and political unrest, which remains one of the biggest unknowns in terms of achieving the objective of eradication by 2000.

Eradication efforts in countries where polio is endemic are proceeding. The People's Republic of China began implementing polio eradication strategies in 1991, began provincial immunization days soon thereafter, and has now carried out NIDs for 2 years in succession (1993 and 1994). Polio is at record low levels in China. WHO's western Pacific region, which includes the People's Republic of China, has a goal of eliminating polio by the end of 1995. In response to the high proportion of polio cases in India, that country is planning its first NIDs in 1995 and 1996. Some parts of Africa still lack major efforts at eradication, but at recent meetings between the United Nations Children's Fund (UNICEF), WHO, and other groups, planning for NIDs has begun.

WHO has expressed two primary concerns about the possibility of a change in polio vaccination strategies in the United States. The first is that a change in policy could undermine financial support for the global polio eradication effort. The U.S. government has been one of the principal supporters of eradication, but substantially more funds will be needed. WHO officials fear that a change to the domestic use of one or more doses of the more expensive IPV could result in reduced U.S. funding for the global effort. WHO's second concern about a strategy shift is that countries where polio is endemic might follow the lead of the United States and decrease their reliance on OPV before it is appropriate for them to do so. In the past, U.S. immunization policy has had a strong influence on physicians and public health professionals in developing countries. The WHO leadership believes that eradication of polio in countries where it is endemic can only be accomplished through mass vaccination with OPV and that a change to IPV in those countries could jeopardize the global eradication effort.

Some participants expressed the belief that, if it were made clear that the United States is considering a change only after more than 10 years without indigenous wild-type polio and that the concern is primarily one of safety rather than efficacy, the impact on other countries could be lessened. Others noted that a sequential schedule of immunization with OPV and IPV might have the least negative global impact on polio eradication efforts, because OPV would still be recommended as part of the vaccination program.



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