Planning and implementing a targeted polio vaccination campaign for Somali mobile populations in Northeastern Kenya based on migration and settlement patterns.

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

Scaling up public health interventions: case study of the polio immunization program in Indonesia.

BACKGROUND: The scaling up of public health interventions has received greater attention in recent years; however, there remains paucity of systematic investigations of the scaling up processes. We aim to investigate the overall process, actors and contexts of polio immunization scaling up in Indonesia from 1988 until 2018. METHODS: A mixed method study with sequential explanatory design was conducted. We carried out a quantitative survey of 323 actors involved in the polio program at national and sub-national levels, followed by Key Informant Interviews (KII)s. Document review was also carried out to construct a timeline of the polio eradication program with milestones. We carried out descriptive statistical analysis of quantitative data and thematic analysis of qualitative data. RESULTS: The scaling up of polio immunization in Indonesia started as a vertical expansion approach led by the Ministry of Health within a centralized health system. The coverage of immunization increased dramatically from 5% in the earlier 80s to 67.5% in 1987; incremental increases followed until achieving Universal Child Immunization (UCI) in 1990 and subsequently 95% coverage in 1995. Engagement of stakeholders and funding made the scaling up of polio immunization a priority. There was also substantial multisector involvement, including institutions and communities. Local area monitoring (LAM) and integrated health posts (Posyandu) were key to the polio immunization implementation strategy. Challenges for scaling up during this centralized period included cold chain infrastructure and limited experience in carrying out mass campaigns. Scaling up during the decentralized era was slower due to expansion in the number of provinces and districts. Moreover, there were challenges such as the negative perception of immunization side-effects, staff turnover, and the unsmooth transition of centralization towards decentralization. CONCLUSION: Vertical scaling up of polio immunization program intervention was successful during the centralized era, with involvement of the president as a role model and the engine of multi sector actors. Posyandu (integrated health posts) played an important role, yet its revitalization after the reform-decentralization era has not been optimum.

National Immunization Campaigns With Oral Polio Vaccine May Reduce All-cause Mortality: An Analysis of 13 Years of Demographic Surveillance Data From an Urban African Area.

BACKGROUND: Between 2002 and 2014, Guinea-Bissau had 17 national campaigns with oral polio vaccine (OPV) as well as campaigns with vitamin A supplementation (VAS), measles vaccine (MV), and H1N1 influenza vaccine. We examined the impact of these campaigns on child survival. METHODS: We examined the mortality rate between 1 day and 3 years of age of all children in the study area. We used Cox models with age as underlying time to calculate adjusted mortality rate ratios (MRRs) between "after-campaign" mortality and "before-campaign" mortality, adjusted for temporal change in mortality and stratified for season at risk. RESULTS: Mortality was lower after OPV-only campaigns than before, with an MRR for after-campaign vs before-campaign being 0.75 (95% confidence interval [CI], .67-.85). Other campaigns did not have similar effects, the MRR being 1.22 (95% CI, 1.04-1.44) for OPV + VAS campaigns, 1.39 (95% CI, 1.20-1.61) for VAS-only campaigns, 1.32 (95% CI, 1.09-1.60) for MV + VAS campaigns, and 1.13 (95% CI, .86-1.49) for the H1N1 campaign. Thus, all other campaigns differed significantly from the effect of OPV-only campaigns. Effects did not differ for trivalent, bivalent, or monovalent strains of OPV. With each additional campaign of OPV only, the mortality rate declined further (MRR, 0.86 [95% CI, .81-.92] per campaign). With follow-up to 3 years of age, the number needed to treat to save 1 life with the OPV-only campaign was 50 neonates. CONCLUSIONS: OPV campaigns can have a much larger effect on child survival than otherwise assumed. Stopping OPV campaigns in low-income countries as part of the endgame for polio infection may increase child mortality.

Conflict, community, and collaboration: shared implementation barriers and strategies in two polio endemic countries.

