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>Subject:      July 24, 1998 ASCII MMWR (emb) 2 of 2

>Wild Poliovirus Transmission in Bordering Areas of Iran, Iraq, Syria,
>and Turkey, 1997-June 1998
>     The European and Eastern Mediterranean regions of the World Health
>Organization (WHO) have made substantial progress toward the goal of
>eradicating poliomyelitis by 2000 (1-3). As of June 1998, only two foci
>of known wild poliovirus transmission remained in the border areas of
>these two WHO regions: southeastern Turkey/northern Iraq and
>Tadjikistan/Afghanistan. This report summarizes progress toward
>interruption of wild poliovirus transmission in the bordering areas of
>the Islamic Republic of Iran, the Republic of Iraq, the Syrian Arab
>Republic, and Turkey.
>     Iran. Since 1992, Iran has consistently reported high routine
>vaccination coverage of infants (greater than or equal to 94%) with
>three doses of {*filter*}poliovirus vaccine (OPV3). Annual National
>Immunization Days (NIDs)* since 1994 achieved high coverage (greater
>than 98%) among children aged less than 5 years. Supplementary rounds in
>selected high-risk provinces covered approximately 3 million children in
>1996 and 1997. During October-November 1997, approximately 200,000
>children were targeted during cross-border mopping-up vaccination
>campaigns** in the three Iranian provinces bordering Turkey and northern
>Iraq (West Azarbaijan, Kordestan, and Kermanshah) (Figure 1).
>     Since 1995, the rate of reported cases of nonpolio acute {*filter*}
>paralysis (AFP) in Iran has exceeded 1.0 case per 100,000 children aged
>less than 15 years, the WHO-established minimum nonpolio AFP rate (4).
>The three border provinces achieved nonpolio AFP rates of 0.9-1.3 cases
>per 100,000 in 1997. In the same year, the percentage of persons with
>AFP from whom adequate stool specimens*** were collected was 73% in Iran
>overall and 81% in the three border provinces (Table 1).
>     The number of reported virologically confirmed cases of wild
>poliovirus was 12 in 1996, 13 in 1997, and two as of June 1998. During
>1997-June 1998, a total of 13 of 15 wild-virus associated cases were
>reported from southeastern Iranian provinces and were frequently linked
>epidemiologically to Afghanistan and Pakistan. Wild poliovirus type 1
>(P1) was isolated from one case in 1997 reported from West Azarbaijan,
>bordering Turkey and northern Iraq, and from one case in Teheran. Wild
>P1 strains isolated from Iran in 1997, including the isolate from West
>Azarbaijan, were closely related genetically to isolates obtained during
>1997 in Pakistan.
>     Iraq. Since 1995, routine OPV3 coverage in Iraq has been greater
>than 90%. Dohuk, Erbil, Ninevah, Suleymaniyah, and Tamim governorates in
>northern Iraq border with Iran, Syria, and Turkey. Since 1993, routine
>OPV3 coverage in Dohuk, Erbil, and Suleymaniyah has been 60%-70%, and
>coverage in Ninevah and Tamim has been 80%-90%. Since 1995, reported
>annual NIDs coverage has been greater than 90% in Iraq. In Erbil, Dohuk,
>and Suleymaniyah, reported NIDs coverage was 70%-80% during 1995-1997
>and greater than 80% for the 1998 NIDs. During November-December 1997,
>two rounds of cross-border vaccination in these three northern
>governorates achieved coverage of 58% and 73%, respectively.
>     Iraq reported a nonpolio AFP rate of 1.5 in 1997, compared with 0.4
>in 1996. Three of the five northern governorates (Erbil, Ninevah, and
>Tamim) met or exceeded a rate of 1.0; AFP surveillance in Dohuk and
>Suleymaniyah is not yet functional (Table 1). In 1997, adequate stool
>specimens were collected from 76% of persons with AFP nationwide and
>from 62% of persons with AFP in the northern governorates.
>     All 24 polio cases reported from Iraq in 1996 were confirmed
>clinically. Two of 28 cases reported in 1997 were confirmed by isolation
>of wild P1; one of these two cases was reported from Ninevah governorate
>in the north and was linked genetically with 1997 isolates from Mardin
>province, southeastern Turkey. As of mid-June 1998, no cases of polio or
>wild poliovirus isolates had been reported from Iraq.
