WHO-EM/POU44/E/L Distribution: Limited
Keport on the
FIRST INTERCOUNTRY SUBREGIONAL (NORTH AFRICA) MEETING ON PKEVBN'I'ION OF CROSS-BOKD&H
TRANSMISSION OF WILD POLIOVIRUS Tunis, Tunisia, 15-1 6 July 1997
'
World Health Organization Regional Office for the Eastern Mediterranean Alexandria, Egypt
1998
O World Health Organization 1998
This document is not issued to the general public and alf rights are reserved by the World Health Organization (WHO). The document may not be reviewed, abstracted, quoted, reproduced or translated, in part or in whole, without the prior written permission of WHO. No part of this document may be stored in a retrieval system or transmitted in any form or by any means--electronic, mechanical or other-without the prlor written permission of WHO. The views expressed in documents by named authors are solely the responsibility of thosc authors.
CONTENTS 1 . INTRODUCTION ..........................................................-........................................ 1
2 . GLOBAL OVERVIEW OF POLIOMYELITIS ERADICATION ............................. 2 3 . REGIONAL OVERVIEW OF POLIOMYELITIS ERADICATION
........................2 3
4 . ERADICATION OF POLIOMYELITIS IN ALGERIA ............................................
5 . ERADICATION OF POLIOMYELITIS I N MOROCCO .........................................4
6. ERADICATION OF POLIOMYELITIS IN THE LIBYAN ARAB JAMAHIRIYA . 5 7. ERADICATION OF POLIOMYELITIS IN TUNISIA ..............................................5
8. RECOMMENDATIONS ....................................................................................
6
Annexes I . PROGRAMME ........................................................................................... 9 2. LIST OF PARTICIPANTS ............................................................................ 1 1 3 . FORMAT FOR ANALYSIS AND REPORTING AFP SURVEILLANCE
DATA ON A QUARTERLY BASIS DIRECTLY TO CONCERNED BOKDEKlNCi COUNI'KIES AND TO WHO AN11 UNICEF
REGIONAL OFFICES ........................................................................... 14 4 . BORDER ZONES FOR COORDINATION TO PREVENT POLIOMYELITIS TRANSMISSION BETWEEN MAGHREB 15 COUNTRIES ..........................................................................................
WHO-E M/POU44/E/L
1.
INTRODUCTION
The First Intercountry Sub-Regional (North Africa) Meeting on Prevention of CrossBorder Transmission of Wild Poliovirus was held in Tunis, Tunisia, from 15 to 16 July 1997. The meeting was attended by national EPI managers and disease surveillance staff from Algeria, Libyan Arab Jamahiriya, Morocco and Tunisia, and directors of national poliovirus laboratories in Algeria and Morocco and the Regional Reference Laboratory in Tunisia. The meeting was also attended by staff from WHO headquarters and the Eastern Mediterranean Regiu~lal Off~ce (EMRO), UNICEF ~ o u n t r y ufficeb ar~d rcprescntalivcs from Rotary International (list of participants is attached in Annex 2). The meeting was opened on behalf of the Minister of Public Health of Tunisia, Dx ElHedi M'henni. In his message, the Minister welcomed all the participants to Tunis on behalf of the government of Tunisia. The Minister stressed the importance and value of the global and the regional goal to eradicate poliomyelitis by the year 2000. He expressed his appreciation of the progress that had been made towards this goal in the Region and urged the participants to continue their admirable efforts to ensure that the eradication of poliomyelitis
from the Eastern Mediterranean Region and other regions. He acknowledged the critical challenge of cross-border wild poliovims transmission, especially into areas of North Africa that have been poliomyelitis-free for a number of years, and higl~lightedthe il~lpor~arice of
.
close collaboration and coordination between the countries concerned, WHO, UNICEF and other partner agencies. He thanked WHO for its support to the regional poliomyelitis eradication initiative in general, and for convening this meetrng in particular. Dr Taky Gaafar, Regional Adviser, Vaccine Preventable Diseases and Immunization, WHO/EMRO, delivered a message fi-om Dr Hussein A. Gezairy, WHO Regional Director, for the Eastern Mediterranean. In his message, Dr Gezairy welcomed all the participants to the meeting and extended his sincere thanks to the Government of Tunisia He acknowledged
with pleasure the participation in the meeting of the main partners in poliomyelitis eradication-national disease control and laboratory staff, WHO, UNICEF and Rotary IntcrnationaI.
