Nov 30, 2013

Syrian Polio Outbreak could spread to Europe

Syrian displaced children line up to receive vaccination against polio at one of the Syrian refugee camps in the southern port city of Sidon, Lebanon,...
Mohammad Zaatari / AP
Displaced Syrian children line up to receive vaccination against polio at one of the Syrian refugee camps in the southern port city of Sidon, Lebanon, this week, following an outbreak of the crippling and highly communicable disease in neighboring Syria.
An outbreak of polio in eastern Syria that has paralyzed at least 10 children could spread to neighboring regions, including Europe — and in such a silent way that no one would know it for a year.
That’s a warning from two infectious disease experts in Germany, who say that large numbers of Syrian refugees now fleeing that conflict-torn country could settle in Europe, bringing the virus to places that have been polio-free for decades.
And it’s a worry echoed by U.S. polio experts, who say that countries around the world — including America — must be vigilant for signs of spread.
“The big issue is to assure that we have good surveillance to pick up polio as quickly as possible,” said. Dr. Walt Orenstein of Emory University, who has been working on eradicating polio for years. “As long as it circulates anywhere, it’s a risk everywhere.”
Because polio causes symptoms — including paralysis — in only about 1 of every 200 people infected, it has the potential to spread widely to others unnoticed, Dr. Martin Eichner of the University of Tubingen and Dr. Stefan Brockmann of the Reutlingen Regional Public Health Office in Germany wrote Thursday in a letter to the journal The Lancet.
“It might take … nearly 1 year of silent transmission before one acute flaccid paralysis case is identified and an outbreak is detected, although hundreds of individuals would carry the infection,” the experts wrote.
The situation will be exacerbated because most European countries, like the U.S., use inactivated polio vaccine, or IPV, rather than oral polio vaccine, or OPV, because the live-virus oral variety caused rare cases of paralysis in people who were vaccinated. While the IPV reduces transmission and protects well against paralysis, it only partially protects against infection, the experts warned.
In places with low vaccination coverage — including Bosnia, Herzegovina, Ukraine and Austria — there might not be enough widespread protection, known as “herd immunity," to prevent sustained transmission, they said.
“Vaccinating only Syrian refugees — as has been recommended by the European Center for Disease Prevention and Control — must be judged as insufficient,” they wrote.
Only a handful of European member states allow use of OPV and none has a stockpile of the live vaccine, the authors note. The U.S. has used only IPV since 2000, after eradicating polio in America in 1979.
Polio is caused by a virus that spreads between people, but it can survive in water and sewage, too. The series of vaccines can protect people for life, but babies too young to have been vaccinated and children who don’t get the full dose can be infected.
The outbreak in Syria has paralyzed at least 10 children in the country’s Del al-Zour province. They’re all younger than 2 and may have gone unvaccinated because of the ongoing conflict that has now left half the population — an estimated 9 million people — homeless and starving.
It’s unclear how polio got back into Syria, which had eradicated the virus in 1999, though officials say this bout may have originated in Pakistan. Polio immunization rates fell from 91 percent in Syria in 2010 to 68 percent in 2012, largely because of the impact of conflict, the World Health Organization says.

Video: International health care workers are providing thousands of vaccinations to prevent polio from spreading any further among Syrians, many of whom are living in squalid refugee camps. And polio isn’t the only threat -- poor sanitation in the camps provides ripe conditions for the spread of other diseases. NBC’s Dr. Nancy Snyderman reports.
Vaccination efforts are focusing on more than 2 million children in Syria, as well as in seven neighboring countries: Iraq, Turkey, Lebanon, Jordan, Israel, the Palestinian territories and Egypt.
“Without a doubt, it can go wider, go beyond Syria’s borders,” said Sarah Crowe, spokeswoman for UNICEF. “Disease knows no borders.”
Hundreds of thousands of refugees have fled the country to seek help in neighboring regions – and Europe. The German disease experts are calling for increased surveillance of sewage in settlements.
“I would agree with them, it is important to develop more use of environmental surveillance,” said Orenstein, the U.S. expert who spearheaded a global declaration by more than 400 scientists that an end to polio is possible.
In the U.S., imported cases of measles have sparked recent outbreaks of the disease, particularly in pockets of un-vaccinated children, raising the very real possibility that other infections could spread as well. 
"Measles is your canary in the coal mine," Orenstein said. "It's much more contagious than polio. With polio, we have been fortunate, so far."
JoNel Aleccia is a senior health reporter with NBC News. Reach her on Twitter at @JoNel_Aleccia orsend her an email.
Post Polio Litaff, Association A.C _APPLAC Mexico

