Reported<unk>  cases in 2019 center Country Wildcases Circulatingvaccine-derivedcases Transmissionstatus Type 147 29 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Total 175 365 The decade of the last recorded case of paralytic<unk> . Since the creation of this image, Nigeria has been certified free of wild<unk>  as of August 2020. Following the widespread use of<unk> virus vaccine in the mid-1950s, new cases of<unk> myelitis declined dramatically in many industrialized countries. A global effort to eradicate<unk>  began in 1988, led by the World Health Organization, UNICEF, and The Rotary Foundation. These efforts have reduced the number of cases diagnosed by 99.9 percent; from an estimated 350,000 cases in 1988 to a low of 483 cases in 2001, after which it remained at a level of about 1,000–2000 cases per year for a number of years. In April 2012, the World Health Assembly declared that the failure to completely eradicate<unk>  would be a programmatic emergency for global public health, and that it "must not happen." In 2015,<unk>  was believed to remain naturally spreading in only two countries, Pakistan and Afghanistan, although it continued to cause outbreaks in other nearby countries due to hidden or reestablished transmission. In 2015, cases decreased to 98 and further decreased in 2016 to 37 wild cases and 5 circulating vaccine-derived cases, but increased in 2019 to 175 wild cases and 365 circulating vaccine-derived cases.<unk>  is one of only two diseases currently the subject of a global eradication program, the other being Guinea worm disease. So far, the only diseases completely eradicated by humankind are smallpox, declared eradicated in 1980, and rinderpest, declared eradicated in 2011. A concern is the presence of circulating vaccine-derived<unk> viruses. The oral<unk>  vaccine is not perfect: while the genetic characteristics are carefully balanced to maximize efficacy and minimize virulence, the<unk> virus in the oral vaccine can mutate. As a result, persons given the oral<unk>  vaccine can acquire acute or chronic infections; or can transmit (circulate) mutated virus to other people. Circulating vaccine-derived<unk> virus cases have exceeded wild-type cases, making it desirable to discontinue the use of the oral<unk>  vaccine as soon as safely possible. Afghanistan and Pakistan The last remaining region with wild<unk>  cases are the South Asian countries Afghanistan and Pakistan. Both major sides of the Afghan civil war support<unk>  vaccination, but after declining rapidly,<unk>  rates are increasing in Afghanistan, with 19 cases in 2015, 13 in 2016, 14 in 2017, 21 in 2018, and 29 in 2019 out of a population of about 35 million. In Pakistan, there were 53 cases in 2015 (out of a population of about 200 million) – the highest number for any country, 20 in 2016, 8 in 2017 12 in 2018, and 146 in 2019. Cases dropped by 97 percent from 2014 to 2018; reasons include 440 million dirham support from the United Arab Emirates to vaccinate more than ten million children, changes in the military situation, and arrests of some of those who attacked<unk>  workers. In Pakistan, the CIA ran a fake vaccination clinic in an attempt to locate Osama bin Laden. As a consequence, there were attacks and deaths among vaccination workers; 66 vaccinators were killed in 2013 and 2014. Several Islamist preachers and militant groups, including some factions of the Taliban, view vaccination as a plot to kill or sterilize Muslims. This is part of the reason Pakistan and Afghanistan are the only countries where<unk>  remained endemic as of 2015. Americas The Americas were declared<unk> -free in 1994. The last known case was a boy in Peru in 1991. Western Pacific In 2000,<unk>  was declared to have been officially eliminated in 37 Western Pacific countries, including China and Australia. Despite eradication ten years earlier, an outbreak was confirmed in China in September 2011, involving a strain common in Pakistan. In September 2019, the Department of Health of the Philippines declared a<unk>  outbreak in the country after a 3-year-old girl was found with the disease on the 14th. In December 2019, acute<unk> myelitis was confirmed in a 3-month-old infant in Tuaran, a town in Sabah state, Borneo, Malaysia. It was the first confirmed case in Malaysia since 1992, and Malaysia had been declared<unk> -free in 2000. The child reportedly had a fever and muscle weakness, and although in stable condition, required assistance to breathe. Testing of the virus indicated that it was related to the strain that had appeared in the Philippines. Local officials said the strain originated from a weakened virus used in an oral vaccine that was then excreted in feces and spread into the unvaccinated population through unsanitary conditions. It was reported that 23 of 199 children in the local community had not received the<unk>  vaccine. Since then, Malaysia has reported another three<unk>  cases, with the last case reported in January 2020. Malaysia also ramped up its effort in detecting cases through acute flaccid paralysis surveillance and rolled out an immunisation campaign in the affected states. WHO declares an end to the outbreak in September 2021. Europe Europe was declared<unk> -free in 2002. On 1 September 2015, WHO confirmed two cases of circulating vaccine-derived<unk> virus type 1 in Ukraine. Southeast Asia The last case of<unk>  in the region was in India (part of the WHO's South-East Asia Region) in January 2011. Since January 2011, there have been no reported cases of the wild<unk>  infections in India, and in February 2012 the country was taken off the WHO list of<unk>  endemic countries. On 27 March 2014, the WHO announced the eradication of<unk> myelitis in the South-East Asia Region, which includes eleven countries: Bangladesh, Bhutan, North Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste. With the addition of this region, 80 per cent of the world population was considered to be living in<unk> -free regions. Middle East In Syria difficulties in executing immunization programs in the ongoing civil war led to a return of<unk> , probably in 2012, acknowledged by the WHO in 2013. 15 cases were confirmed among children in Syria between October and November 2013 in Deir Ezzor. Later, two more cases, one each in rural Damascus and Aleppo, were identified. It was the first outbreak in Syria since 1999. Doctors and international public health agencies report more than 90 cases of<unk>  in Syria, with fears of contagion in rebel areas from lack of sanitation and safe-water services. In May 2014, the World Health Organization declared<unk> 's renewed spread a world health emergency. A vaccination campaign in Syria operated literally under fire and led to the deaths of several vaccinators, but returned vaccination coverage to pre-war levels. Another epidemic of<unk>  was confirmed in 2017 in eastern Syria, probably resulting from a mutated form of the virus spreading through contaminated water. Africa<unk>  vaccination in Egypt In 2003 in northern Nigeria – a country which at that time was considered provisionally<unk>  free – a fatwa was issued declaring that the<unk>  vaccine was designed to render children sterile. Subsequently,<unk>  reappeared in Nigeria and spread from there to several other countries. In 2013, nine health workers administering<unk>  vaccine were targeted and killed by gunmen on motorcycles in Kano, but this was the only attack. Local traditional and religious leaders and<unk>  survivors worked to revive the campaign, and Nigeria was removed from the<unk> -endemic list in September 2015 after more than a year without any cases, only to be restored to the list in 2016 when two cases were detected. In 2013, the Center for Disease Control received reports of 183 cases of<unk>  in Somalia, 14 in Kenya and 8 cases in the Somali Region of Ethiopia, but Africa had no confirmed cases of wild<unk> virus (WPV) since 2016. Cases of circulating vaccine-derived<unk> virus type 2 continue to appear in several countries. On 25 August 2020, the Africa Regional Certification Commission declared Africa free from wild<unk> .
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