, and academics (21) were performed.
Minimal medicine and attention were provided at government hospitals. Therefore, most parents preferred private-practice doctors for their children with AFP. Many were visited at homes to have stool samples collected by authorities. Some were visited repetitively following the sample collection, but had difficulty in understanding the reasons for these visits that pertained no treatment. Financial burden was a common concern among all families. Many parents expressed resentment for their children's disease, notably have been affected despite receiving multiple doses of polio vaccine. Both parents and healthcare providers lacked information and knowledge, furthermore poverty minimised the access to available healthcare services. Medicines, education, and transportation means were identified as foremost needs for children with AFP and residual paralysis.
Despite the high number of children diagnosed with AFP as part of the global polio eradication programme, we found they were not provided with sufficient medical support following their diagnosis. Improvement in the quality and sufficiency of the healthcare system together with integration of AFP surveillance with other services in these underprivileged areas may serve as a key solution.
PMCID: PMC3331818  PMID: 22439606
Acute flaccid paralysis; AFP Surveillance; Healthcare; India; Poliomyelitis; Pulse Polio Programme; Residual paralysis
2.  Surveillance of acute flaccid paralysis in Akwa Ibom State, Nigeria 2004–2009 
The last case of wild polio virus transmission occurred in Akwa Ibom state in October 2001; however, combination high routine immunization coverage with OPV, high quality AFP surveillance, mass immunization campaign in which two doses of potent oral polio vaccine is administered to eligible children and mop-up campaigns in areas with identified immunization or surveillance gaps has help the state in maintaining a free polio status for over ten years. This study was carried out to describe the characteristics of reported acute flaccid paralysis cases between 2004 and 2009, and to evaluate the performance of the acute flaccid paralysis surveillance system using indicators recommended by the World Health Organization.
A retrospective study was conducted among children, 0-15 years, by the World Health Organization (WHO) and Epidemiology unit of State Ministry of Health (SMOH), Uyo. The demographic characteristics and the results of isolation and identification of polio and other enteroviruses in stool samples sent to the WHO Polio Laboratory Ibadan for cases was analyzed.
A total of 521 cases of AFP (270 males and 251 females) aged 0 month to=15 years were reported by the surveillance system between 2004 and 2009. Those below 5 years of age accounted for 82.5% of cases reported and investigated. Of the 521 cases investigated 512 (98.3%) received at least three doses of oral polio vaccine, while 9(1.7) never received any oral polio vaccine (zero-dose). In all 5.1% of the isolates were Sabin, 7.9% non polio enterovirus (NPEV) and 2.3% were classified by national expert committee as compatible with poliomyelitis. There was consistent and steady increase in three critical indicators; Non polio AFP rate in children <15 years from 4.5 to 6.4 per 100 000 population, proportion of AFP cases with 2 stool specimens collected within 14 days of onset of paralysis from 57% in 2005 to 91% in 2009 and proportion of Local Government Areas (Districts) meeting both core indicators from 23% in 2005 to 87% in 2009. The highest numbers of cases were seen in the months of March, May and September.
This study showed high levels of surveillance performance with some challenges in reverse the cold chain system, the continuation and sustained AFP case detection, prompt investigation and response, improvement in the reserve cold chain system would achieve optimal standards recommended by WHO and might provide a good model for the eradication of poliomyelitis.
PMCID: PMC3215554  PMID: 22145065
Acute flaccid paralysis; Surveillance; Poliomyelitis; Nigeria
3.  A Statistical Model of the International Spread of Wild Poliovirus in Africa Used to Predict and Prevent Outbreaks 
PLoS Medicine  2011;8(10):e1001109.
Using outbreak data from 2003–2010, Kathleen O'Reilly and colleagues develop a statistical model of the spread of wild polioviruses in Africa that can predict polio outbreaks six months in advance.
Outbreaks of poliomyelitis in African countries that were previously free of wild-type poliovirus cost the Global Polio Eradication Initiative US$850 million during 2003–2009, and have limited the ability of the program to focus on endemic countries. A quantitative understanding of the factors that predict the distribution and timing of outbreaks will enable their prevention and facilitate the completion of global eradication.
Methods and Findings
Children with poliomyelitis in Africa from 1 January 2003 to 31 December 2010 were identified through routine surveillance of cases of acute flaccid paralysis, and separate outbreaks associated with importation of wild-type poliovirus were defined using the genetic relatedness of these viruses in the VP1/2A region. Potential explanatory variables were examined for their association with the number, size, and duration of poliomyelitis outbreaks in 6-mo periods using multivariable regression analysis. The predictive ability of 6-mo-ahead forecasts of poliomyelitis outbreaks in each country based on the regression model was assessed. A total of 142 genetically distinct outbreaks of poliomyelitis were recorded in 25 African countries, resulting in 1–228 cases (median of two cases). The estimated number of people arriving from infected countries and <5-y childhood mortality were independently associated with the number of outbreaks. Immunisation coverage based on the reported vaccination history of children with non-polio acute flaccid paralysis was associated with the duration and size of each outbreak, as well as the number of outbreaks. Six-month-ahead forecasts of the number of outbreaks in a country or region changed over time and had a predictive ability of 82%.
