Update on Polio Eradication in the World Health Organization South-East Asia Region, 2013

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1 SUPPLEMENT ARTICLE Update on Polio Eradication in the World Health Organization South-East Asia Region, 2013 Patrick Michael O Connor, 1 Robert Allison, 1 Arun Thapa, 1 Sunil Bahl, 2 Supamit Chunsuittiwat, 3 Mainul Hasan, 1 Zainul Khan, 1 and Tika Sedai 1 1 Immunization and Vaccine Development, World Health Organization Regional Office for South-East Asia, and 2 National Polio Surveillance Project, World Health Organization Country Office for India, New Delhi, India; and 3 South-East Asia Regional Certification Commission for Polio Eradication, Nonthaburi, Thailand There has been a tremendous amount of progress toward polio eradication in the World Health Organization South-East Asia Region particularly over the past 4 years. In 1988, there were > reported cases of wild poliovirus infection in the South-East Asia Region, and because of substantial underreporting the estimated polio burden was probably 10-fold higher. Following the initiation of mass polio immunization campaigns in the mid-1990s and years of intense effort, the 11 countries of the South-East Asia Region reported no cases of wild poliovirus infection in With India reporting the last wild poliovirus case in the region, on 13 January 2011, and its subsequent removal from the list of polio-endemic countries, in February 2012, the South-East Asia Region is firmly on track for polio-free certification in early Keywords. polio; eradication; certification; South-East Asia. In 1988, when the World Health Assembly (WHA) passed resolution WHA 41.28, which called for the global eradication of poliomyelitis, the estimated global polio disease burden was > cases, of which the World Health Organization (WHO) South-East Asia Region (comprising Bangladesh, Bhutan, Democratic People s Republic of Korea, India, Indonesia, the Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor Leste) contributed >70% [1 3]. The 11 countries of the South-East Asia Region reported paralytic poliomyelitis cases in 1988, and because of substantial underreporting, the estimated polio burden was probably 10-fold higher [1]. Following the initiation of mass polio immunization campaigns in the mid-1990s and years of intense activities, the last case of wild poliovirus infection in the region was reported from India, on 13 January For many years, India remained the final reservoir for wild polioviruses in the region and Correspondence: Patrick Michael O Connor, MD, Immunization and Vaccine Development, World Health Organization, Regional Office for South-East Asia, World Health House, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi, , India (oconnorp@who.int). The Journal of Infectious Diseases 2014;210(S1):S The Author Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please journals.permissions@oup.com. DOI: /infdis/jit585 was linked to several outbreaks in polio-free areas inside and outside the region. The polio eradication program in India used special strategies that were responsible for much of this progress. These strategies included maintaining a highly sensitive system for surveillance of acute flaccid paralysis (AFP); focusing on the high-risk, endemic states of Uttar Pradesh and Bihar; tracking migrant populations; responding aggressively to new wild poliovirus cases; and, fast-tracking the rapid introduction of new tools, such as bivalent oral polio vaccine. The other 10 countries in the region have supported global efforts toward polio eradication by remaining free of polio for many years. Their last reported wild poliovirus cases were in the following years: 1986, in Bhutan; 2006, in Bangladesh; 1996, in the Democratic People s Republic of Korea; 2007, in Indonesia; 1994, in the Maldives; 2007, in Myanmar; 2010, in Nepal; 1993, in Sri Lanka; 1997, in Thailand; and 1996, in Timor Leste. Consequently, the South-East Asia Region did not contribute any paralytic poliomyelitis cases to the 223 wild poliovirus cases reported globally in 2012 [4]. In addition to no detection of wild poliovirus in the South-East Asia Region, 2012 was a significant year for polio eradication in the region because of the declaration of polio eradication as a global public health emergency by WHO executive board, on 21 January 2012, S216 JID 2014:210 (Suppl 1) O Connor et al