Nov 21, 2013

A Look Back • Arrival of first polio vaccine in St. Louis in 1955 greeted with relief

Lesley Rabon, 8, a student at Jackson Park Elementary School in University City, receives one of the first free polio vaccinations in St. Louis on April 21, 1955. Giving the shot is Dr. Guy Magness, while school nurse Peggy Vaugh assists. The National Foundation for Infantile Paralysis had bought 7.5 million doses to distribute to the nation's schools. The first wave of inoculations was for first- and second-graders. Post-Dispatch file photo
ST. LOUIS • Two leaders of a mothers’ campaign met the train downtown on April 21, 1955. An express worker handed them the first box of a miracle shipment.

“This is a wonderful victory,” said Loretto Gunn, co-chair of the Mothers March on Polio. “The mothers of St. Louis have been looking forward to this for years.”
Mothers, and everyone else, awaited the first cartons of Dr. Jonas Salk’s electric discovery, a vaccine to prevent the dreaded crippler and killer known as poliomyelitis. The baggage car from Indianapolis brought free cartons of Salk vaccine for schoolchildren in St. Louis and St. Louis County.
Three days earlier, a truck from Springfield, Ill., delivered a shipment to Belleville, where the first shots were given at St. Henry’s Catholic School. On that day, the St. Louis group didn’t know when its vaccine would arrive. Such was the confusion in the harried effort to vaccinate the nation’s first- and second-graders as quickly as possible.
Polio is a viral disease transmitted by human contact. (It also was called infantile paralysis, even though it afflicted adolescents and adults.) Most people had no serious symptoms, but a few died or suffered permanent physical disabilities.
Epidemics periodically swept the country. President Franklin D. Roosevelt lost the use of his legs as a young man due to the disease. Polio put children in bulky braces and iron lungs, the barrel-shaped machines that kept them breathing with air pressure to move their paralyzed diaphragms.
The list of symptoms was distressingly unhelpful — fever, tummy ache, aching muscles. If a child complained of a sore leg, parents didn’t sleep that night. In our age of medical wonders, it may be hard to appreciate the depth of the relief that greeted Salk’s vaccine.
Doctors in Europe had formed a diagnosis in the 19th century, but people could do little but fret. Shriners Hospital for Crippled Children opened at 700 South Euclid Avenue in 1924 to serve polio patients. For decades, its 100 beds usually were filled.
Before the vaccine, headlines announced new cases, deaths and the effort to raise money for research. Summer was considered the “polio season,” but that was a function of humans mingling, not temperatures. As clusters of cases erupted, officials closed schools and swimming pools. An epidemic in 1949 killed 64 people in the St. Louis area.
In August 1951, four of the five children of Mr. and Mrs. Joseph Schwane of Marthasville contracted polio. Two of them died within three weeks.
Salk led a research team in Pittsburgh that developed the vaccine. As final tests were conducted, drug manufacturers stockpiled serum. When approval was announced April 12, 1955, the rush was on. The National Foundation for Infantile Paralysis (March of Dimes) bought enough vaccine for the free shots nationwide.
Newspapers ran long lists of vaccination times at schools, and more than 50,000 eligible St. Louis-area children lined up for shots. It took several years of vaccinating children and adults, but the number of cases eventually fell significantly. St. Louis reported its last naturally occurring case in 1963. Salk died in 1995 at age 80.


Dr. Jonas Salk (left at podium) explains development of the vaccine during a gathering on April 13, 1955, at the University of Michigan. With him are (center) Dr. Thomas Francis Jr., who led statistical research; and Basil O'Connor, president of the National Foundation for Infantile Paralysis, which raised money for the research. Associated Press photo


St. Louis-area leaders of the campaign to combat polio greet a passenger train at Union Station on April 21, 1955, that brought the first shipments of free vaccine for first- and second-graders. Station employee Walter Goyda hands the first box to Bernard Dickmann, chairman of the St. Louis March of Dimes committee; and (left) Jessica Barco and Loretto Gunn, co-chairwomen of the local Mothers March on Polio. Behind the box is Dr. J. Earl Smith, city health commissioner. Dickmann also was St. Louis postmaster and a former mayor. Photo by William Dyviniak of the Post-Dispatch

