Intern
ati
o
n
a
l
Jo
urn
a
l
o
f
P
u
b
lic Hea
l
th Science (IJ
P
HS)
V
o
l.3
,
No
.3
, Sep
t
em
b
e
r
20
14, pp
. 143
~157
I
S
SN
: 225
2-8
8
0
6
1
43
Jo
urn
a
l
h
o
me
pa
ge
: h
ttp
://iaesjo
u
r
na
l.com/
o
n
lin
e/ind
e
x.ph
p
/
IJPHS
Epidemiological Characteristics
of Poliomyelitis
d
u
ring th
e 21
st
Century (2000-
2013)
Tahir Ahm
a
d,
Sania Arif, Na
z
i
a
Ch
au
dar
y
, Sadia An
ju
m
Atta-ur-Rahman
School
of
Applied Biosciences,
National Univer
sity
o
f Scieces
and
Technolog
y
,
Islamabad,
Pakis
t
an
Article Info
A
B
STRAC
T
Article histo
r
y:
Received
May 15, 2014
Rev
i
sed
Jun
e
20
, 20
14
Accepted Aug 26, 2014
Poliovirus is the pathogenic ag
ent of pa
raly
tic poliom
y
elitis that belongs to
the picorn
avirid
ae family
. Polio
my
elitis has an extend
ed histor
y dating over
to the
Eg
ypti
an
eight
eenth d
y
n
a
s
t
y
.
It was
re
co
gnized
as
dis
tin
ct dis
e
as
e in
the la
te nin
e
te
en
th centur
y
when
the
world was ravaged b
y
large
number of
outbreaks and
ep
idemics in man
y
countries
. Paraly
tic Polio
, th
e rarest but th
e
most severe for
m
of the disease, is ch
a
r
ac
t
e
ri
ze
d by
a
c
u
t
e
fl
ac
ci
d pa
ra
ly
si
s
of
an
y
or rar
e
ly
both of the limbs. Increasing
epid
emics during the
late 19
th
a
nd
20
th
cen
turies
l
e
ad to th
e in
iti
at
ion of a world
w
ide globa
l eff
o
rt for poli
o
eradication in 1988, super head
ed b
y
WHO and various ot
her organizations
.
The l
a
unch of
Global Polio
Eradi
c
a
tion I
n
itia
tive
toge
th
er with
th
e
introduction of
two polio vaccines resulted in 99% reduction of wild
poliovirus cas
es worldwide while the
total number of polio-end
emic
countries dropped from 24 countries in
th
e
y
e
ar
2000 to only
thr
ee coun
tries
in 2012; Afgh
anistan, Nigeria
and Paki
stan. This
review
will
focus on th
e
general biolog
y
of poliovirus, so
me hi
storic and
geographic epid
emiological
aspects of
polio
my
elitis
eradication during
the
year 2000-2012
and also o
n
the m
a
jor f
a
il
in
g facto
r
s
as
s
o
ci
ated wi
th th
e ef
fici
enc
y
of
the
vacc
ines
to
eradi
cat
e po
lio
i
n
P
a
kis
t
an
.
Keyword:
Ep
id
em
io
lo
g
y
o
f
po
lio
Epidem
ic countries
21
st
ce
nt
ury
Copyright ©
201
4 Institut
e
o
f
Ad
vanced
Engin
eer
ing and S
c
i
e
nce.
All rights re
se
rve
d
.
Co
rresp
ond
i
ng
Autho
r
:
Tahi
r A
h
m
a
d,
At
t
a
-u
r-R
a
h
m
a
n
Sc
h
ool
o
f
Ap
pl
i
e
d
B
i
osci
e
n
ces,
Nat
i
onal
U
n
i
v
e
r
si
t
y
of
Sci
ecn
es an
d Tec
h
nol
goy
,
Isl
a
m
a
bad, Pa
k
i
st
an.
Em
a
il: b
a
ig
4
2
@g
m
a
il.co
m
,
tah
i
r@asab.nu
s
t.ed
u.pk
1.
INTRODUCTION
What
is Po
liomy
elitis?
Dev
e
l
o
p
i
n
g
cou
n
t
ries are confro
n
t
ed
with
a
n
u
m
b
e
r
o
f
d
e
st
ab
ilizin
g
h
ealth
p
r
o
b
l
em
s
to
geth
er with
a
seriou
s sh
ortag
e
of resou
r
ces. On
e su
ch
health
p
r
ob
lem is ‘Po
lio
m
y
el
itis’ wh
ich
was first d
e
scribed
b
y
Mich
ael Un
d
e
rwo
o
d
,
a
p
h
y
sician
fro
m
Britain
, in
17
89
.
He
d
e
scri
b
e
d
p
o
lio
m
y
elit
is as ‘th
e
d
e
b
ility o
f
t
h
e
lo
wer ex
trem
it
ies’ [1
]. Po
liomyel
itis
is d
e
riv
e
d
fro
m
tw
o
words o
f
Greek
o
r
i
g
in
: po
lio
(th
a
t m
ean
s g
r
ay) an
d
myelo
n
(th
a
t
mean
s m
a
rro
w, in
d
i
cating
the sp
in
al co
rd
).
Thu
s
,
p
o
l
i
o
myelit
is, o
f
ten
called
po
lio
or i
n
fan
tile
paral
y
si
s- a
di
sease o
f
m
a
jor
p
ubl
i
c
he
al
t
h
im
port
a
nce
-
is
an ac
ute vi
ral infection that
influe
nces t
h
e
m
o
tor
neu
r
ons
wi
t
h
i
n
t
h
e s
p
i
n
al
c
o
rd
an
d
brai
n l
ead
i
ng t
o
t
h
e
cl
ass
i
c
m
a
ni
fest
at
i
ons
of
pa
ral
y
si
s
[2]
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
S
SN
:
2
252
-88
06
I
J
PH
S Vo
l. 3
,
N
o
. 3
,
Sep
t
emb
e
r
201
4
:
1
43
–
15
7
14
4
E
a
rl
y Hi
st
ory
Pol
i
o
m
y
el
it
i
s
has a l
o
n
g
hi
s
t
ory
,
dat
i
n
g ba
ck t
o
t
h
e Egy
p
t
i
a
n ei
ght
ee
nt
h dy
nast
y
(
1
5
8
0
-
13
5
0
B
C
)
[3]. T
h
e
historical record
o
f
p
o
l
i
o
i
s
very
f
r
a
g
m
e
nt
ary
and i
s
ol
at
ed
cases
of poliom
y
elitis
and acute
pa
ra
lysis
i
n
chi
l
d
re
n ha
ve bee
n
occ
u
r
r
i
n
g si
nce t
h
e
bi
bl
i
cal
t
i
m
e
s [4]
.
R
e
gar
d
l
e
ss of t
h
e p
r
oo
f fo
r occ
u
r
r
e
n
ce of
p
a
ralytic p
o
liomyel
itis was a
v
ailab
l
e in
th
e an
cien
t ti
m
e
s,
it sti
ll n
o
t
d
i
sti
n
gu
ish
e
d
as a d
i
stin
ct d
i
sease en
tity
with
infectiou
s
o
r
ep
i
d
em
ic p
o
t
en
tialities u
n
til th
e en
d of
1
8
th
ce
nt
u
r
y
w
h
en
t
h
e e
p
i
d
e
m
i
c
s bega
n t
o
appea
r
[5]
.
H
uge
n
u
m
ber of t
h
ese
epi
d
em
i
c
s were acc
om
pani
ed
by
va
ri
o
u
s
hy
st
eri
cal
rea
c
t
i
ons
[3]
.
Th
e fi
rst
ep
id
em
ics o
ccu
rred
in
Eu
rope in
th
e
m
i
d
-
1
8
0
0
s
an
d
in
North
Am
erica in
t
h
e 18
90
s, after wh
ich
p
o
lio
beca
me
a g
l
o
b
a
l d
i
sease with
ann
u
a
l ep
id
em
ics
[6
]. Ho
wev
e
r, it was n
o
t
un
til 2
0
th
century that these epide
m
ics
becam
e increasingly se
vere
, i
n
creasi
n
g the
num
b
er of
peopl
e
affecte
d
from th
e
disease in
diffe
re
nt tropic
al as
well as se
m
i
-tr
opical areas of the world [4] until 1952,
wh
e
n
it reached its peak in th
e
United States wit
h
ove
r
2
0
,000
p
a
r
a
lyti
c cases [
2
]. In
1
949
, Jo
hn
End
e
r
s
, Th
om
as
Weller, and Frederic
k Robbi
n
s dem
onstrate
d
that
pol
i
o
vi
r
u
s
br
o
u
g
h
t
a
b
o
u
t
vi
si
bl
e dam
a
ge t
o
pri
m
at
e cel
l
s
deri
ve
d f
r
om
t
i
ssues
ot
he
r t
h
a
n
t
hose
o
f
t
h
e
n
e
rv
o
u
s
syste
m
. This technology leads
to va
st- am
ount ge
neration
of
standardized poliovirus
for vaccine pre
p
a
r
ation
[3]. The introduction
of tw
o effective vacci
nes, killed
vac
c
ine
(Sal
k
vac
c
ine, inactivat
ed
polio
vacci
ne) i
n
1955 a
n
d, e
v
e
n
tually, the
live poliovirus
va
ccines
(Sa
b
in
vaccine, oral polio vaccine
) i
n
1963, we
re t
h
e m
o
st
im
portant
deve
lopm
ents
m
a
de in the history of
poliom
y
e
litis [1].
With these tw
o
vaccines, providi
ng a
one
-
two
pu
n
c
h
,
po
l
i
o
was
d
o
wn
an
d ou
t
for th
e
co
un
t at least i
n
th
e Un
ited
St
ates, wh
ich repo
rted
its last case of
wild
-v
iru
s
po
lio
in
19
79
[2]. Later in 198
8,
Wo
rl
d
He
al
t
h
O
r
ga
ni
zat
i
on
WH
O
l
a
u
n
che
d
a
w
o
rl
dwi
d
e
cam
p
ai
gn wi
t
h
an aim
t
o
erad
i
cat
e pol
i
ovi
r
u
s by
t
h
e y
ear 200
5. T
h
o
u
gh i
t
was not
succ
e
ssful
, t
h
e
num
ber o
f
cases h
a
s
f
a
llen
b
y
9
9
p
e
rcen
t and
in
2
012; o
n
l
y th
r
ee cou
n
t
r
i
es in
th
e
w
o
r
l
d
r
e
m
a
in
e
d
po
lio-
e
nd
emic-
t
h
e
lo
w
e
s
t
cou
n
t
ev
e
r
-
co
mp
a
r
e
d
to
125
e
ndem
i
c co
unt
ri
es i
n
1
9
8
8
[
7
]
.
B
i
ol
og
y of
P
o
l
i
ovi
rus
C
a
usat
iv
e ag
ent
Th
e
i
n
fectiv
e
ag
en
t of p
o
lio
m
y
elit
is
h
a
s b
e
en
d
e
fi
n
e
d in
term
s o
f
its so
urce, its p
a
t
h
og
en
icity an
d its
pat
h
ol
o
g
i
cal
, h
i
st
ol
ogi
cal
an
d
im
m
unol
ogi
c
a
l
charact
eri
s
t
i
c
s [8]
.
P
o
l
i
ovi
rus
(P
V), t
h
e et
i
o
l
ogi
cal
age
n
t
o
f
pol
i
o
m
y
el
i
t
i
s
, was
di
sco
v
ere
d
by
t
w
o
A
u
st
ri
an
phy
si
ci
ans
,
Ka
rl
Lan
d
st
e
i
ner a
nd
Er
wi
n
Po
ppe
r i
n
1
9
0
9
[
9
]
.
The age
n
t is classified as an enter
o
v
i
ru
s of
th
e fam
i
ly
Pic
o
rn
av
irid
ae, a
larg
e fam
i
l
y
o
f
s
m
al
l RNA v
i
ru
ses
and c
o
nsisting of
9 ge
ne
ra
[10],[11]. The
virus exists
i
n
three serotypes, type
1,2 and 3
(each
s
t
rain
desi
g
n
at
ed
by
nam
e
s;
M
a
hon
ey
PV
1, La
nsi
n
g
P
V
2 a
n
d Le
on
P
V
3
res
p
ec
t
i
v
el
y
)
[1
2]
-
[
1
5
]
,
o
n
t
h
e
basi
s
of
t
h
e
four
differe
n
t surface anti
ge
nic determ
inants of the pol
i
oviruses
refe
rred
to a
s
N-Ag 1, 2,
3A and 3B
[16
]
,[17
]. Th
e
p
o
lio v
i
rion
com
p
rise o
f
a si
n
g
l
e-stran
d
e
d
p
o
s
itiv
e sense
RNA m
o
lecu
le en
cap
s
id
ated
b
y
an
i
c
osahe
d
ral
ca
psi
d
w
h
i
c
h
i
s
com
posed
o
f
f
o
u
r
pr
ot
ei
ns
V
P
1,
V
P
2
,
VP
3
and
V
P
4
[
1
8]
.
