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Acute flaccid paralysis (AFP) surveillance is key for global polio eradication. It allows detecting poliovirus (PV) reintroductions from endemic countries. This study describes AFP surveillance in Spain from 1998 to 2015. During this time, 678 AFP cases were reported to the Spanish National Surveillance Network. The mean notification rate was 0.58 AFP cases/100,000 population under 15 years old (range: 0.45/100,000–0.78/100,000). Two periods (P) are described: P1 (1998–2006) with the AFP notification rate ranging from 0.66/100,000 to 0.78/100,000, peaking in 2001 (0.84/100,000); and P2 (2007–2015) when the AFP rate ranged from 0.43/100,000 to 0.57/100,000, with the lowest rate in 2009 (0.31/100,000). No poliomyelitis cases were caused by wild PV infections, although two Sabin-like PVs and one imported vaccine-derived PV-2 were detected. Overall, 23 (3.4%) cases met the hot case definition. Most cases were clinically diagnosed with Guillain–Barré syndrome (76.9%; 504/655). The adequate stool collection rate ranged from 33.3% (7/21) to 72.5% (29/40). The annual proportion of AFP cases with non-polio enterovirus findings varied widely across the study period. AFP surveillance with laboratory testing for non-polio enteroviruses must be maintained and enhanced both to monitor polio eradication and to establish sensitive surveillance for prompt detection of other enteroviruses causing serious symptoms.


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  1. World Health Organization (WHO). Acute flaccid paralysis (AFP) surveillance: the surveillance strategy for poliomyelitis eradication. Weekly Epidemiological Record. Geneva: WHO; 1998. Available from: http://www.who.int/docstore/wer/pdf/1998/wer7316.pdf
  2. World Health Organization (WHO). WHO statement on the 8th IHR Emergency Committee meeting regarding the international spread of poliovirus. Geneva: WHO; 2016. [Accessed 10 Dec 2016]. Available from: http://www.who.int/mediacentre/news/statements/2016/8th-IHR-emergency-committee-polio/en/
  3. World Health Organization (WHO). WHO statement on the meeting of the International Health Regulations Emergency Committee concerning the International spread of wild poliovirus. Geneva: WHO; 2014. [Accessed 20 Dec 2016]. Available from: http://www.who.int/mediacentre/news/statements/2014/polio-20140505/en/
  4. Centers for Disease Control and Prevention (CDC). Update on vaccine-derived polioviruses--worldwide, January 2008-June 2009. MMWR Morb Mortal Wkly Rep. 2009;58(36):1002-6. PMID: 19763076 
  5. Pallansch MA. Ending Use of Oral Poliovirus Vaccine - A Difficult Move in the Polio Endgame. N Engl J Med. 2018;379(9):801-3.  https://doi.org/10.1056/NEJMp1808903  PMID: 30157390 
  6. World Health Organization Regional Office for Europe (WHO/Europe). Report of the 32nd Meeting of the European Regional Certification Commission for Poliomyelitis Eradication. Copenhagen: WHO/Europe; 2018. Available from: http://www.euro.who.int/fr/health-topics/communicable-diseases/poliomyelitis/publications/2018/32nd-meeting-of-the-european-regional-commission-for-certification-of-poliomyelitis-eradication-rcc-report-2018
  7. Ministerio de Sanidad y Consumo. Plan de actuaciones necesarias para la consecución del certificado de erradicación de la poliomielitis. [National Action Plan Aimed at the Achievement of the Certificate of Polio Eradication]. Madrid: Instituto de Salud Carlos III; 1998. Spanish. Available from: http://www.isciii.es/ISCIII/es/contenidos/fd-servicios-cientifico-tecnicos/fd-vigilancias-alertas/fd-enfermedades/fd-enfermedades-prevenibles-vacunacion/Plancertificadoerradicaionpolio.pdf