In his brief account of the overall progress in the Eastern Mediterranean Region towards poliomyelitis eradication Ur Ciezairy highlighted the recent improvements in regional OPV3 coverage, implementation of high quality national immunization days (NIDs) in all but two Member States and establishment of effective systems for acute flaccid paralysis (AFP) surveillance in most countries of the EMR. He expressed his appreciation of the progress in the four countries represented in the meeting, particularly in achieving more than 90% OPV3 coverage and conducting annual coordinated N D s . He acknowledged the high quality of AFP surveillance in Tunisia and improvements in the system in Morocco and emphasized the need for improving AFP surveillance in the Libyan Arab Jamahiriya and Algeria. In his description of the rapid decline in the incidence of poliomyelitis in the Region, Dr Gczairy pointcd out
that of the four countries represented in this meeting, Algeria was the only one that had recently reported virologically confirmed cases of poliomyelitis. He stressed the continued need for hard work to achieve poliomyeliris eradication. Referring to challenges, the Regional
WHO-EM/POU44/E5
Page 2 Director emphasized the importance of cross-border transmission between countries and regions, In this regard, Dr Gezairy pointed out the complex health, social, political, and humanitarian dimensions of the problems affecting the health of people living in borders following migration, conflicts or other pressures which necessitated special attention. He drew attention to activities already in preparation by the WHO Eastern Mediterranean Region and the European Region on the prevention of the potential risk of cross-border transmission of wild poliovirus and to the subsequently planned meeting to address cross-border transmission in the areas around the borders between Iraq, Turkey, Islamic Republic of Iran and Syrian Arab Republic. Finally, Dr Gezairy emphasized the importance of the meeting pointing out to the potential of cross-border transmission as evidenced by recent wild poliovirus isolation from the area around the border between Algeria and Tunisia. He calIed on the participants to develop a joint plan of action to prevent cross-border transmission of wild poliovirus in the Maghrebian countries. 2.
GLOBAL OVERVIEW OF POLIOMYELITIS ERADICATION
As a result of the extensive activities in poliomyelitis eradication globally, only 3995 poIiomyelitis cases were confirmed in 1996, compared with over 35 000 cases in 1988. The geographic distribution of cases is changing also. In the WHO African Region, surveillance is improving remarkably, and the impact of the I996 NIDs will soon be apparent. The African Rggion reported 1670 cases in 1996, i.e. 49% of the global total. The Southeast Asia Region, with 938 cases reported in 1996, now accounts for only 27% of the global total. This results from a 70% decline in cases reported from India, which had previously accounted for more than half the cases reported worldwide. In the wake of the Albanian outbreak, the number of cases in the European Region has remained static at about 200 cases. In the Eastern Mediterranean Rcgiun, wiId poliovii us LI ansulissiun still occurs in Egypt, cvu~ltriesof thc Horn of Africa, Yemen, Iraq, Islamic Republic of Iran, Afghanistan and Pakistan. In the Western Pacific Region, wild poliovirus transmission is apparently confined to the Mekong delta in Cambodia and Viet Nam. The American Region continues to be free of endemic transmission. 3.