B
e
i
ng e
n
t
e
r
o
vi
ruses
,
th
ey are tran
si
en
t resi
d
e
n
t
s
of th
e
g
a
stro
in
t
e
stin
al tr
act and thus, a
r
e st
able at acidic
PH
but they c
a
n
be
rap
i
d
l
y in
activ
ated
b
y
form
a
l
d
e
h
y
d
e
, ch
lo
rin
e
, h
e
at, and u
ltrav
i
o
let lig
h
t
[2
]. Th
e early ev
id
en
ce clearly
in
d
i
cates th
at po
lio
m
y
e
litis
is
a h
i
g
h
l
y con
t
ag
iou
s
in
fecti
o
n sp
read
b
y
a clo
s
e p
e
rso
n
a
l co
n
t
act, m
o
stly
v
i
a th
e
fecal-oral route and occasi
o
nally via oral-oral routes [
19],[20]. T
h
e
hum
a
n rece
ptor
for poliovirus
(CD155)
is
th
e k
e
y
fo
r
p
a
t
h
og
en
esis
as it is th
e
g
a
te
for
en
try
o
f
v
i
ral
p
a
rticles
in
t
o
cells [21
]
,[2
2
]
.
Fo
llowing
infectio
n
,
t
h
e vi
r
u
s
re
pl
i
cat
es i
n
t
h
e
G
I
t
r
act
an
d i
n
v
a
des t
h
e
l
o
cal
l
y
m
phoi
d t
i
s
s
u
es w
h
i
l
e
som
e
t
i
m
e
s;
i
t
m
a
y
cause
virem
i
a and invade t
h
e ce
ntral nervous syst
e
m
, destro
yi
ng the m
o
tor ne
urons a
nd ca
usi
ng
flaccid
para
lysis
[1
8]
,[
2
3
]
,
[
24]
.
Cellula
r lifecycle o
f
po
lio
v
i
rus
On
ce t
h
e po
liov
i
ru
s g
a
i
n
s en
t
r
an
ce in
t
o
th
e
b
o
d
y
, it b
i
nd
s to
th
e N-term
in
al V-typ
e
immu
nog
lob
u
lin-
like dom
ain of the hum
an poli
ovi
rus recept
o
r (hPVR or
CD155), a specifi
c cell surface protein
prese
n
t on the
in
testin
al cells o
f
t
h
e
GI tract
[21
]
,[22
],[2
5
]
.
Th
e R
N
A g
e
no
m
e
o
f
th
e v
i
ru
s is
released in
to
t
h
e cytop
l
asm
o
f
th
e h
o
s
t in
testin
al cells v
i
a ei
th
er
r
ecep
t
or
-med
iated
en
docyto
s
is [
2
6
]-[28
]
o
r
th
rou
g
h
th
e p
o
r
e
s in
the cel
l
m
e
m
b
rane
fo
r
m
ed by
m
y
ri
stoy
l
a
t
e
d
VP
4 a
n
d
V
P
1
am
phi
pha
tic
h
e
lix insertio
n in
t
o
the cell m
e
m
b
ran
e
s of t
h
e
infected
cells [25].
Once in t
h
e cy
toplasm
,
a cellular phos
p
hodiesterase
cleaves
a viral
protein VPg, whic
h
in
itiates th
e p
r
o
cess of tran
slatio
n
of th
e v
i
ral p
o
l
ypr
o
t
ein th
roug
h
a cap-ind
e
p
e
nd
en
t an
d
IRES m
e
d
i
ated
m
echani
s
m
,
as a res
u
l
t
y
i
el
ding m
a
t
u
re st
r
u
ct
ural
an
d
no
n
-
st
r
u
ct
ural
pr
ot
ei
ns [
29]
.
Wi
t
h
t
h
e sy
nt
hesi
s
of t
h
e
vi
ral
pr
ot
ei
ns,
repl
i
cat
i
o
n
o
f
t
h
e R
NA
st
art
s
i
n
t
h
e cy
t
o
pl
as
m
of vari
ou
s
m
e
m
b
rano
us
st
ruct
ures
de
ri
ve
d
fr
om
th
e
h
o
s
t end
oplas
m
i
c reticu
l
u
m
[3
0
]
,[3
1
]
. Th
e
v
i
ral
po
s
itiv
e-sen
s
e strand
serv
es as a t
e
m
p
late to
prom
o
t
e
sy
nt
hesi
s
of
n
e
gat
i
v
e-st
ran
d
s
by
t
h
e R
N
A
de
pen
d
e
n
t
R
N
A
p
o
l
y
m
e
rase. T
h
i
s
pr
od
u
ces an
R
N
A
do
u
b
l
e
-
stran
d
ed
re
plicative f
o
rm
(RF
)
. T
h
e
sin
g
le st
ran
d
of
n
e
g
a
ti
v
e
sen
s
e RNA
m
o
lecu
les th
en serv
e as a temp
late
Evaluation Warning : The document was created with Spire.PDF for Python.
I
J
PH
S I
S
SN
:
225
2-8
8
0
6
Ep
id
emio
l
o
g
i
ca
l Cha
r
a
c
teristics o
f
Po
lio
myelitis d
u
r
ing
2
1
st
century
(
2
000-
2013)
.... (
T
ahir A
h
m
a
d)
14
5
for the
synt
hesis of positive-strand
RNA m
o
lecules and t
h
e
s
e ne
w
recentl
y sy
nthesized strands eithe
r
se
rve
as
mRNA tem
p
la
tes for translatio
n
of m
o
re v
i
ral p
r
o
t
ein
s
or
t
a
r
g
eted
fo
r
en
cap
s
id
ation
in
pr
og
en
y po
lio
v
i
r
i
on
s
[3
2]
,[
3
3
]
.
The
fi
nal
st
eps o
f
t
h
e PV l
i
f
ecy
cl
e i
nvol
ve t
h
e f
o
rm
at
i
on of p
r
ocap
si
d an
d t
h
e con
v
ersi
on
o
f
t
h
e
p
r
ov
irion
in
to
m
a
tu
re, ico
s
ah
edral in
fectiou
s
v
i
ru
s
p
a
rt
i
c
l
e
s [34]
,
[
3
5
]
.
Fi
nal
l
y
,
th
ese in
f
ectio
us pr
og
en
y
pol
i
o
vi
ri
ons
ar
e rel
eased
t
h
ro
ug
h l
y
si
s
of
t
h
e
i
n
fect
e
d
host
c
e
l
l
[3
6]
.
Clinica
l
Ma
ni
festa
t
i
o
ns
Th
e in
cub
a
tio
n p
e
ri
o
d
o
f
po
lio
m
y
e
litis
is aro
und
6
t
o
20
days with
a rang
e fro
m
3
to
35
d
a
ys
[37
]
.
Its clinical
m
a
nifestations can vary and the
y
are cat
egori
zed accordi
ng
to severity. Most of the
poli
ovi
rus
in
fection
s
(u
p
t
o
95
%) cau
s
e
n
o
illn
ess
o
r
are in
app
a
ren
t
an
d
asym
p
t
o
m
atic in
fectio
n
s
. Ind
i
v
i
du
als with
n
o
clin
ical sy
m
p
t
o
m
s
can
sh
ed
th
e v
i
ru
s in
the sto
o
l
and
thu
s
th
ey are able to
tran
smit
th
e v
i
ru
s p
a
rticles to
h
ealth
y in
d
i
v
i
d
u
a
ls. Arou
nd 5
%
o
f
th
e infectio
n
s
are follo
wed
b
y
m
i
n
o
r illn
ess with
ou
t in
v
a
sion
o
f
the
central nervous syste
m
. These are usua
lly up
p
e
r resp
iratory tract in
fecti
ons, G
I
di
st
u
r
ba
nces an
d i
n
fl
u
e
nza-
lik
e illn
ess [3
8]. 1
-
2
%
o
f
th
e p
o
lio
infections are n
o
n
-
p
a
ral
y
tic asep
tic
m
e
n
i
ng
itis, recogn
ized
b
y
stiff
n
eck,
back
pai
n
a
n
d
headac
he
be
fo
r
e
t
h
e
o
n
set
o
f
paral
y
t
i
c
p
o
l
i
o
.
These
sy
m
p
t
o
m
s
l
a
st
fo
r
2-
1
0
day
s
f
o
l
l
o
we
d
by
a
co
m
p
lete reco
v
e
ry [6
]. A
small p
r
o
p
o
r
tion
(0
.1
to
1
%
)
is p
a
ralytic in
fectio
n
s
th
at inv
a
d
e
and
d
e
stro
y th
e
m
o
t
o
r neur
o
n
s
l
eadi
ng t
o
fl
ac
ci
d paral
y
si
s,
m
o
st
co
m
m
only
affect
i
ng t
h
e
l
e
gs and arm
s
[39]
. Thi
s
f
o
r
m
, t
h
e
p
a
ralytic p
o
liomyel
itis, is th
e
m
o
st sev
e
re
an
d
typ
i
cal
m
a
n
i
festatio
n
o
f
t
h
e
d
i
sease. Depen
d
i
n
g
on
th
e ex
ten
t
of C
N
S dam
a
ge, t
h
ey
can
f
u
rt
her
be cl
assi
fi
ed i
n
t
o
t
h
re
e t
y
pes:
spi
n
al
, b
u
l
b
ar a
n
d b
u
l
b
os
pi
nal
f
o
r
m
s [2]
.
Mo
st p
a
tien
t
s reco
v
e
r in
week
s to
m
o
n
t
h
s
after an
acu
t
e
d
i
sease, bu
t resi
d
u
a
l m
o
to
r
d
e
ficits re
m
a
in
in
ab
out
two-th
ird
s
of in
itially p
a
raly
zed
p
a
tien
t
s, so
m
e
ex
p
e
rien
cin
g
m
i
n
o
r
d
e
bilit
y wh
ile o
t
hers fro
m
p
e
rman
en
t
,
flaccid paralysis
[40].
Why
tar
g
et P
o
lio for
eradicati
on?
Eradication
of
m
o
st diseases is not prese
n
tly pos
sibl
e eithe
r
because the
r
e i
s
not an a
d
e
q
uate vaccine
available or t
h
ere is a
n
a
n
im
a
l
or i
n
sect re
se
rvoir t
h
at
p
e
rmits co
n
s
isten
t
rein
trodu
ctio
n of th
e
d
i
sease i
n
to
th
e
hum
an po
p
u
l
a
t
i
on.
Ho
we
ver
,
pol
i
o
era
d
i
cat
i
on i
s
an ach
ie
vable goal and there are
sev
e
ral reason
s to
th
is.
First, there is
a
n
e
ffective
,
in
expe
nsi
v
e a
n
d
easy to
a
d
m
i
nister polio vacci
ne
[10]
. Second, poliovirus have no
ani
m
al
or i
n
se
ct
reser
voi
rs a
s
i
t
affect
s
on
l
y
t
h
e h
u
m
a
n po
p
u
l
a
t
i
on
[
4
1
]
and t
h
i
r
d,
p
o
l
i
o
gi
ves l
o
n
g
-t
erm
imm
unity and t
h
ere
are
no long-ter
m
carriers
of the
disease
[42].
Epidemio
l
og
y o
f
po
li
o
m
y
e
lit
i
s
f
r
o
m
y
e
a
r
2
0
0
0
-2
012
A stri
k
i
ng
featu
r
e of
p
a
ralytic po
lio
m
y
el
itis
h
a
s b
e
en
its ev
er-ch
a
ng
ing
ep
id
em
io
lo
g
y
.
Po
lio
m
y
eli
tis
existed worl
dwide be
fore the eradication i
n
itiative was
unde
rtake
n
in 1988 which m
a
rke
d
the launc
h of the
Glob
al Po
lio
Erad
ication
In
itiativ
e (GPEI),
sp
earh
e
ad
ed
by WHO, Ro
tary In
tern
atio
nal, th
e US Cen
t
ers fo
r
Di
sease C
o
nt
r
o
l
an
d P
r
e
v
ent
i
on
(C
DC
) a
n
d t
h
e
U
n
i
t
e
d
Natio
ns Ch
ildren
’
s Fu
nd
(UNICEF)
[43
]
.