Outbreaks of poliomyelitis resulted primarily from continued transmission in Nigeria and the poor immunisation status of populations in neighbouring countries. From 1 January 2010 to 30 June 2011, reduced transmission in Nigeria and increased incidence in reinfected countries in west and central Africa have changed the geographical risk of polio outbreaks, and will require careful immunisation planning to limit onward spread.
Please see later in the article for the Editors' Summary
Editors' Summary
During the first half of the 20th century, polio (poliomyelitis) was one of the most feared infectious diseases in industrialized countries, paralyzing thousands of young children every year. The virus that causes polio enters the human body through ingestion of contaminated water or food, multiplies in the gut, and is shed through the feces (stool) into the environment, where it spreads rapidly if sanitation or personal hygiene is poor. Most people infected with poliovirus have no symptoms, but about one in 200 infected people develop paralytic polio, in which poliovirus invades and destroys the nerve cells that control the arm and leg muscles, leading to acute flaccid paralysis (AFP; limb paralysis). In the worst cases, poliovirus paralyzes the muscles involved in breathing, which can be fatal unless patients are helped to breathe with an “iron lung” or ventilator. There is no cure for paralytic polio, and although AFP usually lasts less than two weeks, some patients never regain full use of their limbs.
Why Was This Study Done?
From 1955 onwards, routine polio vaccination rapidly reduced or eliminated wild polio (polio occurring through natural infection) in developed countries, but the disease remained common in developing countries. Consequently, in 1988, the Global Polio Eradication Initiative was launched. Between 1988 and 2009, routine vaccination and supplementary immunization activities (additional doses of polio vaccine given to all young children on national immunization days) reduced the annual number of children paralyzed by polio from 350,000 to about 1,600 and the number of countries where polio is endemic (always present) from 125 to four. Unfortunately, continued circulation of wild polioviruses in Nigeria and India resulted in reinfection of 19 African countries in 2009 and re-establishment of polio transmission in four countries. A better understanding of the factors that affect the distribution and timing of wild polio outbreaks might help experts prevent such outbreaks and could facilitate global polio eradication. Here, the researchers develop a statistical model of the spread of wild polioviruses in Africa and assess its ability to predict polio outbreaks in individual African countries.
What Did the Researchers Do and Find?
The researchers used routine AFP surveillance to identify children who developed polio in Africa between 2003 and 2010. They determined whether each case was associated with the importation of wild poliovirus based on genetic analysis the polioviruses and then used “multivariable regression analysis” to identify factors associated with the number, size, and duration of polio outbreaks. During the study period, 142 genetically distinct polio outbreaks (involving one to 228 cases) were recorded in 25 African countries, with the average number of outbreaks in each country declining with reduced population movements from each infected country. The estimated number of people migrating into a country from an infected country was associated with the number of outbreaks in that country. Thus, countries with a high rate of immigration from Nigeria and other countries where polio is still endemic had more polio outbreaks than countries with less immigration from these countries. A country's mortality rate for children under 5 years of age (an indicator of sanitary conditions and access to health care) was also associated with the number of outbreaks, and immunization coverage was associated with the size, duration, and number of outbreaks. Finally, in 82% of instances, for a randomly selected country where an outbreak was observed, the statistical model predicted six months ahead of time more outbreaks for that country than for any randomly selected country where there were no outbreaks. That is, the model's predictive ability was 82%.
What Do These Findings Mean?
These findings indicate that outbreaks of polio in Africa over the study period resulted mainly from continued transmission in Nigeria and other countries that reported polio cases and from poor immunization status. They also highlight how the geographical risk of polio is changing over time in Africa. Importantly, the risk factors included by the researchers in their statistical model are sufficient to describe the scale and geographical distribution of polio outbreaks in Africa six months in advance with a high predictive ability. Although the accuracy of the predictions made by the model is limited by the structure of the model and by the data fed into it, the information provided by this and other predictive models should help the Global Polio Eradication Initiative plan its future immunization and surveillance campaigns and should facilitate the elimination of polio from Africa.
Additional Information
Please access these websites via the online version of this summary at
The Global Polio Eradication Initiative provides information about polio and about global efforts to eradicate the disease; its website includes links to videos about global polio elimination efforts
The World Health Organization provides information about polio and attempts to eradicate the disease (in several languages)
The US Centers for Disease Control and Prevention provides information about polio vaccination
The UK National Health Service Choices website has information on polio
MedlinePlus provides links to more resources on polio (in English and Spanish)
Personal stories about polio are available through the British Polio Fellowship Heritage Project; the National Museum of American History Whatever happened to polio? website includes an archive of polio-related pictures
PMCID: PMC3196484  PMID: 22028632
4.  The effect of mass immunisation campaigns and new oral poliovirus vaccines on the incidence of poliomyelitis in Pakistan and Afghanistan, 2001–11: a retrospective analysis 
Lancet  2012;380(9840):491-498.
Pakistan and Afghanistan are two of the three remaining countries yet to interrupt wild-type poliovirus transmission. The increasing incidence of poliomyelitis in these countries during 2010–11 led the Executive Board of WHO in January, 2012, to declare polio eradication a “programmatic emergency for global public health”. We aimed to establish why incidence is rising in these countries despite programme innovations including the introduction of new vaccines.