Post Polio Litaff, Association A.C _APPLAC Mexico

Wild Poliovirus in Cameroon

 Wild poliovirus type 1 (WPV1) has been confirmed in Cameroon, the first wild poliovirus in the country since 2009. Wild poliovirus was isolated from two acute flaccid paralysis (AFP) cases from West Region. The patients developed paralysis on 1 October and 19 October 2013. Genetic sequencing indicates that these viruses are linked to wild poliovirus last detected in Chad in 2011.
An emergency outbreak response plan is being finalized, including at least three national immunization days (NIDs), the first of which was conducted on 25-27 October 2013. Subnational immunization days (SNIDs) will be implemented in December 2013, followed by two subsequent national immunization days in January and February 2014. Routine immunization rates are reported to be approximately 85.3 percent for oral polio vaccine (OPV3). A response in neighboring countries is also being planned, notably in Chad and Central African Republic
Considering that this strain was last detected in the region in 2011, plans are also being developed to strengthen surveillance activities starting with a detailed analysis of sub-national surveillance sensitivity across the region to more clearly ascertain any gaps.
In 2013, Cameroon also reported four cases due to circulating vaccine-derived poliovirus type 2 (cVDPV2) in the Far North region. The patients developed paralysis between 9 May and 12 August 2013. The viruses are linked to circulation in Chad, which was also detected in Nigeria and Niger. In response, several large-scale supplementary immunization activities (SIAs) had been conducted during the months of August and September, followed by the full national immunization days in October 2013.
This event confirms the risk of ongoing international spread of a pathogen (wild poliovirus) slated for eradication. Given the history of international spread of polio from northern Nigeria across West and Central Africa and subnational surveillance gaps, WHO assesses the risk of further international spread across the region as high.
It is important that all countries, in particular those with frequent travel and contacts with polio-affected countries and areas, strengthen surveillance for acute flaccid paralysis cases in order to rapidly detect any new virus importations and to facilitate a rapid response. Countries, territories and areas should also maintain uniformly high routine immunization coverage at the district level to minimize the consequences of any new virus introduction.From
Post Polio Litaff, Association A.C _APPLAC Mexico

Nov 18, 2013

Global Polio Study Begins

NEW YORK, Nov. 18, 2013 /PRNewswire/ -- An unprecedented surveillance study launches today to contribute to global polio eradication efforts.  Recent outbreaks of Polio in Israel, Syria, Kenya, South Sudan, and Somalia have once again placed the virus at the forefront of Public Health Officials' concerns.
Jeffrey Modell FoundationJeffrey Modell Foundation
The Jeffrey Modell Foundation's surveillance study will focus on patients with Primary Immunodeficiencies (PI) who have either received the Oral Polio Vaccine (OPV), a live-weakened form of the virus, or have been exposed to it. Due to little or no immune system, when a patient with PI receives OPV, he or she is unable to create an immune response and therefore, cannot clear the intestinal vaccine virus infection, which is typically excreted within six to eight weeks by individuals with healthy immune systems. 
After prolonged periods of time, the virus may no longer be the same as the original vaccine-virus as it can genetically alter. This is called Vaccine Derived Poliovirus (VDPV). Although rare, it is expected that patients with PI are at risk of developing Vaccine Associated Paralytic Poliomyelitis (VAPP) and VDPV excretion, which could lead to possible exposure to the community.  The surveillance of these patients will shed light on important questions about vaccine-derived polioviruses throughout the globe. 
This study will include 25 sites across a wide geographical range.  The Jeffrey Modell Centers Network makes it possible to find a large patient population for this surveillance.  JMF Centers in Argentina, Brazil, Colombia, Mexico, China, Hong Kong, India, Israel, Iran, Kuwait, Russia, Poland, Turkey and Tunisia will participate.   JMF will work alongside the World Health Organization (WHO), The Centers for Disease Control and Prevention (CDC), Task Force for Global Health (TFGH), and the Bill & Melinda Gates Foundation. 
Vicki Modell, Co-Founder of JMF, says, "We are excited to begin such a meaningful and crucial surveillance project in so many regions of the world.  We are optimistic and hope to bring our energy, our commitment, and our compassion to this program."   
Once wild poliovirus is eradicated globally, vaccine-viruses will be the only type of live poliovirus in the community and could potentially lead to an outbreak.  In order to prevent this occurrence, the Polio Antivirals Initiative (PAI), an essential part of the TFGH's Polio Eradication effort, aims to create an efficient and inexpensive antiviral.
About Jeffrey Modell FoundationVicki and Fred Modell established the Jeffrey Modell Foundation in 1987, in memory of their son Jeffrey, who died at the age of fifteen from complications of Primary Immunodeficiency – a genetic condition that is chronic, serious, and often fatal.  JMF is a global nonprofit organization dedicated to early diagnosis, meaningful treatments and, ultimately, cures through research, physician education, public awareness, advocacy, patient support, and newborn screening.  The Jeffrey Modell Centers Network (JMCN) includes 556 physicians at 234 academic institutions in 196 cities and 78 countries spanning 6 continents.  For more information about PI, visit or email the Jeffrey Modell Foundation at
Post Polio Litaff, Association A.C _APPLAC Mexico

