Critique of an outbreak of global health importance

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21REVIEW OF THE RESPONSE TO THE POLIO OUTBREAK IN SYRIA

Critique of Poliomyelitis outbreak in Syria as a historical outbreak of Global Health Importance

Introduction

Over the past decades, the World Health Organization in partnership with the health ministries in various countries as well as other non-state actors have put forth efforts to control and ultimately halt the transmission of Poliovirus (Cousins, 2015). The strategies put in place have yielded greater results over the decades with several countries being declared completely free of the virus. However, some countries have continued to experience periodic outbreaks of Poliomyelitis also referred to as Acute Flaccid Paralysis (AFP) orchestrated by several challenges that hamper the response to Polio outbreaks (Böttcher et al., 2015). Some of these countries continue experience political conflicts that interrupt the provision of healthcare services including immunization services (Mushtaq et al., 2015). The insecurity situations also make the working conditions for healthcare workers unbearable thus forcing them to abandon the health facilities in search for greener pastures in less hostile environments (Aylward & Alwan, 2014). Political instabilities also jeopardize response activities to any outbreak of Polio thus providing it with the ideal conditions for spreading rapidly with minimal chances for detection. Consequently, response activities during Polio outbreaks require adequate planning to ensure that all stakeholders are brought on board and the highest impact is realized towards the eradication of the virus (Burki, 2015).

This review seeks to critique and evaluate the quality of the response to the Poliomyelitis outbreak in Syria and provide recommendations for future actions. The review will evaluate the response activities undertaken during the response to this outbreak including the quality of immunization campaigns, surveillance activities, communication strategies as well as social mobilization. The critique will utilize the one health approach by evaluating the role of clinicians, epidemiologists, leaders at both the local and regional level, communities, both state and non-state actors in mitigating the spread of Wild Poliovirus type 1.

Outbreak and response

Syria had received a clean bill of health in regards to new cases of poliomyelitis for approximately twelve years. However, this narrative changed in 2013 during which the nation suffered an outbreak of Wild Poliovirus type 1 (WPV1) that was genetically associated with a similar strain responsible for polio endemics in Pakistan (Mushtaq et al., 2015). During this outbreak, 36 new cases of poliomyelitis were recorded by the close of the year 2013 and an additional one case in January 2014. The virus then spread to Iraq by April 2014 recording two new cases (Asghar et al., 2014). In 2014, poliovirus transmission was declared to be a Public Health Emergency of International Concern (PHEIC) by the World Health Organization in accordance with International Health Regulations (IHR 2005) and subsequently rolled out a raft of measures to curb its spread across other nations (Cousins, 2015). Syria being an affected country with established potential to export WPV1, the WHO recommended the vaccination of all its residents as well as any persons visiting the country for durations longer than four weeks with the Oral Polio Vaccine (OPV) before travelling internationally (Moturi et al., 2014).

Prior to the outbreak, Syria’s program for immunization had been rated the best within the region with a record coverage exceeding 90% in 2010 (Delpeyroux & Colbère-Garapin, 2015). Subsequent years reported a sharp decline with 2012 recording 68% coverage based on administrative reports with attribution to the crisis that was rocking the nation (Sahloul et al., 2014). The conflicts in Syria also had an adverse effect on other services under the Expanded Program of Immunization with approximately 40% of primary healthcare facilities responsible for 90% of immunization services being incapacitated to provide the services (Cousins, 2015). The situation was also exacerbated by challenges involved in transporting the vaccines particularly to regions that were fully under the control of the opposition. In addition, the mass exodus of healthcare workers due to insecurity severely jeopardized provision of the immunization services (Aylward & Alwan, 2014; Kopel, Kaliner, & Grotto, 2014). This situation was ideal for the virus to spread easily without any detection to the neighboring Palestine and Israel. In response to the spread, massive vaccination campaigns were initiated involving eight Middle East Countries that had the highest risk for an outbreak (Gostin, 2014). By September 2014, approximately one hundred million OPV doses had been issued to children aged less than five years in more than 40 supplementary immunization activities that commenced in the year 2013 (Sparrow, 2014).

A six-month response plan for the outbreak was developed by the Syria’s EPI with assistance from the UNICEF and World Health Organization (Vakili, Soltani, Khakshour, Khademi, & Saeidi, 2015). During the initial phase of the plan, the government conducted six nationwide supplementary immunization activities using OPV, strengthened surveillance activities for WPV1, improved other services through routine immunizations, enforced communication as well as efforts geared to social mobilization, and streamlined coordination activities between the partners involved in polio eradication (Sharara & Kanj, 2014). Since February 2014, Syria did not record any new case of poliomyelitis and this permitted the implementation of the second phase of the intervention plan that focused on the quality of SIAs, strategies for ensuring children in hard to reach areas receive the recommended vaccination, strengthening the surveillance activities, routine immunizations and strategies for targeted communication (Sparrow, 2014).

