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Hajj pilgrims must have certain vaccines for pilgrimage; these requirements aim to reduce the spread of infectious diseases. This study analyzed the trends in vaccine adherence for meningitis, yellow fever, and polio from January 2017- December 2019. These trends can help in guiding future policymaking to prevent outbreaks during Hajj and similar mass gatherings. We analyzed data using descriptive statistics for Hajj pilgrims and Hajj seasonal workers arriving in Saudi Arabia over three years (2017–2019). Health Control Centers (HCCs) collected data at points-of-entry (PoE) and entered it into Saudi Arabia’s Health Electronic Surveillance Network (HESN). We reviewed HESN data to collect information on total passengers arriving per country and the number of passengers vaccinated for: meningococcal meningitis, poliomyelitis, and yellow fever. We compared data to identify the difference in vaccination by region. We used chi-square tests to assess differences in compliance rate among these travelers by year and country of origin. The number of participating countries increased from 113 to 132. Meningitis vaccine coverage increased by 5% from 2017–2019. The increase was not statistically significant. Asia had the lowest overall adherence rate (83%). Yellow fever adherence decreased significantly using a difference of mean adherence between 2017 and 2019 (p-value 0.01). Polio vaccination adherence decreased by 5% from 2017 to 2019; this was not significant (p-value = 0.08). The vaccine coverage increased for meningitis and decreased for yellow fever and polio. Less than 100% vaccine adherence among Hajj travelers creates the potential for the spread of infectious diseases. Proof of vaccination should be required in submitted visa applications. Countries of origin and Saudi Arabia must work together to ensure that all Hajjis are adequately vaccinated before departure.

It should be everyone’s basic health right to get immunization. Everyone is responsible for this, every individual, every sector, every community, the entire healthcare system and the country. The aim of this paper is to highlight a few issues concerning polio vaccines in Pakistan and suggest some solution to these issues. The developmental plane of this paper is based on literature on polio and public health in Multan, Pakistan perspective. Inclusion criteria base on public health culture, religion and ethical base published review articles. Religious ideas and views affect almost every part of human behavior, including their views and acceptance towards certain healthcare services. For the past few years, the issues regarding polio vaccination have been a highlighted topic in Pakistan. Many steps have been taken by the government to ensure that more people gain immunity against polio. Even so, a large fraction of population appears to be resistant towards polio vaccination and refuses to get vaccinated. The views, thoughts and beliefs of people are considered more of importance tan health concerns. That is why it is very important to understand the context behind these resistances so that proper strategies can be made for dealing with them. Those who are in charge of making policies in Pakistan must pay attention towards the many challenges that are faced during the polio vaccination so that such a plan could be developed while keeps the ethical norms in mind so success could be achieved.

BACKGROUND Outbreaks of circulating vaccine-derived polioviruses (cVDPVs) pose a threat to the eventual eradication of all polioviruses. In 2017, an outbreak of cVDPV type 2 (cVDPV2) occurred in the midst of a war in Syria. We describe vaccination-based risk factors for and the successful response to the outbreak. METHODS We performed a descriptive analysis of cVDPV2 cases and key indicators of poliovirus surveillance and vaccination activities during 2016-2018. In the absence of reliable subnational coverage data, we used the caregiver-reported vaccination status of children with non-polio acute flaccid paralysis (AFP) as a proxy for vaccination coverage. We then estimated the relative odds of being unvaccinated against polio, comparing children in areas affected by the outbreak to children in other parts of Syria in order to establish the presence of poliovirus immunity gaps in outbreak affected areas. FINDINGS A total of 74 cVDPV2 cases were reported, with paralysis onset ranging from 3 March to 21 September 2017. All but three cases were reported from Deir-ez-Zor governorate and 84% had received

The switch from using only trivalent oral polio vaccine (tOPV) to sequential schedules combining inactivated poliovirus vaccine (IPV) and bivalent oral polio vaccine (bOPV) for polio vaccination will cause changes to mucosal immunity against polio in infants, which plays an important role in preventing the poliovirus spread. Here, we analyzed mucosal immunity against poliovirus in the intestine during different sequential vaccination schedules. We conducted clinical trials in Guangxi Province, China on 1,200 2-month-old infants who were randomly assigned to one of three vaccination schedule groups: IPV-bOPV-bOPV, IPV-IPV-tOPV, and IPV-IPV-bOPV, with vaccine doses administered at 8, 12, and 16 weeks of age. Stool samples were collected from 10% of participants in each group before administration of the second vaccine doses and at 1, 2, and 4 weeks after the administrations of the second and third vaccine doses. Immunoglobulin A (IgA) in the stool samples was measured to analyze the mucosal immune response in the intestine. Because of the absence of poliovirus type 2 in bOPV, the vaccination schedule of IPV-IPV-bOPV did not sufficiently raise intestinal mucosal immunity against poliovirus type 2, although some cross-immunity was seen. The level of intestinal mucosal immunity was related to shedding status; shedders could produce intestinal mucosa IgA more quickly. The intestinal mucosal immunity level was not related to serum neutralizing antibody level. In the combined sequential vaccination schedule of IPV and bOPV, the risk of circulating vaccine-derived poliovirus type 2 (cVDPV2) may be increased owing to insufficient intestinal mucosal immunity against poliovirus type 2.

We conducted the current analysis to determine the potential role of polio vaccination in the context of the spread of COVID-19. Data were extracted from the World Health Organization’s (WHO) Global Health Observatory data repository regarding the polio immunization coverage estimates and correlated to the overall morbidity and mortality for COVID-19 among different countries. Data were analyzed using R software version 4.0.2. Mean and standard deviation were used to represent continuous variables while we used frequencies and percentages to represent categorical variables. The Kruskal-Wallis H test was used for continuous variables since they were not normally distributed. Moreover, the Spearman rank correlation coefficient (rho) was used to determine the relationship between different variables. There was a significantly positive correlation between the vaccine coverage (%) and both of total cases per one million populations (rho = 0.37; p-value < 0.001) and deaths per one million populations (rho = 0.30; p-value < 0.001). Moreover, there was a significant correlation between different income groups and each of vaccine coverage (%) (rho = 0.71; p-value < 0.001), total cases per one million populations (rho = 0.50; p-value < 0.001), and deaths per one million populations (rho = 0.39; p-value < 0.001). All claims regarding the possible protective effect of Polio vaccination do not have any support when analyzing the related data. Polio vaccination efforts should be limited to eradicate the disease from endemic countries; however, there is no evidence to support the immunization with live-attenuated vaccines for the protection against COVID-19.

Vaccination prepares the body’s immune system ready to recognise, destroy and remember foreign disease-causing agents when it encounters them. It is the most effective way of averting communicable diseases if fully accepted and demanded by the population at risk of spreading contagious diseases. Social mobilisation has been a critical way of encouraging demands, as well as acceptance and compliance, by the general public for immunisation services. Vaccination campaign against poliovirus by WHO since 1988 was a huge success across the globe except in three countries: Nigeria, Afghanistan and Pakistan. Up until 3 years ago, polio eradication remained a challenge in Nigeria due mainly to non-acceptance of the vaccination by the hard-to-reach (HtoR) group. In this study, carried out at the height of the epidemic in Nigeria, we investigated the effects that social mobilisation on polio vaccination had on the hard-to-reach group. The participants were selected based on three criteria: age of the child, religion and social status. Semi-structured interview was employed and data analysed using the thematic content analysis. The results revealed that religion, service factor-distance to health facility and health staff behaviour are the key factors limiting the social mobilisation effort among the HtoR group. Nigeria began to make success only when one of the most respected Muslim leaders took ownership of the campaign for the elimination of polio, which has now placed Nigeria among the polio-free countries. Therefore, effective social mobilisation for vaccination programs of the HtoR group could be achieved faster with the involvement of religious leaders because of the enormous influence they have on their followers. This revelation is very important to note for the success of the upcoming vaccination campaign against COVID-19 disease, now that effective vaccines against the disease have been developed and ready for distribution. Keywords: Poliovirus, COVID-19, vaccination, social mobilisation, hard-to-reach population.

After eradication and containment of wild poliovirus (PV) and cessation of oral polio vaccinations, it is critical to minimize the risk of reintroducing PV into PV-free communities via facilities that handle the virus. The potential risk of unintentional PV propagation through unidentified contaminated materials is a serious issue. This study reports the generation of HeLa and RD-A cells deficient in functional CD155 gene (∆PVR cells); these cells are not susceptible to PV but remain susceptible to other picornaviruses. These ∆PVR cells will minimize the risk of unintentional transmission of PV and support performing the experiments more safely.