Nov 11, 2013

The most recent Type Polio 3 viruses seen were spotted in Nigeria in November 2012. Pakistan

One of 2 remaining types of Polio viruses may be wiped out; not seen in a year

TORONTO - The effort to rid the world of polio is too often a journey of one step forward and two steps back, with the heartbreaking news that polio is crippling toddlers in war-ravaged Syria the most recent evidence of that stuttering progress.
Still, there is some good news on the polio front.
Sunday marks one year since Type 3 polio viruses have been found, suggesting vaccination efforts may — heavy stress on may — have wiped out the second of three strains of polio.
If the Type 3 viruses are indeed gone, it will mean that only Type 1 polio viruses remain to be vanquished before the long-overdue goal of polio eradication can be realized.
Reaching the one-year milestone has made people involved in the frustrating and expensive polio eradication program hopeful that transmission of  Type 3 viruses may have stopped. But they warn it would be unwise to declare victory just yet.

"I think the available information is cause for some cautious optimism. But in particular in Nigeria I think we would look for more evidence before we would ... uncork the champagne," says Olen Kew, a senior virologist specializing in polio at the U.S. Centers for Disease Control in Atlanta.
The most recent Type 3 viruses seen were spotted in Nigeria in November 2012. Pakistan, another of polio's strongholds, last reported a Type 3 infection in April of 2012. And the CDC's polio laboratory, which monitors movement of viruses worldwide, had been reporting that the number of lineages of Type 3 viruses — families within the overall group — has been markedly declining in the past couple of years.
But in both Nigeria and Pakistan, the most recent Type 3 cases were found in politically troubled parts of the countries where vaccination teams struggle for access to children. In Nigeria, the experts know, surveillance for the virus is not as strong as it might be — hence Kew's comment urging caution.
In Pakistan, however, environmental surveillance — testing sewage for polio viruses — makes the situation look more promising.

The last Type 3 virus there was seen in the FATA, the federally-administered tribal areas bordering Afghanistan where polio vaccinators have often been refused entry for long periods. The nearest site where environmental testing is done is Peshawar, where last month a bomb was detonated while polio vaccinators collected their kits.
"The viruses from the tribal areas find their way into Peshawar (sewage) regularly," says Kew. "And the fact that we've not seeing it in the environment in Peshawar is really quite encouraging."
The CDC is one of founding partners in the polio eradication project, which started in 1988. The World Health Organization, UNICEF and the service club Rotary International are the other founding partners; in more recent years the Bill and Melinda Gates Foundation has become a key player in the effort.
Buoyed by the success of the smallpox eradication program — the disfiguring disease was declared eradicated in 1979 — and by the ease with which the Americas stopped polio transmission, the world embarked on the plan to get rid of polio by the year 2000.
But this task is vastly more complicated, because of the nature of polio.
Whereas people who were infected with smallpox were easy to spot — they developed the scarring rash — much of polio's spread is invisible to the eye. Only a small portion of cases develop paralytic polio. And where there was one type of smallpox, there were actually three strains or serotypes of polio.
"In a sense, polio eradication should be called polios eradication," says Dr. Walter Orenstein, who works on the eradication effort through the Emory Vaccine Center at Emory University in Atlanta.
"As opposed to smallpox, where we had to get rid of one agent, with polio we're really having to get rid of three agents."
One of those serotypes is actually long gone. Type 2 polio viruses haven't been spotted since 1999. And now it appears Type 3 viruses may be following Type 2 into the history books.
Each of the three viruses has unique qualities. Type 1 is the most aggressive and is able to spread long distances with ease. The viruses responsible for the Syrian outbreak as well as those being discovered in Israel sewage this year are all Type 1s from Pakistan.
Type 3 is a poor traveller. It has rarely been seen to jump long distances. But another quirk of the virus is making the experts watching this situation wary about claiming victory.
Of all the viruses, Type 3s are least likely to paralyze the children they infect. It is estimated that only one in 1,200 Type 3 infections leads to paralysis. By comparison, Type 1 viruses paralyze about one out of every 150 or 200 infected children.