Critique and evaluation

Immunization campaigns

Reports indicate a strong engagement during the SIAs of health managers as well as the staff at different levels despite the fact that only nine polio campaigns had been conducted. In addition, the communities accepted the polio immunization services thus ensuring a steady demand for the services (Taleb et al., 2015a). During the campaign, marking the fingers was used to independently monitor the coverage of the immunization campaigns that were initiated in more than 90% of the districts (Sahloul et al., 2014). The monitoring officers also carried the Oral Polio Vaccine which was used to vaccinate any children that were missed out in the immunization campaigns by healthcare workers. Main partners namely UNICEF, WHO, Syria MOH, UNHCR, UNRWA, and Syrian Red Crescent participated in post campaign evaluation meetings and used the experiences to better the subsequent campaigns (Sharara & Kanj, 2014).

Some of the crucial lessons learned and utilized included strategies for reaching out to all children in difficult and hard to reach conflicted regions (Porter, Diop, Burns, Tangermann, & Wassilak, 2015). The immunization activities by the government mainly relied on the primary health centers whereby parents brought their children for vaccination (Estívariz et al., 2013). However, due to low outreach, the government also employed mobile vaccination teams which either moved with a vehicle to strategic points and provide the vaccination or visited families in their homes to vaccinate all eligible children (Eichner & Brockmann, 2013). The mobile teams were increased substantially with each new campaign thus allowing the campaigns to reach more children who were in need of the vaccine (Moturi et al., 2014).

On the other hand, there was no consistent tracking of the OPV doses issued through health centers and mobile teams. The government developed a system for scoring the risk assessment which was relied upon in providing risk information from the districts and inform planned immunization activities (Maurice, 2014). Despite the fact that new booklets were provided for the purpose of documenting undertaken by supervisors as well as other health personnel, not all of them were completely filled out. However, the data collected was very useful during the monitoring activities particularly in areas where these booklets were completed (Taleb et al., 2015a). The mass campaigns involved several print and electronic media platforms with information, education and communication (IEC) materials distributed to create awareness on the Wild Poliovirus type 1 as well as the need for vaccination. There is no documentation of any partnerships fostered with actors locally to support the implementation of the immunization campaigns which otherwise facilitates the realization of the set objectives (Andre et al., 2014).

The efforts targeting the children who had the highest risk for contracting poliomyelitis were insufficient with no clear strategy to reach out to all children whose parents failed to visit the health centers as well as mobile teams in accessible regions, and the children in inaccessible regions (Cousins, 2015). Very useful information that detailed some reasons why a proportion of children did not receive the Oral Polio Vaccine obtained during the evaluation meetings was used in very few regions to adjust micro plans for subsequent campaigns (Taleb et al., 2015a). Despite the increase in house-to-house vaccinations, vaccination activities by mobile teams were clearly not targeted properly. In fact, there was need for specific micro plans for the mobile teams to ensure realization of the desired objectives (Moturi et al., 2014). The mobile team supervisors did not clearly understand what good supervision entailed hence there was very minimal documentation of the supervisory activities conducted by these teams. Similarly, the comprehensive checklists that would otherwise provide monitoring information on the implementation status of the polio mass campaigns, social demographic data as well as staff performance were not adequately completed (Durry, 2014).

Some strategic partners were involved in delivering the vaccines to children in the inaccessible areas; however, the coordination activities appeared to be weak making the efforts less successful (Vakili et al., 2015). Information from such activities is useful when managed centrally with all the stakeholders in order to device effective strategies for vaccinating the children in those risky regions (Asghar et al., 2014). In fact, the key partners would have explored the possibility of leveraging on local NGOs in such regions to support the distribution of Oral Polio Vaccine to children in need. Despite the fact that the Government of Syria approved the implementation of the WHO recommendations to curb the spread of WPV1 including immunizing all residents and international visitors, it is interesting to note that the Syrian head of state failed to declare poliomyelitis as a health emergency affecting the nation (Sharara & Kanj, 2014). The government established two centers for vaccinating international travelers in Damascus and along the Syrian-Lebanese border and approximately 800 travelers were vaccinated (Sinclair, 2013).