We did a matched case-control analysis based on a database of 46 977 children aged 0–14 years with onset of acute flaccid paralysis between Jan 1, 2001, and Dec 31, 2011. The vaccination history of children with poliomyelitis was compared with that of children with acute flaccid paralysis due to other causes to estimate the clinical effectiveness of oral poliovirus vaccines (OPVs) in Afghanistan and Pakistan by conditional logistic regression. We estimated vaccine coverage and serotype-specific vaccine-induced population immunity in children aged 0–2 years and assessed their association with the incidence of poliomyelitis over time in seven regions of Afghanistan and Pakistan.
Between Jan 1, 2001, and Dec 31, 2011, there were 883 cases of serotype 1 poliomyelitis (710 in Pakistan and 173 in Afghanistan) and 272 cases of poliomyelitis serotype 3 (216 in Pakistan and 56 in Afghanistan). The estimated clinical effectiveness of a dose of trivalent OPV against serotype 1 poliomyelitis was 12·5% (95% CI 5·6–18·8) compared with 34·5% (16·1–48·9) for monovalent OPV (p=0·007) and 23·4% (10·4–34·6) for bivalent OPV (p=0·067). Bivalent OPV was non-inferior compared with monovalent OPV (p=0·21). Vaccination coverage decreased during 2006–11 in the Federally Administered Tribal Areas (FATA), Balochistan, and Khyber Pakhtunkhwa in Pakistan and in southern Afghanistan. Although partially mitigated by the use of more effective vaccines, these decreases in coverage resulted in lower vaccine-induced population immunity to poliovirus serotype 1 in FATA and Balochistan and associated increases in the incidence of poliomyelitis.
The effectiveness of bivalent OPV is comparable with monovalent OPV and can therefore be used in eradicating serotype 1 poliomyelitis whilst minimising the risks of serotype 3 outbreaks. However, decreases in vaccination coverage in parts of Pakistan and southern Afghanistan have severely limited the effect of this vaccine.
Poliovirus Research subcommittee of WHO, Royal Society, and Medical Research Council.
PMCID: PMC3418593  PMID: 22766207
5.  Enhanced surveillance of acute flaccid paralysis following importation of wild poliovirus in Xinjiang Uygur Autonomous Region, China 
BMC Infectious Diseases  2014;14:113.
After being polio free for more than 10 years, an outbreak occurred in China in 2011 in Xinjiang Uygur Autonomous Region (Xinjiang) following the importation of wild poliovirus (WPV) originating from neighboring Pakistan.
To strengthen acute flaccid paralysis (AFP) surveillance in Xinjiang, “zero case daily reporting” and retrospective searching of AFP cases were initiated after the confirmation of the WPV outbreak. To pinpoint all the polio cases in time, AFP surveillance system was expanded to include persons of all ages in the entire population in Xinjiang.
Totally, 578 AFP cases were reported in 2011 in Xinjiang, including 21 WPV cases, 23 clinical compatible polio cases and 534 non-polio AFP cases. Of the 44 polio cases, 27 (61.4%) cases were reported among adults aged 15–53 years. Strengthening AFP surveillance resulted in an increase in the number of non-polio AFP cases in 2011 (148 children < 15 years) compared with 76 cases < 15 years in 2010. The AFP surveillance system in Xinjiang was sensitive enough to detect polio cases, with the AFP incidence of 3.28/100,000 among children < 15 years of age.
Incorporating adult cases into the AFP surveillance system is of potential value to understand the overall characteristics of the epidemic and to guide emergency responses, especially in countries facing WPV outbreak following long-term polio free status. The AFP surveillance system in Xinjiang was satisfactory despite limitations in biological sample collection.
PMCID: PMC3941572  PMID: 24576083
Acute flaccid paralysis; Wild poliovirus; Clinical compatible polio cases; China
6.  Development of a Poliovirus Neutralization Test with Poliovirus Pseudovirus for Measurement of Neutralizing Antibody Titer in Human Serum ▿ 
Clinical and Vaccine Immunology : CVI  2011;18(11):1889-1894.
In the Global Polio Eradication Initiative, laboratory diagnosis plays a critical role by isolating and identifying poliovirus (PV) from the stool samples from acute flaccid paralysis (AFP) cases. In recent years, reestablishment of PV circulation in countries where PV was previously eliminated has occurred because of decreased herd immunity, possibly due to poor vaccination coverage. To monitor the vulnerability of countries to PV circulation, surveillance of neutralizing-antibody titers against PV in susceptible populations is essential in the end game of the polio eradication program. In this study, we have developed a PV neutralization test with type 1, 2, and 3 PV pseudoviruses to determine the neutralizing-antibody titer against PV in human serum samples. With this test, the neutralizing-antibody titer against PV could be determined within 2 days by automated interpretation of luciferase signals without using infectious PV strains. We validated the pseudovirus PV neutralization test with 131 human serum samples collected from a wide range of age groups (ages 1 to >60 years) by comparison with a conventional neutralization test. We found good correlation in the neutralizing-antibody titers determined by these tests. These results suggest that a pseudovirus PV neutralization test would serve as a safe and simple procedure for the measurement of the neutralizing-antibody titer against PV.