  8. Centro Nacional de Epidemiología. Plan de Acción para mantener un estado libre de polio en España, tras obtener el certificado de la interrupción de la transmisión de poliovirus salvaje en la Región Europea. [Action Plan to sustain polio-free status in Spain after elimination certification]. Madrid: Instituto de Salud Carlos III; 2007. Spanish. Available from: http://www.isciii.es/ISCIII/es/contenidos/fd-servicios-cientifico-tecnicos/fd-vigilancias-alertas/fd-enfermedades/fd-enfermedades-prevenibles-vacunacion/PLANESTADOLIBREPOLIO032007.pdf
  9. Ministerio de Sanidad, Asuntos Sociales e Igualdad S. Plan de Acción en España para la Erradicación de la Poliomielitis. [Plan of action in Spain for the eradication of poliomyelitis]. Spain: Government of Spain; 2016. Spanish. Available from: https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/PlanPolio/docs/Plan_erradicacion_poliomielitis.pdf
  10. World Health Organization (WHO). Polio Laboratory Manual, 4th edition. Geneva: WHO;2004. Available from: http://apps.who.int/iris/bitstream/10665/68762/1/WHO_IVB_04.10.pdf
  11. World Health Organization (WHO). An alternative test algorithm for poliovirus isolation and characterization. Polio Laboratory Manual 4th edition. Geneva: WHO;2004: Available from: http://polioeradication.org/wp-content/uploads/2017/05/NewAlgorithmForPoliovirusIsolationSupplement1.pdf
  12. Centro Nacional de Epidemiología. Red Nacional de Vigilancia Epidemiológica. Protocolos de enfermedades de declaración obligatoria. [National Guidelines for Notifiable Disease Reporting and Management]. Madrid: Instituto de Salud Carlos III;2013. Spanish. Available from: http://www.isciii.es/ISCIII/es/contenidos/fd-servicios-cientifico-tecnicos/fd-vigilancias-alertas/PROTOCOLOS_RENAVE.pdf
  13. World Health Organization (WHO) Regional Office for Europe‎. Guidelines on responding to the detection of wild poliovirus in the WHO European Region. Copenhagen: WHO Regional Office for Europe; 2007. Available from: http://www.who.int/iris/handle/10665/107877
  14. Centers for Disease Control and Prevention (CDC). International classification of diseases, ninth revision, clinical modification (ICD-9-CM). Atlanta: CDC. [Accessed 3 May 2014]. Available from: https://www.cdc.gov/nchs/icd/icd9cm.htm
  15. Avellón A, Cabrerizo M, de Miguel T, Pérez-Breña P, Tenorio A, Pérez JL, et al. Paralysis case and contact spread of recombinant vaccine-derived poliovirus, Spain. Emerg Infect Dis. 2008;14(11):1807-9.  https://doi.org/10.3201/eid1411.080517  PMID: 18976579 
  16. Centro Nacional de Epidemiología, Instituto de Salud Carlos III (ISCIII). Resultados de la vigilancia de Parálisis Fláccida Aguda en España, 2002-2017. [Results of the surveillance of Acute Flaccid Paralysis in Spain, 2002-2017]. Madrid; 2018. Spanish. Available from: http://www.isciii.es/ISCIII/es/contenidos/fd-servicios-cientifico-tecnicos/fd-vigilancias-alertas/fd-enfermedades/fd-enfermedades-prevenibles-vacunacion/sistema-vigilancia-paralisis-flacida-aguda.shtml
  17. Trallero G, Avellon A, Otero A, De Miguel T, Pérez C, Rabella N, et al. Enteroviruses in Spain over the decade 1998-2007: virological and epidemiological studies. J Clin Virol. 2010;47(2):170-6.  https://doi.org/10.1016/j.jcv.2009.11.013  PMID: 20007023 
  18. Trallero G, Cabrerizo M, Avellón ARed de Laboratorios de Vigilancia de Parálisis Flácida Aguda. Papel del Laboratorio Nacional de Poliovirus en el Programa de erradicación y vigilancia de la poliomielitis. [Role of the National Poliovirus Laboratory for the Program of eradication and poliomyelitis surveillance]. Rev Esp Salud Publica. 2013;87(5):471-9.  https://doi.org/10.4321/S1135-57272013000500006  PMID: 24322284 