There are only two ways to detect spread of polio viruses — by finding them in sewage, where environmental surveillance is done, and by finding paralyzed children. Type 3's low paralysis-to-infection rate makes it harder to spot.
"Because of the lower case-infection ratio, and because of the state of surveillance, (Type 3 can go) under the radar," says Dr. Steven Wassilak, a medical epidemiologist in CDC's global immunization division.
"And so when we hit the anniversary, particularly in an area" — Nigeria — "where the surveillance is less rigid than even in Pakistan, we have to be extremely cautious about what it means."
Still, the suggestion that Type 3 viruses may be gone is a welcome positive sign, coming in what has been a year of both record low cases and some extremely tough setbacks for the polio program.
"The prospects for completing eradication, they go up substantially with each serotype you knock out," says Dr. Bruce Aylward, the Canadian who has fronted the WHO's polio efforts for years.
"Mainly because of what you learn getting there.... And then of course there's that very real impact it has with governments," says Aylward, the WHO's assistant director-general for polio, emergencies and country collaboration.
The reference to governments is an allusion to the polio eradication program's constant struggle to raise funds. The effort has cost more than US$10 billion so far and it is estimated it will take another US$5.5 billion to complete the job.
Major funders have included Rotary International, the Gates Foundation and a number of governments, including Canada. Earlier this year the federal government pledged to contribute $250 million for polio eradication over the next six years.
Post Polio Litaff, Association A.C _APPLAC Mexico