PMCID: PMC3209023  PMID: 21880850
7.  IDSR as a Platform for Implementing IHR in African Countries 
Of the 46 countries in the World Health Organization (WHO) African region (AFRO), 43 are implementing Integrated Disease Surveillance and Response (IDSR) guidelines to improve their abilities to detect, confirm, and respond to high-priority communicable and noncommunicable diseases. IDSR provides a framework for strengthening the surveillance, response, and laboratory core capacities required by the revised International Health Regulations [IHR (2005)]. In turn, IHR obligations can serve as a driving force to sustain national commitments to IDSR strategies. The ability to report potential public health events of international concern according to IHR (2005) relies on early warning systems founded in national surveillance capacities. Public health events reported through IDSR to the WHO Emergency Management System in Africa illustrate the growing capacities in African countries to detect, assess, and report infectious and noninfectious threats to public health. The IHR (2005) provide an opportunity to continue strengthening national IDSR systems so they can characterize outbreaks and respond to public health events in the region.
Of the 46 countries in the WHO African region, 43 are implementing Integrated Disease Surveillance and Response (IDSR) guidelines to improve their abilities to detect, confirm, and respond to high-priority communicable and noncommunicable diseases. IDSR provides a framework for strengthening the surveillance, response, and laboratory core capacities required by the revised International Health Regulations [IHR (2005)]. In turn, IHR obligations can motivate sustained national commitment to IDSR strategies. The ability to report potential public health events of international concern relies on early warning systems founded in national surveillance capacities. The IHR (2005) provide an opportunity to continue strengthening national surveillance systems so they can characterize outbreaks and respond to public health events in the region.
PMCID: PMC3779000  PMID: 24041192
8.  An evaluation of the sensitivity of acute flaccid paralysis surveillance for poliovirus infection in Australia 
World Health Organization (WHO) targets for acute flaccid paralysis (AFP) surveillance, including the notification of a minimum rate of AFP among children, are used to assess the adequacy of AFP surveillance for the detection of poliovirus infection. Sensitive surveillance for poliovirus infection in both developed and developing countries is essential to support global disease eradication efforts. We applied recently developed methods for the quantitative evaluation of disease surveillance systems to evaluate the sensitivity of AFP surveillance for poliovirus infection in Australia.
A scenario tree model which accounted for administrative region, age, population immunity, the likelihood of AFP, and the probability of notification and stool sampling was used to assess the sensitivity of AFP surveillance for wild poliovirus infection among children aged less than 15 years in Australia. The analysis was based on historical surveillance data collected between 2000 and 2005. We used a surveillance time period of one month, and evaluated the ability of the surveillance system to detect poliovirus infection at a prevalence of 1 case per 100 000 persons and 1 case per million persons.
There was considerable variation in the sensitivity of AFP surveillance for poliovirus infection among Australian States and Territories. The estimated median sensitivity of AFP surveillance in Australia among children aged less than 15 years was 8.2% per month at a prevalence of 1 case per 100,000 population, and 0.9% per month at a prevalence of 1 case per million population. The probability that Australia is free from poliovirus infection given negative surveillance findings following 5 years of continuous surveillance was 96.9% at a prevalence of 1 case per 100,000 persons and 56.5% at a prevalence of 1 case per million persons.
Given the ongoing risk of poliovirus importation prior to global eradication, long term surveillance is required to provide a high degree of confidence in freedom from poliovirus infection in Australia, particularly if a low prevalence of infection is assumed. Adherence to the WHO surveillance targets would considerably improve the sensitivity of surveillance for poliovirus infection in Australia.
PMCID: PMC2761398  PMID: 19788763
9.  Detection of Non-Polio Enteroviruses From 17 Years of Virological Surveillance of Acute Flaccid Paralysis in the Philippines 
Journal of Medical Virology  2012;84(4):624-631.
Acute flaccid paralysis (AFP) surveillance has been conducted as part of the World Health Organization (WHO) strategy on poliomyelitis eradication. Aside from poliovirus, which is the target pathogen, isolation, and identification of non-polio enteroviruses (NPEVs) is also done by neutralization test using pools of antisera which can only identify limited number of NPEVs. In the Philippines, despite the significant number of isolated NPEVs, no information is available with regard to its occurrence, diversity, and pattern of circulation. In this study, a total of 790 NPEVs isolated from stool samples submitted to the National Reference Laboratory from 1992 to 2008 were analyzed; neutralization test was able to type 55% (442) of the isolates. Of the remaining 356 isolates, which were untyped by using neutralization test, 348 isolates were analyzed further by RT-PCR targeting the VP1 gene. A total of 47 serotypes of NPEV strains were identified using neutralization test and molecular typing, including 28 serotypes of human enterovirus B (HEV-B), 12 serotypes of HEV-A, and 7 of HEV-C. The HEV-B group (625/790; 79%) constituted the largest proportion of isolates, followed by HEV-C (108/790; 13.7%), HEV-A (57/790; 7.2%), and no HEV-D. Coxsackievirus (CV) B, echovirus (E)6, E11, and E13 were the most frequent isolates. E6, E11, E13, E14, E25, E30, E33, CVA20, and CVA24 were considered as endemic strains, some NPEVs recurred and few serotypes existed only for 1–3 years during the study period. Despite some limitations in this study, plural NPEVs with multiple patterns of circulation in the Philippines for 17 years were identified. J. Med. Virol. 84:624–631, 2012. © 2011 Wiley Periodicals, Inc.
PMCID: PMC3500505  PMID: 22337302
circulation pattern; epidemiology; neutralization test; NPEV rate; polio eradication
10.  History of polio vaccination 
World Journal of Virology  2012;1(4):108-114.