Introduction: Pakistan remains one of the three polio-endemic countries in the world due to Illiteracy, religious beliefs, conflicts and security issues hindering vaccination efforts. Parental refusal or hesitancy towards vaccinating their children along with low coverage of polio vaccination in high conflict areas remain key problem areas.Objectives: To assess the awareness regarding polio vaccination, and to identify the reasons of parental hesitancy towards oral polio vaccination.Materials & Methods: A cross-sectional survey that included 100 participants was conducted in Jamrud (Khyber Agency) from October 2017 to December 2017. Indigenously structured questionnaire was used for recording data in Khyber Agency through convenience sampling. Questions related to awareness, attitude, practice and reasons for hesitancy regarding polio vaccination. SPSS version 16.0 and Microsoft Excel were used for organizing and analyzing data for descriptive statistics.Results: Of the 100 study subjects, 49% were uneducated and only 2% had a positive family history of polio. Overall awareness regarding polio vaccination was poor; only 27% of study participants knew that immunization was effective for prevention and 24% considered vaccine repetition as necessary. The leading reasons given by 24% were that it causes infertility in male children, 16% had lack of trust on quality of vaccine, and 16.6% reported lack of trust on health workers. Religious belief was also one of the reason of hesitancy recorded to be 14.1%. Some participants (10.7%) recorded security issues as their reason of vaccine hesitancy. About 9.5% responded non-compliant spouse as their reason whereas 9.2% considered that vaccination was not necessary. Conclusion: Lack of awareness and education were the main reasons behind misperception of subjects towards polio immunization, followed by fears of infertility and religious beliefs. Keywords: Polio - Global Polio Eradication Initiative (GPEI), Oral Polio Vaccine (OPV), Immunization & Hesitancy.

Countries face different poliovirus risks, which imply different benefits associated with continued and future use of oral poliovirus vaccine (OPV) and/or inactivated poliovirus vaccine (IPV). With the Global Polio Eradication Initiative (GPEI) continuing to extend its timeline for ending the transmission of all wild polioviruses and to introduce new poliovirus vaccines, the polio vaccine supply chain continues to expand in complexity. The increased complexity leads to significant uncertainty about supply and costs. Notably, the strategy of phased OPV cessation of all three serotypes to stop all future incidence of poliomyelitis depends on successfully stopping the transmission of all wild polioviruses. Countries also face challenges associated with responding to any outbreaks that occur after OPV cessation, because stopping transmission of such outbreaks requires reintroducing the use of the stopped OPV in most countries. National immunization program leaders will likely consider differences in their risks and willingness‐to‐pay for risk reduction as they evaluate their investments in current and future polio vaccination. Information about the costs and benefits of future poliovirus vaccines, and discussion of the complex situation that currently exists, should prove useful to national, regional, and global decisionmakers and support health economic modeling. Delays in achieving polio eradication combined with increasing costs of poliovirus vaccines continue to increase financial risks for the GPEI.

Significance An individual’s decision to vaccinate can be motivated by both self-interest and prosociality, making it difficult to delineate the contribution of prosociality to vaccination uptake. A silent polio epidemic in Israel in which the primary purpose of vaccination was to avert transmission to the general community provides a unique case study through which we quantify, using game-theoretical models, the contribution of prosociality to vaccination decisions. We find that prosociality was a significant driver to rapidly achieving a high coverage of polio vaccination. To further boost coverage, public health communication efforts should be directed toward allaying fears about vaccine risks. Our approach is useful for enhancing participation in diverse disease control measures, Regions with insufficient vaccination have hindered worldwide poliomyelitis eradication, as they are vulnerable to sporadic outbreaks through reintroduction of the disease. Despite Israel’s having been declared polio-free in 1988, a routine sewage surveillance program detected polio in 2013. To curtail transmission, the Israel Ministry of Health launched a vaccine campaign to vaccinate children—who had only received the inactivated polio vaccine—with the oral polio vaccine (OPV). Determining the degree of prosocial motivation in vaccination behavior is challenging because vaccination typically provides direct benefits to the individual as well as indirect benefits to the community by curtailing transmission. However, the Israel OPV campaign provides a unique and excellent opportunity to quantify and model prosocial vaccination as its primary objective was to avert transmission. Using primary survey data and a game-theoretical model, we examine and quantify prosocial behavior during the OPV campaign. We found that the observed vaccination behavior in the Israeli OPV campaign is attributable to prosocial behavior and heterogeneous perceived risk of paralysis based on the individual’s comprehension of the prosocial nature of the campaign. We also found that the benefit of increasing comprehension of the prosocial nature of the campaign would be limited if even 24% of the population acts primarily from self-interest, as greater vaccination coverage provides no personal utility to them. Our results suggest that to improve coverage, communication efforts should also focus on alleviating perceived fears surrounding the vaccine.

Pakistan is a polio endemic country as stated by Global Polio Eradication Initiative. Number of polio cases increased in last few years especially in KPK and tribal areas. Present study was focused to collect opinion regarding information, perception and practices about polio among residents of village Sohan. A sample of 100 was interviewed. Data was entered and analyzed in SPSS. A dominant majority consider polio is treatable. Vaccination helps to get healthy and, risk increased by lack of immunization. Practices represent that 94% vaccinated their children, 89% cooperated with polio teams at the time of survey, and 35 parents reported that they refused polio teams at least once in their life. Study concludes that awareness, perception and practices regarding sensitivity of the topic are very much clear to respondents, and majority fulfilling their responsibilities being a parent and also being a citizen of Pakistan.

This report describes polio cases, vaccination uncertainty and challenges, and the way forward to eradicate polio from Pakistan. Numerous articles, government and non-government documents, and survey reports were studied and an online search was made to collect information on polio in Pakistan. Once again the polio vaccination program has been stopped and accused by the local community in Pakistan as a result an increase has been seen in polio cases in the last year. In 2019, a total of 117 wild poliovirus (WPV) and 18 circulating vaccine-derived poliovirus (cVDPV2) cases were reported from the country. The majority of cases were from the Khyber Pakhtunkhwa (KP) province as a result of polio vaccination uncertainty and many challenges faced by the vaccination program in the region. Pakistan reported their highest annual number of WPV cases as compared to last few years. This increase is not only an alarming threat for the country but also a key challenge for the global polio eradication movement. Increase awareness and raising immunization to over 100% in some areas especially in the remote area where every year many children missed vaccination to achieve global polio eradication goals.

Background Extreme weather events, including droughts, are expected to increase in parts of sub-Saharan Africa and are associated with a number of poor health outcomes; however, to the best of our knowledge, the link between drought and childhood vaccination remains unknown. The objective of this study was to evaluate the relationship between drought and vaccination coverage. Methods and findings We investigated the association between drought and vaccination coverage using a retrospective analysis of Demographic and Health Surveys data in 22 sub-Saharan African countries among 137,379 children (50.4% male) born from 2011 to 2019. Drought was defined as an established binary variable of annual rainfall less than or equal to the 15th percentile relative to the 29 previous years, using data from Climate Hazards Group InfraRed Precipitation with Station (CHIRPS) data. We evaluated the association between drought at the date of birth and receipt of bacillus Calmette–Guérin (BCG), diphtheria–pertussis–tetanus (DPT), and polio vaccinations, and the association between drought at 12 months of age and receipt of measles vaccination. We specified logistic regression models with survey fixed effects and standard errors clustered at the enumeration area level, adjusting for child-, mother-, and household-level covariates and estimated marginal risk differences (RDs). The prevalence of drought at date of birth in the sample was 11.8%. Vaccination rates for each vaccination ranged from 70.6% (for 3 doses of the polio vaccine) to 86.0% (for BCG vaccination); however, only 57.6% of children 12 months and older received all recommended doses of BCG, DPT, polio, and measles vaccinations. In adjusted models, drought at date of birth was negatively associated with BCG vaccination (marginal RD = −1.5; 95% CI −2.2, −0.9), DPT vaccination (marginal RD = −1.4; 95% CI −2.2, −0.5), and polio vaccination (marginal RD = −1.3; 95% CI −2.3, −0.3). Drought at 12 months was negatively associated with measles vaccination (marginal RD = −1.9; 95% CI −2.8, −0.9). We found a dose–response relationship between drought and DPT and polio vaccinations, with the strongest associations closest to the timing of drought. Limitations include some heterogeneity in findings across countries. Conclusions In this study, we observed that drought was associated with lower odds of completion of childhood BCG, DPT, and polio vaccinations. These findings indicate that drought may hinder vaccination coverage, one of the most important interventions to prevent infections among children. This work adds to a growing body of literature suggesting that health programs should consider impacts of severe weather in their programming., Jason M. Nagata and colleagues investigate the association between drought and child vaccination coverage in 22 countries in sub-Saharan Africa, using Demographic and Health Survey data from 2011 to 2019., Author summary Why was this study done? Extreme weather events, including droughts, are associated with food insecurity and poor health outcomes, but the link between drought and childhood vaccination has not been studied, to the best of our knowledge. Potential mechanisms linking drought to lower childhood vaccination include food insecurity, increased human migration, and erosion of the public health infrastructure. What did the researchers do and find? We combined national survey data from 22 countries in sub-Saharan Africa with publicly available historical rainfall data to estimate drought exposure among 137,379 children born from 2011 to 2019 and estimated the association between drought and childhood vaccination completion. Drought was associated with lower odds of completion of childhood bacillus Calmette–Guérin (BCG), diphtheria–pertussis–tetanus (DPT), and polio vaccinations. We found a dose–response relationship between drought and DPT and polio vaccinations, with the strongest associations closest to the timing of drought. What do these findings mean? These findings indicate that drought may hinder vaccination coverage, one of the most important interventions to prevent infections among children. Public health programs should be prepared to address drought and adverse weather events as a barrier to childhood vaccination efforts in the face of a changing climate.