Surveillance activities

After the 2013 outbreak, the government enacted a plan for strengthening surveillance activities for Acute Flaccid Paralysis. This plan entailed undertaking training as well as sensitization forums on surveillance for the virus with health care workers. In addition, a refresher course on AFP surveillance was also rolled out for healthcare personnel. Approximately thirty five training sessions were concluded involving 1400 healthcare personnel. In addition, the surveillance guidelines were updated and used during the training sessions with the distribution of the printed guidelines across the districts of Syria (Sharara & Kanj, 2014). New alert posters for AFP were also designed and distributed to healthcare facilities in order to support surveillance activities. Following these actions, detection of cases of poliomyelitis remarkably improved with cases of non-polio AFP as well as actual AFP cases exceeding the projected levels (Asghar et al., 2014). The surveillance files were properly documented and complete across the various facilities. Surveillance teams conducted regular visits to health facilities, children hospitals, and other primary health centers. Policy guidelines recommend the collection of three specimens upon contact with suspected cases of AFP however; there was varied adherence to this policy requirement (Durry, 2014).

Syria’s national lab dealing with polio was very crucial during the outbreak and has continued to support the surveillance activities despite the existing conflict situation in the country. Syria has an expert group at the national level for classifying cases which meets on a regular basis for the purpose of classifying cases and providing technical assistance required in the surveillance program (Aylward & Alwan, 2014). However, there are some gaps in the awareness of Acute Flaccid Paralysis amongst healthcare workers especially in lower level facilities. Some facilities lacked visible posters providing the case definition for AFP as well as the persons to be contacted in the event there is a suspected case. There were well documented reports of public health officers who conducted surveillance visits in the children’s hospitals located in Damascus on a daily basis (Rutter & Donaldson, 2014). The reporting rates for Acute Flaccid Paralysis stood at greater than 2 per 100,000 however; the rate of reporting was lower specifically in inaccessible regions. Noteworthy is the fact that the new checklists for supervision lacked questions on Acute Flaccid Paralysis. Collected specimens for isolating the non-polio enterovirus took about five to six days in order to reach the national laboratory and were stored in freezers during this period (Sharara & Kanj, 2014).

Social mobilization and communication

The government developed a national strategy for communication to support the response to the polio outbreak. Various print and electronic media were integrated as part of the implementation of this strategy including mobile phones, newspapers, radio communication and televised programs (Aylward & Alwan, 2014). The strategy aimed at streamlining communication to meet the need for information required during supplementary immunization activities as well as routine immunization campaigns. The government held consensus workshops that promoted the communication strategy but the later has not realized full implementation (Peretz, Labay, Zonis, & Glikman, 2014). Workshops for capacity building focal points for health promotion on infection prevention and control were conducted in accordance with the national strategy to meet the identified needs. Rural Damascus had effectively replicated this strategy as opposed to other regions that were lagging behind. However, there is dire need for building the capacity in communication of primary healthcare facilities as well as the districts across the country (Rutter & Donaldson, 2014).

The Ministry of Health communicated with other government ministries through letters that provided the details of the campaigns and SIAs (Mockenhaupt et al., 2016). However, there is need for expansion of inter-sectoral as well as inter-departmental coordination to realize partnerships that are effective in supporting the campaigns. Partnerships across the sectors are useful in the facilitation of campaigns especially in reaching out to children in inaccessible regions (Porter et al., 2015). During this response, the local teams were useful in facilitating the entry of vaccinators, mobilizing people, identifying volunteers, and amicably resolving issues of refusal. Nevertheless, these activities were not clearly documented by some of the supervisory teams involved in the response. The strategy of communication entailed recruiting local volunteers to increase awareness activities regarding the polio supplementary immunization activities (Thompson & Duintjer Tebbens, 2014). This strategy is consistent with previous campaigns particularly in Damascus where community volunteers were engaged. There is also need to include the community volunteers during trainings on infection prevention and control strategies for Acute Flaccid Paralysis. Communication challenges accounted for 60% of the reasons why children were not vaccinated during the SIAs particularly in cases where the caretakers lacked the correct information (Sharara & Kanj, 2014). Moreover, post-campaign evaluation reports containing valuable information were not being shared promptly in good time to inform future campaigns particularly regarding the communication strategies. Consequently, in some levels, the plans of communication only focused on activities as well as the logistical requirements (Nasir et al., 2014).