>     Syria. Routine OPV3 coverage in Syria has been reported at greater
>than 90% since 1995, and high coverage (greater than 95%) has been
>achieved during annual NIDs since 1993. Supplementary rounds of OPV
>vaccination were conducted in four high-risk governorates during
>1996-1997. As part of cross-border vaccination activity during
>October-November 1997, Syria conducted extensive house-to-house
>mopping-up vaccination campaigns in selected districts of four
>governorates bordering Turkey and Iraq. In 1997, of these four
>governorates, only Aleppo reported a nonpolio AFP rate of less than 1.0
>(Table 1). In 1997, the percentage of AFP cases with adequate stool
>specimens collected was 55% overall and 78% in the four border
>governorates. No cases of polio have been reported from Syria during
>1996, 1997, and through mid-June 1998.
>     Turkey. OPV3 coverage was 79% in 1997, with substantial variation
>among the 80 provinces. In six southeastern provinces bordering Syria,
>Iraq, and Iran, OPV3 coverage increased overall in 1997, but ranged from
>8% in Hakkari to 67% in Sanli Urfa. NIDs coverage greater than 80% was
>achieved in at least 58 of 80 provinces each year during 1995-1997. In
>1998, NID coverage nationally was greater than or equal to 93% for each
>round, and in Mardin and Sanli Urfa provinces combined was 79% and 81%
>for each round, respectively. In October and November 1997, mopping-up
>campaigns were conducted in 28 provinces along the border and other
>high-risk provinces throughout Turkey, with overall reported coverage of
>greater than 80%. However, coverage was less than 80% in nine (32%) of
>the participating provinces.
>     In 1997, the nonpolio AFP rate was 0.6 overall and 1.1 in the
>border and other high-risk provinces (Table 1). Through June 1998, the
>national annualized nonpolio AFP rate was 1.1.
>     In 1997, six polio cases with wild P1 were reported in the
>southeast province of Mardin. Through June 1998, five additional cases
>with wild P1 were reported from Sanli Urfa. These isolates were
>genetically similar to the 1997 isolate from northern Iraq and the 1994
>isolates from Turkey.
>Reported by: Offices of the World Health Organization for the Eastern
>Mediterranean and European regions; Global Program for Vaccines and
>Immunization, Geneva, Switzerland. Diagnostic Laboratory for Infectious
>Diseases, National Institute of Public Health and the Environment,
>Bilthoven, Netherlands. Respiratory and Enteric Viruses Br, Div of Viral
>and Rickettsial Diseases, National Center for Infectious Diseases;
>Vaccine Preventable Disease Eradication Div, National Immunization
>Program, CDC.
>Editorial Note: Since 1995, Iran, Iraq, Syria, and Turkey have
>participated in Operation MECACAR, a concerted effort to synchronize
>NIDs among 18 contiguous countries of the European and Eastern
>Mediterranean regions (5). These four countries conducted supplementary
>vaccination campaigns in adjoining border provinces and governorates
>during October-December 1997. These coordinated efforts, along with
>improved AFP surveillance, have reduced substantially transmission of
>wild poliovirus. Within these four countries, one area of transmission
>remains in southeastern Turkey/northern Iraq.
>     Genomic sequencing data indicate that southeastern Turkey and
>northern Iraq share a common reservoir of wild P1 along their national
>borders. Challenges to polio eradication in this area include ongoing
>armed conflict, frequent population movements, difficult terrain, and
>poor access to health-care services. In addition to Turkey and Iraq,
>culturally linked population groups also reside in adjacent border areas
>of Iran and Syria. Despite improvements in AFP surveillance,
>particularly in the border governorates, wild poliovirus has not been
>isolated in Syria since 1995. Genetic analysis of viral isolates
>obtained from Iran during 1997 suggests that wild-virus-associated cases
>are associated with reintroduction of wild poliovirus from neighboring
>Afghanistan and Pakistan, where wild poliovirus circulation is still
>widespread.
>     In the border provinces of southeastern Turkey and the three
>governorates of northern Iraq, measures are being taken by the
>respective ministries of health, WHO, and United Nations Children's Fund
>(UNICEF) to increase the effectiveness of both routine and supplementary
>OPV vaccination and to strengthen AFP surveillance. Interruption of
>poliovirus transmission in this area will require high levels of
>commitment within the countries and among the coalition of partner
>agencies****. Intensive, synchronized supplementary vaccination in these
>and other border areas with poliovirus transmission is necessary to
>eliminate remaining poliovirus reservoirs.
>References
>1. CDC. Progress toward poliomyelitis eradication--Europe and Central
>Asian Republics, 1997-May 1998;47:504-8.
>2. CDC. Progress toward poliomyelitis eradication--Eastern Mediterranean
>Region, 1996-1997. MMWR 1997;46:793-7.