2 and then also by the WHA, on 26 May 2012 [5, 6] and because of the removal of India from the list of polio-endemic countries by the WHO director general, on 25 February 2012, after more than a year without a reported case of wild poliovirus [7]. These events have kept the program focused on realizing the goal of polio eradication in the South-East Asia Region and shifted the focus of programming, from reacting to wild polioviruses to remaining free of polio while preparing for polio-free certification in early Once certified, the South-East Asia Region will be the fourth WHO region to be certified polio free and the first in 12 years since the certification of the European Region in 2002 [8]. AFP SURVEILLANCE AND THE REGIONAL POLIO LABORATORY NETWORK All countries in the South-East Asia Region established casebased AFP surveillance between 1991 and 1997 with the objective of timely detection of wild polioviruses [1]. In the 5 countries with the largest populations in the region, Bangladesh, India, Indonesia, Myanmar, and Nepal, which also had the highest wild poliovirus burden, the WHO provided additional support for AFP surveillance with a network of surveillance medical officers [1]. The AFP surveillance network has been measuring its performance against 2 globally recognized indicators: the non-polio AFP rate and the percentage of adequate stool specimens collected. On the basis of the recommendation at the 11th meeting of the South-East Asia Region Technical Consultative Group for Polio Eradication and Vaccine Preventable Diseases, in June 2005, AFP surveillance was intensified to ensure that it was sensitive enough to detect even low-level poliovirus transmission throughout the region [9]. Consequently, since 2006, the regional minimum standard for the 2 AFP surveillance indicators has been a non polio AFP rate of >2 cases per for children <15 years of age and an adequate stool specimen collection percentage of >80%. Table 1 shows the performance of the AFP surveillance systems by countries from 2009 through the middle of Some of the countries with smaller populations in the region have periodically had difficulty in achieving the minimum AFP surveillance indicators since All of these countries have been free of polio for >10 years and have high routine immunization coverage for the third dose of oral polio vaccine. However, regular joint national and international AFP surveillance reviews and in-country consultations have been conducted to provide additional information and verification of their polio-free status. Since the region s last reported case of wild poliovirus infection, in 2011 by India, the highly sensitive national AFP surveillance systems have been providing evidence of the absence of circulating wild polioviruses and confidence that there are no undetected circulating wild polioviruses. The polio laboratories have been an integral part of the AFP surveillance system in the South-East Asia Region and have been providing laboratory confirmation of wild polioviruses for >20 years. The network was formally established in 1993 but began reporting in 1992, with test results for 1756 stool specimens from 8 laboratories in 4 countries (Bangladesh, India, Thailand, and Sri Lanka) [10]. With the establishment of case-based AFP surveillance, in 1997, the polio laboratory network was expanded to 15 laboratories in 6 countries and provided diagnostic confirmation for 5857 stool specimens that year [11].From 1998 to 2003, the number of stool specimens collected and tested remained relatively constant, at approximately specimens per year [12 15]. From 2003 to 2006, AFP surveillance was intensified in Bangladesh, India, and Nepal [9], which resulted in an increase in the number of AFP cases and approximately stool specimens being tested by the laboratory network per year [16]. As this approach was implement throughout the region, but particularly in India, the sensitivity of the AFP surveillance steadily increased, resulting in the number of specimens collected and tested from 2006 to 2012 increasing nearly 2-fold, to > specimens per year [17, 18]. Currently, the polio laboratory network consists of 16 laboratories that all perform primary virus culture of stool specimens and 10 laboratories that conduct intratypic differentiation of viruses isolated from AFP cases. Because of population size and the need to test a minimum number of specimens to maintain polio-specific laboratory proficiency and accreditation, all but 4 countries in the region have national polio laboratories: Bhutan, the Maldives, Nepal, and Timor Leste. So, the regional reference laboratory in Bangkok, Thailand, has been processing specimens for Bhutan and Nepal; the regional reference laboratory in Colombo, Sri Lanka, has been processing specimens for the Maldives; and the national laboratory in Surabaya, Indonesia has been processing specimens for Timor Leste. The global specialized laboratory for polio in Mumbai, India, has been providing overall support for the regional polio laboratory network. Figure 1 shows the distribution and details of the polio laboratory network in the South-East Asia Region. The Enterovirus Research Centre in Mumbai is one of 7 global specialized laboratories for polio and the only one in a developing country. It has anchored the South-East Asia Regional polio laboratory network for more than a decade. This center has provided outstanding leadership and support for regional AFP surveillance and has contributed to global polio eradication by establishing and expanding environmental surveillance in India; evaluating the immunogenicity of monovalent, bivalent, and trivalent vaccines; designing and evaluating a 14-day laboratory testing algorithm that reduced reporting time by half; and providing data on the molecular epidemiology (RNA nucleotide sequencing) for wild polioviruses, which has given vital information on virus transmission and guided immunization activities since 2001 [19]. 