Ov
erall,
si
nce t
h
en t
h
e
num
ber o
f
cas
es has fal
l
e
n b
y
over
99% a
nd
by
20
0
1
,t
h
e
num
ber of
p
o
l
i
o
-e
n
d
em
i
c
nat
i
o
n
s
dr
o
ppe
d
fr
om
12
5 t
o
une
q
u
i
v
ocal
l
y
[4
4]
.
Y
e
a
r
200
0
Th
e ann
u
a
l
num
b
e
r
o
f
po
lio
cases r
e
po
r
t
ed
w
a
s
7
1
9
i
n
th
e year
200
0,
wh
ich
i
n
clud
ed
2
4
coun
tr
ies
fro
m
th
ro
ugh
ou
t th
e
wo
rld [4
5
]
.
Fo
llowing th
e laun
ch
o
f
Po
lio erad
icatio
n
in
itiativ
e
in
198
8,
p
o
liov
i
rus
t
r
ansm
i
ssi
on was hi
n
d
e
r
ed
i
n
18
of t
h
e
23 c
o
u
n
t
r
i
e
s o
f
East
ern M
e
d
i
t
e
rranea
n
R
e
g
i
on
(E
MR
)
and was
localized to the rem
a
ining five. T
h
e num
b
er of co
n
f
i
r
med
po
liov
i
ru
s
cases reported in
EMR co
un
tries
di
m
i
ni
shed
f
r
o
m
914 i
n
19
9
9
t
o
5
0
5
i
n
20
0
0
[4
6]
.
Su
da
n
re
po
rt
ed
o
n
l
y
4
c
o
n
f
i
r
m
e
d cases
. T
h
ere
was
a
pol
i
o
out
brea
k i
d
ent
i
fi
ed i
n
M
o
ga
di
shu
,
S
o
m
a
l
i
a
duri
n
g
t
h
e y
ear
20
0
0
[4
7]
. Pa
k
i
st
an re
po
rt
ed
t
h
e l
a
r
g
est
num
ber
o
f
p
o
lio cases i
n
20
00
i.e. 173
cases, in
spite o
f
th
e
fact
that the
nu
mber of
c
o
nfirmed
cases de
clined
approxim
a
tely 40% c
o
m
p
ared
wi
t
h
19
9
9
. I
t
was
al
s
o
wi
d
e
sprea
d
i
n
Af
g
h
ani
s
t
a
n havi
n
g
27
cases of
pol
i
o
[4
8]
.
Du
rin
g
t
h
e fi
rst hal
f
of
y
ear 2
0
0
0
,
th
ere we
re i
d
ent
i
fied three cas
es of wil
d
type poliovi
rus
in Uppe
r
Egy
p
t
[
49]
.
Ir
aq
ha
s not detected any case
of poliovirus [50].
Y
ear
2000 also re
ported
t
h
e fi
rst
out
br
eak
o
f
vaccine
-de
r
ive
d
poliovi
ru
s (VDPV) type 1 in
America
: th
ree co
nfirm
e
d
lab
o
r
at
o
r
y po
lio
v
i
ru
s cases in
Haiti
and
14 cases i
n
t
h
e D
o
m
i
ni
can R
e
p
ubl
i
c
w
e
re rep
o
r
t
e
d [
5
1]
. A p
o
l
i
o
o
u
t
brea
k d
u
e t
o
ci
rcul
at
i
ng
vac
c
i
n
e-
deri
ves p
o
l
i
o
vi
ruses
(cV
D
V
P
)
was
doc
um
ent
e
d i
n
Hispanio
la
, a m
a
jor
Isl
a
nd i
n
t
h
e
C
a
ri
bbea
n
c
o
n
t
ai
ni
n
g
th
e states o
f
Do
m
i
n
i
ca an
d
Haiti, rep
o
rting
2
2
po
lio
cas
es
[52
]
. Althou
gh co
nsid
erab
le ad
v
a
n
cem
en
t h
a
s b
e
en
repo
rted
toward
s in
terrup
tion o
f
p
o
liov
i
ru
s
tran
sm
issio
n
in
eastern
and
so
u
t
h
e
rn
Africa, po
lio
v
i
ru
s
re
m
a
in
s
Evaluation Warning : The document was created with Spire.PDF for Python.
I
S
SN
:
2
252
-88
06
I
J
PH
S Vo
l. 3
,
N
o
. 3
,
Sep
t
emb
e
r
201
4
:
1
43
–
15
7
14
6
endem
i
c in west and cent
r
al African
co
un
tries [5
3
]
.
W
i
l
d
p
o
liov
i
ru
s tran
sm
issio
n
was repo
rted
in
cen
tral
Africa and the Ho
rn of Af
rica.
African Regi
on
(AF
R
)
in
corp
orates 4
8
n
a
tio
ns an
d
territo
ries
an
d
is
p
a
rtitio
n
e
d
g
e
o
g
rap
h
i
cally in
to
fiv
e
m
a
j
o
r ep
id
em
io
lo
g
i
c b
l
o
c
k
s
: east
e
rn, western
,
so
u
t
h
e
rn
, cen
t
r
al, an
d
cou
n
t
r
i
e
s i
n
e
x
cept
i
o
nal
si
t
u
at
i
ons [
5
3]
.
F
r
om
am
ong t
h
e
AFR
co
u
n
t
r
i
e
s;
Ni
geri
a r
e
p
o
rt
e
d
6
3
7
cas
es, 3
1
confirm
e
d wild poliovirus
cases in Congo-
Brazzaville,
De
m
o
cratic Republic of
Congo (DRC)
reported 513
cases wh
ile in
Eth
i
op
ia, th
ere were 144
reported
cases [
54]
. The
r
e
were a
total of
33 cas
es re
ported
of
acute
flaccid
paralys
i
s (AFP) a
n
d
se
ve
n
(21%
)
deaths, i
n
Ca
pe
Ve
rde
,
a
n
Is
l
a
nd in Africa
[55]. By
2000, wild
pol
i
o
vi
r
u
s
wa
s di
sco
v
e
r
ed i
n
o
n
l
y
f
o
u
r
o
f
t
h
e
10 c
o
u
n
t
r
i
e
s o
f
t
h
e
So
ut
h
-
East
As
i
a
R
e
gi
on
(S
EAR
)
:
Bangla
d
esh,
Nepal,
India a
n
d Myanm
a
r. On the
whole,
SEA
R
r
e
po
r
t
ed
27
2 conf
ir
m
e
d
w
ild
p
o
liov
i
ru
s cases
in
200
0 in com
p
ar
iso
n
t
o
11
61
cases i
n
19
99
wh
ile th
ere w
e
r
e
2
6
5
cases in year
2
0
0
0
r
e
po
r
t
ed
fro
m
I
n
d
i
a
com
p
ared to 1126
p
o
l
i
o
case
s
i
n
y
ear 19
99
.
Of t
h
ese 2
6
5
con
f
i
r
m
e
d cases, 13
8 (
5
2%)
were
pol
i
o
vi
r
u
s t
y
pe 1
(P1
)
,
12
6 (
4
8
%
) wer
e
p
o
l
i
o
vi
r
u
s t
y
pe 3 (P
3) a
nd
one
pol
i
o
case was a m
i
xt
ure
of P
1
an
d P3
. The
r
e we
re 1
9
8
virus- confi
r
med cases
in Bangla
d
es
h as
com
p
ared t
o
393 cases i
n
t
h
e year1999. T
h
ere
we
re t
w
o wild
polio
vir
u
s case
s
rep
o
rte
d
fr
o
m
My
anm
a
r (located along t
h
e border
of B
a
ngla
d
es
h) and four poliovirus cases
were i
s
ol
at
ed
f
r
om
Nepal
(l
o
cat
ed al
on
g I
n
di
an b
o
r
de
r [
5
6]
. The
r
e were
no i
n
di
ge
no
us
pol
i
o
cases si
nce t
h
e
year 1999 in the
E
u
rope
an R
e
gi
on
, w
h
i
c
h c
o
m
p
ri
se of
51
cou
n
t
r
i
e
s.
Wes
t
ern P
a
cific Region
(WP
R
)
of
t
h
e
world
com
p
ris
e
s 37 countri
e
s and territories and
th
e
Reg
i
on
al Commiss
io
n
for th
e Certificatio
n
of
Po
lio
m
y
eli
tis
Erad
ication
affirm
ed
i
t
to
b
e
p
o
lio-fr
ee tog
e
th
er with
C
h
ina o
n
Octob
e
r
2
000
[5
7
]
. Aft
e
r th
e
Region of Americas certified as polio
-free in
19
94
,
WPR i
s
th
e secon
d
o
f
th
e six
WHO reg
i
on
s to
b
e
certified
as poliom
y
elitis-f
r
ee
[58]
.
D
u
r
i
ng
year
20
00
, adv
a
n
c
emen
t to
w
a
rd
s
g
l
ob
al po
lio
erad
ication
in
co
rpo
r
ated a 60% decline i
n
repo
rted
po
liov
i
ru
s cases
g
l
o
b
a
lly
with
in
1
year.
Wh
ile, at th
e end
of 200
0, less t
h
an
33
%
o
f
th
e g
l
o
b
e
's
p
opu
latio
n
liv
ed
in
coun
tries wh
ere po
lio
was en
d
e
m
i
c,
com
p
ared with greater tha
n
80% p
opu
latio
n
i
n
year
1
988
[
5
9
]
.
Y
e
a
r
200
1
Y
ear
20
01
r
e
po
r
t
ed
483
con
f
ir
m
e
d
p
o
lio
v
i
ru
s cas
es
from
15 c
o
unt
ries com
p
ared to
350,000 case
s
r
e
po
r
t
ed
in
198
8. Th
ese sh
o
t
u
p
t
o
1,920
co
nf
ir
m
e
d
cases
after a
n
out
b
rea
k
in t
h
e India
n
states of Uttar
Pra
d
esh
an
d B
i
har
[
60]
.
A to
tal of
9
1
co
nfirm
e
d
cases o
f
po
lio
were
rep
o
rte
d
f
r
o
m
five diffe
re
nt
c
o
u
n
tries of
EMR
(E
gy
pt
,
Paki
st
an
,
Af
g
h
ani
s
t
a
n,
Som
a
l
i
a
, an
d S
u
da
n)
[
61]
.
Pa
k
i
stan
r
e
po
r
t
ed
11
9 po
lio cases wh
ile Af
gh
an
istan
repo
rted
on
ly 1
1
cases
[62
]
. Fro
m
2
0
0
0
to
2
001
, th
e to
tal cases o
f
p
o
liomyel
itis
in
creased
to
21
in
Ha
iti a
nd
Dominic
a
n
Re
public
.
13 cas
es of ac
ute flac
cid
p
a
ralysis (AFP)
were confirm
e
d
in
th
e
Do
m
i
n
i
can
Rep
u
b
lic,
b
y
iso
l
atio
n
of typ
e
1
p
o
lioviru
s wh
ile 8
AFP cases
were con
f
irm
e
d
v
i
ro
log
i
cally i
n
Haiti [61
]
. WHO’s
strateg
i
es for po
lio
erad
icatio
n
in
AF
R
cau
sed
fast prog
ress in
so
u
t
h
e
rn
an
d
eastern
Afri
ca, still
tran
smission
of
wi
l
d
pol
i
o
v
i
rus c
ont
i
nue
d
i
n
f
o
u
r
i
m
port
a
nt
co
u
n
t
r
i
e
s
:
Ni
geri
a,
De
m
o
crat
i
c
R
e
publ
i
c
of C
o
ng
o
(D
R
Co
ngo
)
,
An
go
l
a
an
d
Et
h
i
op
ia. Th
er
e w
e
r
e
w
ild
po
liov
i
rus cases fo
und
in
An
go
la and D
R
Con
g
o
,
on
ly 1
0
cases were re
p
o
rt
e
d
i
n
Ni
ge
ri
a and wi
l
d
pol
i
o
vi
r
u
s was
also isolated from a child
i
n
Et
hi
opi
a
[
6
1
]
.
I
n
Yea
r
20
0
1
,
31 case
s
were
rep
o
rt
e
d
fr
om
4 nort
h
er
n st
at
es of B
i
h
a
r, Ha
ry
ana
,
U
t
t
a
r Prade
s
h a
n
d Del
h
i
i
n
I
ndi
a;
and
t
h
ere was
no
wi
l
d
p
o
l
i
ovi
ru
s fo
un
d el
sew
h
ere i
n
any
co
unt
ry
of
SEAR
[56
]
. As th
e ep
id
em
ic
sp
read
in
t
o
Indian states, t
h
e num
b
er of
polio-inf
ected
districts increa
sed from
a tota
l o
f
63
to
1
5
9
in
year
2
001
and
because of
long border
sha
r
e
d
by
In
dia wit
h
Ba
ngla
d
es
h
and Ne
pal, the
s
e c
ountries were
als
o
affecte
d
by
the
polio epi
d
em
ic
[63].