  19. Tello Anchuela O. Fase actual de control de la vigilancia epidemiológica de la poliomielitis en España. [Current phase of control of epidemiological surveillance of poliomyelitis in Spain]. Rev Esp Salud Publica. 2013;87(5):481-96.  https://doi.org/10.4321/S1135-57272013000500007  PMID: 24322285 
  20. Hovi T, Stenvik M. Surveillance of patients with acute flaccid paralysis in Finland: report of a pilot study. Bull World Health Organ. 2000;78(3):298-304. PMID: 10812725 
  21. Suresh S, Forgie S, Robinson J. Non-polio Enterovirus detection with acute flaccid paralysis: A systematic review. J Med Virol. 2018;90(1):3-7.  https://doi.org/10.1002/jmv.24933  PMID: 28857219 
  22. European Centre for Disease Prevention and Control (ECDC). Rapid Risk Assessment –Enterovirus detections associated with severe neurological symptoms in children and adults in European countries, 8 August 2016. Stockholm: ECDC; 2016. Available from: http://ecdc.europa.eu/en/publications/Publications/01-08-2016-RRA-Enterovirus%2071-Spain,%20France,%20Netherlands.pdf
  23. Antona D, Kossorotoff M, Schuffenecker I, Mirand A, Leruez-Ville M, Bassi C, et al. Severe paediatric conditions linked with EV-A71 and EV-D68, France, May to October 2016. Euro Surveill. 2016;21(46):30402.  https://doi.org/10.2807/1560-7917.ES.2016.21.46.30402  PMID: 27918268 
  24. Casas-Alba D, de Sevilla MF, Valero-Rello A, Fortuny C, García-García JJ, Ortez C, et al. Outbreak of brainstem encephalitis associated with enterovirus-A71 in Catalonia, Spain (2016): a clinical observational study in a children’s reference centre in Catalonia. Clin Microbiol Infect. 2017;23(11):874-81.  https://doi.org/10.1016/j.cmi.2017.03.016  PMID: 28344164 
  25. Cabrerizo M, Grupo Para El Estudio de Las Infecciones Por Enterovirus Y Parechovirus GPEELIPEYP. Importancia de los enterovirus en neuropediatria: de los poliovirus a otros enterovirus. [Importance of enteroviruses in neuropaediatrics: from polioviruses to other enteroviruses]. Rev Neurol. 2017;64(s03):S35-8. PMID: 28524217 
  26. Cabrerizo M, García-Iñiguez JP, Munell F, Amado A, Madurga-Revilla P, Rodrigo C, et al. First cases of severe flaccid paralysis associated with enterovirus D68 infection in Spain, 2015-2016. Pediatr Infect Dis J. 2017;36(12):1214-6.  https://doi.org/10.1097/INF.0000000000001668  PMID: 28661963 
  27. Lang M, Mirand A, Savy N, Henquell C, Maridet S, Perignon R, et al. Acute flaccid paralysis following enterovirus D68 associated pneumonia, France, 2014. Euro Surveill. 2014;19(44):20952.  https://doi.org/10.2807/1560-7917.ES2014.19.44.20952  PMID: 25394254 
  28. Pariani E, Pellegrinelli L, Merlone AD, Piralla A, Baldanti F, Binda S. Letter to the editor: Need for a European network for enterovirus D68 surveillance after detections of EV-D68 of the new B3 lineage in Sweden and Italy, 2016. Euro Surveill. 2017;22(2):30440.  https://doi.org/10.2807/1560-7917.ES.2017.22.2.30440  PMID: 28106530 
  29. Weil M, Shulman LM, Heiman S, Stauber T, Alfandari J, Weiss L, et al. Prolonged excretion of type-2 poliovirus from a primary immune deficient patient during the transition to a type-2 poliovirus-free world, Israel, 2016. Euro Surveill. 2016;21(47):30408.  https://doi.org/10.2807/1560-7917.ES.2016.21.47.30408  PMID: 27918258 
  30. World Health Organization (WHO). Seventieth World Health Assembly A70/14 Provisional Agenda item 12.3. Poliomyelitis. Geneva: WHO; 2017. Available from: http://apps.who.int/gb/ebwha/pdf_files/WHA70/A70_14-en.pdf

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