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Psychometric properties of the Walking Impact Scale (Walk‐12) in persons with late effects of polio | PM&R.

[Pay to View Full Text] [Manuscript received: 06 February 2020; Manuscript revised: 01 May 2020; Manuscript accepted: 06 May 2020; Accepted manuscript online: 15 May 2020]


Background: Many persons with late effects of polio (LEoP) perceive walking limitations in everyday life. A common rating scale to assess walking limitations is the Walking Impact Scale (Walk-12). However, there is limited knowledge about its psychometric properties.

Objective: To investigate the psychometric properties of Walk-12 in persons with LEoP.

Design: Rasch model analysis of cross-sectional data.

Setting: University Hospital.

Participants: A total of 325 persons with LEoP (175 women; mean age 70 ± 10 yr).

Main outcome measurement: The Walk-12, comprising 12 items with five response categories ranging from 1 (not at all) to 5 (extremely).

Methods: Data of Walk-12 were collected by a postal survey. The Rasch model analysis was used to analyze unidimensionality of the scale, local dependency, targeting, hierarchical order of items, Differential Item Functioning (DIF), response category functioning and reliability (Person Separation Index, PSI). Raw score transformation to interval measurements was also performed.

Results: The analysis revealed that Walk-12 was multidimensional and suffered from some local dependency. Targeting was compromised among persons with less and worse walking limitations. Hierarchically, the most difficult item to perform was "running" and the easiest was "walking indoors with support". There was a minor DIF for gender in one item ("support when walking outdoors"). Reliability was high (PSI = 0.94). Disordered response category thresholds were found for three items; when merging the middle response categories for these items model fit slightly improved and unidimensionality was achieved.

Conclusion: The Walk-12, in its current version, does not fully meet the rigorous psychometric Rasch measurement standards in persons with LEoP. Further development of the scale is warranted, including merging response categories and complementing Walk-12 with objective measures of gait in order to improve targeting. As these limitations can be considered minor, the current version of Walk-12 can still be useful for research and clinical practice. This article is protected by copyright. All rights reserved.

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Severe Acute Flaccid Myelitis Associated With Enterovirus in Children: Two Phenotypes for Two Evolution Profiles? | Frontiers in Neurology.

[Open Access] [Received: 20 January 2020; Accepted: 07 April 2020; Published: 28 April 2020]


Acute flaccid myelitis (AFM) is an acute paralysis syndrome defined by a specific inflammation of the anterior horn cells of the spinal cord. From 2014, worrying waves of life-threatening AFM consecutive to enterovirus infection (EV-D68 and EV-A71) have been reported. We describe 10 children displaying an AFM with an EV infection, the treatments performed and the 1 to 3-years follow-up. Two groups of patients were distinguished: 6 children (“polio-like group”) had severe motor disability whereas 4 other children (“brainstem group”) displayed severe brainstem weakness requiring ventilation support. Electrodiagnostic studies (n = 8) support the presence of a motor neuronopathy associated to myelitis. The best prognosis factor seems to be the motor recovery after the first 4 weeks of the disease.

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Tracking echovirus eleven outbreaks in Guangdong, China: a metatranscriptomic, phylogenetic, and epidemiological study | Virus Evolution.

[Open Access] [Published: 10 May 2020]