Poliomyelitis is an acute paralytic disease caused by three poliovirus (PV) serotypes. Less than 1% of PV infections result in acute flaccid paralysis. The disease was controlled using the formalin-inactivated Salk polio vaccine (IPV) and the Sabin oral polio vaccine (OPV). Global poliomyelitis eradication was proposed in 1988 by the World Health Organization to its member states. The strategic plan established the activities required for polio eradication, certification for regions, OPV cessation phase and post-OPV phase. OPV is the vaccine of choice for the poliomyelitis eradication program because it induces both a systemic and mucosal immune response. The major risks of OPV vaccination are the appearance of Vaccine-Associated Paralytic Poliomyelitis cases (VAPP) and the emergence of Vaccine Derived Polioviruses strains. The supplementary immunization with monovalent strains of OPV type 1 or type 3 or with a new bivalent oral polio vaccine bOPV (containing type 1 and type 3 PV) has been introduced in those regions where the virus has been difficult to control. Most countries have switched the schedule of vaccination by using IPV instead of OPV because it poses no risk of vaccine-related disease. Until 2008, poliomyelitis was controlled in Romania, an Eastern European country, predominantly using OPV. The alternative vaccination schedule (IPV/OPV) was implemented starting in September 2008, while beginning in 2009, the vaccination was IPV only. The risk of VAPP will disappear worldwide with the cessation of use of OPV. The immunization for polio must be maintained for at least 5 to 10 years using IPV.
PMCID: PMC3782271  PMID: 24175215
Poliomyelitis; Formalin-inactivated polio vaccine; Oral polio vaccine
11.  The final stages of the global eradication of poliomyelitis 
The global incidence of poliomyelitis has dropped by more than 99 per cent since the governments of the world committed to eradication in 1988. One of the three serotypes of wild poliovirus has been eradicated and the remaining two serotypes are limited to just a small number of endemic regions. However, the Global Polio Eradication Initiative (GPEI) has faced a number of challenges in eradicating the last 1 per cent of wild-virus transmission. The polio endgame has also been complicated by the recognition that vaccination with the oral poliovirus vaccine (OPV) must eventually cease because of the risk of outbreaks of vaccine-derived polioviruses. I describe the major challenges to wild poliovirus eradication, focusing on the poor immunogenicity of OPV in lower-income countries, the inherent limitations to the sensitivity and specificity of surveillance, the international spread of poliovirus and resulting outbreaks, and the potential significance of waning intestinal immunity induced by OPV. I then focus on the challenges to eradicating all polioviruses, the problem of vaccine-derived polioviruses and the risk of wild-type or vaccine-derived poliovirus re-emergence after the cessation of oral vaccination. I document the role of research in the GPEI's response to these challenges and ultimately the feasibility of achieving a world without poliomyelitis.
PMCID: PMC3720038  PMID: 23798688
poliovirus; poliomyelitis; polio; eradication; vaccine; public health
12.  Potential for the Australian and New Zealand paediatric intensive care registry to enhance acute flaccid paralysis surveillance in Australia: a data-linkage study 
BMC Infectious Diseases  2013;13:384.
Australia uses acute flaccid paralysis (AFP) surveillance to monitor its polio-free status. The World Health Organization criterion for a sensitive AFP surveillance system is the annual detection of at least one non-polio AFP case per 100,000 children aged less than 15 years, a target Australia has not consistently achieved. Children exhibiting AFP are likely to be hospitalised and may be admitted to an intensive care unit. This provides a potential opportunity for active AFP surveillance.
A data-linkage study for the period from 1 January 2005 to 31 December 2008 compared 165 non-polio AFP cases classified by the Polio Expert Panel with 880 acute neurological presentations potentially compatible with AFP documented in the Australian and New Zealand Paediatric Intensive Care (ANZPIC) Registry.
Forty-two (25%) AFP cases classified by the Polio Expert Panel were matched to case records in the ANZPIC Registry. Of these, nineteen (45%) cases were classified as Guillain-Barré syndrome on both registries. Ten additional Guillain-Barré syndrome cases recorded in the ANZPIC Registry were not notified to the national AFP surveillance system.
The identification of a further ten AFP cases supports inclusion of intensive care units in national AFP surveillance, particularly specialist paediatric intensive care units, to identify AFP cases that may not otherwise be reported to the national surveillance system.
PMCID: PMC3765192  PMID: 23964831
Acute flaccid paralysis; Clinical surveillance; Poliovirus; Paediatric intensive care
13.  Feasibility of Quantitative Environmental Surveillance in Poliovirus Eradication Strategies 
Applied and Environmental Microbiology  2012;78(11):3800-3805.