BACKGROUND: Afghanistan and Nigeria are two of the three remaining polio endemic countries. While these two countries have unique sociocultural characteristics, they share major polio risk factors. This paper describes the countries' shared contexts and highlights important lessons on implementing polio eradication activities among hard-to-reach populations relevant for future global health programs. METHODS: A grey literature review of the Global Polio Eradication Initiative (GPEI) followed by an online survey was conducted in both countries. The survey was targeted to individuals who have been involved continuously in polio eradication activities for 12 months or more since 1988. A sub-set of respondents from the survey was recruited for key-informant interviews (KII). The survey and KIIs were conducted between September 2018-April 2019. A cross-case comparison analysis was conducted to describe shared implementation challenges, strategies, and unintended consequences of polio eradication activities across these contexts. RESULTS: Five hundred thirteen and nine hundred twenty-one surveys were completed in Afghanistan and Nigeria respectively; 28 KIIs were conducted in Afghanistan and 29 in Nigeria. Major polio eradication activities in both countries include house-to-house campaigns, cross-border stations, outreach to mobile populations, and surveillance. Common barriers to these activities in both countries include civil unrest and conflict; competing political agendas; and vaccine refusal, fatigue, and mistrust, all of which are all bases for describing hard-to-reach populations. Both countries employed strategies to engage community leadership, political and religious groups through advocacy visits, and recruited community members to participate in program activities to address misconceptions and distrust. Recruitment of female workers has been necessary for accessing women and children in conservative communities. Synergy with other health programs has been valuable; health workers have improved knowledge of the communities they serve which is applicable to other initiatives. CONCLUSIONS: The power of community engagement at all levels (from leadership to membership) cannot be overstated, particularly in countries facing civil unrest and insecurity. Workforce motivation, community fatigue and mistrust, political priorities, and conflict are intricately interrelated. Community needs should be holistically assessed and addressed;programs must invest in the needs of health workers who engage in these long-term health programs, particularly in unsafe areas, to alleviate demotivation and fatigue.

The experiences of using polio outbreak simulation exercises to strengthen national outbreaks preparedness and response plans in sub-Saharan Africa.

INTRODUCTION: globally, by 2020 the paralytic poliomyelitis disease burden decreased to over 99% of the reported cases in 1988 when resolution 41.8 was endorsed by the World Health Assembly (WHA) for global polio eradication. It is clearly understood that, if there is Wild Poliovirus (WPV) and circulating Vaccines Derived Poliovirus (cVDPV) in the world, no country is safe from polio outbreaks. All countries remain at high risk of re-importation depending on the level of the containment of the types vaccine withdrawn, the laboratory poliovirus isolates, and the population immunity induced by the vaccination program. In this regard, countries to have polio outbreak preparedness and response plans, and conducting the polio outbreak simulation exercises for these plans remain important. METHODS: we conducted a cross-section qualitative study to review to 8 countries conducted polio outbreak simulation exercises in the East and Southern Africa from 2016 to 2018. The findings were categorized into 5 outbreak response thematic areas analyzed qualitatively and summarized them on their strengths and weaknesses. RESULTS: we found out that, most countries have the overall technical capacities and expertise to deal with outbreaks to a certain extent. Nevertheless, we noted that the national polio outbreak preparedness and response plans were not comprehensive enough to provide proper guidance in responding to outbreaks. The guidelines were inadequately aligned with the WHO POSOPs, and IHR 2005. Additionally, most participants who participated in the simulation exercises were less familiar with their preparedness and response plans, the WHO POSOPs, and therefore reported to be sensitized. CONCLUSION: we also realized that, in all countries where the polio simulation exercise conducted, their national polio outbreak preparedness and response plan was revised to be improved in line with the WHO POSOPs and IHR 2005. we, therefore, recommend the polio outbreak simulation exercises to be done in every country with an interval of 3-5 years.

Transboundary nomadic population movement: a potential for import-export of poliovirus.