In April 2019, a suspect cluster of enterovirus cases was reported in a neonatology department in Guangdong, China, resulting in five deaths. We aimed to investigate the pathogen profiles in fatal cases, the circulation and transmission pattern of the viruses by combining metatranscriptomic, phylogenetic, and epidemiological analyses. Metatranscriptomic sequencing was used to characterize the enteroviruses. Clinical and environmental surveillance in the local population was performed to understand the prevalence and genetic diversity of the viruses in the local population. The possible source(s), evolution, transmission, and recombination of the viruses were investigated by incorporating genomes from the current outbreak, from local retrospective surveillance, and from public databases. Metatranscriptomic analysis identified Echovirus 11 (E11) in three fatal cases. Seroprevalence of neutralization antibody to E11 was 35 to 44 per cent in 3–15 age groups of general population, and the viruses were associated with various clinical symptoms. From the viral phylogeny, nosocomial transmissions were identified and all E11 2019 outbreak strains were closely related with E11 strains circulating in local population 2017–19. Frequent recombination occurred among the 2019 Guangdong E11 outbreak strains and various genotypes in enterovirus B species. This study provides an example of combining advanced genetic technology and epidemiological surveillance in pathogen diagnosis, source(s), and transmission tracing during an infectious disease outbreak. The result highlights the hidden E11 circulation and the risk of viral transmission and infection in the young age population in China. Frequent recombination between Guangdong-like strains and other enterovirus genotypes also implies the prevalence of these emerging E11 strains.

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In Pakistan, missed immunisations drive new disease fears | The New Humanitarian.

[18 May 2020]

'I don't know if the coronavirus, or missing vaccinations, is more dangerous to my kid.'

A health worker checks a girl’s temperature at a COVID-19 screening and testing facility in Karachi on 21 April. Routine vaccinations have been at a standstill amid coronavirus lockdowns, doctors say. (Akhtar Soomro/REUTERS)

Imran Mukhtar, Multimedia journalist based in Islamabad, writes:

Weeks of missed immunisations could drive new outbreaks of preventable diseases like measles, according to doctors in Pakistan, who warn another health emergency is looming even as the country battles the coronavirus pandemic.

Routine immunisations have been at a standstill since late March, when the government imposed coronavirus lockdown measures that shuttered schools and public transport. Overwhelmed with COVID-19 patients, many public and private hospitals also closed the out-patient departments where newborns and mothers would normally receive immunisations.

Already, there are early signs of an uptick in vaccine-preventable diseases, doctors say.

“The government has diverted all its resources and staff to tackle the coronavirus,” said Dr. Afzal Khan Khattak, a paediatrician and provincial president for the Pakistan Paediatric Association in northwest Khyber Pakhtunkhwa Province, which has a large refugee population and poor health access. “We are already receiving increasing cases of measles.”

Public transport shutdowns have also made it difficult to reach facilities that are open, including government-run immunisation clinics known as EPI centres. Fear of contracting the coronavirus also continues to keep many parents away, though the World Health Organisation says older people generally have the highest risk.

“There is a perception among parents that children are more vulnerable to the virus,” said Dr. Anjum Qadeer, the coordinator for immunisation in Chakwal district in eastern Punjab, a province that has recorded more than a third of the country’s total cases.

To reduce the risk of inadvertently spreading the coronavirus, the WHO and global vaccine advocates have recommended that countries postpone mass vaccination campaigns, such as door-to-door polio programmes, in areas with no active outbreaks. 

“The government has diverted all its resources and staff to tackle the coronavirus.”

But they also urged routine immunisation programmes in fixed clinics and hospitals to continue. In Pakistan and many parts of South Asia, however, these routine immunisations have been “severely disrupted”, according to UNICEF.

Global health advocates have warned that more than 117 million children worldwide may miss out on measles vaccines alone as campaigns and routine immunisations get suspended. The risks are magnified in countries with already low immunisation rates. Pakistan’s routine immunisation coverage stood at 66 percent in 2018, according to a government health survey published last year – far short of the 95 percent target health experts say is needed to prevent outbreaks.

A new study by Johns Hopkins University researchers, published in The Lancet on 13 May, projects that between 42,000 and 192,000 more children worldwide could die each month due to COVID-19’s indirect impacts on health and food access – with more than one in 20 of these additional deaths related to vaccine-preventable diseases. The data projects Pakistan could face the third-highest total of additional child deaths of 118 countries measured, behind India and Nigeria. 

National health authorities say more out-patient departments and immunisation clinics have started re-opening as of 9 May, when Pakistan began to ease some of its lockdown measures. The coordinator of Pakistan’s Expanded Programme on Immunisation (EPI), Dr. Rana Muhammad Safdar, said missed vaccinations are driven by parental fears and closed public transport.