>3. CDC. Progress toward poliomyelitis eradication--Turkey, 1994-1997.
>MMWR 1998;47:116-20.
>4. CDC. Progress toward global eradication of poliomyelitis, 1997. MMWR
>1998;47:414-9.
>5. CDC. Mass vaccination with {*filter*}polio vaccine--Asia and Europe, 1995.
>MMWR 1995;44:234-6.
>* Mass campaigns over a short period (days to weeks) in which two doses
>of {*filter*}poliovirus vaccine are administered to all children aged less
>than 5 years, regardless of prior vaccination history, with an interval
>of 4-6 weeks between doses.
>** Focal mass campaign in high-risk areas over a short period (days to
>weeks) in which two doses of OPV are administered during house-to-house
>visits to all children in the target age group, regardless of previous
>vaccination history, with an interval of 4-6 weeks between doses.
>*** Two stool specimens collected at an interval of at least 24 hours
>within 14 days of onset of paralysis. The WHO-recommended target is
>collection of adequate stool specimens from at least 80% of persons with
>AFP.
>**** WHO, UNICEF, Rotary International, U.S. Agency for International
>Development, CDC, and other national and international organizations.

>Behavi{*filter*}Risk Factors Among U.S. Air Force Active-Duty Personnel, 1995
>     Preventive medicine and public health policymakers need data to
>assess health-promotion efforts, track progress toward meeting national
>health goals, and focus interventions. To collect such data for U.S. Air
>Force (USAF) personnel, USAF's Office for Prevention and Health Services
>Assessment conducted a pilot project to measure the prevalence of
>behavi{*filter*}risk factors and preventive health practices. Core questions
>were used from CDC's Behavi{*filter*}Risk Factor Surveillance System (BRFSS).
>Minor changes were made to selected questions from the 1995 survey
>instrument. This report summarizes the results of the survey, which
>indicate that USAF personnel met several of the national health
>objectives. In addition, the report documents that a surveillance system
>designed to assess health behaviors and practices among the general
>population can be successfully adapted for a survey of a special
>population.
>     A stratified, random sample of all active-duty USAF personnel was
>selected, but the sampling frame excluded members in training, members
>in classified duty locations, members pending relocation, and general
>officers. After stratifying by echelon (major command), sex, and rank (a
>proxy for socioeconomic status), a random sample of 3930 members was
>selected. Members were interviewed by telephone during the workday at
>their worldwide duty locations during July-August 1995.
>Poststratification weighting (1) was used to adjust for differences in
>the sex and rank distribution between the sample and the entire USAF
>population. Data were analyzed by CDC using SESUDAAN (2). Prevalence
>estimates and 95% confidence intervals (CIs) were calculated for
>selected risk behaviors and health practices.
>     National health objectives for 2000 (3) have been set for some of
>the risk factors and preventive health measures examined. The USAF was
>considered to have met the objective if the USAF estimate significantly
>exceeded the objective level in the appropriate direction. Statistical
>significance was determined by whether the 95% CI around the USAF
>estimate excluded the objective level. Estimates for {*filter*} and smoking
>behaviors were adjusted demographically and compared with USAF results
>from the 1995 Department of Defense (DoD) Survey of Health Related
>Behaviors Among Military Personnel (4) and with findings from civilians
>in the 1994 National Household Survey on Drug Abuse (NHSDA) (5). The DoD
>survey included USAF members stationed only in the United States
>(including Alaska and Hawaii) rather than worldwide. Data for civilians
>in the NHSDA were standardized directly to the age, sex, education,
>race/ethnicity, and marital status distribution of the entire USAF in
>1995.
>     Interviews were completed for 1931 (49%) persons. Many persons were
>unavailable for interview because of deployment, base closures, or
>natural disasters. However, of the persons contacted, few refused to be
>interviewed (98% response rate). The demographic characteristics of the
>respondents did not differ meaningfully from those of the sample, except
>that the respondent population contained a slightly smaller percentage
>of members located in Europe.
>     Of the 1931 respondents, 1460 (76%) rated their health as very good
>or excellent (Table 1). Respondents reported few days during the
>previous month when their physical or mental health was not good and few
>days during the previous month when their activity was limited because
>of health problems (Table 1). Current smoking (ever smoked 100
>cigarettes and a smoker at the time of the survey) was reported by 22.4%
>of respondents. Binge drinking (five or more drinks on at least one
>occasion during the previous month) was reported by 26.2% of
>respondents, and chronic drinking (greater than or equal to 60 drinks
>during the previous month) was reported by 4.1%.