REGIONAL OVERVIEW OF POLIOMYELITIS ERADICATION
The number of confirmed cases of poliurnyelili5 repurted in t l ~ r Eastelrl Mediterrarlean Region decreased 33%, from 789 in 1995 to 532 in '1996. This decline in reported cases occurred mainly through NIDs conducted in 20 Member States in 1996 and improved AFP surveillance and control in many countries. Despite a marked decrease in the number of cases reported between 1993 and 1996 (1803 and 341 cases, respectively), Pakistan continues to report the most cases of any country in the Region. Poliomyelitis control in Pakistan is critical to the success of both the regional and global poliomyelitis eradication initiative, since several poliomyelitis outbreaks in the Eastern Mediterranean Region and other WHO Regions have been linked to importation of
WHO-EM/POU44/E/L Page 3 wild poliovirus from the Indo-Pakistan subcontinent. Egypt reported 100 labaratory confirmed
cases, Sudan 5 1 cases, Iraq 2 1 cases, Islamic Republic of Iran 12 laboratory-confirmed cases and Yemen 7 cases. In 1996, the Regional average of coverage with at least three doses of OPV by one year of ages was 85%, showing an increase compared with 1994 and 1995 coverage (78% and 80% respectively). Of 21 Member States reporting in 1996, 17 (73%) reported OPV3 coverage more than or equal to 90%. During 1996, a11 Member States except Afghanistan, Djibouti and Somalia conducted NIDs, compared with only five countries in 1994. Most of the Member States achieved high (above 95%) coverage of the target age group of under five years of age. To maximize the impact of NIDs, neighbouring countries coordinated activities so that NIDs were implemented simultaneously. The most impressive results were achieved under Operation MECACAR (above 95%), a joint EuropeardEastern Mediterranean initiative in central Asia. All Member States with the exception of Afghanistan, Somalia and Yemen have established AFP surveillance. However, the quality of these systems in the Region remains highly variable. Eight member states (Bahrain, Islamic Republic of Iran, Jordan, Kuwait, Oman, Saudi Arabia, Syrian Arab Republic, Tunisia) have achieved or exceeded the minimum required sensitivity for detecting and reporting cases nf non-pnliomyelitis AFP (1 case per .A
100 000 children younger than 15 years). The overall regional average rate for nonpoliomyelitis AFP in 1996 was 0.71 case/100 000 with a wide range (0 to 1.51100 000). Laboratory-based surveillance for wild poliovirus in the Eastern Mediterranean Region, the core component of AFP surveillance, also made substantial progress in 1996. AFP cases from 16 member states were investigated in the Kegtonal Poliomyelitis Laboratory Network. Of the 1774 AFP cases reported in the Eastern Mediterranean Region during 1996, 1642 (93%) were investigated in network laboratories. The laboratory performance indicators continued to improve during 1996. Isolation of wild poliovirus type 1 has been documented in Egypt, Pakistan and Islamic Republic of Iran. 4.
ERADICATION OF POLIOMYELITIS IN ALGERIA '
The poliomyelitis eradication programme svas launched rn 1993. The first NIDs were conducted in 1993 and 1994 using, OPV for the first time. Poliomyelitis incidence decreased since these NIDs. Subnational immunization days were conducted in 1986, 1987 and 1988. In 1994 the Ministry of Health made recommendations for clinical and virological surveillance. Only one case was reported in 1993, two in 1994, one in 1995 and one in 1996. No intratypic differentiation was made for isolates from 1993 and 1994 The isolate in 1995 was type 3 and
that of 1996 was type 1.
WHO-EM/POY44/EL
Page 4 One of the main difficulties in preventing wild poliovirus transmission is the length and the permeability of borders in the country and population movements. The geographical distribution of wild poliovirus shows that all cases are localized in border regions, particularly around the Tunisian and Libyan borders. These regions have maintained high coverage both for routine immunization and during the NIDs in 1995 and 1996. Performance indicators show a clear improvement, although performance is still inferior to the objectives. The main problems in surveillance include: The main university hospitals do not report AFP cases. No line listing of AFP cases occurs at district and provincial levels. There is no system for monitoring data reported. AFP investigation forms are incomplete. Stools are not collected as recommended. The national laboratory has not been appointed the national reference laboratory and specimens are sent to the Pasteur Institute, Tunis, for intratypic differentiation. 5.
ERADICATION OF POLIOMYELITIS IN MOROCCO
.. The routine OPV3 coverage rate increased significantly after the restructuring of EPI into the National Programme of Immunization (NPQ in 1987 and reached 95% in 1996. The Moroccan Ministry of Public Health is committed to eradicating poliomyelitis by the year 2000 by implementing WHO recommendations. Nowadays, the NPI buys all of its vaccine through the vaccine-independent initiative of UNICEF; costs are totally paid from the govcrnmcnt budgct.
In 1987, the Ministry of Public Health started to organize NLDs for all vaccines and in 1995 NIDs against poliomyelitis started. During these NIDs the coverage rate reached 95% in 1995 and 93% in 1996. Training sessions were held to train health professionals in immunization activities, and other sessions are planned in 1997 in order to help health professionals to better implement the programme recommendations.
AFP surveillance effectively began in 1994 and improved in 1995. but has not yet rearhed the required indicative level of good performance, i.e. 1 case/100 000 children < I5 years of age. The National Reference Laboratory was accredited in 1994 and since then has improved its indicators with respect to proficiency testing, enterovirus isolation and turn-around time. Intratypic differentiation of the poliomyelitis isoIate is carried out' at the regional poliomyelitis laboratory in Tunisia (Pasteur Institute).