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3 Table 1. Acute Flaccid Paralysis (AFP) Surveillance Indicators and Wild Poliovirus (WPV) Case Count in South-East Asia Region (SEAR) Countries, Year, Country AFP Cases, No. NP-AFP Rate AFP Cases With Adequate Specimens, % Confirmed WPV Cases, No Bangladesh Bhutan DPR Korea India a Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor Leste Overall Bangladesh Bhutan DPR Korea India b Indonesia Maldives Myanmar Nepal b Sri Lanka Thailand Timor Leste Overall Bangladesh Bhutan DPR Korea India c Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor Leste Overall Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand S218 JID 2014:210 (Suppl 1) O Connor et al

4 Table 1 continued. Year, Country AFP Cases, No. NP-AFP Rate AFP Cases With Adequate Specimens, % Confirmed WPV Cases, No. Timor Leste Overall (as of 24 June) d Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor Leste Overall References [32 34]. All data are as of 24 June Abbreviations: DPR Korea, Democratic People s Republic of Korea; NP-AFP, non polio-associated acute flaccid paralysis. a In 2009, India reported 741 cases of WPV infection, of which 661 were due to WPV type 3, 79 were due to WPV type 1, and 1 was due to WPV types 1 and 3. b In 2010, India reported 42 cases of WPV infection, of which 24 were due to WPV type 3, and 18 were due to WPV type 1. In 2010, Nepal reported 6 cases of WPV type 1 infection. c In 2011, India reported 1 case of WPV type 1. d Pending cases are not included in the calculation of the NP-AFP rate for 2013 data. In 2012, the South-East Asia Regional laboratory network worked effectively to support the AFP surveillance network by testing stool specimens, which accounted for approximately 60% of the global polio laboratory workload while exceeding the global indicator with an overall regional adequate stool collection percentage of 87% [17, 20]. Despite this heavy and increasing workload over the years, the laboratory network has consistently achieved global proficiency standards. The South-East Asia Region has a well-established AFP surveillance network with an extensive, integrated laboratory network that has been sensitive enough to detect, analyze, and report wild polioviruses over the past 16 years. Since 2010, the AFP surveillance and polio laboratory networks have successfully documented the decline and disappearance of wild polioviruses throughout the region [16, 32 35]. ENVIRONMENTAL SURVEILLANCE In the South-East Asia Region, India has been the only country using environmental surveillance to complement its national AFP surveillance system. Figure 2 shows the distribution of the current and proposed environmental surveillance sites among Indian states and metropolitan regions. Environmental surveillance in India was started in 2001 with 3 collection sites in Mumbai, Maharashtra. As an important transit area for migrants and to help with the early detection of wild polioviruses, environmental surveillance was expanded in 2010 to 5 sites in Delhi. Two additional sites were added in Delhi, as well as an expansion to 3 sites in Patna, Bihar, and 2 sites in Kolkata, West Bengal, in In the second quarter of 2013, the network was again expanded to the state of Punjab, with 4 sites in 4 cities: Amritsar, Patiala, Mohali, and Sangrur. Additional sites in the state of Gujarat are being considered for inclusion in the network toward the end of From 2001 to 2010, the environmental surveillance network successfully identified type 1 and type 3 wild polioviruses. Since 2010, the environmental surveillance system has not detected any wild polioviruses. So, in combination with the highly sensitive AFP surveillance system, environmental surveillance has provided additional confidence in the polio-free status of India. As with environmental surveillance in other WHO regions, the 21 collection sites in India are now functioning as an early warning system for the rapid detection and response to wild polioviruses, if needed. ROUTINE IMMUNIZATION All 11 countries in the region have routine immunization schedules that are using trivalent oral polio vaccine. However, in Indonesia, the province of Yogyakarta has been using inactivated polio vaccine as part of a demonstration project to understand the performance of this vaccine in tropical climates. Polio Eradication in the WHO South-East Asia Region JID 2014:210 (Suppl 1) S219