BACKGROUND: Nomadic populations have a considerably higher risk of contracting a number of diseases but, despite the magnitude of the public health risks involved, they are mostly underserved with few health policies or plans to target them. Nomadic population movements are shown to be a niche for the transmission of diseases, including poliomyelitis. The nomadic routes traverse the northern states of Nigeria to other countries in the Lake Chad subregion. As part of the February 2016 polio supplemental immunization activity (SIA) plans in Bauchi state, a review of nomadic routes and populations identified a nomadic population who originated from outside the international borders of Nigeria. This study describes the engagement process for a transboundary nomadic population and the interventions provided to improve population immunity among them while traversing through Nigeria. METHODS: This was an intervention study which involved a cross-sectional mixed-method (quantitative and qualitative) survey. Information was collected on the nomadic pastoralists entry and exit points, resting points, and health-seeking behavior using key informant interviews and semistructured questionnaire. Transit vaccination teams targeted the groups with oral polio vaccines (OPVs) and other routine antigens along identified routes during the months of February to April 2016. Mobile health teams provided immunization and other child and maternal health survival interventions. RESULTS: A total of 2015 children aged under 5 years were vaccinated with OPV, of which 264 (13.1%) were zero-dose during the February 2016 SIAs while, in the March immunization plus days (IPDs), 1864 were immunized of which 211 (11.0%) were zero-dose. A total of 296 children aged under 1 year old were given the first dose of pentavalent vaccine (penta 1), while 119 received the third dose (penta 3), giving a dropout rate of 59.8%. CONCLUSIONS: Nomadic pastoralists move across international borders and there is a need for transboundary policies among the countries in the Lake Chad region to improve population immunity and disease surveillance through a holistic approach using the One-health concept.

Immunity against poliomyelitis in the Netherlands, assessed in 2006 to 2007: the importance of completing a vaccination series.

Europe has been declared polio-free since 2002. Here we describe the seroprotection against poliomyelitis in the Dutch population using banked serum samples. Samples from 1,581 inhabitants of eight municipalities with low vaccination coverage (LVC) and an additional 6,386 samples from a nationwide (NS) group (clinical trial number: ISRCTN20164309; collected in 2006­07) were tested for neutralising antibodies (log² reciprocal titres (GMT); non-protection <3) against all three poliomyelitis serotypes. Demographic and epidemiological data were used for statistical regression analysis. Seroprevalence in the NS was 94.6% (type 1), 91.8% (type 2) and 84.0% (type 3). Infants (0­7 months-old) had ≥80% seroprevalence for all serotypes. The highest seroprevalence was found in children, with type 1 and type 2 in five year-olds and type 3 in nine to 10 year-olds. In the LVC group, orthodox protestants, many of whom refuse vaccination, showed seroprevalence rates of 64.9% (type 1), 61.0% (type 2) and 62.1% (type 3). In the NS group, non-Western immigrants and travellers to non-European continents had higher seroprevalences compared to Western immigrants and travellers within Europe, respectively. The Dutch National Immunisation Programme against poliomyelitis has provided good seroprotection, with high and long-lasting GMTs against all serotypes upon completion. The unvaccinated population remains at risk.

Comorbidity profile of poliomyelitis survivors in a Chinese population: a population-based study.

Previous reports of comorbid conditions in poliomyelitis survivors mainly focused on some disease categories, such as respiratory diseases, gastrointestinal diseases, psychiatric diseases, neurological diseases and cancer. Data regarding a wide spectrum of medical comorbidities in patients with poliomyelitis is still sparse. This study aimed to investigate and profile the wide range of comorbidities among the survivors of paralytic poliomyelitis in a Chinese population. In total, 2,032 paralytic poliomyelitis patients were selected as the study group and the comparison group consisted of 10,160 randomly selected enrollees. The comorbidities for analysis were based on a modified version of the Elixhauser Comorbidity Index. Conditional logistic regression analyses were computed to investigate the risk of comorbidities for these two groups. As compared to controls, patients with paralytic poliomyelitis had significantly higher prevalence of hypertension, ischemic heart disease, hyperlipidemia, congestive heart failure, cardiac arrhythmias, peripheral vascular disorder, stroke, paralysis, migraines, Parkinson's disease, rheumatoid arthritis, ankylosing spondylitis, pulmonary circulation disorders, chronic pulmonary disease, liver disease, peptic ulcers, hepatitis B or C, deficiency anemias, depression, and lymphoma. Most of the differences are of clinical interest, ORs often being between 2 and 3. No significant difference between poliomyelitis patients and controls was observed in the prevalence of SLE, tuberculosis, alcohol abuse and drug abuse. Our findings demonstrate that survivors of paralytic poliomyelitis in Taiwan are at higher risk of having multiple medical comorbidities although some potential confounding factors including educational level, marital status, obesity and physical activity are not available in our database. The pattern is generally consistent with previous observations from Western populations. Nevertheless, we found several novel associations which have rarely, if ever, been reported previously.