WHO-EM/POU44/E/L Page 5 The main priority of the national programme is to strengthen AFP surveillance by training all health professionals involved in epidemiological surveillance, including those working at university hospitals and in the private sector,
Supervision, monitoring and evaluation are very important activities for improving NPI activities and AFP surveillance, but help and financial support from international organizations is needed. 6. ERADICATION OF POLIOMYELITIS IN THE LIBYAN ARAB JAMAHIRiYA
There have been no poliomyelitis cases in the Libyan Arab Jamahiriya since the first half of 1991. a
The national routine coverage by immunization against the targeted disease and hepatitis B is approaching 96%. The surveillance system has just started by training 13 health inspectors, who in return wiIl supervise the surveillance activities in their districts There is no virology laboratory in the country and it has been decided by the Secretary, General People's Committee for Health and Social Security, that a virology laboratory is to be established as soon as possible. Currently notification concerning AFP is made by the district to headquarters, but the system is still weak. Immigration from neighbouring countries remains a problems, and the General People's Committee for Health and Social Security has enforced check-up points at the frontiers.
7 .
ERADICATION OF POLIOMYELITIS IN TUNISIA
Poliomyelitis eradication activities implemented in Tunisia had a significant impact on OPV immunization coverage and AFP surveillance. During 1996, OPV3 immunization coverage increased above 90% and the non-poliomyelitis AFP rate increased from 1.37 to 1.5 per 100 000 children below 15 years of age. However, surveillance should be strengthened, especially it] the area of stool specimen . collection, as only 44% of AFP cases had adequate stool samples collected. The 1996 quarterly report shows a real improvement in the third and fourth quarters: this indicator
increased to 67% and 100% respectively. In addition, Tunisia organized NIDs during 1995 and 1996 and is planning NIDs in November 1997. This supplemental immunization helped to immunize 1 034 168 children in the first round in 1996, and 1 104 566 children in the second round. All these efforts helped to
WHO-EM/POU44/E/L Page 6
achieve and maintain an important reduction of poliomyelitis incidence as no cases of poliomyelitis have been reported since January 1997.
8.
RECOMMENDATIONS
General 1.
All countries in the subregion should continue to conduct NIDs targeting children under 5 years of age. Based on evaluation of NIDs, countries should identify high-risk populations and children missed by the routine programme and previous campaigns and target special efforts to reach them during subsequent NIDs. Countries that have achieved suboptimal NID coverage during previous campaigns should determine the reasons for the low coverage and take corrective measures to achieve uniformly high coverage of all target children in each round. All countries should review their epidemiological situation with respect to poliomyelitis eradication. Based on this evaluation countries should consider implementing additional supplementary immunization activities on an annual basis in high-risk areas. Definition of high-risk may include areas with routine immunization coverage below the national average, areas with populations Iikely to facilitate introduction or sustained wild poliovirus transmission following introduction or areas bordering poliomyelitis-endemic countries. All countries should regularly analyse their AFP surveillance monitoring indicators (see Annex 3) and continue to improve the surveillance system through increasing sensitivity
2.
-3. of case detection , rapid reporting and improving quality of case investigation and follow up. 4. The existing coordination in poliomyelitis eradication activities between the Maghrebian countries (Algeria, Libyan Arab Jamahiriya, Mauritania, Morocco and Tunisia) should continue. Special attention should be given to coordination of activities in border areas, Although routine collection of contact specimens is no longer recommended, contact specimen collection should still be considered in high risk areas, or when specimens are collected late fiom a clinically or epidemioIogically suspicious index case.
5.
Border areas
6.
Coordination of poliomyelitis eradication activities should begin immediately in the border areas mutually agreed upon by Algeria, Libyan Arab Jamahiriya, Morocco and Tunisia (Annex 4). Special efforts to strengthen A F P AsurveiLlance and improve immunization coverage should be focused on these areas.
WHO-EM/POU44/E/L
Page 7 7.
Based on analyses of AFP surveillance data (see recommendation 3 abovc), any additional areas (districts/governorates/regions)identified as "high risk" for crossborder poliovirus transmission should be included in coordination of cross-border activit~es.
8.