Philippines
docu
m
e
nted 3
cases
of polio out
brea
k due
to vaccine
-de
r
ive
d
polioviruse
s
cVDVPs
[52]. There we
re
no cas
es
o
f
po
lio
repo
rted
in
t
h
e
Eur
o
pe
an region
i
n
t
h
e
begi
nni
ng
o
f
t
h
e y
ear
2
001
[57
]
bu
t d
u
ring
Janu
ary
to
March
,
th
ere were two
AFP cases d
e
tected
in
Bu
lg
aria. Th
e to
tal n
u
m
b
e
r of
A
FP
cases id
en
tif
ied
i
n
cr
eased
r
a
p
i
d
l
y
r
each
i
ng
to
33
cases of
AFP i
n
N
o
v
e
m
b
er
2001
[64
]
. Th
e
r
e
g
i
on
o
f
America,
th
e
Western P
a
cific region WP
R
and China,
all
reporte
d
no cases
follo
w
i
ng
th
e year
20
01
[
6
5
]
.
Y
e
a
r
200
2
In t
h
e y
ear
20
0
2
, t
h
e n
u
m
b
er of c
o
u
n
t
r
i
e
s i
n
f
ect
ed fr
om
t
h
e
pol
i
o
vi
r
u
s i
n
fe
ct
i
on re
duce
d
f
r
om
125 t
o
o
n
l
y
7
co
un
tr
ies [6
0
]
.
19
18
ann
u
a
l cases
w
e
re r
e
p
o
r
t
ed
f
r
om
th
ese 7 countr
i
es n
con
t
r
a
st
to
an
ev
alu
a
ted
3
50
00
0
ca
ses
i
n
1
9
8
8
[
59]
. To
ge
t
h
er wi
t
h
t
h
e R
e
gi
o
n
of
Am
ericas
an
d th
e
WP
R
, bei
n
g cert
i
f
i
e
d
t
o
be free o
f
p
o
lio infection in
19
94
and
2
000
respectively,
Euro
pea
n
Region
additionally cam
e to
be t
h
e t
h
ird
WHO
regi
on ce
rt
i
f
i
e
d as
pol
i
o
-f
ree
i
n
2
0
0
2
[5
8]
,[
59]
. T
h
e
r
e was
a si
gni
fi
ca
nt
r
i
se i
n
p
o
l
i
ovi
r
u
s cases
fr
om
48
3 i
n
20
0
1
t
o
1,
9
20
pol
i
o
cases i
n
20
0
2
[
59]
. C
o
n
s
i
d
era
b
l
e
ad
va
ncem
ent
has been m
a
de i
n
t
h
e
EMR
n
a
tions in
th
e
m
i
dst
of 2
0
0
2
[6
6]
. Fe
w ca
ses we
re re
po
r
t
ed fr
om
Afg
h
a
ni
st
an (
1
1 ca
ses),
7 cases
det
ect
ed f
r
o
m
Up
pe
r
Eg
yp
t
d
u
r
i
ng
t
h
e seco
nd
h
a
lf o
f
200
2, wh
il
e Pak
i
stan r
e
po
r
t
ed
22
% lesser
po
lio
cases
in
200
2
(9
3 cases)
as
Evaluation Warning : The document was created with Spire.PDF for Python.
I
J
PH
S I
S
SN
:
225
2-8
8
0
6
Ep
id
emio
l
o
g
i
ca
l Cha
r
a
c
teristics o
f
Po
lio
myelitis d
u
r
ing
2
1
st
century
(
2
000-
2013)
.... (
T
ahir A
h
m
a
d)
14
7
com
p
ared to
year 2001
(119 cases
). T
h
ere were ze
ro c
a
ses of
po
lio
r
e
po
r
t
ed
fro
m Sud
a
n. In
t
h
e
AF
R
countries, there were
no cas
es re
po
rt
ed fr
om
Et
hi
opi
a
a
nd A
n
g
o
l
a
[5
9]
.
T
h
ere wer
e
t
h
ree vi
r
o
l
o
gi
cal
l
y
co
nfirm
e
d
po
lio
cases ind
e
n
tified
i
n
So
m
a
lia
wh
ile it rep
o
r
t
ed
t
h
e last
p
o
l
i
o
case in O
c
t
o
b
e
r 200
2 [67
]
(2
8)
, 3
cases from
Niger a
n
d an
outbrea
k of
circ
ulating vacci
ne-deri
v
ed
poliovi
rus c
V
DVP
was
detected in yea
r
2
002
in
Mad
a
g
a
scar
[59
]
. Desp
ite a su
b
s
tan
tial p
r
ogress
in
th
e
SEAR
co
un
tries,
po
li
ovi
rus tra
n
sm
ission
cont
i
n
ue
d d
u
ri
ng
20
0
2
i
n
no
rt
her
n
I
ndi
a [
68]
. A f
o
ur
-f
o
l
d i
n
crease i
n
pol
i
o
i
n
ci
de
n
ce gl
obal
l
y
, f
o
cu
sed
m
a
i
n
l
y
on
In
di
a an
d
no
rt
he
rn
Ni
ge
ri
a [
5
9]
.
In
I
ndi
a,
t
h
e
r
e
was a
drastic
increase i
n
pol
io cases
re
ported in
2
002
.
Th
e
p
o
l
i
o
cases
b
u
ilt fro
m
2
6
8
in year
2
001
to
1
,
5
9
9
p
o
l
i
o
cases
i
n
2
002
; o
f
th
e aforem
en
tio
n
e
d
,
59
%
w
e
r
e
in
squ
i
r
t
s f
r
o
m
Mu
sli
m
g
r
o
u
p
s
, w
h
ich
r
e
pr
esen
t m
o
r
e
o
r
less
2
0
% o
f
th
e total I
n
d
i
an
popu
lation
(6
9)
.
1,
36
3 (
8
5
%
) o
f
t
h
e cases
rep
o
rt
e
d
f
r
om
In
di
a we
re i
d
e
n
t
i
f
i
e
d i
n
a
r
eas
of
Ut
t
a
r Pra
d
e
s
h an
d B
i
ha
r a
nd
4
9
i
n
W
e
st
B
e
n
g
a
l
[70]
. Ni
geri
a
rep
o
rt
e
d
2
01
p
o
l
i
o
cases [
59]
.
There w
e
re n
o
wi
l
d
pol
i
ovi
r
u
s cases i
d
ent
i
f
i
e
d i
n
Nepal
a
n
d B
a
n
g
l
a
des
h
[7
1]
.
All end
e
m
i
c c
o
un
tries
with
t
h
e ex
cep
tion
of So
m
a
l
i
a cont
i
nue
d t
o
re
po
rt
i
n
creasi
n
g
wi
l
d
pol
i
o
vi
r
u
s
cases in
year
20
03
.
Y
e
a
r
200
3
Rum
o
rs concerning t
h
e safety of
polio
vaccine i
n
year 2003, and co
nsequent
refusal of vaccine
use
in Nige
ria, he
aded to a buil
d in cas
es an
d
sprea
d
o
f
t
h
e
vi
rus t
o
s
u
r
r
o
un
di
n
g
p
o
l
i
o
-f
ree co
unt
ri
es [
72]
. I
n
20
0
3
, t
h
ere
we
re
onl
y
7
8
4
co
nfi
r
m
e
d cases
of
p
o
l
i
o
gl
obal
l
y
,
an
d
pol
i
o
r
e
m
a
i
n
ed e
nde
m
i
c i
n
si
x c
o
u
n
t
r
i
e
s
wo
rl
d
w
i
d
e
[7
3
]
. These si
x e
n
dem
i
c count
ri
e
s
i
n
cl
ude
Ni
ge
ri
a, Ni
ge
r, Pa
k
i
st
an, I
ndi
a,
Af
gha
ni
st
an a
nd
Egy
p
t
[74]. In
2003, there we
re 51 cases of
p
o
l
i
o
re
po
rt
ed f
r
om
eight
co
u
n
t
r
i
e
s
in
W
e
st and Central Africa that were
p
r
ev
iou
s
ly po
lio
-free.
In
Pak
i
s
t
an
, r
e
po
r
t
ed
po
lio
cases
ex
p
a
nd
ed
f
r
om 9
0
in
year
2
002
to
103
in
20
03
.
India
, t
h
e j
u
st
rem
a
i
n
i
ng SE
AR
co
unt
ry
w
i
t
h
pr
o
g
ressi
ng
i
ndi
ge
n
o
u
s
t
r
ansm
i
ssi
on of
WP
V, m
a
de m
a
jor
adva
ncem
ent
in 2
0
03
fo
r p
o
l
i
o
dest
r
u
ct
i
o
n
[7
0]
. I
ndi
a re
po
rt
ed
22
5
wi
l
d
p
o
l
i
ovi
r
u
s
(
W
P
V
) cases
,
whi
c
h
marked a si
gni
ficant
decline
from
a glob
al t
o
tal of
1
,
6
0
0
cases repo
rted i
n
2
002
.
Of th
e
to
tal 2
25 po
lio cases,
20
3 cases
(9
0
%
) we
re t
y
pe 1
WPV (
P
1
)
,
and
2
2
(
10%
)
were t
y
pe
3
WPV (P
3
)
. O
u
t
of
22
5 t
o
t
a
l
ca
ses, 8
8
were re
p
o
rt
e
d
i
n
Ut
t
a
r P
r
ades
h, 1
8
i
n
B
i
ha
r,
and
28 i
n
W
e
st
B
e
ngal
[
70]
.
Nigeria
, th
e mo
st po
pu
lated
African
cou
n
t
r
y
re
p
o
rt
ed a t
o
t
a
l
n
u
m
b
er
of
3
55
wi
l
d
p
o
l
i
o
vi
r
u
s (
W
P
V
) cases i
n
20
0
3
, m
a
ki
ng
up
fo
r
45%
of
gl
o
b
al
l
y
rep
o
rte
d
cases
and >
8
0
%
of c
a
ses rep
o
rte
d
f
r
om
the
Africa
n Region (AFR). Of the reported 355
W
P
V
cases,
19
2
were P
V
t
y
pe 1, a
n
d 1
6
3
were P
V
t
y
pe
3 [
75]
.
Eg
y
p
t
recorde
d
one
polio case in c
o
ntrast to se
ven cases
r
e
po
r
t
ed
in year
200
2. Th
e
n
u
m
b
er of case
s
i
d
entifie
d in
Ni
ger
,
w
h
i
c
h
fri
n
g
es
Ni
ge
ri
a, e
x
pan
d
e
d
f
r
o
m
3 pol
i
o
cases in
20
02
to
40
cases i
n
year
200
3 wh
i
l
e
Af
gh
ani
s
ta
n
, sh
ar
i
n
g a cro
ss-bo
rd
er r
e
ser
v
o
i
r
of
p
r
og
ressin
g
pol
i
o
vi
r
u
s
t
r
an
sm
i
ssi
on wi
t
h
Paki
st
an
,
re
p
o
r
t
ed 8 polio
cas
es in
t
h
e
year 2003 [69].
World was
ne
ver so nea
r
t
o
success
,
with
just six
countri
e
s
rem
a
ining free of
polio
i
n
fection. Thus,
in
200
4, th
e wo
rl
d
h
a
s its
b
e
st ch
an
ce to stop
p
o
lio fo
rev
e
r.
Y
e
a
r
200
4
I
n
2
004
, im
p
o
r
t
ation
of
w
i
ld
p
o
l
i
o
v
i
ru
s
cau
sed
r
e
-
i
n
f
ectio
n
in
countr
i
es th
at h
a
d p
r
ev
iou
s
ly
in
terru
p
t
ed
tran
sm
issio
n
.
Th
is in
creased th
e
n
u
m
b
e
r
o
f
cases to
1
,
26
3 in
18
co
un
tr
ies
[7
6].
The Africa
n Region (
AF
R)
co
un
tr
ies r
e
po
r
t
ed
a to
tal o
f
7
2
8
con
f
i
r
m
e
d
p
o
lio
v
i
ru
s cases in
year
2004
[7
7]
, o
u
t
of w
h
i
c
h 1
2
co
n
f
i
r
m
e
d wi
l
d
-
pol
i
ovi
rus cases
w
e
re rep
o
r
t
e
d i
n
Ni
ger w
h
i
l
e
Ni
ge
ri
a rep
o
rt
ed 1
3
3
cases o
f
wi
l
d
p
o
l
i
ovi
rus
[
69]
.