The progress of the Global Polio Eradication Initiative is monitored by acute flaccid paralysis (AFP) surveillance supplemented with environmental surveillance in selected areas. To assess the sensitivity of environmental surveillance, stools from (re)vaccinated elderly persons with a low seroprevalence and from wastewater were concurrently collected and analyzed in the Netherlands over a prolonged period of time. A total number of 228 healthy individuals with different levels of immunity were challenged with monovalent oral polio vaccine serotype 1 or 3. Poliovirus concentrations were determined by the titration of fecal suspensions on poliovirus-sensitive L20B cells and of sewage concentrates by L20B monolayer plaque assay. Almost half of the individuals (45%) shed poliovirus on day 3 after challenge, which peaked (57%) on day 8 with an average poliovirus excretion of 1.3 × 105 TCID50 per g of feces and gradually decreased to less than 5% on day 42. The virus concentrations in sewage peaked on days 6 to 8 at approximately 100 PFU per liter, remained high until day 14, and subsequently decreased to less than 10 PFU per liter on day 29. The estimated poliovirus concentration in sewage approximated the measured initial virus excretion in feces, within 1 log10 variation, resulting in a sensitivity of detection of 100 infected but mostly asymptomatic individuals in tens of thousands of individuals. An additional second peak observed in sewage may indicate secondary transmission missed by enterovirus or AFP surveillance in patients. This enables the detection of circulating poliovirus by environmental surveillance, supporting its feasibility as an early warning system.
PMCID: PMC3346415  PMID: 22447593
14.  Poor immunity status against poliomyelitis in medical students: a semi-anonymous study 
In spite of almost complete eradication, poliomyelitis continues to be a global threat even in non-endemic countries due to the ever-increasing international travel activities. Health care workers are at a special risk in acquiring pathogens from travelers returning from endemic countries. Polio vaccines are fairly well accepted throughout the German population. Yet, laboratory controls for successful immunization are carried out only sporadically in the general population, and not even the medical staff are routinely tested for polio immunity. The present study was initiated in order to assess the immunity status of young people at the very beginning of their career in clinical medicine. Within their first clinical semester, all students are supposed to undergo an obligatory health check in our Occupational Medicine Unit. A blood sample is taken and sent under a personal code to our diagnostic laboratories for virus serology, and for cryoconservation of residual serum, if available. Within the periods 2004–2006 and 2008–2010, we analyzed sera from 424 and 427 individuals, respectively, for anti-polio types 1, 2, 3 antibodies by a microneutralization assay. In the latest study period, there was a slight increase in the rate of fully protected persons: 63.9 % triple-seropositivity versus 57.1 % in the period 2004–2006. By the end of the second clinical semester, students with low or negative antibody levels (1:<10) were informed, and a (booster) vaccination was recommended.
PMCID: PMC3562434  PMID: 22692773
Polioviruses; Immunity status; Medical students
15.  Human Enteroviruses isolated during acute flaccid paralysis surveillance in Ghana: implications for the post eradication era 
Surveillance of acute flaccid surveillance (AFP) has been used world-wide to monitor the control and eradication of circulating wild polioviruses. The Polio Laboratory since its accreditation in 1996 has supported the Disease Surveillance Department for AFP surveillance. This study aims to isolate and characterize human enteroviruses from patients with AFP in Ghana.
Stool suspension was prepared from 308 samples received in 2009 from the surveillance activities throughout the country and inoculated on both RD and L20B cell lines. Isolates that showed growth on L20B were selected for real-time RT-PCR using degenerate and non-degenerate primers and probes. RD isolates were however characterized by microneutralisation technique with antisera pools from RIVM, The Netherlands and viruses that were untypable subjected to neutralization assay using antibodies specific for E71.
Of the 308 samples processed, 17 (5.5%) grew on both L20B and RD cells while 32 (10.4%) grew on RD only. All 28 isolates from L20B were characterized by rRT-PCR as Sabin-like polioviruses. No wild poliovirus or VDPV was found. However from the microneutralisation assay, six different enteroviruses were characterized. Among these, Coxsackie B viruses were most predominant followed by Echovirus. Three children from whom non-polio enteroviruses were isolated had residual paralysis while one child with VAPP found. The non-polio enteroviruses circulated throughout the country with the majority (20.7%) from Ashanti region.
This study showed the absence of wild or vaccine-derived poliovirus circulation in the country. However, the detection of three non-polio enteroviruses and one Sabin-like poliovirus with residual paralysis call for continuous surveillance even in the post polio eradication era.
PMCID: PMC3473960  PMID: 23077695
Poliovirus; non-polio enterovirus; surveillance; acute flaccid paralysis; Ghana
16.  Human enterovirus surveillance in the Slovak Republic from 2001 to 2011 
Epidemiology and Infection  2013;141(12):2658-2662.
We report the outcome of an 11-year programme monitoring sewage water and acute flaccid paralysis (AFP) cases as part of the World Health Organization (WHO) strategy for polio eradication in the Slovak Republic (SR). Polioviruses (PV) and non-polio enteroviruses (NPEV), prior to and after the change in polio vaccination strategy, were detected. Sewage treatment plant samples from 48 localities spread over the Western, Central and Eastern regions and clinical material from AFP cases were examined. The WHO standard procedures were followed with regard to virus isolation and identification. There were 538 commonly detected human enteroviruses (HEVs) including 213 (40%) coxsackie B viruses (CBV), 200 (37%) echoviruses and 113 (21%) Sabin-like PVs (PV1, 2, 3) including vaccine-derived poliovirus (VDPV) isolates. The percentage of PV isolates fell from 66% to 30% during 2001–2005 and thereafter fell to zero. CBV5, CBV2 and echovirus 3 were the NPEVs endemic during the study period.
PMCID: PMC3821400  PMID: 23507533
Enterovirus; surveillance
17.  Public Health Response to Imported Case of Poliomyelitis, Australia, 2007 
Emerging Infectious Diseases  2009;15(11):1733-1737.