5 Figure 1. Reference [16, 17]. South-East Asia Regional (SEAR) Polio Laboratory Network and Environmental Surveillance sites, There is 1 global specialized polio laboratory (Enterovirus Research Centre, Mumbai, India), 2 regional reference laboratories (1 each in Colombo, Sri Lanka, and Bangkok, Thailand), 15 laboratories conducting intratypic differentiation (1 each in Dhaka, Bangladesh; Pyongyang, Democratic People s Republic of Korea; Ahmedabad, Bangalore, Chennai, Delhi, Kolkata, Lucknow, and Mumbai, India; Bandung, Jakarta, and Surabaya, Indonesia; Yangon, Myanmar; Colombo; and Bangkok), and 11 laboratories conducting primary virus culture (1 each in Ahmedabad, Bangalore, Chennai, Delhi, Kolkata, Lucknow, Kasauli, and Mumbai; Bandung; Colombo; and Bangkok). The project started in 2008, and at its completion in 2012 the government of Indonesia decided to continue using the inactivated vaccine in the Yogyakarta routine immunization program instead of reverting back to oral polio vaccine (O. Mach, personal communication, 3 June 2013). Routine immunization coverage surveys, serologic information, and environmental surveillance data from the project are being analyzed to formulate policies for the evolving polio endgame strategy and help develop routine immunization schedules following the eradication of wild poliovirus [22]. At the end of 2012, the routine immunization coverage of the third dose of oral polio vaccine for the South-East Asia Region was 86%. Table 2 shows the routine polio immunization schedules for 2012, as well as the official coverage for the third dose of oral polio vaccine in the region. While the overall coverage for the region and at the national level is adequate, uniformly high routine polio immunization coverage at all subnational levels is important for keeping the region polio free and contributing to global polio eradication targets. SUPPLEMENTARY IMMUNIZATION Countries in the South-East Asia Region have been using supplementary immunization activities (SIAs) as an important strategy toward accelerating polio eradication efforts in the region [16]. SIAs have been used as a means either to maintain or improve population immunity. These activities include mop-up campaigns after the identification of wild poliovirus, national immunization days, and subnational immunization days. Table 3 displays a summary of the regional supplementary polio immunization activities during These activities were focused on the 6 largest countries in the region and were concentrated on the polio-endemic and -outbreak areas. As opposed to routine polio immunization, the choice of oral S220 JID 2014:210 (Suppl 1) O Connor et al

6 Figure 2. Reference [29]. Subnational blocks for polio-free certification by the India National Certification Committee for Polio Eradication. Block 1: Andaman and Nicobar Islands, Arunachal Pradesh, Chandigarh, Chhattisgarh, Dadra and Nagar Haveli, Daman and Diu, Goa, Gujarat, Karnataka, Kerala, Lakshadweep, Manipur, Meghalaya, Mizoram, Nagaland, Puducherry, Sikkim, Tamil Nadu, and Tripura. Block 2: Assam, Andhra Pradesh, Jammu and Kashmir, Jharkhand, Haryana, Himachal Pradesh, Madhya Pradesh, Maharashtra, Odisha, Punjab, Rajasthan, and Uttarakhand. Block 3: Bihar, Delhi, Uttar Pradesh, and West Bengal. polio vaccine for supplementary immunization activities has varied on the basis of national and subnational wild poliovirus epidemiology. POLIO-FREE CERTIFICATION AND PHASE 1 LABORATORY CONTAINMENT A formal process for the certification of polio eradication was established on the basis of experience gained during smallpox eradication. Independent groups of experts have been designated at the global, regional, and national levels to set criteria and monitor the process with the concept that there should be an independent, external verification of the polio-free certification process [8]. The WHO director general established the Global Certification Commission for Polio Eradication (GCCPE), in 1995, to oversee the polio eradication certification activities at the global level and guide the process in the WHO region [8]. The GCCPE established 2 main criteria as prerequisites for global polio-free certification: (1) the absence of wild poliovirus isolated from AFP cases, healthy individuals, and environmental samples in all WHO regions for a period of at least 3 years, in the presence of high-quality surveillance; and (2) the containment of all wild poliovirus stocks in laboratories [23, 24]. The International Certification Commission for Polio Eradication (ICCPE) in the South-East Asia Region was established in 1997, and all National Certification Committees for Polio Eradication (NCCPEs) were established by the end of 1998 [9, 24]. From 1997 to 2006, the ICCPE guided countries through the polio-free certification process and accepted national documentation for polio-free certification and phase 1 laboratory containment from Polio Eradication in the WHO South-East Asia Region JID 2014:210 (Suppl 1) S221

