Emerging trends and insights in acute flaccid myelitis: a comprehensive review of neurologic manifestations.

Acute Flaccid Myelitis (AFM) is a neurological condition in the anterior portion of the spinal cord and can be characterised as paraplegia (paralysis of the lower limbs), and cranial nerve dysfunction. These lesions are caused by the infection due to Enterovirus 68 (EV-D68); a member of the Enterovirus (EV) family belongs to the Enterovirus species within the Picornavirus family and a Polio-like virus. In many cases, the facial, axial, bulbar, respiratory, and extraocular muscles were affected, hence reducing the overall quality of the patient's life. Moreover, severe pathological conditions demand hospitalisation and can cause mortality in a few cases. The data from previous case studies and literature suggest that the prevalence is high in paediatric patients, but careful clinical assessment and management can decrease the risk of mortality and paraplegia. Moreover, the clinical and laboratory diagnosis can be performed by Magnetic resonance imaging (MRI) of the spinal cord followed by Reverse transcription polymerase chain reaction (rRT-PCR) and VP1 seminested PCR assay of the cerebrospinal fluid (CSF), stool, and serum samples can reveal the disease condition to an extent. The primary measure to control the outbreak is social distancing as advised by public health administrations, but more effective ways are yet to discover. Nonetheless, vaccines in the form of the whole virus, live attenuated, sub-viral particles, and DNA vaccines can be an excellent choice to treat these conditions. The review discusses a variety of topics, such as epidemiology, pathophysiology, diagnosis/clinical features, hospitalisation/mortality, management/treatment, and potential future developments.

Epidemiology of Traumatic Spinal Cord Injury in Developing Countries from 2009 to 2020: A Systematic Review and Meta-Analysis.

INTRODUCTION: Traumatic spinal cord injury (TSCI) is a catastrophic event with a considerable health and economic burden on individuals and countries. This study was performed to update an earlier systematic review and meta-analysis of epidemiological properties of TSCI in developing countries published in 2013. METHODS: Various search methods including online searching in database of EMBASE and PubMed, and hand searching were performed (2012 to May 2020). The keywords "Spinal cord injury," "epidemiology," "incidence," and "prevalence" were used. Based on the definition of developing countries by the International Monetary Fund, studies related to developing countries were included. Data selection was according to PRISMA guidelines. The quality of included studies was evaluated by Joanna Briggs Institute Critical Appraisal Tools. Results of meta-analysis were presented as pooled frequency, and forest, funnel, and drapery plots. RESULTS: We identified 47 studies from 23 developing countries. The pooled incidence of TSCI in developing countries was 22.55/million/year (95% CI: 13.52; 37.62/million/year). Males comprised 80.09% (95% CI: 78.29%; 81.83%) of TSCIs, and under 30 years patients were the most affected age group. Two leading etiologies of TSCIs were motor vehicle crashes (43.18% [95% CI: 37.80%; 48.63%]) and falls (34.24% [95% CI: 29.08%; 39.59%], respectively). The difference among the frequency of complete injury (49.47% [95% CI: 43.11%; 55.84%]) and incomplete injury (50.53% [95% CI: 44.16%; 56.89%]) was insignificant. The difference among frequency of tetraplegia (46.25% [95% CI: 37.78%; 54.83%]) and paraplegia (53.75% [95% CI: 45.17%; 62.22%]) was not statistically significant. The most prevalent level of TSCI was cervical injury (43.42% [95% CI: 37.38%; 49.55%]). CONCLUSION: In developing countries, TSCIs are more common in young adults and males. Motor vehicle crashes and falls are the main etiologies. Understanding epidemiological characteristics of TSCIs could lead to implant-appropriate cost-effective preventive strategies to decrease TSCI incidence and burden.

Comorbidities and COVID-19 hospitalization, ICU admission and hospital mortality in Austria : A retrospective cohort study.