Inactivated polio vaccine was offered, and the index case-patient and household contacts were quarantined.
Australia, along with 36 other countries in the Western Pacific Region, was declared free of poliomyelitis by the World Health Organization in October 2000. Yet, the persistence of wild poliovirus in the 4 remaining polio-endemic countries—Afghanistan, India, Nigeria, and Pakistan—poses a risk for its importation into all countries declared polio free. We describe the public health response and outcomes resulting from the importation of a wild poliovirus infection in Melbourne, Australia, in July 2007. This response, based on an assessment of the risk for transmission, included offering vaccination with inactivated polio vaccine to the contacts and placing the index patient in isolation and the household contacts in quarantine until consecutive fecal specimens were negative for poliovirus by culture. The experience gained from the polio importation event in Australia may assist other polio-free countries to prepare for, and respond to, a similar event. No secondary clinical cases resulted from this importation.
PMCID: PMC2857217  PMID: 19891859
Poliomyelitis; wild poliovirus type 1; polio vaccine; inactivated polio vaccine; importation; viruses; synopsis
18.  Strengthening systems for communicable disease surveillance: creating a laboratory network in Rwanda 
The recent emergence of a novel strain of influenza virus with pandemic potential underscores the need for quality surveillance and laboratory services to contribute to the timely detection and confirmation of public health threats. To provide a framework for strengthening disease surveillance and response capacities in African countries, the World Health Organization Regional Headquarters for Africa (AFRO) developed Integrated Disease Surveillance and Response (IDSR) aimed at improving national surveillance and laboratory systems. IDSR emphasizes the linkage of information provided by public health laboratories to the selection of relevant, appropriate and effective public health responses to disease outbreaks.
We reviewed the development of Rwanda's National Reference Laboratory (NRL) to understand essential structures involved in creating a national public health laboratory network. We reviewed documents describing the NRL's organization and record of test results, conducted site visits, and interviewed health staff in the Ministry of Health and in partner agencies. Findings were developed by organizing thematic categories and grouping examples within them. We purposefully sought to identify success factors as well as challenges inherent in developing a national public health laboratory system.
Among the identified success factors were: a structured governing framework for public health surveillance; political commitment to promote leadership for stronger laboratory capacities in Rwanda; defined roles and responsibilities for each level; coordinated approaches between technical and funding partners; collaboration with external laboratories; and use of performance results in advocacy with national stakeholders. Major challenges involved general infrastructure, human resources, and budgetary constraints.
Rwanda's experience with collaborative partnerships contributed to creation of a functional public health laboratory network.
PMCID: PMC3142247  PMID: 21702948
19.  Capacity-building efforts by the AFHSC-GEIS program 
BMC Public Health  2011;11(Suppl 2):S4.
Capacity-building initiatives related to public health are defined as developing laboratory infrastructure, strengthening host-country disease surveillance initiatives, transferring technical expertise and training personnel. These initiatives represented a major piece of the Armed Forces Health Surveillance Center, Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) contributions to worldwide emerging infectious disease (EID) surveillance and response. Capacity-building initiatives were undertaken with over 80 local and regional Ministries of Health, Agriculture and Defense, as well as other government entities and institutions worldwide. The efforts supported at least 52 national influenza centers and other country-specific influenza, regional and U.S.-based EID reference laboratories (44 civilian, eight military) in 46 countries worldwide. Equally important, reference testing, laboratory infrastructure and equipment support was provided to over 500 field sites in 74 countries worldwide from October 2008 to September 2009. These activities allowed countries to better meet the milestones of implementation of the 2005 International Health Regulations and complemented many initiatives undertaken by other U.S. government agencies, such as the U.S. Department of Health and Human Services, the U.S. Agency for International Development and the U.S. Department of State.
PMCID: PMC3092414  PMID: 21388564
20.  Detection of Imported Wild Polioviruses and of Vaccine-Derived Polioviruses by Environmental Surveillance in Egypt 
Applied and Environmental Microbiology  2012;78(15):5406-5409.
Systematic environmental surveillance for poliovirus circulation has been conducted in Egypt since 2000. The surveillance has revealed three independent importations of wild-type poliovirus. In addition, several vaccine-derived polioviruses have been detected in various locations in Egypt. In addition to acute flaccid paralysis (AFP) surveillance, environmental surveillance can be used to monitor the wild poliovirus and vaccine-derived poliovirus circulation in populations in support of polio eradication initiatives.
PMCID: PMC3416427  PMID: 22582070
21.  The role of nurses and midwives in polio eradication and measles control activities: a survey in Sudan and Zambia 
Nurses and midwives are the key providers of nursing and midwifery services; in many countries, they form the major category of frontline workers who provide both preventive and curative services in the community. When the skills and experience of nursing and midwifery personnel are maximized, they can contribute significantly to positive health outcomes. We conducted a survey among nurses and midwives working at district level in Sudan and Zambia to determine their roles and functions in polio eradication and measles elimination programmes.
Nurses and midwives practising in four selected districts in Sudan and in Zambia completed a self-administered questionnaire on their roles and responsibilities, their routine activities and their functions during supplementary immunization campaigns for polio and measles.
Nurses and midwives were found to play significant roles in implementing immunization programme activities. The level of responsibilities of nurses and midwives in their routine work related more to existing opportunities than to their job descriptions.