“There is no issue of service delivery from the government end,” he said.

But several doctors told The New Humanitarian that many hospital out-patient departments, or OPDs, are still closed.

“We have received no order of the government that OPDs should be opened,” said Dr. Muhammad Zubair, the medical officer at Sir Ganga Ram Hospital, one of the biggest public sector hospitals in Lahore, Punjab’s capital.

Parents fear hospital outbreak risks.

Pakistan faces a two-pronged problem in scaling up routine immunisation coverage: keeping hospitals and clinics open and accessible, and convincing parents to use them in the middle of a pandemic.

“We have to increase both demand and supply to ensure maximum coverage,” said Dr. D S Akram, a Karachi-based paediatrician and founder of the Health Education and Literacy Programme, or HELP, a non-governmental organisation working on maternal and child health.

But rising hospital worker infections – there were more than 900 coronavirus cases among Pakistani health workers as of 12 May, according to government data – have pushed some major hospitals to scale back services or close, and driven parental fears.

On 5 May, for example, the government sealed a maternal hospital and the operating room at a children’s hospital at the Pakistan Institute of Medical Sciences – Islamabad’s biggest medical university – after 15 staffers contracted the coronavirus. A separate hospital in Peshawar also closed its gynaecology unit.

“I can’t risk visiting the public sector hospital for vaccinating my child, when hundreds of doctors and health workers themselves have contracted the virus,” said Madiha Naz, a 27-year-old mother in Islamabad whose newborn child missed his scheduled vaccinations.

She said a private hospital in an upscale area of the Pakistani capital had suspended vaccinations and closed its out-patient department to discourage large crowds. Now, she plans to buy the needed vaccines herself and find a health worker to administer them.

“I can’t risk visiting the public sector hospital for vaccinating my child, when hundreds of doctors and health workers themselves have contracted the virus.”

“My child is at risk of contracting preventable diseases,” she said. “I don’t know if the coronavirus, or missing vaccinations, is more dangerous to my kid.”

It’s unclear how many children have missed immunisations since Pakistan’s coronavirus outbreak began. The EPI programme targets 7.9 million children this year, as well as the same number of pregnant women. It offers free essential vaccinations covering 10 diseases, including tuberculosis, polio, diarrhoea, pneumonia, whooping cough, tetanus, hepatitis-B, meningitis, diphtheria, and measles.

Safdar, the programme’s coordinator, said it was “difficult to ascertain” exact figures.

But Akram of HELP said between 12,000 and 15,000 children are born every day in Pakistan according to government statistics, suggesting that the number of newborns potentially missing their first immunisations for tuberculosis and polio could stretch into the hundreds of thousands.

Older children requiring vaccinations for measles, tetanus, and other diseases will have also gone without, she warned, adding that more measles cases are already being reported in Karachi’s hospitals. Pakistan, one of only three countries where polio is still endemic, has recorded 47 wild poliovirus cases this year as of mid-May – more than double the number recorded at the same point last year. The country has suspended its nationwide, door-to-door polio vaccination campaign until at least the end of May.

“All these things indicate the threat that cases of vaccine-preventable diseases among children is likely to increase,” Akram said.

How to restart immunisations.

Though re-openings of hospital out-patient departments and the government EPI centres vary across the country, health workers say they’re trying to jumpstart vaccinations as soon as possible.

“Our vaccination services were affected by the closure of the OPDs of large hospitals but now we are trying to resume our services at all EPI centres,” said Qadeer, the immunisation coordinator in Punjab’s Chakwal district, adding that many families are still not coming due to fear of the coronavirus and mobility issues.

Khattak, the paediatrician in Khyber Pakhtunkhwa, said the government could improve the situation by easing fears among parents – marking off separate spaces for immunisations in public hospitals, for example.