The c
o
u
n
t
r
i
e
s i
n
East
er
n M
e
d
i
t
e
rranea
n
R
e
g
i
on
(
EMR)
r
e
po
r
t
ed
54
po
lio
cases
al
t
oget
h
e
r
.
Af
gha
ni
st
an
re
po
rt
ed
o
n
l
y
t
w
o
pol
i
o
vi
r
u
s ca
se
s [
69]
,
o
n
e cas
e was
re
po
rt
ed
fr
om
Egy
p
t
a
n
d
1
2
wild
po
liov
i
rus cases fro
m
Pa
k
i
stan
[78
]
. Ind
i
a, th
e on
ly po
lio
-end
em
ic
SE
AR
co
un
tr
y,
r
e
po
r
t
ed
134
cases in
20
0
4
,
hi
st
o
r
i
cal
l
y
t
h
e l
o
west
ever
, m
o
st
of
whi
c
h we
re
fr
om
west
ern
Ut
t
a
r Pra
d
es
h a
n
d B
i
ha
r [
79]
.
Al
so i
n
year
2
004
, th
e
Western P
a
cific
Reg
i
on
W
P
R, th
e
E
u
rope
an Re
gi
o
n
and the re
gion of
America
rem
a
ine
d
polio-free, re
porting ze
ro cas
es of
polio
[78]. There wa
s a
n
out
brea
k
of
vaccine
-de
r
ive
d
poliovirus (c
VDVP)
doc
um
ent
e
d i
n
Chin
a
i
n
year
2
004
r
e
po
r
ting tw
o po
lio
cases [8
0
]
.
Y
e
a
r
200
5
In
year
20
05
, t
h
e wo
rl
d
h
a
s m
o
v
e
d
qu
ite a lo
t
m
ilesto
n
e
s clo
s
e to
po
lio
erad
ication
,
togeth
er wit
h
th
e
success
of introducing new
m
onovalent
oral polio vacci
nes
[81]. Since
year 1988, the
efforts of gl
obal polio
eradi
cat
i
o
n ha
ve decre
a
sed t
h
e n
u
m
b
er of pol
i
o
cases
by
nearl
y
99%
, i
.
e. fr
om
350,
0
00
per y
ear t
o
1,4
6
9
cases i
n
2
0
05
[
82]
.
The
r
e
wer
e
onl
y
4 c
o
unt
ri
es rem
a
i
n
i
ng
wi
t
h
en
dem
i
c
pol
i
o
:
In
di
a, P
a
ki
st
an,
Af
g
h
a
n
i
s
t
a
n
and
Ni
ge
ri
a. The l
a
st
pol
i
o
v
i
rus i
n
E
g
y
p
t
was i
s
ol
at
ed
fr
om
an envi
r
o
n
m
ent
a
l
sam
p
l
e
i
n
Jan
u
ary
2
0
05
[8
3]
,
and ni
ne polio
cases re
ported
in
Ni
ger
were
all th
e du
e to
i
m
p
o
r
tatio
n
s
o
v
er its’
h
eav
ily-
trav
eled bo
rd
er with
Evaluation Warning : The document was created with Spire.PDF for Python.
I
S
SN
:
2
252
-88
06
I
J
PH
S Vo
l. 3
,
N
o
. 3
,
Sep
t
emb
e
r
201
4
:
1
43
–
15
7
14
8
Ni
ge
ri
a. O
n
t
h
e ot
her h
a
n
d
,
Nigeria
rep
o
rt
ed 8
30
wi
l
d
p
o
l
i
ovi
r
u
s cases [
84]
. Te
n co
unt
ri
es, w
h
i
c
h ha
v
e
been
r
e
-
i
nf
ected w
i
t
h
p
o
liov
i
ru
s, i
n
clud
e: Ch
ad
,
Y
e
m
e
n
,
So
m
a
lia, An
go
la, Sud
a
n, Et
h
i
op
ia,
Ca
m
e
r
o
on
,
In
do
n
e
sia,
Er
itr
ea an
d M
a
li. Th
er
e
w
e
re 1
,
00
0 po
lio
cases (54%
of the case
s
re
port
e
d
globally) from
these count
ries
with
sev
e
ral ou
tbreak
s i
n
itiated
b
y
im
p
o
r
tatio
n
s
[85
]
. Si
n
c
e th
e d
i
sease su
rv
eillan
ce started
in
19
96
,
Yem
e
n
becam
e free of any polio infection.
In year
2005,
Yem
e
n i
d
entified 478
poliovirus cases in
the country, 185
cases
were
re
p
o
rt
e
d
fr
om
So
m
a
l
i
a
[83]
a
n
d
Su
da
n
re
po
rt
ed
2
4
c
o
n
f
i
r
m
e
d
wi
l
d
p
o
l
i
ovi
r
u
s ca
ses.
The
r
e we
re
22 case
s
re
po
rt
ed i
n
va
ri
o
u
s
d
i
st
ri
ct
s of
Ethi
o
p
ia
i
n
2
0
0
5
[
86]
. I
n
do
nesi
a
had
n
o
t
rep
o
rt
ed any
case o
f
pol
i
o
since 1995. T
h
e country'
s la
r
g
est-e
v
er rec
o
rded
out
brea
k of vaccine
-de
r
ived type 1 poliovirus (cVDVP) was
doc
um
ent
e
d i
n
cent
r
al
Ja
va,
S
u
m
a
t
r
a and Ja
k
a
rt
a pa
rt
s o
f
I
n
donesi
a
rep
o
rt
i
ng 2
25 p
o
l
i
o
c
a
ses
[
87]
. The
hi
g
h
disease burde
n in Indonesia raises a
co
n
c
ern o
f
po
ten
tial spread
o
f
po
lio
v
i
ru
s acro
ss Asia, in
clud
ing
co
un
tries
su
ch
as Ph
ilip
p
i
n
e
s, Malaysia an
d
C
h
in
a.
Th
ere
we
re two
larg
e
po
lio
-end
em
ic Asi
a
n
coun
tries
wh
ich
accounted
for
50% reduction in cases from
year 2004 to
2005 [83]. Alt
oget
h
er, the num
b
er of poli
ovi
rus
cases in
India
and
Pa
k
i
st
an
in
th
e fin
a
l qu
arter of 20
05
fell b
y
m
o
re
than half c
o
m
p
ared
with
th
e p
a
st year,
reason being the m
o
re effect
ive im
m
unization procedures
and a
d
equate
use of m
onovalent polio vaccine
[8
8]
. Pa
ki
st
an
rep
o
rt
e
d
2
8
po
l
i
ovi
r
u
s cases i
n
year 2005.
Out
of thes
e
28 cases, all polio cases were
WPV
typ
e
1
ex
cep
t
on
e case th
at
was
W
P
V typ
e
3
(id
e
n
tified
from Qu
etta d
i
stri
ct Balu
ch
istan
p
r
ov
in
ce) [8
9
]
. Ind
i
a,
a hi
g
h
l
y
po
p
u
l
a
t
e
d an
d a p
o
l
i
o-e
ndem
i
c SEAR
co
unt
ry
, i
n
t
e
nsi
f
i
e
d p
o
l
i
o
dest
ruct
i
o
n e
f
f
o
rt
s
by
i
n
t
r
o
duci
n
g
extra surveilla
nce and im
m
unization
proc
edures togethe
r
with introducing m
onova
lent oral poli
ovi
rus
vaccine
for types 1 and
3. The reported
cases reduced
fr
om
134 i
n
2004 to
66 in
year 2005 [90]. India was the
only
polio-e
nde
m
ic count
ry of SE
AR in 2005
while
Nep
a
l
also
r
e
po
r
t
ed
4
w
ild
po
li
ovi
rus cases i
n
this
year.
Ban
g
l
ad
esh r
e
main
ed
po
lio-f
r
ee t
h
rou
ghou
t th
e year
20
05
.
Af
ghanist
a
n
repo
rted
a to
tal of n
i
ne wild
pol
i
o
vi
r
u
s ca
se
s i
n
y
ear
2
0
0
5
[
83]
.
Y
e
a
r
200
6
By year
200
6,
th
er
e
w
e
r
e
lesser
th
an 2,000
po
lio
cases
r
e
por
ted
all ar
oun
d
the worl
d—a decrease
of
>99
%
fr
om
year 1
9
8
8
—a
n
d
pol
i
o
was
no
w en
dem
i
c i
n
onl
y
fo
ur c
o
unt
ri
es wo
rl
d
w
i
d
e [
1
0]
.
T
h
e
s
e fo
ur
countries i
n
clude: Afgha
nistan
,
I
ndi
a,
Ni
geri
a, an
d
Paki
st
a
n
[
87]
.
6%
of the to
tal cases i
n
20
06
were from
th
e
ni
ne ot
he
r
c
o
u
n
t
r
i
e
s wi
t
h
i
m
p
o
rt
at
i
o
ns of p
o
l
i
ovi
r
u
s [9
1]
.
F
r
om
am
ong
t
h
e EM
R
cou
n
t
r
i
e
s
,
Iran
r
e
po
r
t
ed 107
pol
i
o
case
s
i
n
20
0
6
[
92]
. I
n
Pakis
t
an
, an i
n
crease i
n
poliovi
rus cases
wa
s obse
r
ved
fr
om
28 cases, i
s
ol
at
ed
fr
om
17 di
st
ri
ct
s i
n
200
5 t
o
4
0
cases fr
om
2
0
di
st
ri
ct
s i
n
200
6. H
o
we
ver,
appr
o
x
i
m
at
el
y 80% o
f
di
st
ri
c
t
s of
Paki
st
an
we
re
pol
i
o
-f
ree i
n
2
0
0
6
[9
3]
.
In
t
h
e sam
e
y
ear, t
h
e
Af
gha
ni
st
a
n
a
n
d
Ni
geri
a
rep
o
rt
e
d
t
h
e
hi
ghe
st
n
u
m
b
e
r
o
f
cases co
m
p
ared
t
o
a su
m
to
tal
o
f
cases in
t
h
e p
a
st six years, wh
ile th
e to
t
a
l p
o
lio
cases
in
In
d
i
a
were
hi
ghe
r t
h
an t
h
e
cases
r
e
po
rt
ed
i
n
a
n
y
o
f
t
h
e
p
r
e
v
i
o
us
fo
u
r
y
ears
[
73]
.
M
o
st
of
Af
gh
ani
s
t
a
n
, anot
her
EMR co
un
try, rem
a
in
s witho
u
t
an
y po
lio
in
fection
,
w
ith th
e excep
tion o
f
con
tinu
o
u
s
tran
sm
issio
n
in
th
e
So
ut
he
rn R
e
gi
on
. 3
1
cases
w
e
re re
po
rt
ed i
n
20
0
6
, i
n
c
o
nt
r
a
st
t
o
9
pol
i
o
c
a
ses i
n
y
ear
20
05
[
93]
.
Am
on
g t
h
e
SEA
R
coun
tr
i
e
s, an
ou
tbr
e
ak
of
po
lio
in
U
t
t
a
r Pra
d
es
h
rei
n
t
r
od
uce
d
p
o
l
i
ovi
rus i
n
va
ri
o
u
s
Indi
a
territo
ries
th
at w
e
r
e
p
r
ev
i
o
u
s
ly
f
r
e
e of
po
lio
g
i
v
i
n
g
10
ti
m
e
s r
i
se in
po
lio
cases in year
2
006
as com
p
ar
ed
to
year 20
05
(i.e. 676
polio cases
ve
rs
us 66
cases
re
spect
ively) [94]. Si
nce year 2000,
Ba
ng
ladesh
r
e
po
rted
its firs
t poli
o
case in
Ch
andu
r
d
i
strict in
C
h
ittag
o
n
g
and
b
y
th
e end
of
year 2
006
, th
e
to
tal p
o
liov
i
rus cases add
e
d
u
p
t
o
18
cases from
the country [95] while the
r
e we
re 5 case
s
of
wild
po
liov
i
rus reported
from Nep
a
l [9
6
]
.
In
year
2
006
,
Nigeri
a
reported
1
,
12
3 wild
po
liov
i
ru
s cases, in
co
n
t
rast to 83
0
po
lio
cases in
year
2
005
.
App
r
ox
im
ate
l
y
6
0
%
of th
e to
tal wild
p
o
liov
i
ru
s cases we
re rep
o
rte
d
fr
o
m
three states
of n
o
r
ther
n Ni
geria
(Ka
n
o,
Kat
s
i
n
a
an
d Ji
gawa
).
There
wa
s a
n
out
brea
k
of
2
2
cases
of
cV
D
V
P
re
po
rt
ed i
n
Ni
ge
ri
a i
n
t
h
i
s
y
ear
[9
3]
. I
n
2
0
0
6
Ni
ge
r an
d E
g
y
p
t
pass
one y
e
ar wi
t
h
out
a
n
y
pol
i
o
case
s
[
8
5]
.