>     The USAF has met the 2000 health objectives in the following areas:
>overweight, safety-belt use, child safety-belt use, mammography and
>clinical {*filter*} examination, and Papanicolaou smears (Table 1). The USAF
>has not met the 2000 health objectives for current smoking and
>cholesterol testing (Table 1). Data were insufficient to determine
>whether the objective for child bicycle helmet use had been met.
>Reported by: AS Robbins, MD, Information, Studies, and Analysis Div,
>Office for Prevention and Health Svcs Assessment; JM Miller, DVM
>Epidemiology Svcs Br, Epidemiologic Research Div, Aerospace Medicine
>Directorate, United States Air Force, Brooks Air Force Base, Texas.
>Behavi{*filter*}Surveillance Br, Div of {*filter*} and Community Health, National
>Center for Chronic Disease Prevention and Health Promotion, CDC.
>Editorial Note: The findings in this report indicated that USAF
>personnel reported generally good health despite some days of poor
>mental health and limited activity per month. The prevalence of current
>smoking (22.4%) was lower than that reported in the 1995 DoD survey
>(26.0) and the demographically adjusted estimate reported in the 1994
>NHSDA (31.3%). Although the difference between the USAF and civilian
>populations in prevalences of current smoking is statistically
>significant, the USAF has not met the military-specific goal for 2000.
>The definition of binge drinking used in this survey was similar to that
>of heavy drinking (average of five or more drinks at a time at least
>once per week) reported by 9.4% of USAF respondents to the 1995 DoD
>survey. The prevalence of binge drinking among respondents to the 1994
>NHSDA was 12.0%. As a result, both surveys reported substantially lower
>estimates than those reported by USAF personnel in the survey described
>in this report (26%). In general, preventive health practices (e.g.,
>screening tests and the use of safety devices) were common among USAF
>members.
>     Many 2000 objectives were not set for military populations. For
>example, because the USAF has weight standards, the prevalence of
>overweight in the USAF was significantly below the national objective.
>In addition, because military security personnel strictly enforce infant
>and child safety-belt use on all military bases, the prevalence of such
>use is nearly 100% in the USAF survey.
>     The BRFSS survey instrument and methodology designed for use among
>the U.S. civilian population in home telephone interviews was
>successfully used to interview active-duty military personnel at their
>duty stations. Because each branch of the U.S. military has a complete
>listing of all active-duty personnel, probability sampling was also
>possible for this population.
>     The worldwide scope of this survey and the high mobility of
>active-duty personnel, particularly those deployed overseas, made this
>pilot project particularly challenging. For example, additional time was
>required to obtain international telephone codes, calling times were
>extended to reach personnel in overseas locations, and some personnel
>were difficult to reach because of overseas deployment. In addition, the
>exclusion of some categories of personnel was made before sampling, but
>these exclusions probably did not result in substantially biased
>estimates for several reasons. Inclusion of trainees could have biased
>the results because certain behaviors required of this group may not
>represent the usual behavior of members. At any given time, a
>substantial number of USAF members are pending relocation.
>Self-selection bias probably did not result from exclusion of these
>personnel because relocation caused by assignment changes affects all
>military members. Although the behavior patterns of general officers and
>members in classified duty locations may differ from those of other USAF
>personnel, these groups represent only a small proportion of the USAF.
>Thus, their exclusion probably did not affect the overall estimates.
>     Behavi{*filter*}risk factors in the active-duty USAF population should
>be measured continuously to enable observation of both healthful and
>deleterious trends. Objective data then become available to help
>policymakers direct resources and evaluate the effect of health
>promotion and disease prevention programs among military personnel.
>References
>1. Aday LA. Designing and conducting health surveys. San Francisco,
>California: Jossey-Bass, 1989:124-8.
>2. Shah BV. SESUDAAN: standard errors program for computing standardized
>rates from sample survey data. Research Triangle Park, North Carolina:
>Research Triangle Institute, 1981.
>3. Public Health Service. Healthy people 2000: national health promotion
>and disease prevention objectives--full report, with commentary.
>Washington, DC: US Department of Health and Human Services, 1991; DHHS
>publication no. (PHS)91-50212.
>4. Bray RM, Kroutil LA, Wheeless SC, et al. 1995 Department of Defense
>survey of health related behaviors among military personnel. Research
>Triangle Park, North Carolina: Research Triangle Institute, 1995.
>5. Substance Abuse and Mental Health Administration. National Household
>Survey on Drug Abuse: population estimates, 1994. Rockville, Maryland:
>US Department of Health and Human Services, 1995; DHHS publication no.
>SMA 95-3063.