IntroductionThe debate over the impact of vertical programmes, including mass vaccination, on health systems is long-standing and often polarised. Studies have assessed the effects of a given vertical health programme on a health system separately from the goals of the vertical programme itself. Further, these health system effects are often categorised as either positive or negative. Yet health systems are in fact complex, dynamic and tightly linked. Relationships between elements of the system determine programme and system-level outcomes over time.MethodsWe constructed a causal loop diagram of the interactions between mass polio vaccination campaigns and government health systems in Ethiopia, India and Nigeria, working inductively from two qualitative datasets. The first dataset was 175 interviews conducted with policymakers, officials and frontline staff in these countries in 2011–2012. The second was 101 interviews conducted with similar groups in 2019, focusing on lessons learnt from polio eradication.ResultsPursuing high coverage in polio campaigns, without considering the dynamic impacts of campaigns on health systems, cost campaign coverage gains over time in weaker health systems with many campaigns. Over time, the systems effects of frequent campaigns, delivered through parallel structures, led to a loss of frontline worker motivation, and an increase in vaccine hesitancy in recipient populations. Co-delivery of interventions helped to mitigate these negative effects. In stronger health systems with fewer campaigns, these issues did not arise.ConclusionIt benefits vertical programmes to reduce the construction of parallel systems and pursue co-delivery of interventions where possible, and to consider the workflow of frontline staff. Ultimately, for health campaign designs to be effective, they must make sense for those delivering and receiving campaign interventions, and must take into account the complex, adaptive nature of the health systems in which they operate.

Background: Africa was certified polio-free in 2020 and to maintain the polio-free status, African countries need to attain and maintain optimal routine polio vaccination coverage. One indicator for optimal polio vaccination coverage is the prevalence of children who have received no polio vaccination through routine services. The objective of the study was to examine the individual-, neighbourhood-, and country-level factors associated with non-vaccination against polio in Africa. Methods: We applied multivariable multilevel logistic regression analyses on recent demographic and health survey data collected from 2010 onwards in Africa. We identified 64,867 children aged 12–23 months (Level 1) nested within 16,283 neighbourhoods (Level 2) from 32 countries (Level 3). Results: The prevalence of non-vaccination for polio ranged from 2.19% in Egypt to 32.74% in Guinea. We found the following factors to be independent predictors of the increased odds of non-vaccination for polio: being a male child, born to mother with no formal education, living in poorer households, being from a polygamous family, living in neighbourhoods with high maternal illiteracy, high unemployment rate, and low access to media. Conclusions: We found that both individual and contextual factors are associated with non-vaccination for Polio.

Madam, Despite being eradicated all over the world, Pakistan is one of the few countries still struggling to defeat the paralyzing enemy – polio [1]. As Coronavirus Disease 2019 (COVID-19) exposed the already struggling health care system in Pakistan, the Global Polio Eradication Initiative announced to suspend all polio vaccination programs, to stop the spread of COVID-19 [2]. The suspension of mass-immunization campaigns has led to an upsurge in the polio cases, with 50 cases already reported in Pakistan so far [3]. Even though Pakistan was on the brink of becoming polio-free in 2017, with only a total of 8 cases reported, the anti-vaccination propaganda and lack of proper measures by the government the country saw a massive upsurge in polio cases in 2019 with the total number of cases being 147 [3]. As our healthcare sector has already been stretched thin with COVID-19 cases, the threat of another pandemic is the last thing the country needs. Pakistan is destined to see the birth of 5 million children in the next 9 months following recognition of COVID-19 as a pandemic in March 2020 [4]. Thus, if the state does not take any step to heighten further the measures of preventing this likely emergency, hundreds and thousands of children may be at risk of getting infected with the crippling poliovirus. The spread of polio has been declared as an international public health concern [5]. The currently suspended immunization campaigns only add to the insult, which could cause an uprise in cases in those countries which have already been declared polio-free and can lead to travel restrictions for travel to and from Pakistan. With a weak healthcare system, and low budget, showing that the government spends just 1% of GDP on each person’s healthcare, it is unlikely for the country to be well-equipped to tackle this huge burden of polio cases whilst struggling to deal with COVID-19 [6]. Continuous...

Certification of global eradication of indigenous wild poliovirus type 2 occurred in 2015 and of type 3 in 2019. Since the launch of the Global Polio Eradication Initiative (GPEI) in 1988 and broad use of live, attenuated oral poliovirus vaccine (OPV), the number of wild poliovirus cases has declined >99.99% (1). Genetically divergent vaccine-derived poliovirus* (VDPV) strains can emerge during vaccine use and spread in underimmunized populations, becoming circulating VDPV (cVDPV) strains, and resulting in outbreaks of paralytic poliomyelitis.† In April 2016, all oral polio vaccination switched from trivalent OPV (tOPV; containing vaccine virus types 1, 2, and 3) to bivalent OPV (bOPV; containing types 1 and 3) (2). Monovalent type 2 OPV (mOPV2) is used in response campaigns to control type 2 cVDPV (cVDPV2) outbreaks. This report presents data on cVDPV outbreaks detected during January 2018-June 2019 (as of September 30, 2019). Compared with January 2017-June 2018 (3), the number of reported cVDPV outbreaks more than tripled, from nine to 29; 25 (86%) of the outbreaks were caused by cVDPV2. The increase in the number of outbreaks in 2019 resulted from VDPV2 both inside and outside of mOPV2 response areas. GPEI is planning future use of a novel type 2 OPV, stabilized to decrease the likelihood of reversion to neurovirulence. However, all countries must maintain high population immunity to decrease the risk for cVDPV emergence. Cessation of all OPV use after certification of polio eradication will eliminate the risk for VDPV emergence.

Civil war broke out in South Sudan in 2013 just 2 years after the country gained independence, leading to the internal displacement of 1.9 million people. More than two million people sought refuge in neighboring countries.1 Many health facilities were destroyed and a large portion of the health facility staff members were displaced or killed leading to a collapse of the health system, including immunization and surveillance functions. Jonglei, Upper Nile, and Unity State were among the most affected states. The non-polio acute flaccid paralysis (NPAFP) rate per 100,000 children younger than 15 years as recorded by the surveillance system declined considerably between 2013 and 2014: from 3.3 to 1.0 in Jonglei; 1.7 to 1.4 in Unity State; and 3.5 to 1.3 in Upper Nile–all substantially lower than the expected rate of at least two cases per 100,000 children.2,3 In addition, there were several silent counties and subcounties that reported no cases at all. South Sudan experienced an outbreak of circulating vaccine-derived poliovirus (cVDPV) in Unity State in 2014 and 2015. The Horn of Africa Technical Advisory Group concluded that the AFP surveillance system at the subnational level in South Sudan was not sensitive enough to detect low levels of ongoing wild poliovirus (WPV) transmission. A surveillance review conducted in South Sudan by external reviewers in 2011 indicated that AFP surveillance was only sensitive in areas that were accessible to the Polio Eradication Initiative field staff. The review revealed that clear gaps existed in inaccessible areas as a result of insecurity, isolated geographical locations because of flooding, and unusable roads. The WHO reported in 2016 that although South Sudan had been polio-free since 2009, it was still at risk of WPV transmission because of inadequate AFP surveillance, low immunization coverage, insecurity, and population movement.4 Polio situation in South Sudan. Although the last indigenous WPV case was reported in 2001, South Sudan experienced large imported WPV outbreaks in 2004, 2005, 2008, and 2009, affecting nine of the 10 states. The last case was reported in June 2009.5 In 2010, the Global Polio Eradication Initiative categorized South Sudan as one of the four countries in Africa with re-established WPV transmission.6 In addition, South Sudan experienced repeated outbreaks of cVDPV in Warrap and Western Equatoria States in 2011 and 2012. In 2014, South Sudan reported another outbreak of cVDPV type 2 (cVDPV2) in the Protection of Civilian Sites1 and in Bentiu, Rubkona County, Unity State. An additional case of cVDPV2 was reported in June 2015 from Mayom County, Unity State. A detailed investigation of this case showed that the child had no history of polio vaccination (classified as a “zero dose child”) and the community had not been reached with routine immunization or supplementary immunization activities since December 2013.