Each country should provide AFP surveillance data from the border areas in the agreed format on a quarterly basis (Annex 3). These data should be sent directly to the concerned bordering countries and to WHO and UNICEF Regional offices. To monitor sharing of information, WHO Regional Ofices should ensure these data are summarized and distributed annually. Detailed epidemiological information on each shared ("cross-border") AFP case should be immediately provided to the countries concerned and partner agencies (WHO and UNICEF). The countries concerned should ensure local level cross-border coordination so that all such cases are completely investigated, including timely collection of stool samples from cases and contacts, active search for additional cases and 60-day follow up examination. If wjld poliovirus is isolated from a case or its contacts in any country, the case should be urgently notified through official channels to all the countries and regional offices of WHO. Additionally: an emergency meeting of key persons should be convened through WHO, with
9.
10.
participation from the countries concerned and the UN and other international agencies to discuss the appropriate measures and responsibilities -
a plan should be made to obtain political commitment and identify the resources required for the response prompt and complete additional virological investigations should be ensured.
-
Supplementary immunization campaigns 11
To ensure maximal ~affect and achieve high coverage cnuntries in the subregion should:
-
strengthen coordination and conduct Nms on similar dates annually make special efforts to ensure the immunization of border area populations include a unlform target age group (all chlldren under 5 years of age)
use joint social mobilization through mass media, such as popular television channels, for dissemination of information and common social rnobilizatjon messages.
W H O - E m 0U44/E/L Page 8 -
facilitate planning and coordination of all supplementary immunization activities between local-level focal points across border areas.
- .-
Monitoring of cross-border coordination 12.
Focal points to monitor coordination of activities in border areas shol~ld be identified in
each country with the following responsibilities:
-
to review all aspects of poliomyelitis eradication in border areas
-
to monitor progress in coordination of joint poliomyelitis eradication activities in border areas to review all border area AFP cases and refer selected cases for further review by experts to identifjr resource requirements f o r cross-border activities
-
-"
to review the communication network between the countries to report on all activities during the annual Maghrebian MCH meeting and annual meeting of the EPI managers in the Eastern Mediterranean Region.
Title of focal points should be provided to EMRO as soon as possible.
WHO-EMA'OU44/E/L. Page 9 Annex 1
PROGRAMME Tuesday, I S July 1997 08:30-09:00 09:00-09:30 Registration
Opening session Message of Regional Director, UNICEFMENARO Message of Regional Director, WHO/EMRO the Minister of Public Health, Message of H.E. Tunisia Global overview of poliomyelitis eradication Discussion Regional overview on poliomyelitis eradication Discussion Progress towards poliomyelitis eradication in participating countries (Algeria, Libyan Arab Jamahiriya, Morocco, and Tunisia) Discussion Importation and cross border transmission of wild poliovirus-strategies for high-risk areas - global experience Dr Jean-Marc OlivC, WHOMQ Dr Taky Gaafar, W P I Country representatives
10:00-10:30
10:30-11:OO
11:00-12:OO .A
13:00-14:30
DLJean-Mac Olivk, WHO/HQ Dr Hamid Jafari, Medical Officer/Poliomyelitis,
- regional experience
EMRO - national experience (Algeria, Libyan Arab Jamahiriya, Morocco, Tunisia) Discussion
Country representatives
14:30-15:OO
Briefing on small working group session objectives, task and assignments
Dr Hamid Jafari, Medical O~cer/Poliomyelitis, EMRO
WI10-EM/rOU44/EL Page 10
Wednesday, I16 July 1YY7 08:OO-12300
Group work* Working group presentation Discussion
10:30-12:OO
12:OO-13:30
Conclusion and recommendations Closing session
* OBJECTIVES: Objective I :
Identify border areas within each country that require special immunization and AFP surveillance activities. Define strategies and mechanisms for coordinating AFP surveillance in border areas.
Objective 2:
Objective 3: -' Objective 4:
Define local and national level logistics for NIDs/SNIDs and mopping-up Determine key policy issues and mechanisms for coordination of poliomyelitis eradication activities in border areas.