From emergence to eradication: the epidemiology of poliomyelitis deconstructed.

Poliomyelitis has appeared in epidemic form, become endemic on a global scale, and been reduced to near-elimination, all within the span of documented medical history. Epidemics of the disease appeared in the late 19th century in many European countries and North America, following which polio became a global disease with annual epidemics. During the period of its epidemicity, 1900-1950, the age distribution of poliomyelitis cases increased gradually. Beginning in 1955, the creation of poliovirus vaccines led to a stepwise reduction in poliomyelitis, culminating in the unpredicted elimination of wild polioviruses in the United States by 1972. Global expansion of polio immunization resulted in a reduction of paralytic disease from an estimated annual prevaccine level of at least 600,000 cases to fewer than 1,000 cases in 2000. Indigenous wild type 2 poliovirus was eradicated in 1999, but unbroken localized circulation of poliovirus types 1 and 3 continues in 4 countries in Asia and Africa. Current challenges to the final eradication of paralytic poliomyelitis include the continued transmission of wild polioviruses in endemic reservoirs, reinfection of polio-free areas, outbreaks due to circulating vaccine-derived polioviruses, and persistent excretion of vaccine-derived poliovirus by a few vaccinees with B-cell immunodeficiencies. Beyond the current efforts to eradicate the last remaining wild polioviruses, global eradication efforts must safely navigate through an unprecedented series of endgame challenges to assure the permanent cessation of all human poliovirus infections.

Economic analysis of the global polio eradication initiative.

The global polio eradication initiative (GPEI), which started in 1988, represents the single largest, internationally coordinated public health project to date. Completion remains within reach, with type 2 wild polioviruses apparently eradicated since 1999 and fewer than 2000 annual paralytic poliomyelitis cases of wild types 1 and 3 reported since then. This economic analysis of the GPEI reflects the status of the program as of February 2010, including full consideration of post-eradication policies. For the GPEI intervention, we consider the actual pre-eradication experience to date followed by two distinct potential future post-eradication vaccination policies. We estimate GPEI costs based on actual and projected expenditures and poliomyelitis incidence using reported numbers corrected for underreporting and model projections. For the comparator, which assumes only routine vaccination for polio historically and into the future (i.e., no GPEI), we estimate poliomyelitis incidence using a dynamic infection transmission model and costs based on numbers of vaccinated children. Cost-effectiveness ratios for the GPEI vs. only routine vaccination qualify as highly cost-effective based on standard criteria. We estimate incremental net benefits of the GPEI between 1988 and 2035 of approximately 40-50 billion dollars (2008 US dollars; 1988 net present values). Despite the high costs of achieving eradication in low-income countries, low-income countries account for approximately 85% of the total net benefits generated by the GPEI in the base case analysis. The total economic costs saved per prevented paralytic poliomyelitis case drive the incremental net benefits, which become positive even if we estimate the loss in productivity as a result of disability as below the recommended value of one year in average per-capita gross national income per disability-adjusted life year saved. Sensitivity analysis suggests that the finding of positive net benefits of the GPEI remains robust over a wide range of assumptions, and that consideration of the additional net benefits of externalities that occurred during polio campaigns to date, such as the mortality reduction associated with delivery of Vitamin A supplements, significantly increases the net benefits. This study finds a strong economic justification for the GPEI despite the rising costs of the initiative.

[Roles and functions of WHO Enterovirus Collaborating Center].