BACKGROUND: Health economic evaluations are often required before implementing a vaccination programme. Such evaluations rarely consider the historical context of a vaccination programme. We review the financial history of vaccination programmes in the Netherlands, and compare these to demographic and macroeconomic developments as well as avoided mortality burden.METHODS: Previously uncatalogued historical expenditures on the Dutch National Immunisation Programme (NIP) and influenza vaccination were obtained from official reports. Costs were adjusted for inflation using Consumer Price Indices and expressed in Euro of 2016. Estimates on mortality burden averted were obtained from previous research and used to calculate the ratio of expenses to averted mortality burden for vaccinations against diphtheria, tetanus, pertussis, polio, measles, mumps and rubella for birth cohorts 1953-1992.RESULTS: Developments towards a uniform government funded NIP started early 1950s with vaccinations against diphtheria, pertussis and tetanus, culminating in its official launch in 1957 together with polio vaccinations. Since the 1980s, expenditure increased nearly five-fold mostly due to the addition of new vaccines, while spending on already implemented vaccinations tended to decline. Overall, expenditure increased from € 5 million in 1957 to € 93 million in 2014. Relative to total healthcare expenditure, the NIP contributed little, ranging between 0.05% and 0.14%. Spending on influenza vaccination increased from € 37 million in 1996 to € 52 million in 2014, while relative to total healthcare expenditure it decreased from 0.069% to 0.055%. In 2014, 0.15% of healthcare expenditure and € 533 per birth was spent on vaccination programmes. Overall, for birth cohorts 1953-1992, € 5.4 thousand (95% confidence interval: 4.0-7.3) was expended per year-of-life-lost averted.CONCLUSION: The actual costs per year-of-life gained are more favorable than estimated here since averted medical costs were not included. Although expenditure on vaccination programmes increased substantially, the contribution to overall healthcare expenditure remained small.

In Japan, the oral poliovirus vaccine (OPV) was changed to 2 types of inactivated poliovirus vaccine (IPV), the standalone conventional IPV (cIPV) and the Sabin-derived IPV combined with diphtheria-tetanus-acellular pertussis vaccine (DTaP-sIPV), for routine immunization in 2012. We evaluated polio vaccination coverage and the seroprevalence of poliovirus antibodies using data from the National Epidemiological Surveillance of Vaccine-Preventable Diseases (NESVPD) from 2011 to 2015. Several years before the introduction of IPV in 2012, OPV administration for children was refused by some parents because of concerns about the risk of vaccine-associated paralytic poliomyelitis. Consequently, in children aged1 years who were surveyed in 2011-2012, polio vaccination coverage (45.0-48.8%) and seropositivity rates for poliovirus (type 1: 51.7-65.9%, type 2: 48.3-53.7%, and type 3: 15.0-29.3%) were decreased compared to those surveyed in 2009. However, after IPV introduction, the vaccination coverage (95.5-100%) and seropositivity rates (type 1: 93.2-96.6%, type 2: 93.1-100%, and type 3: 88.6-93.9%) increased among children aged1 years in 2013-2015. In particular, seropositivity rates and geometric mean titers (GMTs) for poliovirus type 3 in5-year-old children who received 4 doses of IPV (98.5% and 247.4, respectively) were significantly higher than in those who received 2 doses of OPV (72.5% and 22.9, respectively). Furthermore, in5-year-old children who received 4 doses of either DTaP-sIPV or cIPV, the seropositivity rates and the GMTs for all 3 types of poliovirus were similarly high (96.5-100% and 170.3-368.8, respectively). Our findings from the NESVPD demonstrate that both the vaccination coverage and seropositivity rates for polio remained high in children after IPV introduction.

