Polio in Pakistan--A public health event of international concern with implications for travellers' vaccination.

As well as describing the huge inroads made globally towards the eradication of polio, Mushtaq and colleagues explore, in their compelling review, the challenges and frustrations of Pakistan's strategies to contain and eradicate polio circulation by vaccination and to stop the international spread to vulnerable areas by those exiting the country. They show the difficulties of implementing polio eradication measures where there is mistrust of government intentions and other negative factors such as resistance to vaccination on religious grounds and civil conflict. These circumstances may be difficult to comprehend for those of us living in countries that have been polio-free for decades and where polio vaccination uptake is generally well accepted and high [2]. Is this relevant for public health and travel? Yes, the situation in Pakistan impacts directly on us all; Pakistan remains one of two countries where wild poliovirus (WPV) has never been eradicated. To date, while there has been no exportation of WPV from Pakistan since October 2014, Pakistan has had 85% of all global WPV cases in 2015, and therefore travellers to Pakistan remain at risk of exposure to WPV, and polio-free countries remain at risk for imported cases . In recent years, for example, imported WPV from Pakistan has been reported in sewage samples in Egypt, Israel, the West Bank and Gaza, and caused outbreaks in Iraq and Syria. WPV has also been exported from Pakistan to Australia by a traveller who visited friends and relatives in Pakistan.

In 2014, an Emergency Committee was convened by the World Health Organization (WHO) in response to the worrying situation regarding the number of cases of WPV globally and the potential for the virus to spread. In May 2014 the WHO declared the international spread of WPV to be a Public Health Event of International Concern (PHEIC) under International Health Regulations (IHR 2005) Temporary recommendations were issued (summarised in Table 1) forming a strategy to reduce the potential for spread of WPV from infected countries