The Laboratory of Enteroviruses of the Department of Virology II, National Institute of Infectious Diseases, is functioning as a WHO-designated Collaborating Center for Virus Reference and Research (Enterovirus) in virus isolation and identification, development, evaluation, and quality control of new laboratory diagnosis methods, training technical staffs and experts, preparing, maintaining and supplying of standard reagents and reference materials for the laboratory diagnosis of enterovirus infections including poliomyelitis. The infectious agents surveillance of polioviruses is one of the critical components for the Global Polio Eradication Initiative, and the laboratory diagnosis of non-polio enteroviruses is also important in current outbreaks of hand, foot and mouth disease, mainly due to enterovirus 71. Thus, human resources and consistent international cooperation among technical staffs, based on the global and regional polio laboratory networks, are playing critical roles also in the surveillance activities for non-polio enterovirus infections in the Western Pacific Region.

Surveillance of acute flaccid paralysis in the Marches region (Italy): 1997-2007.

BACKGROUND: The last case of poliomyelitis due to transmission of indigenous wild poliovirus occurred in Italy in 1982, however, it is important to guarantee a high quality surveillance as there is a risk of importation of cases from areas where polio is endemic. Stopping poliovirus transmission is pursued through a combination of high infant immunization coverage and surveillance for wild poliovirus through reporting and laboratory testing of all cases of acute flaccid paralysis (AFP) among children under fifteen years of age. The aim of this study was to describe and to evaluate 11 years of active surveillance in the Marches (Italy) in terms of: incidence, aetiology and clinical manifestation of AFP cases. METHODS: The active Acute Flaccid Paralysis surveillance has been carried out in the Marches region since February 1997 by the Chair of Hygiene which established a regional hospital network. Active surveillance involves 15 hospital centres. RESULTS: In the considered period, 0-15 years population varied between 187,051 in 1997 to 201,625 in 2007, so the number of AFP expected cases is 2 per year. From February 1997 to October 2007, 27 cases were found with rates of 1.0/100,000 in 1997; 2.0/100,000 in 1998; 1.0/100,000 in 1999; 0.5/100,000 in 2000; 2.5/100,000 in 2001; 1.0/100,000 in 2002; 0 in 2003; 0.5/100,000 in 2004; 1.5/100,000 in 2005; 2.0/100,000 in 2006; 1.5/100,000 in 2007. In 29.6% of cases two stool samples were collected in 14 days from the symptoms onset. The 60-days follow-up is available for 23 out of 27 cases reported. In 44.5% of cases the definite diagnosis was Guillain Barrè syndrome. CONCLUSION: In general, the surveillance activity is satisfactory even if in presence of some criticalities in biological samples collection. The continuation of surveillance, in addition to the maintenance of current levels of performance, will tend to a further and more detailed sensitization of all workers involved, in order to obtain spontaneous and prompt reporting, and to achieve the optimal standards recommended by the WHO both in the collection of biological samples and the availability of 60 days follow-up, with the goal of eradicating polio from all countries.

Annual report of the Australian National Poliovirus Reference Laboratory 2005.

In May 1988 the World Health Assembly adopted a resolution for the global eradication of poliomyelitis. Since then two target dates for eradication (2000 and 2003) have passed and the struggle to eradicate the poliovirus continues. Australia's commitment to the worldwide campaign began in December 1994 with the designation of the National Poliovirus Reference Laboratory at the Victorian Infectious Diseases Reference Laboratory and the initiation of acute flaccid paralysis (AFP) surveillance in March 1995. During 2005 the National Poliovirus Reference Laboratory did not isolate any wild or vaccine derived polioviruses from the 42 samples collected from eighteen cases of acute flaccid paralysis in Australian residents. Three Sabin-like polioviruses were isolated from three cases of acute flaccid paralysis but all were considered incidental isolations by the Polio Expert Committee and not implicated in the disease of the patients. After exceeding the World Health Organization target of one case of AFP per 100,000 children aged less than 15 years in 2004, Australia's non-polio AFP rate in 2005 fell to 0.75 cases per 100,000 children. The high number of wild poliovirus importations reported globally in 2005 into previously polio free countries, highlights the need for a sensitive AFP surveillance system within Australia and for specimens from AFP cases to be forwarded to the National Poliovirus Reference Laboratory.