In 2016, the World Health Organization (WHO) announced a global shortage of inactivated poliovirus vaccine that was expected to last until 2020 at least. In response, WHO's Strategic Advisory Group of Experts on Immunization recommended that countries consider a strategic shift to fractional-dose inactivated poliovirus vaccine, which involves a new dosing schedule (i.e. administered at 6 and 14 weeks of age) and has a different mode of delivery than full-dose inactivated poliovirus vaccine (i.e. intradermal rather than intramuscular). Introduction of fractional-dosing requires careful planning and management to ensure adequate vaccine supplies, to prevent wastage, to provide training for health workers, and to ensure accurate record-keeping. In early 2016, given the global vaccine shortage and a limited supply from domestic manufacturers, India's Expert Advisory Group on polio recommended the staggered introduction of fractional-dosing. India was the first country to introduce fractional-dose inactivated poliovirus vaccine into routine immunization, initially in eight states in 2016. Following a rapid assessment of its initial implementation, fractional-dosing was extended and, by June 2017, all Indian states were covered. Here we summarize India's experience with the introduction, discuss the challenges faced and the strategies used to address them, and report on the outcomes achieved. We also describe the lessons learnt, especially managing vaccine supplies and wastage, monitoring and supervision, and training needs. As the use of fractional-dose inactivated poliovirus vaccine is dose-sparing and reduces the cost of the immunization programme, it will remain an important part of India's long-term strategy for polio vaccination.En 2016, l’Organisation mondiale de la Santé (OMS) a annoncé une pénurie mondiale du vaccin antipoliomyélitique inactivé, prévue pour durer jusqu'à 2020 au minimum. Face à cette situation, le Groupe stratégique consultatif d’experts sur la vaccination a recommandé aux pays d'envisager un changement de stratégie afin de privilégier l’utilisation du vaccin antipoliomyélitique inactivé en doses fractionnées, ce qui implique un nouveau calendrier de vaccination (administration du vaccin à l'âge de 6 et de 14 semaines) et un mode d’administration différent de celui du vaccin antipoliomyélitique inactivé en dose complète (par voie intradermique et non pas par voie intramusculaire). L’introduction d'une vaccination en doses fractionnées exige de la rigueur en matière de planification et de gestion, afin de garantir des stocks de vaccins suffisants, d’éviter les gaspillages, de former les agents de santé et d’assurer une tenue précise des dossiers médicaux. Début 2016, du fait de la pénurie mondiale du vaccin et d’un approvisionnement limité par les fabricants nationaux, le Groupe consultatif d’experts de l’Inde sur l’éradication de la poliomyélite a recommandé d’introduire progressivement les doses fractionnées. Si bien que l’Inde est le premier pays à avoir introduit le vaccin antipoliomyélitique inactivé en doses fractionnées dans le calendrier de vaccination systématique, d’abord dans huit États en 2016. Après une rapide évaluation de cette mise en œuvre initiale, l’utilisation des doses fractionnées s’est étendue, pour finalement être effective dans tous les États indiens en juin 2017. Dans cet article, nous récapitulons l’expérience de l’Inde à ce sujet, nous évoquons les défis rencontrés et les stratégies employées pour les surmonter ainsi que les résultats obtenus. Nous décrivons également les enseignements tirés de cette expérience, notamment en matière de gestion des stocks de vaccins, de prévention des gaspillages, de suivi et de supervision, mais aussi concernant les besoins en formation. Étant donné que l'utilisation de doses fractionnées du vaccin antipoliomyélitique inactivé permet d’économiser des doses vaccinales et de réduire le coût du programme de vaccination, cela restera un élément essentiel dans la stratégie à long terme de l’Inde en matière de vaccination contre la poliomyélite.En 2016, la Organización Mundial de la Salud (OMS) anunció una escasez mundial de vacunas inactivadas del poliovirus que se esperaba que se prolongara al menos hasta 2020. En respuesta, el Grupo de asesoramiento estratégico de expertos en inmunización de la OMS recomendó que los países consideraran la posibilidad de un cambio estratégico hacia una vacuna inactivada del poliovirus de dosis fraccionada, que incluye un nuevo esquema de dosificación (es decir, administrada a las seis y a las catorce semanas de edad) y que tiene un modo de administración diferente al de la vacuna inactivada del poliovirus de dosis completa (es decir, intradérmica y no intramuscular). La introducción de la dosis fraccionada requiere una planificación y una gestión minuciosas para garantizar el suministro adecuado de las vacunas, evitar el despilfarro, formar a los trabajadores sanitarios y garantizar el mantenimiento de registros precisos. A principios de 2016, dada la escasez mundial de vacunas y el limitado suministro de los fabricantes nacionales, el Grupo de asesoramiento experto sobre la polio de la India recomendó la introducción escalonada de dosis fraccionadas. La India fue el primer país en introducir la vacuna inactivada del poliovirus de dosis fraccionada en la inmunización sistemática, inicialmente en ocho estados en 2016. Tras una rápida evaluación de la aplicación inicial, se amplió la dosificación fraccionada y, para junio de 2017, se cubrieron todos los estados de la India. En este documento se resume la experiencia de la India con la introducción, se examinan los problemas encontrados y las estrategias utilizadas para resolverlos y se informa sobre los resultados alcanzados. También se describen las lecciones aprendidas, especialmente en lo que se refiere a la gestión de los suministros de vacunas y el desperdicio, el seguimiento y la supervisión, y las necesidades de formación. Dado que el uso de la vacuna inactivada del poliovirus de dosis fraccionada ahorra dosis y reduce el coste del programa de inmunización, seguirá siendo una parte importante de la estrategia a largo plazo de la India para la vacunación contra la polio.في عام 2016، أعلنت منظمة الصحة العالمية (2016 年，世界卫生组织 (WHO) 宣布灭活脊髓灰质炎疫苗面临全球范围内的短缺，此情况预计将至少持续至 2020 年。为了应对此情况，世卫组织免疫接种战略咨询专家组建议各国将分剂量灭活脊髓灰质炎疫苗的战略性转变纳入考量，这涉及新的给药方案（即在 6 和 14 周时给药）并具有不同于全剂量灭活脊髓灰质炎疫苗的注射方式（即皮内注射而非肌肉注射）。引入分剂量注射方式需要细致规划和管理，从而保证疫苗供应充足、避免损耗，对医务工作者进行培训，确保精准记录。2016 年初，鉴于全球疫苗短缺以及国内疫苗制造商供应不足，印度脊髓灰质炎专家咨询小组建议错开分剂量灭活脊髓灰质炎疫苗的接种时间。印度是第一个将分剂量灭活脊髓灰质炎疫苗纳入常规免疫接种的国家，并于 2016 年开始在 8 个邦实施接种。对首次实施分剂量疫苗接种进行快速评估后，印度迅速扩大了分剂量灭活脊髓灰质炎疫苗的接种范围。截至 2017 年 6 月，印度各邦均已覆盖。本文归纳总结了印度在接种分剂量疫苗方面的经验，对其面临的挑战以及应对策略予以讨论并汇报了所取得的成果。我们还对以往的经验教训进行了回顾总结，尤其是在疫苗的供应、损耗管理方面、监测与监督方面以及培训需求方面。由于分剂量灭活脊髓灰质炎疫苗的使用可以节省剂量并降低免疫计划的成本，因此它将成为印度脊髓灰质炎疫苗接种长期战略计划的重要组成部分。.В 2016 году Всемирная организация здравоохранения (ВОЗ) объявила о глобальной нехватке инактивированной полиовакцины, которая может продлиться как минимум до 2020 года. В ответ на это Стратегическая консультативная группа экспертов ВОЗ по иммунизации рекомендовала странам рассмотреть стратегию перехода на частичную дозировку инактивированной полиовакцины, что подразумевает новый режим дозирования (в 6 и 14 недель после рождения) и иной способ введения (внутрикожно, а не внутримышечно, как это делалось в случае введения полноценной дозы инактивированной полиовакцины). Переход на частичную дозировку требует тщательного планирования и отслеживания, чтобы обеспечить достаточные поставки вакцины, предотвратить потери, обучить медицинских работников, а также гарантировать точное ведение документации. В начале 2016 года, ввиду глобальной нехватки вакцины и ограниченных поставок от отечественных производителей, Консультативная группа экспертов Индии по полиомиелиту рекомендовала поэтапный переход на частичную дозировку. Индия стала первой страной, внедрившей инактивированную полиовакцину в частичной дозировке в график плановых мероприятий по иммунизации изначально в восьми штатах в 2016 году. На основании оперативной оценки начального этапа перехода было принято решение расширить использование частичной дозировки, и к июню 2017 года все штаты Индии перешли на использование новой схемы. В статье приведен краткий обзор опыта Индии по переходу на новую схему, обсуждаются возникшие проблемы и стратегии, используемые для их решения, а также представлен отчет о достигнутых результатах. Авторы описывают полученный опыт, в частности мероприятия по управлению поставками вакцины и предотвращению потерь, мониторингу и надзору, а также потребности в области профессиональной подготовки. Поскольку использование инактивированной полиовакцины в частичной дозировке позволяет экономить дозы и сокращает стоимость программы иммунизации, данный подход станет неотъемлемой частью долговременной программы Индии по вакцинации от полиомиелита.

A 16 week newborn vaccinated with bOPV 4 weeks after his first routine IPV vaccination. Nineteen days later, asymmetrical paralysis was developed on his legs, and it was diagnosed to be VAPP. Perianal abscess is suspected to be a risk factor based on some limited results of retrospective studies in China. This is a risk factor similar to the multiple intramuscular injections found by researchers in last century. The two risk factors remind us that, apart from the routine infection route of the fecal to mouth and intestinal tract, skin injury (ulceration) exposure pathway should not be ignored as another possible way of causing polio, for the local injury and lesions of the skin may increase the possibility of oral poliovirus vaccine's entry into the body. As a result, to further reduce the incidence of VAPP, bOPV should be avoided for perianal abscess. If there is perianal abscess, skin injury, or if injection is unavoidable after bOPV vaccination of an infant, much attention should be paid to the treatment and cleaning of infant feces.