BACKGROUND: The protection of vulnerable populations is a central task in managing the Coronavirus disease 2019 (COVID-19) pandemic to avoid severe courses of COVID-19 and the risk of healthcare system capacity being exceeded. To identify factors of vulnerability in Austria, we assessed the impact of comorbidities on COVID-19 hospitalization, intensive care unit (ICU) admission, and hospital mortality. METHODS: A retrospective cohort study was performed including all patients with COVID-19 in the period February 2020 to December 2021 who had a previous inpatient stay in the period 2015-2019 in Austria. All patients with COVID-19 were matched to population controls on age, sex, and healthcare region. Multiple logistic regression was used to estimate adjusted odds ratios (OR) of included factors with 95% confidence intervals (CI). RESULTS: Hemiplegia or paraplegia constitutes the highest risk factor for hospitalization (OR 1.61, 95% CI 1.44-1.79), followed by COPD (OR 1.48, 95% CI 1.43-1.53) and diabetes without complications (OR 1.41, 95% CI 1.37-1.46). The highest risk factors for ICU admission are renal diseases (OR 1.76, 95% CI 1.61-1.92), diabetes without complications (OR 1.57, 95% CI 1.46-1.69) and COPD (OR 1.53, 95% CI 1.41-1.66). Hemiplegia or paraplegia, renal disease and COPD constitute the highest risk factors for hospital mortality, with ORs of 1.5. Diabetes without complications constitutes a significantly higher risk factor for women with respect to all three endpoints. CONCLUSION: We contribute to the literature by identifying sex-specific risk factors. In general, our results are consistent with the literature, particularly regarding diabetes as a risk factor for severe courses of COVID-19. Due to the observational nature of our data, caution is warranted regarding causal interpretation. Our results contribute to the protection of vulnerable populations and may be used for targeting further pharmaceutical interventions.

Perceived Clinical Barriers to Employment for Males with Spinal Cord Injury in Saudi Arabia.

Return to work is a challenging aspect of community integration for individuals with disabilities. The reintegration of individuals with spinal cord injury (SCI) is multifactorial; hence, regional challenges need to be investigated in the context of their clinical attributes and perceptions. A total of 121 male participants above 18 years of age with diagnosis of SCI and living at home were included in this cross-sectional survey. The study was conducted at a tertiary care rehabilitation facility in Saudi Arabia. The most common reported clinical barriers to employment were mobility, bladder incontinence, spasticity, musculoskeletal pain, and neuropathic pain. Bladder incontinence and musculoskeletal pain were the most common perceived clinical barriers for individuals with paraplegia and tetraplegia, respectively. A significant difference was observed for bowel incontinence as a reported barrier (p = 0.024) among adults less than thirty years of age in comparison with those older than thirty years. Spasticity as a barrier was reported more among patients who were older than thirty years (54.0%) compared to those younger than thirty years of age (37.9%) (p = 0.077). Twenty-two (23.7%) participants with paraplegia reported transfers as a perceived barrier to employment, which was significant (p = 0.014), and it was also reported as a significant barrier (p = 0.001) in individuals with tetraplegia (56%). This study shows that clinical conditions associated with SCI are considered potential barriers to employment by individuals with SCI. In terms of priority, the perceived barriers between individuals with tetraplegia and paraplegia were mostly different. This shows the need to consider relevant secondary health care conditions in goal setting while planning for employment in individuals with SCI.

Epidemiological changes in traumatic spinal cord injuries for the last 30 years (1990-2019) in South Korea.

STUDY DESIGN: Retrospective descriptive study. OBJECTIVES: To identify the characteristics of and epidemiological trends in traumatic spinal cord injuries (TSCIs) in Korea from 1990 to 2019. SETTING: National Rehabilitation Center affiliated with the Ministry of Health and Welfare in Korea. METHODS: The medical records of 3395 individuals with TSCIs were retrospectively reviewed. Three groups were formed based on onset period (1990-1999, 2000-2009, and 2010-2019) and six groups based on age (≤15, 16-30, 31-45, 46-60, 61-75, and ≥76 years). Pearson's chi-square and analysis of variance tests were used for statistical analysis. RESULTS: From 1990 to 2019, the mean age (standard deviation, [SD]) at the time of injury increased from 32.4 (SD = 12.4) years in the 1990s to 47.1 (SD = 16.2) years in the 2010s (F = 222.317 p = <0.001). Land transport and falls were the most common causes of TSCIs. The number of injuries from land transport gradually decreased, while that from falls increased (24.9% in 1990s to 46.3% in 2010s [χ2 = 134.415 p < 0.001]). In the >60 years group, falls were the most common cause of injury, which resulted in 42.9% TSCIs in the 1990s to 59.1% in the 2010s (χ2 = 10.398, p > 0.05). Tetraplegia (n = 769, 58.6%) was more common than paraplegia; incomplete tetraplegia (entire population: =564, 43%; >60 years group: n = 186, 43%) was the highest in the 2010s. CONCLUSIONS: Falls have been the most common cause of TSCIs after 2010s. Implementing national education and campaigns for preventing falls is important to reduce/prevent TSCIs caused by falls in the aged population.