Na
mibia
, an A
F
R
co
unt
r
y
, ha
s
d
e
tected
no
wild
po
liov
i
ru
s
(WPV) transm
i
ssio
n
fo
r te
n years
u
n
til fi
re-b
ack of
po
liomyel
itis cases in
200
6,
sub
s
eq
ue
nt
l
y
due t
o
im
port
a
t
i
on
of wi
l
d
pol
i
ovi
rus t
y
pe 1 (
W
P
V
1
)
fr
om
nei
g
h
b
o
r
i
n
g A
n
gol
a.
It
m
a
de up t
o
19
cases
o
f
pol
i
o
m
y
el
i
t
i
s
[9
7]
. Ot
her
ni
ne
no
n-e
n
dem
i
c
count
ri
es rep
o
r
t
e
d a
t
o
t
a
l
o
f
1
2
8
wi
l
d
pol
i
ovi
r
u
s
case
s
in
th
e year
2
006
[
9
8
]
.
Y
e
a
r
200
7
2
7
po
lio
-f
r
e
e co
un
tr
ies
w
e
r
e
re-
i
n
f
ected
w
ith i
m
p
o
r
ted po
lio
v
i
r
u
s b
e
t
w
een 2
003
an
d 2007
.
20
of
th
e
t
o
t
a
l
re-i
nfect
e
d
co
unt
ri
es we
re a resul
t
o
f
t
h
e vi
r
u
s t
h
at
o
r
i
g
i
n
at
e
d
fr
om
no
rt
he
rn
Ni
ge
r
i
a [95]
. T
h
e ot
her si
x
co
un
tr
ies in
cl
ud
e, Ang
o
l
a (9
cases)
,
Ch
ad
(6
cases),
D
e
mo
cr
atic Repu
b
l
ic o
f
Con
g
o
(32
cases), N
i
g
e
r
(
209
cases), Myanmar (11 cases
) a
n
d Som
a
lia, [99].
A
gl
o
b
al
t
o
t
a
l
of
1,
3
15 case
s
were
re
po
rt
ed i
n
t
h
e y
e
a
r
2
0
0
7
.
Am
ong t
h
e f
o
ur c
o
u
n
t
r
i
e
s t
h
at
ha
v
e
neve
r i
n
t
e
rr
upt
ed
pol
i
o
vi
r
u
s t
r
ansm
i
ssi
on,
Ni
ge
ri
a i
s
o
n
e
t
h
em
whi
l
e
t
h
e
ot
her
s
bei
n
g I
n
di
a, Pa
ki
st
an a
n
d
Af
gh
ani
s
t
a
n
[
1
00]
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
J
PH
S I
S
SN
:
225
2-8
8
0
6
Ep
id
emio
l
o
g
i
ca
l Cha
r
a
c
teristics o
f
Po
lio
myelitis d
u
r
ing
2
1
st
century
(
2
000-
2013)
.... (
T
ahir A
h
m
a
d)
14
9
I
n
year
200
7,
35
3 w
ild
po
lio
vir
u
s cases w
e
r
e
r
e
por
ted
in
Ni
geria
. Th
e first case of
wild
po
lio
v
i
ru
s
3
(W
PV 3)
si
n
c
e 200
4 w
a
s al
so
r
e
por
ted fr
om
So
u
t
h
e
rn N
i
g
e
r
i
a i
n
20
07
[
100
]. And
also
an
ou
tbr
eak
o
f
71
cases o
f
c
V
DV
P wa
s re
p
o
rt
e
d
fr
om
Ni
geri
a.
In
2
0
0
7
,
c
o
n
s
t
r
ai
ned
ad
va
nce
m
ent
occ
u
r
r
ed
t
o
wa
rds
i
n
t
e
r
r
u
pt
i
ng
wild
po
lio
v
i
rus in
fectio
n
and
tran
sm
issio
n
in
th
e
EMR
cou
n
t
r
i
e
s:
Af
gha
ni
st
an an
d
Paki
st
an.
Pakistan
obs
er
ved
decl
i
n
e i
n
t
o
t
a
l
nu
m
b
er of co
n
f
i
r
m
e
d pol
i
o
vi
r
u
s
cases fr
om
40
(re
po
rt
ed
fr
o
m
22 di
st
ri
ct
s)
i
n
2
0
0
6
t
o
32 cases (
r
e
p
o
r
t
e
d f
r
om
18
di
st
ri
ct
s) i
n
20
07
.
Whi
l
e
, i
n
t
h
e sam
e
y
ear,
Af
gh
ani
s
t
a
n
rep
o
r
t
ed
17
conf
ir
m
e
d
pol
i
o
vi
r
u
s
case
s
, (
f
r
o
m
13
di
s
t
ri
ct
s), c
o
m
p
ared t
o
a
total of 31 cas
es
(from
17 di
st
ri
ct
s)
i
n
t
h
e
pre
v
i
o
u
s
y
e
a
r
[
101
]. I
n
March
20
07
,
So
ma
lia
becam
e polio-free EMR
coun
try after reporting its
last case of polio in
M
u
d
u
g
p
r
ovi
n
ce, i
n
ce
nt
ral
Som
a
l
i
a
[102]
.
Ira
n, i
n
20
0
7
,
rep
o
r
t
e
d a t
o
t
a
l
of
5
8
p
o
l
i
o
cases [
50]
.
In
dia
was
th
e on
ly SEAR
cou
n
t
ry th
at
remain
ed
po
lio en
d
e
m
i
c r
e
po
r
t
i
n
g 894
w
ild
p
o
lio
v
i
ru
s cases in
2
007
[10
3
]
.
Y
e
a
r
200
8
The y
ear 2
0
0
8
pr
ove
d t
o
be
a t
u
rni
ng
poi
nt
i
n
t
h
e
fi
ght
a
g
ai
nst
pol
i
o
. 1,
6
52
wi
l
d
p
o
l
i
o
v
i
rus (
W
P
V
)
cases were cal
cu
lated
wo
rl
dwid
e in
1
8
co
un
tries of th
e
worl
d, which
represents a
n
increase of
26% c
o
m
p
ared
t
o
20
0
7
. 9
7
6
cases were wi
l
d
pol
i
o
vi
r
u
s t
y
pe 1 (
W
P
V
1)
, 6
75 cases
were
wi
l
d
p
o
l
i
ovi
rus
t
y
pe 3 (
W
P
V
3) a
n
d
one
case
was a
m
i
xt
ure
of
wi
l
d
pol
i
o
vi
r
u
s t
y
pe
1 a
n
d
3
[
1
0
4
]
.
91
% o
f
al
l
p
o
l
i
o
cases
occu
rr
ed i
n
t
h
e f
o
ur
pre
v
i
o
usl
y
p
o
l
i
o
-e
n
d
em
i
c
count
ri
es:
Ni
geri
a,
Paki
st
a
n
,
In
di
a an
d
Af
gh
ani
s
t
a
n [
1
05]
.
Nigeria,
th
e
on
ly p
o
lio-ex
portin
g
cou
n
t
ry i
n
th
e
world, poses th
e sing
le
b
i
gg
est
th
r
eat to
th
e
g
l
o
b
a
l er
ad
ication
of
p
o
lio
[
104]. Th
e nu
m
b
er
o
f
cases n
e
ar
ly tr
ip
led
in
20
08
, in
N
i
g
e
r
i
a,
du
e to
a
ri
se i
n
t
y
pe 1 pol
i
o
rep
o
rt
i
n
g
a su
m
t
o
t
a
l of 80
1 wi
l
d
pol
i
ovi
r
u
s cases [
1
0
5
]
.
I
n
y
ear 20
0
8
, west
e
r
n
Ut
t
a
r
Pra
d
esh
– a gl
obal
l
y
est
a
bl
i
s
hed
reser
v
oi
r
o
f
wi
l
d
pol
i
o
vi
r
u
s i
n
In
dia
, st
op
pe
d t
h
e t
r
a
n
s
m
i
ssi
on of i
ndi
gen
o
u
s
t
y
pe 1
p
o
l
i
ovi
r
u
s
bri
ngi
ng t
y
p
e
1 t
o
t
h
e
ve
rg
e of
era
d
i
cat
i
o
n i
n
b
o
t
h
Ut
t
a
r
Pra
d
es
h an
d B
i
har st
at
es.
H
o
weve
r,
there we
re 559 polio cases re
ported in
200
8 in
I
n
d
i
a du
e to
a lar
g
e ou
tb
r
eak of t
y
pe 3
WP
V i
n
cent
r
a
l
B
i
har
an
d
w
e
stern
U
t
tar
Pr
ad
esh
[1
04
],
[1
05
].
Ne
pa
l
also reporte
d
six cases of po
lio
v
i
ru
s du
e to
sin
g
l
e im
p
o
r
tatio
ns
fro
m
ei
th
er Bih
a
r
o
r
Uttar Prad
esh
.
In
sp
ite o
f
in
ten
s
e actions take
n to
eradicat
e po
lio in
Afg
h
an
istan
and
Pak
i
stan, tran
smissio
n
of
wild
po
liov
i
ru
s ex
p
a
nd
ed in
Pak
i
s
t
an
an
d as
hel
d
o
n
i
n
t
h
e
so
ut
he
rn
re
gi
on
o
f
Af
gh
ani
s
t
a
n
[
1
04]
.
Paki
st
an
r
e
po
rt
ed a t
o
t
a
l
of
1
18
wi
l
d
po
l
i
ovi
r
u
s cases i
n
2
0
08
w
h
i
l
e
Af
gh
ani
s
t
a
n
rep
o
r
t
ed
31
ca
ses onl
y
.
In 2
0
0
8
, 1
4
cou
n
t
r
i
e
s ha
d ci
rcul
at
i
on o
f
im
port
e
d p
o
l
i
o
vi
r
u
s. Of
t
h
es
e,
1
0
c
o
u
n
t
r
i
e
s
were
i
n
fect
ed
by
WPV o
f
Ni
ge
ri
a
n
ori
g
i
n
a
nd f
o
u
r
by
W
P
V o
f
In
di
an
ori
g
i
n
. These co
u
n
t
r
i
e
s rep
o
rt
e
d
a t
o
t
a
l
of
14
6 cases
o
f
i
m
port
e
d wi
l
d
pol
i
o
vi
r
u
s
[1
0
5
]
.
Al
on
g wi
t
h
Ni
ge
ri
a, t
h
e
o
t
her
AFR
coun
tries repo
rting
wild
p
o
liov
i
ru
s cases in
20
08
in
cl
ud
e: Sud
a
n
,
rec
o
r
d
i
n
g 2
6
pol
i
ovi
rus case
s
, E
t
hi
opi
a
rep
o
rt
e
d
t
h
ree ca
ses o
f
p
o
l
i
o
on i
t
s
b
o
r
d
e
r
wi
t
h
so
ut
he
r
n
Su
dan
,
DR
C
a
nd
A
n
g
o
l
a
also ide
n
tified fe
w cases . Cha
d
, in ce
ntral
Africa
rep
o
rt
e
d
t
h
e
hi
ghe
st
n
u
m
b
er
of
cases c
o
m
p
ared to a
n
y
African c
o
untry
[104].
Vaccine
-de
r
ive
d
polioviruses
(VDPVs
) type 2 was ide
n
tified in year
2008
from
the AFP cases from
seve
n c
o
u
n
t
r
i
e
s.
14
8 ca
ses
w
e
re i
n
de
nt
i
f
i
e
d
i
n
n
o
rt
he
r
n
N
i
geri
a,
2
cases
fr
om
Et
hi
o
p
i
a
an
d t
h
ere
we
r
e
t
w
o
i
ndi
vi
dual
o
u
t
b
reaks
o
f
2 a
n
d
11
cases
o
f
t
y
p
e
2 c
V
DV
Ps i
n
DR
C
o
n
g
o
[1
0
6
]
.
Y
e
a
r
200
9
Im
p
o
r
tatio
n
s
of wild
po
liov
i
ru
s in
year 20
09
-20
1
0
lead
to re-infectio
n
of 23
p
r
ev
iou
s
l
y
p
o
lio
-free
co
un
tries
o
f
the world
[43
]
. Glob
al to
tal o
f
1
,
606
cases
of wild
po
liov
i
ru
s in
fecti
o
n
o
c
cu
rred
i
n
con
t
rast to
1,
65
1 case
s
i
n
t
h
e p
r
evi
o
u
s
y
ear,
20
0
8
.
I
n
ci
dence
o
f
wi
l
d
pol
i
o
vi
r
u
s t
y
pe
3 i
n
2
0
0
9
i
n
cr
eased
by
6
7
%
whi
l
e
t
h
at
o
f
wi
l
d
pol
i
ovi
r
u
s dec
r
eas
ed 51
% [1
0
7
]
.