In Zambia, where nurses reported constraints in performing their tasks, the reasons cited were an increase in the burden of disease and the shortage of health personnel. Factors identified as key to improving work performance included written job descriptions, opportunities for staff and career development and opportunities to earn extra income through activities associated with their jobs.
Other non-monetary incentives mentioned included reliable transport, resources and logistics to support routine work in the district. However, in both countries, during supplementary immunization activities or mass campaigns for polio eradication and measles control, nurses and midwives took on more management responsibilities.
This study shows that nurses and midwives play an important role in implementing immunization activities at the district level and that their roles can be maximized by creating opportunities that lead to their having more responsibilities in their work and in particular, their involvement in early phases of planning of priority health activities. This should be accompanied by written job descriptions, tasks and clear lines of authority as well as good supportive supervision. The lessons from supplementary immunization activities, where the roles of nurses and midwives are maximized, can be easily adopted to benefit the rest of the health services provided at district level.
PMCID: PMC2754417  PMID: 19737379
22.  Emerging Subspecialties in Neurology: Global health 
Neurology  2013;80(8):e78-e80.
Global health is the study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide.1 In contrast to the public health concerns of a particular country or region, global health looks at populations irrespective of borders. One of the key elements in advancing the field of global health was the establishment of the WHO in 1948. Since its inception, the WHO has helped coordinate global efforts toward eradication of diseases such as smallpox and polio as well as elimination of onchocerciasis. It now assumes responsibility for the International Classification of Diseases. More recently, the field of global health has received considerable attention from world leaders, philanthropists, and academics. In 2009, President Obama introduced his Global Health Initiative that proposed spending $63 billion over 6 years to support global health programs specifically targeting areas such as HIV/AIDS, malaria, tuberculosis, nutrition, and reproductive health. On his first day of work as NIH Director, Francis Collins announced global health as one of his 5 themes of “exceptional opportunity” that would receive special priority during his tenure.2 The Fogarty International Center is a branch of the NIH that helps to support global health research for US and foreign researchers, often in resource-limited settings. The research initiatives encompass a diverse range of disciplines within the field of medicine.
PMCID: PMC3589295  PMID: 23420898
23.  Canada must be alert to threat of imported wild poliovirus, working group says. 
Even though the Western Hemisphere is certified as being polio free, countries such as Canada must be alert to the continuing threat posed by the importation of wild poliovirus from polio-endemic regions, according to a report from Canada's Working Group on Polio Eradication and the Laboratory Centre for Disease Control. The working group recommends the maintenance of high immunization-coverage levels and strengthened surveillance activities for polio.
PMCID: PMC1337948  PMID: 7796379
24.  Evaluation of Acute Flaccid Paralysis in Hamadan, Iran from 2002 to 2009 
Epidemiology and Health  2011;33:e2011011.
To achieve a polio-free certification in Iran, a nationwide active surveillance program for acute flaccid paralysis (AFP) was set up following World Health Organization guidelines. This article describes the results of an eight-year surveillance of AFP in Hamadan, in the west of Iran.
A standard set of minimum core variables were collected. All cases of non-polio AFP in children aged <15 years old were reported. Two stool specimens were collected within 14 days of the onset of paralysis.
During the eight-year survey, 88 AFP cases aged <15 years old were reported. About 40% (35/88) of cases were aged ≤5 years, 56% (49/88) were boys, 19 (21.6%) had fever at the onset of paralysis, 74 (84.0%) had complete paralysis within four days of onset, and 22 (24.7%) had asymmetric paralysis. More than one AFP case was detected per 100,000 children aged <15 years old in all years. The risk of AFP in patients aged <5 years old was almost double that of older patients. Guillain-Barré Syndrome was the major leading cause of AFP (66/88). Adequate stool specimens were collected from 85% of AFP patients. All stool specimens were tested virologically, but no wild polioviruses were detected.
The active surveillance of non-polio AFP was efficient over the last eight years and exceeded 1.0 case per 100,000 children aged <15 years old. Nonetheless, there was a decreasing trend in the detection of AFP cases during the last two years and should be the focus of the policymakers' special attention, although AFP cases were still above the target level.
PMCID: PMC3221035  PMID: 22111031
Paralysis; Poliomyelitis; Population surveillance; Guillain-Barré syndrome; Iran
25.  Determinants of Health Disparities: The Perennial Struggle against Polio in Nigeria 
Polio remains a global public health issue, and even though it has been eradicated from most countries of the world, countries like Nigeria, the largest black nation on earth, threatens the dream of total eradication of polio from the surface of the earth. Transmission of wild polio virus has never been eliminated in Nigeria, but even worse is the number of countries, both in Sub-Saharan Africa and all over the world that has become re-infected by polio virus strains from Northern Nigeria in recent past. Although a lot has been documented about the Nigerian polio struggle, one aspect that has received little attention on this issue is ethnic and geographic disparities between the Southern and the Northern parts of Nigeria. Understanding these disparities involved in polio virus transmission in Nigeria, as well as the social determinants of health prevalent in Northern Nigeria will help government and other stakeholders and policy makers to synergize their efforts in the fight against this perennial scourge.
PMCID: PMC3143522  PMID: 21811651
Healthcare disparities; Poliomyelitis; Nigeria

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