Annual report of the Australian National Poliovirus Reference Laboratory, 2002.

Acute flaccid paralysis is the main clinical manifestation of poliomyelitis. Faecal specimens from cases of acute flaccid paralysis in Australia are referred to the National Poliovirus Reference Laboratory for virus culture to determine if poliovirus is the causative agent. Isolations of poliovirus are tested to determine whether they have characteristics of the Sabin oral polio vaccine virus strains or wild type polioviruses. In 2002, a poliovirus type 3, which tested as Sabin vaccine-like, was isolated from an Australian patient with acute flaccid paralysis. A non-polio enterovirus, Echovirus type 18, was isolated from the faecal specimens of another case of acute flaccid paralysis. In the same period, the laboratory identified 35 Sabin-like polioviruses from 52 referred specimens and isolates from cases without acute flaccid paralysis. Australia is a member nation of the World Health Organization's Western Pacific region that was declared free of endemic wild poliovirus in October 2000. Poliomyelitis remains endemic in three of the WHO regions of the world and wild poliovirus may be re-introduced to Australia. While the number of polio-endemic countries has been reduced to seven, the total number of wild polioviruses identified increased in 2002 compared to 2001 due to a sharp rise in isolations of wild virus from Northern India. Until global eradication of poliomyelitis is achieved, it is essential that a high level of poliovirus vaccination coverage, and surveillance for cases of acute flaccid paralysis, be maintained in Australia.

Reasons for non-vaccination during national immunization days: a case study in Istanbul, Turkey.

OBJECTIVE: The member states of the 41st World Health Assembly agreed to aim for the global eradication of polio by the year 2000. Turkey adopted this goal and made substantial progress. In this report, we present the results of a coverage and risk factor survey conducted to evaluate vaccine delivery during the 1999 national immunization days (NIDs) in a large district of Istanbul, Turkey. This study provides important information regarding risk factors and reasons for non-vaccination during the NIDs, defines rumours about the NIDs, and provides estimates of vaccination coverage. SETTING AND PARTICIPANTS: A survey was conducted 3-10 days after the second round of 1999 NIDs using the standard expanded programme on immunization cluster survey method, for each of 10 health centre areas in Umraniye. In total, 2102 children were included in the analysis. RESULTS: The vaccination coverage rate was 82.2%. Logistic regression analysis showed increased risk of non-vaccination in people who did not know the purpose of the NIDs, who had not had contact with a mobile vaccination team, who were unvaccinated in the first round of 1999 NIDs and who lived in the area of the Central Health Centre. Use of primary-level state healthcare facilities for routine childhood immunizations, and living in the area of the Adem Yavuz Health Centre had significant positive effects on vaccination. CONCLUSIONS: To achieve better results, better publicity of national campaigns using mass media, and improved use of mobile teams, are necessary.

Polio eradication--global initiative; strategy challenged in Kerala, India.

The 'polio eradication initiative' launched by the World Health Assembly in 1988, although successfully implemented in several countries, could not achieve the goal of global eradication by the year 2000. It has components on strengthening routine immunization system, observance of National Immunization Days (NIDs) and strengthening of surveillance for Acute Flaccid Paralysis (AFP). Recently, this strategy was challenged in Kerala, India. Kerala has excellent health indicators compared with other Indian states. In 1999, Intensified Pulse Polio Immunization (IPPI) was introduced with four NIDs throughout India. More than 2000 doctors working under the Kerala Government challenged the strategy, demanding its redesign. Zero prevalence of polio for 2 years, near-complete coverage of children by the routine system, probable business interests of vaccine manufactures and suppliers, dubious interests of officials, and weakening of the routine system by concentrating more on NIDs were all cited as reasons for discontinuing current strategy. The authorities, citing the success stories of polio eradication by the global initiative in several countries, discard the allegations as baseless. They alleged that the medical officers who were on strike demanding higher pay and better conditions were using the 'polio issue' to win their strike. The incidence of two polio cases in Malappuram in northern Kerala during September 2000 has further complicated the issue. As the controversy continues it is felt that the 'eradication initiative' will have to be revisited.