7 Table 2. Routine Polio Vaccine Schedule and Oral Polio Vaccine Third Dose (POL3) Coverage in South-East Asia Region Countries, POL3 Coverage, % Country Age Schedule (2012) Bangladesh 6 wk, 10 wk, 14 wk, 38 wk Bhutan Birth, 6 wk, 10 wk, 14 wk DPR Korea 6 wk, 10 wk, 14 wk India Birth, 6 wk, 10 wk, 14 wk, 99 a mo Indonesia b 1 mo, 2 mo, 3 mo, 4 mo Maldives Birth, 6 wk, 10 wk, 14 wk Myanmar 6 wk, 10 wk, 14 wk Nepal 6 wk, 10 wk, 14 wk Sri Lanka 2 mo, 4 mo, 6 mo, 18 mo, y Thailand 2 mo, 4 mo, 6 mo, 1.5 2y, y Timor Leste Birth to 2 wk, 6 wk, 10 wk, wk Overall Reference [35]. Abbreviation: DPR Korea, Democratic People s Republic of Korea. a Reported coverage of >99.5%. b Inactivated polio vaccine was used in Yogyakarta Province (age schedule, 2 mo, 3 mo, 4 mo). 9 countries in the South-East Asia Region: Bhutan, Bangladesh, Democratic People s Republic of Korea, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, and Thailand. In 2008, the ICCPE was renamed as the South-East Asia Regional Certification Commission for Polio Eradication (SEA-RCCPE) and has remained active in reviewing annual reports through 2013 [26 30]. In January 2012, at the second meeting of the SEA-RCCPE, the commission decided to intensify activities beyond its annual meeting, based on the progress being made in India and the need to accelerate activities [27]. Over the next 14 months, the SEA-RCCPE met 4 times, with 2 main objectives: to ensure that the polio-free certification and phase 1 laboratory containment documents of the 9 countries that have already been accepted were updated and to support the submission of the full documentation from the 2 remaining countries, India and Timor Leste. As part of their intensified activities, the commission has also provided support to the NCCPEs with advocacy and review missions to each country in The Timor Leste NCCPE completed its polio-free certification documentation in February 2013 and will complete its phase 1 laboratory containment documentation by September The Timor Leste NCCPE will submit its full polio-free certification and phase 1 laboratory containment documentation at the sixth meeting of the SEA-RCCPE in November The India-NCCPE submitted preliminary polio-free certification documentation for review during the third meeting of the SEA- RCCPE in August 2012 [28]. Because of the massive volume of information in the preliminary documentation, the commission requested that the India-NCCPE organize the India information on a subnational basis, as well as provide a detailed description of the phase 1 laboratory containment plan and brief the commission at additional meetings over the next year [27]. On the basis of the SEA-RCCPE recommendation, the India- NCCPE grouped states and union territories into 3 blocks based on the year of the last detected case of wild poliovirus [28]. The first block consists of 19 low-risk states and union territories that reported their last case of wild poliovirus infection before 2007 [26]. The second block consists of 12 medium-risk states that reported their last case of wild poliovirus infection between 2007 and 2009 [29]. The third block consists of 4 high-risk states that reported their last case of wild poliovirus infection between 2009 and Data from the first and second blocks were presented to the SEA-RCCPE in December 2012 and March 2013, respectively. The SEA-RCCPE was convinced that the AFP surveillance system has been sensitive enough to detect any circulating wild polioviruses and that there has not been any undetected circulating wild poliovirus in those areas [28, 29]. The India-NCCPE will present data from the third block of high-risk states in November 2013 and then prepare its complete polio-free certification and phase 1 laboratory containment documentation for submission in February The completion of phase 1 laboratory containment is a requirement in order for the India-NCCPE to submit its national polio-free certification documentation [30]. If phase 1 laboratory containment is not completed and verified by December 2013, the SEA-RCCPE will not be able to consider the poliofree certification documentation from India, and consequently regional polio-free certification will be delayed [31]. SUMMARY The South-East Asia Region has made tremendous progress in interrupting wild poliovirus transmission and has