Nov 2, 2013

Syria’s Polio Outbreak Is a Reminder of the Disease’s Power

Photo of Syrian children in a refugee camp.
A polio outbreak in Syria has health officials worried about a comeback by the disease.
Photograph by Muhammed Muheisen, AP
Published November 1, 2013
Polio has returned to Syria, which had been free of the potentially paralyzing and at times fatal disease since 1999. “There are ten cases confirmed right now in the Deir Al Zour province” in northeast Syria and 12 more suspected cases, says Oliver Rosenbauer, spokesman for the World Health Organization’s Global Polio Eradication Initiative.
The cases in Syria are mostly among children who are age two or younger. In this conflict-ridden country, it has been difficult to reach all children for immunization. No one can say how the disease reached Syria, but what the outbreak shows, says Rosenbauer, is "that this is an epidemic-prone disease.”
There is worry that the highly infectious disease will spread farther, as people move in and out of the area to other parts of the country and across borders to refugee camps and nearby countries. “The whole region is now at risk,” Rosenbauer says.
To prevent that, response to the outbreak has already begun. Last month, shortly before the polio cases were confirmed, Syria launched a previously planned vaccination program to inoculate 1.6 million children throughout the country against polio, measles, mumps, and rubella. According to WHO, vaccinations in the Deir Al Zour province are being implemented. In addition, plans are under way to coordinate immunization and other outbreak response programs in Iraq, Jordan, Lebanon, Gaza, West Bank, Southern Turkey, and Egypt.
“What we’re seeing is a lot of momentum and recognition that this is a major risk that needs to be addressed,” says Rosenbauer. “Everyone is pulling together to help make it happen.”
In the rest of the world, progress has been made but there is still work to be done. The disease is now endemic in only three countries around the globe—Afghanistan, Nigeria, and Pakistan—and its incidence has decreased by more than 99 percent from an estimated 350,000 cases in 1988. ("Endemic" is the term used to describe countries with an ongoing incidence of the disease.)
But we're not quite there yet, as this year's spring outbreaks in previously polio-free Somalia and Kenya reminded us. In addition, the discovery of sewage samples containing poliovirus in Israel has led to a countrywide campaign to offer oral polio vaccines to children between the ages of four months and nine years, as a precaution.
No cases have appeared in Israel. And the numbers of those affected in Somalia and Kenya are small—110 as of August 7—with 177 reported cases worldwide so far this year, according to data from the Global Polio Eradication Initiative. In April the group issued a detailed strategic plan to eliminate polio "for all time" by 2018. Fully funded, the comprehensive vaccination and monitoring and surveillance plan would cost about $5.5 billion.
But in the meantime, this highly infectious nerve disease persists, potentially causing lifelong paralysis in the young children it most often targets.
Why has the end remained elusive, and what is being done to protect against future setbacks?
Polio in Perspective
It's important to remember there is no cure for polio; it exists only in humans, and it can only be prevented by vaccination, says Dr. Jay Wenger, director of the polio eradication program at the Bill and Melinda Gates Foundation. Put those factors together and it means that "to eradicate polio we essentially have to vaccinate enough children so that the poliovirus has no place to go," he says.
In the United States, effective vaccine campaigns have kept the population polio free since 1979. But as recently as the late 1940s and early 1950s—before the anti-polio vaccines were developed—the disease disabled approximately 35,000 people, many of them children, in the U.S. each year.
By contrast, between 1988 and today, the number of polio-endemic countries has gone from 125 to just three, and in 2012 only 223 cases were recorded worldwide.
Given that larger picture, "it's important to put the issue of setbacks into the context of the program and recognize that progress continues," says Dr. Hamid Jafari, director of the WHO's Global Polio Eradication Initiative. Or, as Dr. Wenger puts it: "These outbreaks highlight the importance of eliminating the virus" in the remaining endemic countries.
Logistics, Logistics, Logistics
Vaccines are the answer. The challenge lies in identifying, locating, and then reaching people of all ages who have not yet been vaccinated. For example, highly mobile groups, such as Nigeria's nomadic livestock herders, may spread the disease as they travel from place to place. (According to the WHO, the polio strains affecting residents of the Horn of Africa originated in West Africa.)
At the same time, armed conflict, political unrest, and what Dr. Jafari calls "complex geopolitical situations" can make access by vaccine workers at times dangerous or difficult, if not impossible. Such conditions are present in parts of all three countries where polio is endemic, making different pockets or areas insecure for efficient vaccine delivery at different times. Public health infrastructure can also be spotty, if it exists at all.
Because each area can present a distinct set of obstacles, detailed and tailored strategies need to be worked out for each situation, including partnerships with local authorities, community groups, traditional leaders, and non-governmental organizations (NGOs), says Dr. Jafari. "Fundamental commitment to the program from the top of the government down to the local authorities" is needed if everyone is to be vaccinated.
Resistance, Distrust, and Violence
Mistrust of outsiders is another major obstacle, brutally dramatized by the targeted killings of polio vaccine workers in Nigeria and Pakistan over the past year. In Pakistan's North and South Waziristan, the Taliban have banned vaccination since June 2012, leaving children without immunity and at high risk for the disease.
Dr. Jafari is stoic, but not despairing. "As long as there are authorities on the ground and mothers who want to protect their children," there is a way to make progress, he says. "That is why, despite the shootings, the people come out with their children to get them vaccinated … and these brave men and women are going out in their communities to vaccinate" the children.
Environmental Vigilance
Beyond vaccination, surveillance and monitoring the presence of the virus in the environment are essential to eradicating polio. It's not known how the virus was carried to Israel, which detected poliovirus in sewage samples starting in February 2013. According to the WHO, the strain in Israel is related to the South Asian cluster of wild poliovirus currently circulating in Pakistan, which had recently also been detected through environmental sampling in Egypt.
The current oral vaccine campaign in Israel—which is polio free and has a very high rate of immunization—is a safeguard, a direct response to the detection of poliovirus in its sewage. The goal of Israel's vaccine campaign is to boost immunity levels even in children who have already received the injected vaccine, as well as to protect against further spread to anyone traveling in or out of Israel.
Setbacks on the Radar
Against the backdrop of all these issues, the setbacks in Kenya and Somalia show how quickly and far poliovirus can travel, and demonstrate the importance of maintaining high immunity levels within populations and the need for strong surveillance to halt its spread.
According to Dr. Jafari, such setbacks will happen "as long as the virus is alive and people are moving with the virus, and it will spread as people move. And when it lands in places where immunization and sanitation are not in place, that is where the setbacks will take place."
The key is being prepared to deal with them, while continuing to move forward. "We're on track, and we'll deal with these outbreaks," he says. “They are not obstacles; they are part of the course."

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