Dr. Asher Pervaiz, a programme officer on immunisation with the Pakistan Red Crescent Society, said the organisation’s regular 15-day vaccination programmes at EPI centres have been on hold since the start of the outbreak in March. But Red Cross vaccinators are now doing shorter, seven-day programmes, including targeting villages in two districts of southwestern Balochistan, which has seen years of instability and is one of the country’s poorest provinces.

Akram said she hoped normal immunisation schedules could get back on track within a month. But even then it could still take two months or longer for routine immunisations to catch up with the number of children who have already missed vaccinations, she said.

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UN chief renews call for COVID-19 solidarity as WHO warns ‘majority’ of world still at risk | UN News.

[18 May 2020]

A “massive” and combined effort by all countries is needed to tackle the COVID-19 pandemic, UN Secretary-General António Guterres said on Monday, as UN health agency head, Tedros Adhanom Ghebreyesus, insisted that “the majority of the world’s population remains susceptible to this virus”.

Addressing World Health Organization (WHO) Member States attending the foreshortened and virtual World Health Assembly in Geneva via videoconference, the UN chief pointed out that despite “some solidarity”, there had been “very little unity” in the global response to the new coronavirus so far.

Because of this, “a microscopic virus has brought us to our knees,” he said, before reiterating his support for the “irreplaceable” WHO.

WHO advice ‘ignored’.

“Many countries have ignored the recommendations of the World Health Organization”, the UN chief said. “As a result, the virus has spread across the world and is now moving into the Global South, where its impact may be even more devastating, and we are risking further spikes and waves.”

Likening the “sometimes contradictory” strategies adopted by countries to a global failure to address climate change, Mr. Guterres repeated his call for more nations to address the pandemic’s health impact and economic and social fallout. “Unless we control the spread of the virus, the economy will never recover”, he explained.

Support was needed “that will keep households afloat and businesses solvent”, the UN Secretary-General insisted, reiterating his call for the G20 group of nations to consider launching a stimulus package equivalent to a double-digit percentage of global GDP.

He also called for greater support through the International Monetary Fund (IMF), the World Bank Group and other international financial institutions.

WHO delivered medical supplies to fight the COVID-19 pandemic to the Republic of Congo in April 2020. , by WHO

Most vulnerable need targeted support.

The most affected individuals should receive help, Mr. Guterres explained, before singling out women, older people, children and low-wage earners, among others.

While developed countries can do this by themselves, we must massively increase the resources available to the developing world: “And we are all paying a heavy price.”

Blame game.

Acknowledging calls by some countries for an inquiry into how the new coronavirus threat spread so rapidly, the UN chief insisted that it was too early to do so.

“The lessons learned will be essential to effectively address similar challenges, as they may arise in the future”, he said. “But now is not that time. Now is the time for unity, for the international community to work together in solidarity to stop this virus and its shattering consequences.”  

‘Either we stand together, or we fall apart’.

After paying tribute to frontline health workers “who are the heroes of this pandemic”, Mr. Guterres also reiterated his support for the WHO, describing the organization as “irreplaceable” and one that needed more resources to support at-risk developing countries.

“Either we get through this pandemic together, or we fail”, he said, in a speech which also underscored the “lawless multilateral environment”, under threat from constant breaches in cybersecurity to the “ever-increasing risk” of nuclear proliferation.  “Either we stand together, or we fall apart,” he said.

300,000 lives and counting

To date, the WHO has reported more than 4.5 million cases of COVID-19 infection and more than 300,000 lives lost, Director-General Tedros Adhanom Ghebreyesus told Member States on Monday.

The infection has moved “like a bushfire”, Tedros continued, before warning that the early blood test studies consistently indicated that only between one and two people in 10, appeared to have come into contact with the disease, triggering an immune reaction shown by the existence of antibodies.

“Even in the worst-affected regions, the proportion of the population with the tell-tale antibodies is no more than 20 per cent, and in most places, less than 10 per cent”, Tedros said. “In other words, the majority of the world’s population remains susceptible to this virus.”