Paraplegia After Open Surgical Repair Versus Thoracic Endovascular Aortic Repair for Thoracic Aortic Disease: A Retrospective Analysis of Japanese Administrative Data.

OBJECTIVES: To comparatively examine the risk of postoperative paraplegia between open surgical descending aortic repair and thoracic endovascular aortic repair (TEVAR) among patients with thoracic aortic disease. DESIGN: Retrospective cohort study. SETTING: Acute-care hospitals in Japan. PARTICIPANTS: A total of 6,202 patients diagnosed with thoracic aortic disease. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The main outcome of this study was the incidence of postoperative paraplegia. Multiple logistic regression models, using inverse probability of treatment weighting and an instrumental variable (ratio of TEVAR use to open surgical repair and TEVAR uses), showed that the odds ratios of paraplegia for TEVAR (relative to open surgical descending aortic repair) were 0.81 (95% confidence interval: 0.42-1.59; p = 0.55) in the inverse probability of treatment-weighted model and 0.88 (0.42-1.86; p = 0.75) in the instrumental-variable model. CONCLUSIONS: There were no statistical differences in the risk of paraplegia between open surgical repair and TEVAR in patients with thoracic aortic disease. Improved perioperative management for open surgical repair may have contributed to the similarly low incidence of paraplegia in these two surgery types.

The prognosis and recovery of major postoperative neurological deficits after corrective surgery for scoliosis : an analysis of 65 cases at a single institution.

AIMS: The outcome following the development of neurological complications after corrective surgery for scoliosis varies from full recovery to a permanent deficit. This study aimed to assess the prognosis and recovery of major neurological deficits in these patients, and to determine the risk factors for non-recovery, at a minimum follow-up of two years. METHODS: A major neurological deficit was identified in 65 of 8,870 patients who underwent corrective surgery for scoliosis, including eight with complete paraplegia and 57 with incomplete paraplegia. There were 23 male and 42 female patients. Their mean age was 25.0 years (SD 16.3). The aetiology of the scoliosis was idiopathic (n = 6), congenital (n = 23), neuromuscular (n = 11), neurofibromatosis type 1 (n = 6), and others (n = 19). Neurological function was determined by the American Spinal Injury Association (ASIA) impairment scale at a mean follow-up of 45.4 months (SD 17.2). the patients were divided into those with recovery and those with no recovery according to the ASIA scale during follow-up. RESULTS: The incidence of major deficit was 0.73%. At six-month follow-up, 39 patients (60%) had complete recovery and ten (15.4%) had incomplete recovery; these percentages improved to 70.8% (46) and 16.9% (11) at follow-up of two years, respectively. Eight patients showed no recovery at the final follow-up. The cause of injury was mechanical in 39 patients and ischaemic in five. For 11 patients with misplaced implants and haematoma formation, nine had complete recovery. Fisher's exact test showed a significant difference in the aetiology of the scoliosis (p = 0.007) and preoperative deficit (p = 0.016) between the recovery and non-recovery groups. A preoperative deficit was found to be significantly associated with non-recovery (odds ratio 8.5 (95% confidence interval 1.676 to 43.109); p = 0.010) in a multivariate regression model. CONCLUSION: For patients with scoliosis who develop a major neurological deficit after corrective surgery, recovery (complete and incomplete) can be expected in 87.7%. The first three to six months is the time window for recovery. In patients with misplaced implants and haematoma formation, the prognosis is satisfactory with appropriate early intervention. Patients with a preoperative neurological deficit are at a significant risk of having a permanent deficit. Cite this article: Bone Joint J 2022;104-B(1):103-111.

"Endemic paraplegia of Koza in Kii" in Honcho Koji Innen Shu published in 1689 is probably the earliest description of amyotrophic lateral sclerosis of Kii Peninsula: Presentation of the original and investigation of factuality.

High prevalence of amyotrophic lateral sclerosis (ALS) in Kii Province (Kii) located in southern Kii Peninsula was first pointed out by Kinnosuke Miura in 1911, and epidemiological studies by Kiyoshi Kimura et al. verified extremely high incidence after World War II. In 1970s, Yoshiro Yase pointed out that "endemic paraplegia of Koza in Kii" in Honcho Koji Innen Shu published in 1689 would mean the same disorder as that of ALS and be the earliest description of Kii ALS although he gave no clear grounds. In this study, the original of the article was presented with an English translation, and factuality of it was investigated from the viewpoints of geography, geology, culture and history of Kii. As a result, it was shown that the article was probably written based on historical events and that the "endemic paraplegia" meant the same disorder as Kii ALS. The author has concluded that "endemic paraplegia of Koza in Kii" is likely to be the earliest description of Kii ALS since ALS is included in the causes of paraplegias of these kinds.