Working Groups
Group I : Policy and coordination of activities and surveillance Participants:
Algeria Tunisia Libyun Arub Jurnuhiriyu Morocco
Director of Preventive Health, Surveillance Coordinator EPI Manager, Surveillance Coordinator Direclur of Prevenlivt: Health
EP1 Manager
Group 1 1 :Local level logistics for NIDsISNIDs and mopping-up activities
Participants: Morocco Libynn Arab Jamahiriya Tunisia Algeria
Director of Preventive Health, Surveillance Coordinator EPI Manager, Surveillance Coordinator Director of Preventive Health . EPI Manager Two WHO technical staff
WHO-EM/POU44/E/L Page 11 Annex 2
LIST OF PARTICIPANTS ALGERIA Dr Djarnel Fourar National EPI Manager Ministry of Health Algiers
Dr Houria Hamimed Poliomyelitis Survey unit
Ministry of Health Algiers Dr Mohamed Segheir Responsible Officer Algerian Poliomyelitis Laboratory Algiers
-i
LIBYAN ARAB JAMAHIRIYA Dr Ibrahim Ali Jabail Director of Primary Health Care General People's Committee for Health and Security Tripoli Dr Sulieman S. Abusreweil National EPI Manager General People's Committee for Health and Security Tripoli
MOROCCO Dr Ahmed Zidouh Chief of Epidemiological Surveillance Directorate of Epidemiology and Disease Control Ministry of Publrc Health Rabat
Dr Rajae El Aouad Emmunology Laboratory National Institute of Hygiene Rabat
WHO-EM/'POU44/E/L
Page 12
Mr M'hamed Braikat EPI Manager Directorate o f Population Ministry o f Public Health Rabat
TUNISIA Dr Naceur Kame1 Deputy Director Basic Health Care Ministry of Public Health Tunis
Dr Ezzedine El Mohsni EPI Programme Manager Ministry of Public Health
Tunis Dr Mohanied Ben Ghorbal
Responsible Oficer, Surveillance Ministry of Public Health Tunis Dr Hinda Triki Director of Regional Reference Laboratory Tunis
NONGOVERNMENTAL ORGANIZATIONS ROTARY INTERNATIONAL Dr Hedi Briki President, Natlonai Poliomyelitis Plus Committee Tunis TUNISIA
UNICEF Dr Kame1 Ben Abdallah Project Off~cer
UNICEF, Tunisia
WHO-EMPOU44WL. Page 13 Ms Yanina Bouguermouh Programme Assistant UNICEF,Algeria
WHO SECRETARIAT Dr Taky Gaafar, Regional Adviser, Vaccine Preventable Diseases and Immunization WHO/EMRO Dr Hamid Jafari, Medical Oficer, Poliomyelitis Eradication WHO/EMRO Dr Jean-Marc OlivC, Medical Oficer, Global Programme on Immunization WHO/HQ Dr L. Belgharbi, Technical Officer, Global Programme on Immunization, WHOMQ
Dr Youcef Ait-Chellouche, WHO Representative, Algeria Liaison Officer Ms Engy Hamdy, Secretary, WHO Regional Ofice for the Eastern Mediterranean
Annex 3 Format for analysis and reporting AFP surveillance data on a quarterly bad$ directly to concerned bordering cou regional offices I
Country: Area
Year: Border with (2)
Quarter: Population
OPV3 (4)
NID Coverage (5)
(1)
(3)
Round 1st 2nd
Expected Reported 2 adequatb Poiio c aon-polio non-polio stools AFP AFP (8) (6) (7) 9.1
1
I I Districtlprovincelgavernonte Any country the area borders Total population ofchildren under I5 years of age Routine OPV3 coverage rate (Sb) for the previous year OPV immunization covcrage (%) achieved during the last two rounds of the previous NlDs Number of non-poliomyelitis AFP cases among childr:n aged <I5 years estinated to occur during the current year Curnularive number of non-poliomyelitis AFP cases among children aged <I5 years reported upto cate Curnulalive number of AFP cases with two adequate s:ool samples Curnulalive number of poliomyelitis-compatible cases, except for 9. I and 9.2 where the annual total must be indicated 9.2 Currcnt ycar (-I), 9.3 Current year [If current year is 1997 then year (-1) = 1996 and year (-2) = 19951 9.1 Currcnl year (-2), Curnulativc number of cases from whom wild poliovirus was isolated 10.2 Currcnt ycar (-I), 10.3 Current year [If current year is 1997 then year (- 1) = 1996 and year (-2) = 19951 10.1 Current year (-2),
WHO-EM/POU44/EL Page 15
Annex 4 BORDER ZONES FOR COORDINATION TO PREVENT POLIOMYELITIS TRANSMISSION BETWEEN MAGIIREB COUNTRTES
Ain Temouchent