The Ministry of Health’s supervisory checklist is comprehensive and entailed questions relating to communication that assisted the supervisors to monitor the implementation of SIAs, staff performance, as well as collection of social demographic data. The focal points for health education reports from different levels of government showed the monitoring activities conducted during the campaigns and identified the scheduled supervisory visits for every week (Wassilak et al., 2014). Nevertheless, there are some facilities in which no supervisory visits were conducted. The available reports indicate low levels of knowledge amongst health workers on expanded program for immunization, response to AFP outbreaks, and the key messages for campaigns. This was coupled with lack of availability of adequate information, education and communication materials in certain health facilities. The Ministry of Health recognized the contribution of the media to ensuring successful campaigns through mobilization and developed a strategy for engaging the media (Nasir et al., 2014). Despite the milestones realized in the implementation of communication and mobilization strategies, there is need to build more capacity of both central and local governments’ human resource personnel to enhance the communication strategies. Relevant agencies should also streamline the supervisory activities that support communication as well as social mobilization (Porter et al., 2015).

Routine immunization

Syria’s conflict situation negatively influenced provision of services under the Expanded Program for Immunization. Approximately 40% of the primary healthcare facilities became inaccessible following the destruction of roads, lack of electricity supply that would otherwise make the maintenance of the cold chain impossible, and insufficient resources to provide the services (Taleb et al., 2015b). The conflict situation also diminished social mobilization and made supervision activities impossible. Despite all this, SIA s and the response to the polio outbreak was utilized in strengthening the provision of EPI services specifically in the inaccessible regions (Andre et al., 2014).

In addition, the supportive supervision visits conducted during the Polio supplementary immunization activities, implementation, and social mobilization for SIAs supported the provision of EPI services allowing OPV as well as other vaccines to gain access into the inaccessible regions (Asghar et al., 2014). The Syrian Ministry of Health in c ollaboration with other partners developed a communication plan that integrated routine Polio and EPI SIAs during the review process of the first phase of the response to the outbreak in the Middle-East. The ministry then embarked on revising the EPI manual to include aspects of infection prevention and control as well as a plan to strengthen the provision of routine services under the expanded program for immunization (Sharara & Kanj, 2014). There is need to continue sensitizing mothers on the need to ensure their children receive all the recommended doses of vaccinations under the EPI schedule regardless of whether they get vaccinated during the supplementary immunization activities (Maurice, 2014).

Coordination amongst the partners involved in the response

A coordinating committee that comprised of the Ministry of Health, UNICEF, WHO, SARC, and UNHCR was established during the outbreak in Syria. The committee was set to incorporate other partners including NGOs and government ministries for instance the Ministry of Education and Higher Learning (Sparrow, 2014). The committee received regular updates regarding AFP as well as the Expanded Program for Immunization. The polio response team in Syria also took part in review meetings that targeted regional response to the Polio outbreak. The meetings were instrumental in synchronizing the mitigation activities especially the SIAs and equally afforded the participants an opportunity to share experiences as well as best practices (Thompson & Duintjer Tebbens, 2014).

Despite these milestones, there is need to bridge the gaps existing in the coordination activities of various partners by engaging additional partners who would otherwise support the access into contested regions that are under the control of the opposition. In addition, the partners need to share data on the quantity of vaccines supplied to these regions as well as the immunization rates realized against AFP (Porter et al., 2015).

Future directions

Future campaign activities against AFP should pay close attention to ensuring that children who are likely to be missed out during the campaigns are targeted and vaccinated (Aylward, 2014; Kosal, 2015). In addition, microplans for SIAs should be continuously revised to ensure a higher coverage of children who stand the risk of missing the vaccination and that all the reasons hindering access to immunization are addressed (Porter et al., 2015). Moreover, there is need to increase the house-to-house vaccinations specifically targeting the children who are likely to be missed during the SIAs for poliomyelitis. Furthermore, planners for the SIAs should rationalize the workloads for mobile teams, develop detailed microplans with clear demarcations, orient the supervisors during the training sessions prior to the SIAs, and improve their supervision for quality improvement (Sharara & Kanj, 2014). The Ministry of Health and other government departments should collaborate with strategic partners and effectively communicate with community volunteers purposely to improve the immunization coverage in inaccessible regions (Aylward & Alwan, 2014). The Ministry of Health should not stall on the implementation of the temporary measures stipulated by the World Health Organization aimed at containing the halting the spread of the Wild Poliovirus to other regions not previously affected. The government of Syria should declare the Polio transmission as a national emergency, strengthen the monitoring of international travelers for any symptoms of AFP, and avail regular reports to the World Health Organization regarding the progress realized (Thompson & Duintjer Tebbens, 2014).