remained free of polio for >2.5 years because of the concerted efforts of Member States and partners from the national to village level. The AFP surveillance and polio laboratory networks have played an integral part in the timely detection and rapid response to the evolving polio epidemiology, as well as in tracking the decline and absence of wild polioviruses throughout the region. National immunization programs have ensured that, in addition to supportive routine immunization programs, countries have had aggressive supplementary immunization activities to maintain high population immunity against wild poliovirus. In line with this progress, the region is firmly on track for poliofree certification in early 2014, after completing 3 years without detection of any circulating indigenous wild polioviruses. Of the S222 JID 2014:210 (Suppl 1) O Connor et al

8 Table 3. Summary of Polio Supplementary Immunization Activities (SIAs) in South-East Asia Region (SEAR) Countries, Median Target Median Administrative Country No., Activity a (Vaccine[s]) Target Age, y Population, No. Coverage, % Bangladesh 8 NIDs (topv) b Bhutan None performed DPR Korea None performed India 9 NIDs (topv, bopv, mopv1, mopv3) SNIDs (topv, bopv, mopv1, mopv3) mop-ups (topv, bopv, mopv1, mopv3) Indonesia 4 SNIDs (topv) c Maldives None performed Myanmar 2 mop-ups (topv) SNIDs (topv) NIDs (topv) Nepal 7 NIDs (bopv, topv) SNIDs (bopv) c mop-ups (bopv, mopv1) Sri Lanka None performed Thailand 8 SNIDs (topv) SNIDs (topv) for migrants < Timor Leste None performed References [32 35]. Abbreviations: bopv, bivalent oral polio vaccine; DPR Korea, Democratic People s Republic of Korea; mopv1, monovalent oral polio vaccine type 1; mopv3, monovalent oral polio vaccine type 3; topv, trivalent oral polio vaccine. a Defined as national immunization days (NIDs), subnational immunization days (SNIDs), or mop-up activities (mop-up). b Administrative coverage of >99%. c Indicates that 1 dose of oral polio vaccine was provided during SIAs involving measles-containing vaccine. 6 WHO regions, the following 3 have already been certified to be free of polio: the Region of the Americas, in 1994; the Western Pacific Region, in 2000; and the European Region, in 2002 [8]. In 2014, the South-East Asia Region will be the first region to be certified free of polio in 12 years, showing that with strong government support and the coordinated efforts of partners, polio eradication is possible even in challenging environments. There is a wealth of experience in the South-East Asia Region from years of eradicating wild polioviruses. Lessons learned from nearly 2 decades of building an extensive polio eradication infrastructure for laboratory-supported surveillance and polio immunization activities need to be transformed to strengthen routine immunization and advance the measles elimination and rubella control agendas throughout the region. The legacy of the polio eradication program in the South-East Asia Region has yet to be written. It does, however, have the potential to be transformative for the improvement of health through the delivery of immunizations to over a billion people. Notes Supplement sponsorship. This article is part of a supplement entitled The Final Phase of Polio Eradication and Endgame Strategies for the Post- Eradication Era, which was sponsored by the Centers for Disease Control and Prevention. Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed References 1. Andrus JK, Banerjee K, Hull BP, Smith JC, Mochny I. Polio eradication in the World Health Organization South-East Asia Region by the year 2000: midway assessment of progress and future challenges. J Infect Dis 1997; 175 (suppl 1):S World Health Assembly. Global eradication of the poliomyelitis by the year WHA Resolution WHA Geneva, Switzerland: World Health Organization, Progress towards poliomyelitis eradication, Wkly Epidemiol Rec 1995; 70: Vaccine Preventable Disease Surveillance Bulletin. Immunization and vaccine development, Regional Office for South-East Asia. Vol 17, week 8. New Delhi, India: World Health Organization, World Health Assembly. Poliomyelitis: intensification of the global eradication initiative. WHA Resolution WHA65.5. Geneva, Switzerland: World Health Organization, 26 May Executive Board. Poliomyelitis: intensification of the global eradication initiative. EB130.R10. Geneva, Switzerland: World Health Organization, 21 January Three to go... The Global Polio Eradication Initiative. New stories March Newsstories2012/tabid/461/iid/201/Default.aspx. Accessed 3 May Smith J, Leke R, Adams A, Tangerman RH. Certification of polio eradication: process and lessons learned. Bull World Health Organ 2004; 82: Polio Eradication in the WHO South-East Asia Region JID 2014:210 (Suppl 1) S223

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