No country has been spared in coming to grips with the infection, he added, before noting that while some are still “bracing for the worst”, others have begun to ease lockdown measures.

Proceed with caution.

“WHO fully understands and supports the desire of countries to get back on their feet and back to work,” he said, nonetheless urging caution.

“It’s precisely because we want the fastest possible global recovery that we urge countries to proceed with caution. Countries that move too fast, without putting in place the public health architecture to detect and suppress transmission, run a real risk of handicapping their own recovery.”

UNHCR continues to support Rohingya refugees in Bangladesh during the COVID-19 pandemic.

Global health risks unwinding.

At the same time, the ongoing pandemic risks unwinding “decades of progress” against maternal and child mortality, HIV, malaria, tuberculosis, noncommunicable diseases, mental health, polio”, among other urgent health threats, the WHO chief said.

The 73rd session of the Assembly – which is the decision-making body of the World Health Organization (WHO) - is being held virtually over two days – instead of the usual two weeks, because of the COVID-19 pandemic.

Under the assembly’s cut-down agenda, country delegations are expected to deliver statements focusing specifically on the COVID-19 pandemic, with other business pushed back to later in the year.

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Donors pledge to strengthen immunization and accelerate fight against COVID-19 | GPEI.


Continued funding is crucial to respond to COVID-19, end polio and tackle other vaccine-preventable diseases.

Tahira and daughter Dua attend a routine immunization session in Punjab province, Pakistan in January 2018. It is critical that immunization delivery systems are sustained through the COVID-19 pandemic. ©WHO Pakistan/Asad Zaidi

This month, world leaders have joined together to make several important commitments to strengthening public health infrastructure during the COVID-19 response – investments that will go a long way in protecting the most vulnerable communities, including those affected by polio.

On 4 May 2020, heads of government, institutions and industry pledged USD $7.4 billion (of the USD $8 billion goal) to ensure equitable access to new tools for COVID-19 globally. The funding will support the Access to COVID-19 Tools Accelerator, which will help develop new global health technology solutions to test, treat and protect people, and prevent the disease from spreading.

A day later, several donors pledged new funding to Gavi, one of the partners of the Global Polio Eradication Initiative (GPEI), ahead of its upcoming replenishment in June 2020. This funding will not only help vaccinate hundreds of millions of children against diseases such as polio, but also ensure that immunization delivery systems are sustained through the pandemic.

The GPEI greatly appreciates outstanding donor community support for both the COVID-19 response effort and routine immunization programmes around the world.

The GPEI is continuing to do its part to support the COVID-19 pandemic, in solidarity with other health initiatives. In March, the Polio Oversight Board made the recommendation to pause polio vaccination campaigns to limit further spread of the disease. Countries extended their key polio eradication assets, like infrastructure and human resources, to support countries’ COVID-19 response efforts, while continuing essential activities. As of May, GPEI resources, including surveillance laboratories, and social mobilization and communication networks, are supporting COVID-19 response in at least 55 countries.

The pause of vaccination campaigns and the disruption of routine immunization services leaves millions of children at high risk of contracting polio, measles and other vaccine preventable diseases (VPDs). The COVID-19 pandemic has demonstrated that vaccines, against both COVID-19 and VPDs, are crucial to protecting individuals, communities and economies.

As countries continue to implement their COVID-19 response plans, WHO and UNICEF are working with emergency and immunization partners to ensure the polio infrastructure not only supports the response, but also is fully funded in alignment with the ongoing efforts to finance COVID-19. While work is ongoing to cost those requirements, the GPEI hopes that specific COVID funds will be able to contribute towards its response efforts.

It is critical that essential health services and systems, including polio eradication efforts, have necessary support during both the response and recovery phases of this pandemic. While the GPEI has extended its assets to the global COVID-19 response effort, sustaining these programmatic resources is imperative. Continued donor commitments will enable the safe and effective resumption of polio vaccination campaigns as the situation evolves.

Related resources.