The Ministry of Health should fully implement the AFP surveillance plan that was developed specifically in inaccessible regions. Furthermore, continuous training as well as sensitization forums are essential for healthcare workers for enhanced surveillance. In addition, designating active focal points in the surveillance sites is essential to enhance the collaboration with public health officers who visit the sites (Sparrow, 2014). Moreover, posters and other information, education and communication materials should be made available in all the primary healthcare facilities for improved surveillance. AFP reporting at all levels of healthcare provision should be prioritized and emphasized during training of healthcare workers to prevent the likelihood of an outbreak (Aylward & Alwan, 2014). The Ministry of Health should emphasize the need to collect at least three specimens from suspected cases as stipulated by the policy guidelines for improved surveillance (Minor, 2014). Similarly, the government should streamline the transportation of stored specimens so that they are delivered to the national laboratory promptly to prevent chances of contamination. Besides, active temperature monitoring of the specimens is essential during the period of transportation. Finally, there is need for every district to have an active site for conducting surveillance activities for AFP (Sahloul et al., 2014).

Regarding communication as well as social mobilization, the government should engage more experienced personnel to build the human resource capacity for communication relevant issues regarding the outbreaks (Orenstein et al., 2015). In addition, full implementation and periodic review of the communication strategy enacted by the government remains very crucial (Aylward & Alwan, 2014). The government needs to integrate more partners to support its response to the Polio outbreak particularly in regions that are under the full control of the opposition that have been made inaccessible to the government. Moreover, the relevant persons in government should closely supervise and document all the activities related to the Polio outbreak communication (Porter et al., 2015). Furthermore, data obtained from the monitoring activities following the SIAs regarding the reasons that contributed to children missing immunizations should be promptly reviewed and made available to all the actors to ensure that future campaigns address the identified gaps. The available information, education, and communication materials regarding the Polio outbreak should be shared in a systematic manner with the healthcare workers as well as the general public (Porter et al., 2015). Lastly, the government should conclude and roll out the integrated plan of communication for response to polio outbreaks as well as the Expanded Program for Immunization (EPI) (Sharara & Kanj, 2014).

In reference to routine immunizations, the government should finalize as well as distribute the EPI manual to all healthcare workers (Kopel et al., 2014). Secondly, it should strengthen the national plan for routine immunizations under the EPI schedule based on the agreement arrived at during the review of the second phase of the response to the Polio outbreak in the Middle East (Sahloul et al., 2014). Lastly, vaccinators as well as supervisors overseeing the Polio supplementary immunization activities should strive to adequately utilize the contact with several families afforded to them during the campaigns by sensitizing parents on the need to ensure their children receive the full range of recommended vaccinations under the EPI schedule (Sparrow, 2014).

The Ministry of Health should also strive to engage new additional partners who are no doubt instrumental as part of the response team in the event there is an outbreak of Polio (Alexander, Zubair, Khan, Abid, & Durry, 2014; Tajaldin, Almilaji, Langton, & Sparrow, 2015). The partners are also useful in addressing some issues associated with social mobilization of communities to uptake the immunization services (Sparrow, 2014). To realize successful immunization campaigns against Acute Flaccid Paralysis, the various stakeholders should combine their efforts to ensure that hard-to-reach regions gain optimum access to the immunization services. Strengthening the coordination of various partners involved in the response to a Polio outbreak remains imperative to the success of supplementary immunization activities against Acute Flaccid Paralysis (Sharara & Kanj, 2014)

Conclusion

This review critiqued the response activities linked to the Polio outbreak in Syria reported in 2013. The conflict situation in the country was a great disadvantage to the response activities against the Polio virus. Relevant authorities undertook various activities to support the response activities against the virus. The strategies integrated the activities of different actors involved in promoting the health and well being of persons in the affected areas. The response activities in Syria involved polio supplementary immunization activities, strengthening the routine immunizations in accordance with the Expanded Program for Immunizations’ schedule, streamlining the communication strategies as well as social mobilization, and strengthening the coordination of partners involved in the response against Polio outbreak. Ministries of health should continue implementing the recommendations from the World Health Organization regarding the strategies for mitigating outbreaks of Polio virus. In addition, there is need for capacity building various technical teams particularly those involved in communication as well as social mobilization so that immunization activities yield desired results. Similarly, critical lessons learned from previous immunizations campaigns should be utilized to inform subsequent campaigns against Poliovirus. Most importantly, multidisciplinary collaboration between various health experts should be enhanced to help prevent any future outbreaks through active surveillance activities. Finally, ministries of health should enact active surveillance sites to ensure identification of all the new cases of Acute Flaccid Paralysis and ensuring outbreaks are quickly brought under control.

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