From
am
ong t
h
e f
o
u
r
p
o
l
i
o
-i
nfect
e
d
co
unt
r
i
es of t
h
e w
o
r
l
d,
Indi
a
was
a country where highes
t
num
bers of
p
o
l
i
o
cases were r
e
po
rt
ed
i
n
20
0
9
af
fect
i
n
g 56 di
st
ri
ct
s
o
f
I
n
d
i
a.
The
r
e
w
e
re 74
1 wi
l
d
pol
i
o
vi
r
u
s
cases
re
po
rt
ed
[1
0
8
]
.
8
9
p
o
l
i
o
cases (6
0 WP
V1
, 28 W
P
V
3
,
a
n
d
o
n
e m
i
xed WPV
1
/
W
P
V
3
)
were r
e
po
rt
e
d
fr
om
Pakistan
in
2
009
wh
ile it’s n
e
ig
hbo
ri
n
g
cou
n
t
y,
A
f
gh
ani
s
t
a
n
repo
rted
38
wild
p
o
liov
i
ru
s cases in
the
sam
e
y
ear;
15 WP
V t
y
pe 1 and
23
WP
V t
ype 3)
, com
p
are
d
wi
t
h
a t
o
t
a
l
of 3
1
wi
l
d
pol
i
ovi
rus cases i
n
20
08
[
107
]. I
n
Ni
ge
ri
a,
po
lio
cases f
e
ll f
r
o
m
7
9
8
in
2
0
0
8
to
388
in
year
2
009. A
s
a co
n
s
equen
ce o
f
im
p
o
r
t
a
tio
n
s
carried
o
u
t
i
n
t
h
e year
2
008
,
wild
po
lio
v
i
rus tran
sm
issio
n
was
re-estab
lish
e
d in Ang
o
l
a
an
d Ch
ad as
well as
i
n
DR
C
o
n
g
o
a
nd
so
ut
he
rn
S
u
dan
.
T
h
e i
m
port
e
d
pol
i
o
vi
r
u
s
cause
d a t
o
t
a
l
of
1
78 ca
ses i
n
20
0
9
.
WP
V t
y
pe 1
out
brea
ks
i
n
K
e
ny
a a
n
d
U
g
a
nda
i
n
2
0
0
9
al
so
occ
u
r
r
ed
as
a r
e
sul
t
of
i
m
po
rt
at
i
ons
f
r
o
m
sout
her
n
Su
dan
.
In
2009, the
r
e
were 175 cases
of circ
ulating vacci
ne-d
eri
v
ed poliovi
rus
e
s
(cVDPV
s
)
, reporte
d
from six
countries: 153
cases from
Nigeria,
one case
from
Guinea
, 4
cases from
DR
C
o
n
g
o
, t
w
o c
a
ses fr
om
Et
hi
opi
a,
4 cases
from
Som
a
lia and 11
cases from
India [107].
Evaluation Warning : The document was created with Spire.PDF for Python.
I
S
SN
:
2
252
-88
06
I
J
PH
S Vo
l. 3
,
N
o
. 3
,
Sep
t
emb
e
r
201
4
:
1
43
–
15
7
15
0
Y
e
a
r
201
0
In
year 2010
, th
e G
l
ob
al Po
lio
Erad
icatio
n
In
itiativ
e (G
PEI) in
co
rporated
n
e
w
tech
n
i
q
u
e
s for
checki
ng a
d
va
ncem
ent and s
p
ecific m
echanis
m
s
for taki
ng
cu
rativ
e step
s, in
o
r
d
e
r to
in
t
e
rru
p
ting
p
o
liov
i
rus
t
r
ansm
i
ssi
on b
y
t
h
e fi
ni
sh
of
y
ear 2
0
12
[
1
0
7
]
.
P
o
l
i
o
case
s
ha
ve
di
m
i
ni
sh
ed
by
o
v
er
9
9
%
si
nce t
h
e l
a
unc
h
o
f
G
P
EI
in
year
19
88
,
f
r
o
m
an
ap
pro
x
i
m
a
te o
f
3
5
0
0
0
0
cases
acr
o
s
s m
o
r
e
th
an
125
end
e
m
i
c co
un
tr
ies to
ar
ound
13
5
2
re
p
o
rt
ed
cases i
n
y
ear
2
0
1
0
[
4
3]
.
Al
l
t
h
e f
o
ur
pol
i
o
-
endem
i
c count
ri
es (Ni
g
eri
a
,
Af
gh
ani
s
t
a
n
,
P
a
ki
st
an
an
d Ind
i
a)
observ
e
d a sub
s
tan
tial fall in th
e
reported
cases of
wild po
lio
v
i
ru
s
in the year
2010 e
x
cept
Pakistan.
Pa
k
i
s
t
an
ha
d t
h
e
wo
rst
i
n
di
cat
or
s of
ch
ildren a
ffected from
the disea
s
e in
2010 in com
p
arison t
o
o
t
h
e
r
co
un
tr
ies [
9
8
]
. I
t
’
s
po
lio
cases in
cr
eased
f
r
o
m
8
6
in
2
009
to
14
0
in 2
0
1
0
[89
]
. D
u
r
i
n
g
th
e year
s 2
010
and 20
1
1
,
Ind
i
a
m
a
d
e
su
b
s
t
a
n
tial ad
v
a
n
c
emen
t to
ward
s p
o
lio
d
e
stru
ctio
n, record
ing
9
4
% d
eclin
e in
po
li
o
cases, t
h
us gi
v
i
ng t
h
e c
o
unt
r
y
a great
o
p
p
o
r
t
u
ni
t
y
t
o
anni
hi
l
a
t
e
t
h
e di
sabl
i
ng
di
sease [
98]
. C
ont
ra
st
ed wi
t
h
a
to
tal o
f
741
cases of
po
lio
in
2
009
,
In
d
i
a
r
e
co
rd
ed
o
n
l
y
4
2
cases in year
2
010
,
18
cases w
e
r
e
r
e
po
r
t
ed to
b
e
fr
om
W
P
V t
y
p
e
1 and
24 case
s
from
W
P
V t
y
pe 3 [
1
0
9
]
.
I
n
d
i
a al
so repo
rt
e
d
2
1
cases of c
i
rcul
at
i
ng
VD
P
V
s i
n
th
e fo
llowing
year [11
0
]
, wh
ile in
Nige
ria
t
h
ere
we
re
388 cases i
n
2009
, which decreased to 21
wi
l
d
pol
i
o
vi
r
u
s case
s
i
n
2
0
1
0
[
99]
.
WP
V t
y
pe
1 h
u
g
e
out
brea
k
oc
cur
r
ed
i
n
fol
l
o
wi
n
g
y
ear i
n
t
h
e
Eu
r
o
p
e
a
n
reg
io
n
,
a reg
i
on
d
eclared
to
b
e
po
lio
-free in
2
002
an
d
no
po
lio
v
i
ru
s cases w
e
re
repo
rted
sin
ce
th
en
u
n
til 2
010, w
h
en
th
e first wild
po
lio
v
i
ru
s im
p
o
rtatio
n
was don
e in
to
t
h
e
Eu
r
opea
n
R
e
gi
o
n
.
Thi
s
res
u
lted
in
47
6
co
nfirm
wild
pol
i
o
vi
r
u
s case
s
:
14 ca
ses i
n
R
u
ssi
a,
45
8 ca
ses i
n
Ta
ji
ki
st
a
n
,
3 i
n
Tu
rkm
e
ni
st
an, a
n
d
o
n
e i
n
Kaza
kh
st
an.
1
9
i
m
p
o
r
tatio
ns of
W
P
V
typ
e
1
an
d
11
im
p
o
r
ts o
f
WPV
type 3
too
k
p
l
ace d
u
ring
2
008
-2
009
resu
ltin
g in
208
p
o
liov
i
ru
s cases in
1
5
coun
tr
i
e
s of
th
e wo
r
l
d
in year
20
09 and
7
ex
tr
a cases in
year
201
0 [1
11
]. Th
ere w
e
r
e
seve
n i
m
port
a
t
i
ons
o
f
wi
l
d
p
o
l
i
ovi
rus
t
y
pe
1 a
nd t
w
o
i
m
p
o
rt
at
i
o
ns
of
wi
l
d
p
o
l
i
o
vi
ru
s t
y
pe 3 t
h
at
res
u
l
t
e
d i
n
ove
ral
l
2
6
p
o
l
i
ovi
rus ca
ses i
n
4
African
countries
.
In
A
n
g
o
la, the
r
e we
re
33
WP
V c
o
n
f
i
r
m
e
d cases rep
o
rte
d
in
2
010
, in
C
h
ad
th
ere
were
2
6
cases
du
e to
im
p
o
r
tatio
n
s
fro
m
Nig
e
ria
wh
ile in
th
e De
m
o
cratic Rep
u
b
lic of
C
o
n
g
o
(DR
C
)
,
arou
n
d
1
00
WP
V cases w
e
re i
d
ent
i
f
i
e
d
[
99]
. I
n
2
0
1
0
, a
s
a resul
t
of p
o
l
i
ovi
rus i
m
port
a
t
i
ons,
t
h
ere
were t
w
o
out
brea
ks
o
b
s
e
rve
d
i
n
t
h
e
A
s
i
a
n co
u
n
t
r
i
e
s
of
Ne
pal
an
d T
j
i
k
i
s
t
a
n
.
I
n
Ne
pal
,
fi
ve
WP
V
t
y
pe 1
(WPV
1
)
cases were id
en
tified
fo
llo
wed
b
y
two
sep
a
ra
te im
p
o
r
tatio
n
s
wh
ile in
Taj
i
k
i
st
an
, 452
WPV1 cases
were
con
f
irm
e
d
in
20
10
[112
].
Add
itio
n
a
l wild
p
o
lio
vi
r
u
s t
y
pe 1
(
W
P
V
1
)
case
was
con
f
i
r
m
e
d i
n
2
0
1
0
i
n
Po
in
te
No
i
r
e,
a resid
e
n
t
of th
e port city. Th
is was t
h
e
fi
rst wild
po
liov
i
ru
s case in
1
0
years rep
o
rted
fro
m
Rep
u
b
lic of
the Co
ngo
(
R
OC)
[1
09
].
I
n
year
201
0, cVD
V
P typ
e
2
cases w
e
r
e
inden
tif
ied
;
2
7
cases in
Nige
ria,
18 cas
es in
DRC,
2 c
a
ses in
India a
n
d 5 cases
i
n
Af
gh
anistan
w
e
re re
p
o
rte
d
. E
t
hiopia als
o
re
po
rted
6
cases of c
V
DVP type
3
[110].
Y
e
a
r
201
1
Gl
o
b
al
t
o
t
a
l
o
f
co
nfi
r
m
e
d ca
ses o
f
pol
i
o
re
po
rt
ed c
o
m
p
re
hen
s
i
v
el
y
di
m
i
ni
she
d
by
5
2
%
(i
.e
fr
o
m
1,
35
2 cases i
n
20
1
0
t
o
65
0 ca
ses i
n
2
0
1
1
)
.
F
r
om
t
h
e
m
e
nt
ione
d
65
0 case
s
of y
e
a
r
2
0
1
1
,
i
n
cl
ude
s 3
4
1
(
5
3
%
)
cases fr
om
t
h
e fo
ur
p
o
l
i
o
-e
n
d
em
i
c
count
ri
e
s
i
.
e. Ni
geri
a,
Af
gh
ani
s
t
a
n
,
P
a
ki
st
an a
nd
In
di
a, 2
3
0
(
3
5%
) cases
fro
m
th
e co
u
n
tries th
at were p
r
ev
iou
s
ly free o
f
po
lio
i.e. Ch
ad
,
Ango
la, an
d
Dem
o
cratic Rep
u
b
lic o
f
the
C
o
n
g
o
DR
C
)
,
and
79
(1
2%
) cases were i
d
e
n
t
i
f
i
e
d f
r
om
ni
ne co
unt
ri
es af
fect
ed by
t
h
e h
uge
out
brea
ks
of
pol
i
o
[9
8]
.
In c
o
m
p
arison with year 2010, the
r
e was a
rise of
w
ild
polio
v
i
ru
s cases in
year
20
11
,
ob
serv
ed
in
Af
gh
ani
s
t
a
n
(
6
9%)
,
Ni
geri
a
(
6
6
%
),
an
d P
a
k
i
st
an (
27%
),
b
u
t
i
n
In
di
a, t
h
e
cases fel
l
by
98
%(
98
).