Susceptibility and cytokine responses of human neuronal cells to multiple circulating EV-A71 genotypes in India.

Enterovirus-A71 (EV-A71) associated Hand, foot and mouth disease (HFMD) is a highly contagious viral infection affecting children in Asia-Pacific region and has become a major threat to public health. Although several EV-A71 genotypes (C, D, and G) were isolated in India in recent years, no recognizable outbreak of EV-A71 caused HFMD, Acute Flaccid paralysis (AFP) or encephalitis have been reported so far. It is essential to study the pathogenicity or cell tropism of these Indian isolates in order to understand their tendency to cause disease. We investigated the susceptibility and cytokine responses of indigenous EV-A71 genotypes (D and G) isolated from cases of AFP and genotype C viruses isolated from cases of HFMD and encephalitis, in human cells in-vitro. Although all three EV-A71 genotypes could infect and replicate in human muscle and neuronal cells, the genotype D virus showed a delayed response in human neuronal cells. Quantification of cytokine secretion in response to these isolates followed by confirmation with gene expression assays in human neuronal cells revealed significantly higher secretion of pro-inflammatory cytokines TNF-α IL-8, IL-6, IP-10 (p < 0.001) in G genotype infected cells as compared to pathogenic C genotypes whereas the genotype D virus could not induce any of the inflammatory cytokines. These findings will help to better understand the host response to indigenous EV-A71 genotypes for management of future EV-A71 outbreaks in India, if any.

The Potential Causes of Paraplegia after Coronary Artery Bypass Grafting: A Literature Review.

Paraplegia is an unpredictable neurologic complication after coronary artery bypass grafting (CABG) surgery. It is rare but fatal, and the mechanism still is unclear. We aimed to make a summary of the possible causes of paraplegia after CABG. Pubmed database was searched from January 1, 1978 to December 31, 2019, and 14 studies were finally included. Paraplegia after CABG is a multifactorial consequence, but spinal cord ischemia is the key pathological factor to postoperative paraplegia.

Perceived sleep problems after spinal cord injury: Results from a community-based survey in Switzerland.

Objective: To investigate the burden of sleep problems within the Spinal Cord injured (SCI) community with respect to the general population (GP) in Switzerland. The study further explored potential predictors for receiving treatment for sleep problems after SCI.Design: Cross-sectional study.Setting: SCI community in Switzerland.Participants: Individuals diagnosed with an SCI, aged 16 years or older that permanently reside in Switzerland (N = 1549).Interventions: Not applicable.Outcome measures: Perceived sleep problems within the SCI community and GP. For those with sleep problems and SCI, an indicator for having received treatment was measured.Results: 58.8% of survey participants indicated having a sleep problem; 69.4% of those with a sleep problem did not indicate receiving treatment. Amongst people living with an SCI, individuals between the ages of 46-60 years (adjusted Odds Ratio, OR = 3.07; 95% CI 1.54-6.16), participants reporting severe financial hardship (OR = 2.90; 95% CI) 1.69-4.96, and those that indicated having pain (OR = 5.62; 95% CI 3.52-8.98) were more likely to have a chronic sleep problem. In comparison to the Swiss GP, the prevalence of having a sleep problem was 18% higher among persons with SCI, with the largest discrepancy for males with paraplegia between the ages of 46-60 years (Prevalence ratio, PR = 1.28; 95% CI, 1.21-1.36).Conclusion: Individuals with SCI experience more sleep problems compared to the Swiss GP. Findings from this study suggest that clinical screening for sleep issues targeting high risk groups is needed to reduce the large prevalence of non-treatment in individuals with SCI.

Methodology and study population of the second Swiss national community survey of functioning after spinal cord injury.