For more than three decades, humankind has pursued the possibility of a “polio-free world.”1 However, outbreaks following wild poliovirus (WPV) importations into previously polio-free countries remain an ongoing risk; this risk disappears only when polio is eradicated.2 Even after gaining polio-free certification, countries have struggled to remain polio-free. In 2010, the first WPV importation into the European region since the region was declared polio-free in 2002 resulted in 476 confirmed cases: 458 in Tajikistan, 14 in Russia, three in Turkmenistan, and one in Kazakhstan. In Africa and Asia, 11 new importations into six countries were observed in 2010; 30 WPV importations during 2008–2009 resulted in 215 WPV cases in 15 African countries during 2009–2013. Across six African and Asian countries, 11 new importations were recorded in 2009–2010.3 Kenya and Somalia have not been spared from the impact of WPV importation.4 In Somalia, the first importation occurred during 2005–2007, resulting in more than 200 cases of paralytic polio.5 Likewise, in Kenya, two cases in Garissa County were reported in 2006, 19 cases in Turkana County in 2009, and one case in Rongo district in 2011. Somalia experienced a polio-free period from 2007 to 2013.5 This period of calm was upset when an outbreak of WPV type 1 (WPV1) rattled the Horn of Africa (HOA).6 In May 2013, the Somalia Ministry of Health (MOH) and the WHO reported a confirmed WPV1 case in a child from Mogadishu (Banadir region). Subsequently, in May 2013, eight additional WPV1 cases were confirmed in Somalia: seven in the Banadir region and one in the Bay region.7 Just 3 weeks after the initial polio cases were detected in May 2013 in Somalia, Kenya reported its first case across the border in the Dadaab refugee camp. As a result, five people were paralyzed by polio, including young adults, in the northeastern part of Kenya.8 Polio quickly spread from Somalia to its neighboring countries of Ethiopia and Kenya. By April 2013, the case count stood at 223: 199 cases in Somalia, 14 in Kenya, and 10 in Ethiopia. All the Somalia polio cases belonged to cluster N5A,† which was known to have been circulating in northern Nigeria since 2011. The 2013 HOA outbreak vividly confirmed that “All countries will continue to have some level of risk for WPV outbreaks as long as endemic circulation continues in Afghanistan, Nigeria, and Pakistan.”9 At the same time, the Global Polio Eradication Initiative entered a new phase, with a significant reduction in cases in endemic countries and a heightened recognition of the risk for the international spread of the virus.10 To combat the threat of an international outbreak, the WHO declared polio a public health emergency of international concern in May 2014 and issued recommendations requiring proof of polio vaccination for travel to and from countries experiencing polio cases.10 Frequent cross-border movement of the high-risk mobile populations between Kenya and Somalia and the low level of population immunity in the region continue to be major contributing factors to the spread of poliovirus and the risk of ongoing transmission.11 In 2014, Kenya’s MOH requested the United States Agency for International Development (USAID)-funded CORE Group Polio Project (CGPP) Kenya and Somalia HOA Secretariat based in Nairobi, Kenya, to initiate polio eradication activities in five counties along the Kenya–Somalia border deemed at high risk for poliovirus importation. It was clear that effective immunization activities across borders and migration pathways were essential to improve immunization rates. Under the leadership of the respective MOHs of Kenya and Somalia and in collaboration with the WHO, the CGPP began holding cross-border meetings in October 2014—a significant and instrumental move that would shape a systematic, unified, and well-coordinated response in the form of the Cross-Border Health Initiative (CBHI).12 Objectives arising from the 2015 cross-border meetings targeted improving collaboration between the health and administrative authorities of border regions through enhancing acute flaccid paralysis (AFP) surveillance sensitivity, increasing coverage of supplemental immunization activities (SIAs), and improving coverage and access to quality routine immunization services in the HOA border regions. Before the formation of the CBHI, cross-border committee meetings were first initiated by the WHO in collaboration with the Intergovernmental Authority on Development (IGAD) under the “Health for Peace Initiative” in 1996. However, these cross-border committees were formed in only a few selected sites and the meetings were ad hoc, resulting in limited capacity for implementation, monitoring, accountability, resource allocation, and sustainability of cross-border polio eradication activities. To address these gaps yet keeping and reaffirming the same set of valuable original objectives, the CGPP Kenya and Somalia HOA Secretariat over a 1-year period transformed the ad hoc cross-border meetings into a full CBHI in October 2015. The secretariat subsequently established more CBHI committees in Kenya and Somalia. The work of the committees funded by the CGPP set the course for the eventual full implementation of the CBHI. The overarching goal of the CBHI is to reach every child with polio vaccine.13 Cross-border coordination bridges the disease surveillance gaps by forming partnerships among institutions, agencies, and communities in cross-border areas. Specifically, the CBHI works to ensure the vaccination of all cross-border populations, to support the detection of cases of AFP, to conduct joint case investigations of transborder AFP and WPV cases, and to synchronize all polio SIAs. The Cross-Border Health Initiative. In October 2015, the CGPP established a total of seven CBHI committees in five polio high-risk counties‡ in Kenya and two regions of Somalia. Results of a risk assessment identified Turkana, Garissa, Wajir, Marsabit, and Mandera counties in Kenya for inclusion in the CBHI; all share a border with either South Sudan, Somalia, Ethiopia, or Uganda’s northern region. Based on the risk assessment, the CGPP established more committees in Kenya’s 14 subcounties bordering Somalia and Ethiopia§; in Somalia, the CGPP selected six districts from the Gedo and Lower Juba regions‖ for committee work. The MOH officials from the respective governments provided the leadership for the establishment of the CBHI and the formation of the committees, with funding from the CGPP. In Kenya, the government-led committees consisted of representatives from the five counties and subcounties. At the county level, the representatives included the director for health, the disease surveillance coordinator, the Expanded Program on Immunization (EPI) coordinator, the health records and information officer, and the community health strategy focal person. At the subcounty level, representation included subcounty coordinators and disease surveillance or EPI officers. In addition, the CGPP implementing partner officers, WHO and United Nations Children’s Fund (UNICEF) county coordinators, and officers from border administration, immigration, and security completed the committee membership. In Somalia, the committees consisted of regional and district medical officers and a regional EPI coordinator. Similar to the Kenya committees, representation included the CGPP implementing partner officers, WHO regional and district coordinators, UNICEF field staff, and officers from border administration, immigration, and security. To reach high-risk mobile populations, the CGPP, in collaboration with the local authorities and CBHI, identified and profiled both formal and informal crossing points and communities at borders, transit hubs, and migratory routes. This exercise was beneficial; after developing detailed micro-planning to identify and document all border towns, villages, and settlements and their inhabitants, it was possible to estimate the number of children in the catchment areas. Moreover, the major transit points in the area provided pertinent information about population movement patterns, whereas joint mapping of border crossing points and border communities served to improve micro-planning for country-specific and joint country cross-border activities. The CGPP’s non-governmental organization (NGO) implementing partners and local health authorities mapped 11 border health facilities, 161 formal/informal border crossing points, and 372 villages along the border as shown in Table 1. The estimated population of children younger than 5 years is 557,036 and of children younger than 1 year is 120,068. Table 1 Mapping border crossing points, border villages, and population sizes

Ethiopia’s last indigenous case of wild poliovirus occurred in 2001, and its last case of imported wild poliovirus was reported in 2014.1 Ethiopia remains a high-priority country in the Global Polio Eradication Initiative (GPEI) because of the high risk of importation of wild poliovirus from the neighboring countries of Kenya, Djibouti, and especially from the conflict-affected countries of Somalia and South Sudan.2 In addition, Ethiopia is also a high-priority country for the GPEI because of its large population of highly dispersed and often mobile people living in areas of low population density, making high levels of immunization coverage a challenge. In the most recent Ethiopian Demographic and Health Survey (EDHS) published in 2016, only 30% of children living in rural areas in Ethiopia were fully vaccinated at the appropriate ages. Furthermore, only 53% of children in rural areas had received the full recommended three doses of oral polio vaccine (OPV 3).3 The CORE Group Polio Project (CGPP) has been active in Ethiopia since 2001, focusing on promotion of routine immunization services, polio immunization in particular, and surveillance for vaccine-preventable diseases in hard-to-reach pastoralist and semi-pastoralist populations and in high-risk border areas of Ethiopia in the following regional states: Somali; Oromia; Southern Nations, Nationalities, and Peoples (SNNP); Benshangul-Gumuz; and Gambella Region (Figure 1). A history of the CGPP and its work in Ethiopia are described elsewhere in this series.2 The CGPP implements its programs through a network of international and national non-governmental organizations coordinated by a national secretariat. Open in a separate window Figure 1. CORE Group Polio Project/Ethiopia implementation districts and non-governmental organization partners in Ethiopia.4

Objective: To assess knowledge, attitude and practice (KAP) about poliomyelitis (polio) vaccination in District Abbottabad, province Khyber Pakhtunkhwa (KPK), Pakistan, to identify reasons of failure of polio vaccination/ eradication campaign and to make recommendations in the light of the study. Setting: District Abbottabad, province KPK, Pakistan including both urban and rural areas. Period: Three months from 1st June to 31st August 2012. Methods: This cross-sectional descriptive explorative study was conducted in District Abbottabad, of province KPK, Pakistan. A structured questionnaire was submitted to people in the urban and rural population using convenient sampling. Out of 200, only 142 questionnaires were filled by interviewing parents and guardians of the children followed by focused group discussions with the community heads and the parents of the children. Results: Majority (61.78%) of respondents were of low income category with the mean age of 31 years. Amongst those (75%) were earning Rs.7,000-12,000 per month. Literacy rate was low with 45.77%. Out of which 40.67% fathers and 59.33% mothers were illiterate. Therefore a few respondents were aware about the mode of transmission of polio. Majority (80%) said that polio could be prevented by polio drops and about 86% said that this vaccine had no side effects. About 45% respondents refused to cooperate with polio teams, and 28% respondents believed, that Abbottabad Operation had bad effect on anti-polio campaign. Regarding the use of boiled drinking water, 95.8% respondents knew that it was good for health. While only 4.20% were using boiled water for drinking. Advice of the health professionals (69.71%) and other family members (7.74%) was respected in making health care decisions, therefore it was an opportunity for the government to involve these persons as well as media men in conveying message to the community to achieve ultimate goal of polio free Pakistan. Conclusions: Unawareness among the population of District Abbottabad, especially the knowledge about the disease, mode of transmission and its prevention are the most deficient areas. Secondly misconceptions about the nature of polio drops, and religious misinterpretations in masses, created by general public and religious leaders, are the major obstacles in the real success of vaccination campaign.

Background The Kamacha river is one of the five polio environmental surveillance sites in Kaduna State where 13 circulating vaccine-derived polioviruses (cVDPDs) were isolated between 2014 and 2015. Kamacha river accounted for 5 of all reported cVDPVs in Kaduna State between 2014 and 2015. Poor quality Supplemental Immunization Activities (SIAs) and low population immunity have been reported in the 10 LGAs with tributaries that flow into the river. We described the processes of implementing the various health interventions in these targeted LGAs along the Kamacha River and assessed the effectiveness of the interventions in stopping cVDPV in Kaduna, state, Nigeria. Methods Special interventions that had been proven to be functional and effective in reaching unreached children with potent vaccines in the state were scaled up in these targeted 10 LGAs along the Kamacha River. These interventions included revision of house based microplans, scaling up of transit vaccination, scaling up of youth engagement, intensified supportive supervision, scaling up of Directly Observed Polio Vaccination (DOPV) and in-between rounds vaccination activities. We analyzed immunization plus days (IPDs) administrative tally sheet and monitoring data from 10 rounds before and 10 rounds after the special interventions. Results The number of children immunized increased from 1,862,958 in December 2014 before the intervention to 1,922,940 in March 2016 after the intervention. Lot Quality Assurance Sampling (LQAS) results showed an increase in the proportion of LGAs accepted at coverage > 90% after the interventions, from 67% before intervention to 84% after intervention. The proportion of non-polio AFP children with > 4 doses of oral polio vaccine increased from 2 to 8% before to 93–98% after the interventions.. No new environmental cVDPV has been isolated since the introduction of the interventions in April 2015 until July 2016. Conclusion Scaling up known working interventions in the 10 LGAs with tributaries that drain to Kamacha River environmental sample site may have contributed to improved immunity and interruption of cVDPV in Kaduna state. These interventions should be replicated in LGAs and states with persistent poliovirus isolation.