Indi
a,
th
e
only SE
AR polio-endem
ic count
ry left,
re
ported last case of poliom
y
elitis
on 13
Janua
r
y
2011
in a two-year-
o
l
d
g
i
r
l
i
n
W
e
st Ben
g
a
l
[9
8
]
.
Th
er
e w
e
r
e
no
cases of
W
P
V
r
e
po
r
t
ed
i
n
India sin
ce Janu
ary 2
011
,
bu
t,
d
e
sp
ite
th
is, th
e
h
azard
for
WPV ci
rcu
l
ation
rem
a
in
ed
i
n
th
e
hi
gh
-ri
s
k
a
r
eas i
n
ce
nt
ral
B
i
ha
r an
d
west
er
n
Ut
t
a
r
Pra
d
esh
[1
0
9
]
.
In
di
a i
s
no l
o
nge
r p
o
l
i
o
-en
d
e
m
i
c, l
eavi
ng behi
nd t
h
e t
h
r
ee cou
n
t
r
i
e
s:
Af
gh
ani
s
t
a
n
,
P
a
ki
st
a
n
and Ni
ge
ri
a, w
h
i
c
h ha
ve
ne
ve
r
st
o
ppe
d p
o
l
i
o
.
Fo
r
y
ear 2
0
1
1
,
Pa
k
i
st
an
ex
peri
e
n
ced t
h
e t
h
i
r
d hi
ghe
st
n
u
m
ber
of
rep
o
rt
e
d
cas
es acros
s t
h
e g
l
obe,
be
hi
n
d
C
h
ad a
n
d
Dem
o
cratic Republic of C
o
ngo. T
h
ere
were
198 case
s
rep
o
rte
d
fr
om
Pakistan; 1
9
6
WP
V1
an
d
t
w
o WP
V3
. In
A
f
gh
ani
s
ta
n
, wi
ld
po
liov
i
ru
s tran
sm
issio
n
was lower
in
2
010
, co
m
p
ar
ed
w
i
t
h
2
009
bu
t
i
t
i
n
creased d
u
ri
ng t
h
e
y
ear, 20
11 [
1
13]
.
It reported 80 cases, all of wil
d
pol
i
o
vi
r
u
s t
y
p
e
1 [
9
8]
. D
u
ri
ng y
e
a
r
2
0
1
1
,
t
h
e p
o
l
i
o
d
e
s
t
ruct
i
o
n ef
fo
rt
s i
n
A
fri
ca
ha
ve ha
d i
n
t
e
rm
i
ngl
ed
effect
s.
3
50 ca
ses o
f
wi
l
d
p
o
l
i
ovi
r
u
s we
re c
a
l
c
ul
at
ed f
r
om
12
AF
R c
o
u
n
tries
, recordi
ng
a decline by
47%
(i
.e. f
r
om
t
h
e 657 cases
rep
o
r
t
e
d i
n
2
0
1
0
)
.
W
P
V cases i
n
A
n
g
o
l
a
dec
r
ease
d
fr
om
33 i
n
2
0
1
0
t
o
just
5 i
n
20
11
,
DRC reported
93 case
s
com
p
ared to
100
cas
es in 2010
whi
l
e In Cha
d
, t
h
e
num
ber of cas
es also dec
r
eas
ed to
26
fr
om
132 c
a
ses i
n
2
0
1
0
.
Nigeria,
a po
lio
-
e
nd
em
ic
A
F
R co
un
tr
y, show
ed
an
in
crease in
wild
po
liov
i
ru
s
cases in
2
011
to
62
p
o
lio
cases (4
7
o
f
th
e
to
tal cas
es were
W
P
V type
1 and 15 cases
were
WPV type
3)
com
p
ared t
o
21 cases
in
201
0 [99
]
. In
201
1, th
er
e
w
e
r
e
n
i
n
e
coun
tr
ies aff
ected
b
y
a to
tal of
1
1
W
P
V
out
brea
ks,
rep
o
rt
i
n
g 7
9
cases
[9
8]
. C
h
i
n
a
w
a
s one
of t
h
ese
ni
ne af
fect
ed
cou
n
t
r
i
e
s re
p
o
r
t
i
ng a fi
rst
o
u
t
b
rea
k
of 2
1
WP
V 1
i
n
t
h
e
WH
O
W
e
stern P
a
cific
Re
gion
si
nce 19
9
7
[
9
8]
.
I
n
t
h
i
s
y
ear,
t
h
ere
was
a
n
out
bre
a
k o
f
Evaluation Warning : The document was created with Spire.PDF for Python.
I
J
PH
S I
S
SN
:
225
2-8
8
0
6
Ep
id
emio
l
o
g
i
ca
l Cha
r
a
c
teristics o
f
Po
lio
myelitis d
u
r
ing
2
1
st
century
(
2
000-
2013)
.... (
T
ahir A
h
m
a
d)
15
1
cVDVP type 2 in Ni
geria, re
porting 34 cas
es, 11 case
s
we
re also
re
po
rt
ed in
DR C
o
n
g
o
,
9 in
Som
a
lia, 9
i
n
Y
e
m
e
n
an
d one case each
in
N
i
g
e
r
an
d in
Af
gh
an
istan
[
110
].
Toward
s t
h
e en
d of year
2
011
- 23
years later si
n
c
e th
e Gl
o
b
a
l
Po
lio Erad
icatio
n In
itiativ
e (GPEI)
was in
itiated
,
th
e tran
sm
issio
n
o
f
wild
po
liov
i
ru
s (WPV
h
a
d
b
een h
i
n
d
e
red
in all cou
n
t
ri
es with
t
h
e ex
cep
tio
n
of
Ni
geri
a, Pak
i
st
an
an
d Af
g
h
a
ni
st
an [9
9]
.
Y
e
a
r
201
2
I
n
Janu
ar
y 2012
, t
h
e Ex
ecu
tiv
e B
o
ard
o
f
the
W
o
r
l
d
H
ealth
O
r
g
a
n
i
zatio
n (W
HO
) anno
un
ced g
l
ob
al
p
o
lio erad
icatio
n as a “programma
tic e
m
er
gency
f
o
r
gl
obal
p
ubl
i
c
heal
t
h
”
[1
1
4
]
.
Onl
y
t
h
ree c
o
unt
ri
es of t
h
e
wo
rl
d (
P
aki
s
t
a
n, A
f
g
h
a
n
i
s
t
a
n an
d Ni
geri
a) rem
a
i
n
pol
i
o
-i
n
f
ect
ed
,
com
p
ared to more tha
n
125 infected
coun
tries in
1
9
8
8
- th
e sm
a
llest
p
o
lio
-in
f
ected
g
e
og
rap
h
i
c area in
histo
r
y
[4
3]
.
From
Jan
u
ary
-
M
a
rch
2
0
1
2
, t
h
ere
we
re 6
ca
ses o
f
wi
l
d
p
o
l
i
ovi
r
u
s t
y
pe
1
r
e
po
rt
ed
fr
om
Af
gh
ani
s
t
a
n
,
28 pol
i
o
cases (2
1 W
P
V
1
an
d
seven WPV
3
) were
i
d
e
n
t
i
f
i
e
d
from
Nigeria
, an
d
15
cases were id
en
tified fro
m
Paki
st
an
,
f
r
om
whi
c
h 13 we
re WPV
1
, o
n
e
W
P
V3
,
a
nd one
m
i
xed WPV
1
/
W
P
V
3.
T
h
ere
i
s
n
o
cas
e
y
e
t
reporte
d
from
India since the last case
in January
20
11
. Th
u
s
, I
n
Janu
ar
y 201
2
India r
eco
rd
ed
o
n
e year
w
ith
ou
t an
y
polio
case p
a
v
i
ng th
e w
a
y
f
o
r re
gi
o
n
al
cert
i
f
i
c
a
t
i
on o
f
t
h
e
so
ut
h-east
regi
on
(
S
EAR
)
i
n
Fe
br
uary
2
012
[98
]
.
T
h
ere
we
re few
cou
n
tries w
h
o
re-esta
b
lishe
d
p
o
lio
tran
sm
i
ssio
n
as a
resu
lt o
f
im
p
o
r
tatio
n
s
:
An
g
o
l
a
an
d D
R
C
ong
o re
p
o
r
t
ed n
o
p
o
l
i
o
case du
ri
n
g
Jan
u
ary
t
o
M
a
rc
h
20
12
w
h
i
l
e
C
h
ad i
d
ent
i
f
i
e
d
2 wi
l
d
pol
i
o
vi
r
u
s t
y
p
e
2 cases. In
y
ear 201
0 a
nd
20
1
1
, m
a
ny
count
ri
es
w
e
re affect
e
d
b
y
t
h
e out
bre
a
k
s o
f
p
o
lio
m
y
elit
is b
u
t
th
ere is
n
o
case, as yet,
r
e
po
r
t
ed
in 201
2 in
an
y coun
tr
y
w
o
r
l
dw
id
e.
In year
2012,
1 cases of cVDVP type 2
was report
e
d
in
Nige
ria and
14 cases in DR
Congo [98].
A
sum
m
ary of incidence
of poli
o
ove
r
d
ecade
(2000-2012) in
epidem
ic count
ri
es,
diffe
re
nt regions
of worl
d a
n
d
th
ro
ugh
ou
t th
e
w
o
r
l
d is sh
ow
n in
g
r
aph
1
,
2
an
d 3.
Grap
h 1.
The
incidenc
e of polio
cases
in
t
h
e ep
id
em
ic co
un
tries is sho
w
n.
T
h
e
x-a
x
is s
h
ows
num
b
er
of years
wh
ile th
e y-ax
is shows
n
u
m
b
e
r
o
f
po
lio
cases rep
o
rted
Evaluation Warning : The document was created with Spire.PDF for Python.
I
S
SN
:
2
252
-88
06
I
J
PH
S Vo
l. 3
,
N
o
. 3
,
Sep
t
emb
e
r
201
4
:
1
43
–
15
7
15
2
Grap
h 2.
EM
R
(Easter
n
M
e
diterra
nea
n
Re
gio
n
)
,
AFR (A
frican
Regi
on
) and
SE
AR (S
o
u
th
-East Asia
Reg
i
on
)
r
e
p
o
r
t
p
o
lio cases i
n
t
h
e
p
e
r
i
o
d
of
2
0
0
0
-2
012
Grap
h 3
.
The
num
ber
of
p
o
l
i
o
cases
re
p
o
rt
e
d
gl
o
b
al
l
y
(x
-a
xi
s) a
r
e
pl
ot
t
e
d
agai
n
s
t
t
h
e
1
2
y
ears (
2
00
0-
2
0
1
2
)
.
The
gra
p
h line
shows
ave
r
a
g
e
of re
ported cas
es
Y
e
a
r
201
3
The m
a
in reservoi
r area
in Pa
kistan is in Nort
h
Waziristan, Fede
rally Ad
ministered Are
a
s (FAT
A).
Du
ri
n
g
t
h
e p
a
s
t
fou
r
m
ont
hs
(A
ug
ust
t
o
De
cem
b
er, 2
0
1
3
)
,
52 cases
of
w
i
l
d
pol
i
o
vi
r
u
s
have
bee
n
re
p
o
rt
e
d
,
with
ev
i
d
ence
o
f
po
ten
tial th
reat o
f
wi
des
p
r
ead ge
o
g
ra
p
h
i
c
t
r
ansm
i
ssi
on acros
s t
h
e c
o
unt
ry
. Ne
w
wi
l
d
t
y
pe
p
o
lio cases ar
e
b
e
ing
r
e
-
i
nf
ect
ed
d
u
e
to
n
e
i
g
hb
or
ing
A
f
gh
an
i
s
tan
an
d in
Mi
d
d
l
e
East countr
i
es.
In
Afg
h
a
n
i
stan, all wild
typ
e
p
o
lio
cases are lin
k
e
d t
o
c
r
o
ss bo
r
d
er t
r
a
n
s
m
i
ssi
on wi
t
h
Paki
st
an
. I
n
N
i
g
e
r
i
a, ov
er
th
e past fo
ur
(Sep
tem
b
er
to
Dece
m
b
er
,
2
013)
m
o
n
t
h
s
o
n
l
y
f
o
u
r
cases
h
a
ve o
c
cu
rr
ed
wh
ich
are
geographically restricted area
s prim
arily to Kanod and Borno states. Bu
t
with
in
Africa, lik
e Ban
d
a
d
i
r an
d
So
m
a
lia, n
o
cases of
w
ild
type po
lio
v
i
r
u
s h
a
v
e
b
een r
e
po
r
t
ed
si
n
ce Ju
ly 20
13
(
T
ab
le 1,
2)
[11
5
]
.
Evaluation Warning : The document was created with Spire.PDF for Python.