STUDY DESIGN: Descriptive study of the second community survey of the Swiss Spinal Cord Injury Cohort Study (Survey 2017) conducted between 03/2017 and 03/2018. OBJECTIVES: To describe the methodology, recruitment results, characteristics of participants and non-participants, and non-response of the Survey 2017. SETTING: Community. METHODS: Description of the sampling strategy and sampling frame. Recruitment results and characteristics of participants and non-participants of the two Survey 2017 questionnaire modules were analyzed using descriptive statistics. Determinants of survey participation were examined using multivariable logistic regression, and the impact of non-response bias on survey results was evaluated using inverse-probability weighting. RESULTS: Out of 3959 persons who met the eligibility criteria, 1530 responded to module 1 (response rate 38.6%) and 1294 to module 2 (response rate 32.7%) of the Survey 2017. Of the 4493 invited persons, 1549 had participated in the first SwiSCI community survey conducted in 2012/2013. Of these, 1332 were invited to the Survey 2017 and 761 participated in module 1 (response rate 58.9%) and 685 in module 2 (response rate 53.1%). The majority of module 1 participants were male (71.2%, 95% CI: 68.9, 73.5), with a median age of 57 (IQR: 46.0, 67.0) years and incomplete paraplegia (41.9%, 95% CI: 39.3, 44.5). Survey non-response was higher in the oldest age group, among females, and those with tetraplegia. CONCLUSIONS: The design of the Survey 2017 was successful in recruiting a substantial proportion of the SCI source population in Switzerland. To counteract survey non-response, survey weights may be applied to subsequent analyses. SPONSORSHIP: none.

＜Editors' Choice＞ Which is superior, the frozen elephant trunk technique alone or the classical elephant trunk technique followed by second-stage thoracic endovascular aortic repair for extensive aortic arch repair?

Paraplegia is one of the most devastating complications during extensive aortic arch repair. We retrospectively analyzed our results by comparing primary repair using the frozen elephant trunk technique (FET) and the classical elephant trunk technique (CET) followed by second-stage thoracic endovascular aortic repair (TEVAR), which has been performed since 2009. Between March 1997 and September 2015, 91 patients (the mean age: 70 ± 8.6 years old, 73 men and 18 women) underwent total aortic arch replacement with either the FET (54 cases) or CET (37 cases). The CET was followed by second-stage TEVAR with a median duration of 36 days. The number of in-hospital deaths was 2 (3.7%) in FET and none in CET. The overall survival was 73% in FET and 83% in CET at 5 years with no significant difference (p=0.73). Aortic events occurred in 12 cases (22%) in FET and 3 (8%) in CET. The rate of freedom from aortic events was 77% in FET and 91% in CET at 5 years with no significant difference (p=0.45). Five neurologic events (9%) occurred after the FET, and 3 events (8%) occurred after the CET (p=0.85). No patients in the CET group experienced paraplegia, while the FET group showed a relatively high paraplegia rate (17%, p=0.014).The FET with primary repair for extensive aortic arch repair had an acceptable hospital mortality rate and aortic events but was associated with a high incidence of paraplegia. The CET followed by second-stage TEVAR achieved better early results with a low risk of paraplegia and may produce a favorable mid-term surgical outcome for extensive aortic arch repair.

Football (soccer)-related spinal cord injury-reported cases from 1976 to 2020.

STUDY DESIGN: An analysis of reported cases. OBJECTIVES: To analyze the existing data on soccer (international football)-related spinal cord injury (SCI). SETTING: Cases of soccer (international football)-related SCI that were reported globally. METHODS: PubMed/MEDLINE, EMBASE, and online news publication databases were searched. RESULTS: Fourteen cases of football-related SCI that occurred between 1976 and 2020 were found. Average age at the time of injury was 19 and 86% of individuals were males. Eight of 14 individuals had vertebral fracture/dislocation, whereas two individuals had concomitant traumatic brain injury. Neurologically, 54% had tetraplegia, 39% had paraplegia, and 8% each suffered from hemiplegia and sensory deficit. Two cases could regain ability to walk with orthosis and four had full mobility with "Return to Play" (RTP). The mortality was 14%. CONCLUSIONS: Younger males were most commonly affected. The most common etiology, vertebral level of injury, and neurological manifestation was fall, cervical spine, and tetraplegia respectively. More than 50% of the individuals with football-related SCI were able to walk or RTP after rehabilitation. Further studies are required to establish universal RTP criteria and formulate preventive measures.

Australian National Enterovirus Reference Laboratory annual report, 2015.