Background: Poliomyelitis, often called polio is a viral paralytic disease caused by Polioviruses. Although all susceptible individuals are at risk of getting infected, only about 1% become paralyzed. During the 2013 Polio Outbreak in Garissa County in Kenya, 50% of the confirmed cases were from the nomadic population although it comprises of only less than 20% of the total population in the county. Following concerns from the Horn of Africa Polio Technical Advisory Group (TAG) regarding inadequate vaccine coverage of nomadic population, several strategies were put in place to improve coverage and Acute Flaccid Paralysis case reporting among nomads in the rest of the planned 2014 polio vaccination campaigns. We describe strategies initiated from April 2014 by the Ministry of Health and partners to reach children in nomadic settlements in the two sub-counties of Dadaab and Fafi of Garissa County. Methods: The strategies involved improving the mapping and tracking of the nomadic population by establishing lists of nomadic settlements obtained from local clan leaders and government administrators, their

Introduction: Established in 1994, Pakistan's polio program demonstrated early success. However, despite over 120 supplementary immunization activities in the last decade, polio eradication efforts in Pakistan have been unable to achieve their objective of halting polio transmission. Variable governance, and inconsistent leadership and accountability have hindered the success of the polio program and the quality of the campaigns. Insecurity and terrorism has interrupted polio activities, and community fears and misbeliefs about polio vaccinations continue to persist.Areas covered: The article consists of a systematic review of the barriers and facilitators associated with the delivery of polio eradication activities in Pakistan. We also provide a comprehensive review of the policy and programmatic decisions made by the Pakistan Polio Programme since 1994. Searches were conducted on Embase and Medline databases and 25 gray literature sources.Expert opinion: Polio eradication efforts must be integrated with other preventive health services, particularly immunization services. Addressing the underlying causes of polio refusals including underdevelopment and social exclusion will help counteract resistance to polio vaccination. Achieving polio eradication will require building health systems that provide comprehensive community-centered care, and improving governance and systems of accountability.

Polio or poliomyelitis is a disabling and life-threatening disease caused by poliovirus (PV). As a consequence of global polio vaccination efforts, wild PV serotype 2 has been eradicated, and wild PV serotypes 1- and 3-transmitted cases have been largely eliminated except for in limited regions around the world. However, vaccine-derived PV, pathogenically reverted live PV vaccine strains in vaccinated humans, has become a serious issue. For the global eradication of polio, the World Health Organization is conducting the third edition of the Global Action Plan, which is requesting stringent control of potentially PV-infected materials. To facilitate the mission, we generated a PV-nonsusceptible Vero cell subline, which may serve as an ideal replacement of standard Vero cells to isolate emerging/re-emerging viruses without the risk of generating PV-infected materials.

Background Vaccination is crucial for human immunodeficiency virus (HIV)-exposed children because of their increased risk of morbidity and mortality from various vaccine-preventable diseases. However, studies have shown that they are at high risk of incomplete vaccination. Although China has developed prevention of mother-to-child transmission (PMTCT) of HIV programs substantially over the past decades, few studies have investigated the immunization levels of Chinese HIV-exposed children. Therefore, we aimed to evaluate vaccination coverage and its associated factors among HIV-exposed children in China during 2016‒2018. Methods We conducted a retrospective cohort review of all cases of Chinese HIV-exposed children born between July 1, 2016 and June 30, 2018 recorded in the Chinese information system on PMTCT. The vaccination coverage indicators refer to the percentage of children who received recommended basic vaccines, including Bacillus Calmette-Guérin (BCG), hepatitis B (HepB), polio, measles-containing vaccine (MCV), and diphtheria-tetanus-pertussis-containing (DTP) vaccine. Univariate and multivariate logistic regression analyses expressed as crude odds ratios (cORs) and adjusted odds ratios (aORs), each with 95% confidence intervals (95% CI), were performed to compare the proportional differences of factors associated with vaccine coverage. Results Among the enrolled 10 033 children, the vaccination rate was 54.1% for BCG, 84.5% for complete HepB vaccination, 54.5% for complete polio vaccination, 51.3% for MCV, and 59.5% for complete DTP vaccination. Children with perinatally acquired HIV (PHIV) were 2.46‒3.82 times less likely to be vaccinated than HIV-exposed uninfected children. Multivariate logistic regression indicated that children of Han ethnicity (aOR = 1.33‒2.04), children with early infant diagnosis (EID) of HIV (aOR = 1.86‒3.17), and children whose mothers had better education (college or above, aOR = 1.63‒2.51) had higher odds of being vaccinated. Most of the deceased children (aOR = 4.28‒21.55) missed vaccination, and PHIV (aOR = 2.46‒3.82) significantly affected immunization. Conclusions Chinese HIV-exposed children had low vaccination coverage, which is a serious health challenge that needs to be addressed thoroughly. Interventions should be developed with a focus on minority HIV-exposed children whose mothers do not have formal education. Particularly, more attention should be paid to EID to increase access to immunization. Graphical abstract

The COVID-19 pandemic has disrupted routine childhood immunization coverage for many vaccine-preventable diseases at the global, regional and national levels. In Pakistan, more than 40 million children were unable to receive measles vaccination and around 50 million children missed polio vaccination in 2020. Moreover, more than 36 million children did not receive vitamin A supplementation in 2020. Implementing catch-up vaccination services to prevent outbreaks of vaccine-preventable diseases, particularly polio and measles, in malnourished children is urgently required to prevent a global resurgence of these deadly diseases., Muhammad Suleman Rana and colleagues from the National Institute of Health in Pakistan discuss the urgent need to implement catch-up vaccination programmes for measles and polio to prevent resurgence of these deadly diseases.

A number of states, starting with California, have recently removed all non-medical exemptions from their laws requiring vaccinations for schoolchildren. California was also one of the earliest states to include a broad non-medical, or personal, belief exemption in its modern immunization law, which it did with a 1961 law mandating polio vaccination for school enrollment, Assembly Bill 1940 (AB 1940). This paper examines the history of AB 1940’s exemption clause as a case study for shedding light on the little-examined history of the personal belief exemption to vaccination in the United States. This history shows that secular belief exemptions date back further than scholars have allowed. It demonstrates that such exemptions resulted from political negotiation critical to ensuring compulsory vaccination’s political success. It challenges a historiography in which antivaccination groups and their allies led late-nineteenth and early-twentieth century opposition to vaccination mandates while religious groups drove mid-twentieth century opposition. It also complicates the historiographic idea of a return to compulsion in the late 1960s, instead dating this return a decade earlier, to a time when belief exemptions in polio vaccination mandates helped reconcile the goal of a widely vaccinated population with the sacrosanct idea of health as a personal responsibility.

The U.S. troop withdrawal from Afghanistan is imperiling the 3-decade global quest to eradicate polio. The Taliban, which now controls large swaths of the country, has blocked house-to-house polio vaccination in areas under its reign the past 3 years, putting up to 3 million children out of reach of the campaign. The Taliban may well wrest complete control from the Afghan government—which supports the eradication campaign—after U.S. forces are gone. But some inside and outside the Global Polio Eradication Initiative say a clear resolution to the conflict, regardless of who prevails, may actually aid eradication efforts. They hope the campaign will be able to work with the Taliban to keep vaccinations going if it consolidates power.