Australia conducts surveillance for cases of acute flaccid paralysis (AFP) in children less than 15 years as recommended by the World Health Organization (WHO) as the main method to monitor its polio-free status. Cases of AFP in children are notified to the Australian Paediatric Surveillance Unit or the Paediatric Active Enhanced Disease Surveillance System and faecal specimens are referred for virological investigation to the National Enterovirus Reference Laboratory. In 2015, no cases of poliomyelitis were reported from clinical surveillance and Australia reported 1.2 non-polio AFP cases per 100,000 children, meeting the WHO performance criterion for a sensitive surveillance system. Two non-polio enteroviruses, enterovirus A71 and coxsackievirus B3, were identified from clinical specimens collected from AFP cases. Australia complements the clinical surveillance program with enterovirus and environmental surveillance for poliovirus. Two Sabin-like polioviruses were isolated from sewage collected in Melbourne in 2015, which would have been imported from a country that uses the oral polio vaccine. The global eradication of wild poliovirus type 2 was certified in 2015 and Sabin poliovirus type 2 will be withdrawn from oral polio vaccine in April 2016. Laboratory containment of all remaining wild and vaccine strains of poliovirus type 2 will occur in 2016 and the National Enterovirus Reference Laboratory was designated as a polio essential facility. Globally, in 2015, 74 cases of polio were reported, only in the two remaining countries endemic for wild poliovirus: Afghanistan and Pakistan. This is the lowest number reported since the global polio eradication program was initiated.

Australian National Enterovirus Reference Laboratory annual report, 2016.

Australia monitors its polio-free status by conducting surveillance for cases of acute flaccid paralysis (AFP) in children less than 15 years of age, as recommended by the World Health Organization (WHO). Cases of AFP in children are notified to the Australian Paediatric Surveillance Unit or the Paediatric Active Enhanced Disease Surveillance System and faecal specimens are referred for virological investigation to the National Enterovirus Reference Laboratory. In 2016, no cases of poliomyelitis were reported from clinical surveillance and Australia reported 1.38 non-polio AFP cases per 100,000 children, meeting the WHO performance criterion for a sensitive surveillance system. Several non-polio enteroviruses, coxsackievirus A6, enterovirus A71, enterovirus A74 and enterovirus D68, were identified from clinical specimens collected from AFP cases. The global withdrawal of Sabin poliovirus type 2 from oral polio vaccine occurred in April 2016. This event represents the start of the polio endgame with an increased focus on the laboratory containment of all remaining wild and vaccine strains of poliovirus type 2. The National Enterovirus Reference Laboratory was designated as a polio essential facility as part of this process. In 2016, 37 cases of wild polio were reported with three countries remaining endemic: Afghanistan, Nigeria and Pakistan. Nigeria was declared polio-free in 2015, after 12 months without detection of wild poliovirus, but was reinstated as an endemic country after the reporting of four cases in August 2016. This is a salient reminder of the need to maintain sensitive surveillance for poliovirus until global eradication is certified.

Australian National Enterovirus Reference Laboratory annual report, 2017.

Australia monitors its polio-free status by conducting surveillance for cases of acute flaccid paralysis (AFP) in children less than 15 years of age, as recommended by the World Health Organization (WHO). Cases of AFP in children are notified to the Australian Paediatric Surveillance Unit or the Paediatric Active Enhanced Disease Surveillance System and faecal specimens are referred for virological investigation to the National Enterovirus Reference Laboratory. In 2017, no cases of poliomyelitis were reported from clinical surveillance and Australia reported 1.33 non-polio AFP cases per 100,000 children, meeting the WHO performance criterion for a sensitive surveillance system. Three non-polio enteroviruses, coxsackievirus B1, echovirus 11 and enterovirus A71, were identified from clinical specimens collected from AFP cases. Australia established enterovirus and environmental surveillance systems to complement the clinical system focussed on children and an ambiguous vaccine-derived poliovirus type 2 was isolated from sewage in Melbourne. In 2017, 22 cases of wild polio were reported with three countries remaining endemic: Afghanistan, Nigeria and Pakistan.

Australian National Enterovirus Reference Laboratory annual report, 2018.

Australia monitors its polio-free status by conducting surveillance for cases of AFP in children less than 15 years of age, as recommended by the WHO. Cases of AFP in children are notified to the Australian Paediatric Surveillance Unit or the Paediatric Active Enhanced Disease Surveillance System and faecal specimens are referred for virological investigation to the National Enterovirus Reference Laboratory. In 2018, no cases of poliomyelitis were reported from clinical surveillance and Australia reported 1.24 non-polio AFP cases per 100,000 children, meeting the WHO performance criterion for a sensitive surveillance system. Several non-polio enteroviruses, coxsackievirus A4, coxsackievirus B1, echovirus 9, echovirus 30, enterovirus D68 and enterovirus A71, were identified from clinical specimens collected from AFP cases. Australia also performs enterovirus and environmental surveillance to complement the clinical system focussed on children. In 2018, 33 cases of wild polio were reported with three countries remaining endemic: Afghanistan, Nigeria and Pakistan.