Poliomyelitis was a disease feared worldwide, striking suddenly and paralysing mainly children for life. Monitoring of suspected cases of poliomyelitis is carried out with Acute Flaccid Paralysis (AFP) surveillance in Turkey. This study examines national data of AFP surveillance and the epidemiology of enteroviruses (EV) in Turkey from 2000 to 2019 and gives an overview of the detected serotypes of EVs. A total of 13,640 samples collected from patients with 5216 AFP pre-diagnosed cases (2 samples from each patient) and 3,208 contacts, during a 20-year period (2000–2019) were investigated. All isolated polioviruses were tested for their wild or vaccine origin according to the WHO recommended protocol by PCR and sequencing analysis were performed. Enterovirus positivity was detected in a total of 915 cases, which were identified as 204 Sabin-like polio virus (SLPV) and 711 non-polio enterovirus (NPEV). Of the 204 SLPV, 141 (69.1%) AFP were detected in patients and 63 (30.9%) were detected in samples taken from their contacts. Of the 711 NPEVs, 516 (72.5%) were from AFP cases and 195 (27.5%) were detected in samples taken from their contacts. It is concluded that the reason for the higher detection rate of NPEV in samples from AFP pre-diagnosed cases is attributed to the polio vaccination rates reaching 97% between 2008 and 2019 in Turkey. The most frequently detected NPEV serotypes were Coxackie A24, B3, and Echo 30. This retrospective study is the first comprehensive study in Turkey to evaluate the results of the AFP surveillance in the last 20 years.

Background A social mobilization (SM) initiative contributed to India’s success in polio elimination. This was the CORE Group Polio Project (CGPP) India, a partner of the Uttar Pradesh (UP) SM Network and which continued its SM activities, even during the polio-free period through a network of multi-level social mobilizers. This paper assesses the effects of this community-level SM (CLSM) intervention on the extent of community engagement and performance of polio Supplementary Immunization Activity campaigns (SIAs) during the post-polio-endemic period (i.e., from March 2012 to September 2017). Methods This study followed a quasi-experimental design. We used secondary, cluster-level data from CGPP India’s Management Information System, including 52 SIAs held from January 2008 to September 2017, covering 56 blocks from 12 districts of UP. We computed various indicators and performed Generalized Estimating Equations based analysis to assess the statistical significance of differences between the outcomes of intervention and non-intervention areas. We then estimated the effects of the SM intervention using Interrupted time-series, Difference-in-Differences and Synthetic Control Methods. Finally, we estimated the population influenced by the intervention. Results The performance of polio SIAs changed over time, with the intervention areas having better outcomes than non-intervention areas. The absence of CLSM intervention during the post-polio-endemic period would have negatively impacted the outcomes of polio SIAs. The percentage of children vaccinated at polio SIA booths, percentage of ‘X’ houses (i.e., households with unvaccinated children or households with out-of-home/out-of-village children or locked households) converted to ‘P’ (i.e., households with all vaccinated children or households without children eligible for vaccination), and percentage of resistant houses converted to polio acceptors would have gone down by 14.1 (Range: 12.7 to 15.5), 6.3 (Range: 5.2 to 7.3) and 7.4 percentage points, respectively. Community engagement would have reduced by 7.2 (Range: 6.6 to 7.7) percentage points. Conclusions The absence of CLSM intervention would have significantly decreased the level of community engagement and negatively impacted the performance of polio SIAs of the post-polio-endemic period. The study provides evidence of an added value of deploying additional human resource dedicated to social mobilization to achieve desired vaccination outcomes in hard-to-reach or programmatically challenging areas.

Poliomyelitis, a crippling viral disease, has been affecting many children in Pakistan despite the numerous efforts that have been taken to curb its spread. The COVID-19 pandemic has halted mass polio vaccination campaigns globally, including Pakistan, resulting in a resurgence of new cases. Pakistan managed to flatten the COVID-19 curve from July to October that made three immunization drives possible, but the COVID-19 cases are on the rise again which can again complicate the polio situation in the country if left unmonitored. The efforts of Pakistan have been effective with no significant rise in polio cases in 2020 as compared with 2019. We discuss the numerous challenges faced by the polio eradication program in Pakistan. To help eliminate polio, Pakistan needs to enhance its efforts in the struggle against polio with the same zeal and stringency used to flatten the curve of COVID-19 in these challenging times.

Supporting the global eradication of wildpoliovrisu (WPV), this project aimed to provide polio and measles vaccines to a population frequenty missed by immunization services and campaigns, ethnic Somali children living among mobile populations within Kenya’s Northeastern Region. Additionally, nutritional support, albendazole (for treatment of intestinal parasites) and vitamin A were provided to improve children’s health and in accordance with regional vaccination campaign practices. To better understand movement patterns and healthcare-seeking behaviors within this population, we trained community-based data collectors in qualitative and geospatial data collection methods. Data collectors conducted focus group and participatory mapping discussions with ethnic Somalis living in the region. Qualitative and geospatial data indicated movement patterns that followed partially definable routes and temporary settlement patterns with an influx of ethnic Somali migrants into Kenya at the start of the long rainy season (April–June). Community members also reported concerns about receiving healthcare services in regional health facilities. Using these data, an 8-week vaccination campaign was planned and implemented: 2196 children aged 0–59 months received polio vaccine (9% had not previously received polio vaccine), 2524 children aged 9–59 months received measles vaccine (27% had not previously received measles vaccine), 113 were referred for the treatment of severe acute malnourishment, 150 were referred to a supplementary feeding program due to moderate acute malnourishment, 1636 children aged 12–59 months were provided albendazole and 2008 children aged 6–59 months were provided with vitamin A. This project serves as an example for how community-based data collectors and local knowledge can help adapt public health programming to the local context and could aid disease eradication in at-risk populations.

The pandemic of coronavirus disease 2019 (COVID-19) has disrupted immunization programs around the globe, potentially increasing life-threatening vaccine-preventable diseases. Pakistan and Afghanistan are the only countries, which are still struggling to eradicate wild poliovirus. All vaccination campaigns in Pakistan were suspended in April due to the COVID-19 outbreak, leading 40 million children to miss out on polio vaccination. Like the climate crisis, the COVID-19 pandemic could be regarded as a child-rights crisis because it could have life-threatening impact over children, who need immunization, now and in the long-term. Delays in polio vaccination programs might not have immediate impact but, in the long-term, the increase in polio cases in Pakistan could result in the global export of infections. Therefore, healthcare authorities must intensify their efforts to track and vaccinate unvaccinated children in countries like Pakistan and Afghanistan. Polio vaccination campaigns need to resume immediately, so we suggest applying social distancing measures along with standard operating procedure to flatten the transmission curve of COVID-19. Furthermore, the concurrent emergence of cVDPV2 means that tOPV should temporarily be used for primary immunization. In the current review, we have discussed delays in polio vaccination, surveillance of polio viruses, reported cases in Pakistan along with recommendations to overcome interrupted immunization.

Polio is a deadly viral disease that has been paralyzing many children in Afghanistan. Despite fundamental efforts, primarily vaccination, to reduce the number of cases in Afghanistan, there are still many children who are deprived of the vaccine every year. Afghanistan is one of the two remaining countries endemic for polio, and the country has undergone various challenges that have hampered the eradication of this disease. The underlying challenges include inaccessibility of unsecured areas, illiteracy, refusal, and, most recently, COVID-19. The country is in the midst of a battle against COVID-19, and polio has almost entirely been neglected. Sadly, polio cases are increasing in the country, particularly in polio-free provinces. After an initial lockdown, many businesses have been allowed to resume, but the mass polio vaccination campaign has not restarted. New cases of polio will surge if endemic regions remain unvaccinated or inaccessible. To curb the further spread of polio, Afghanistan needs to resume nationwide house-to-house vaccination as restrictions due to COVID-19 are loosened.

Introduction Polio, which is caused by poliovirus, is a contagious, potentially crippling, and deadly disease. Pakistan is one of the countries in which polio is still endemic in the 21st century. In 2019, 146 polio cases were reported across the country with some resulting in deaths. Following the spread of rumors insinuating that children were falling sick after receiving an anti-polio vaccine, a mob attacked and set fire to a small hospital in the Peshawar district in April 2019. The present study investigates readers’ discussions that emerged from Dawn’s online readers’ comments on polio-related news stories in Pakistan. Methods Using thematic analysis, we analyzed (N = 2216) comments made by readers in the polio-related news stories published on Dawn.com from January 1, 2012, to March 1, 2020. Results Seven major themes emerged from the analysis of the comments: 1) reasons for and challenges resulting in the failure to eradicate polio; 2) proposed solutions and policy changes to eradicate polio; 3) misinformation; 4) criticism, frustration, and shame; 5) comparison of Pakistan to other countries; 6) the internet as a public sphere; 7) suffering, empathy, and appreciation. Overall, our findings suggested that commenters are knowledgeable about polio vaccines and consider polio a serious threat to public health in Pakistan. Conclusion Our study not only validated previous study findings such as reasons, challenges, and issues related to polio vaccination, but also found new challenges in online news sites concerning misinformation on polio and polio vaccination in Pakistan.