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Over quarter of a million children in Libya are at risk from vaccine-preventable diseases | ReliefWeb.

[Sources: UNICEF WHO] [Posted: 18 May 2020] [Originally Published: 18 May 2020]

Joint WHO/UNICEF press release.

Tripoli, 18 May 2020 - The lives and health of over a quarter of a million children under one year of age in Libya are at risk from vaccine-preventable diseases due to critical shortages in vaccine supplies.

UNICEF and WHO are raising the alarm over severe vaccine shortages in Libya that are putting more than 250,000 children at severe risk. The situation is made worse by the continued armed conflict, the COVID-19 pandemic, disrupted health care services, regular power cuts, shortages of safe water supplies and the closure of schools and child-friendly spaces.

For the past two months, access to routine immunization services has been disrupted as a result of the COVID-19 lockdown, leading to an increased risk of a resurgence of measles and polio outbreaks. There are acute shortages of hexavalent vaccine, which protects against six diseases (diphtheria, tetanus, pertussis, poliomyelitis, haemophilus influenzae type b and viral hepatitis B). Similarly, oral polio vaccine, which is administered at birth and at nine months of age, is in critically short supply. Children in hard-to-reach and conflict-affected areas are at particular risk because they may have already missed some vaccination doses. WHO and UNICEF are also concerned that many migrant, refugee or internally displaced children may not have received their basic vaccination doses in their country of origin or may have missed the required doses in Libya.

Procurement orders for essential vaccines have been delayed because of lengthy governmental approval processes. Libya’s Expanded Programme on Immunization (EPI) was disrupted due to vaccine stockouts in 2019. With a saturated global supply chain and constraints arising from the COVID-19 pandemic, the country is likely to face an extended stockout for a second year running.

“Immunization is one of the most effective public health interventions and when routine vaccinations are missed, there is a high chance of a resurgence of a measles outbreak, other preventable diseases, and fatalities among the children”, said Mr Abdel-Rahman Ghandour, UNICEF Special Representative. “There is an urgent need to ensure an uninterrupted flow of funds for vaccine procurement to cater for the current shortfall. UNICEF renews offering its procurement services to the Government of Libya to procure WHO prequalified vaccines at competitive prices and have them delivered to Libya urgently ”,.

“WHO has successfully advocated with the health authorities for the continuation of the EPI during the COVID-19 pandemic”, said Ms Elizabeth Hoff, WHO Representative in Libya. “Although we have overcome that hurdle, we face far more serious obstacles if the vaccine supply dries up. This will place the lives of hundreds of thousands of children in Libya at risk. WHO stands with UNICEF in offering its full support to the Government of Libya to address this critical challenge.”

UNICEF promotes the rights and wellbeing of every child in everything we do. Together with our partners, we work in some of the toughest places in the world and across 190 countries and territories to translate that commitment into practical action, with a special focus on reaching the most vulnerable and excluded children everywhere. Follow UNICEF on Twitter and Facebook. For more information about COVID-19 and guidance on how to protect children and families, visit

About WHO
Under its vision of Universal Health Coverage and the right to health care for all people, everywhere, WHO works worldwide to promote health, keep the world safe, and serve the vulnerable. Its goal is to ensure that a billion more people have universal health coverage, to protect a billion more people from health emergencies, and provide a further billion people with better health and well-being. Follow WHO on Twitter and Facebook and get acccess to comprehensive resources on COVID here.

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Characterizing Environmental Surveillance Sites in Nigeria and Their Sensitivity to Detect Poliovirus and Other Enteroviruses | The Journal of Infectious Diseases.

[Open Access] [Received: 20 December 2019; Editorial decision: 02 April 2020; Accepted: 08 April 2020; Published: 09 April 2020; Corrected and typeset: 16 May 2020] [CORRECTED PROOF]



Environmental surveillance (ES) for poliovirus is increasingly important for polio eradication, often detecting circulating virus before paralytic cases are reported. The sensitivity of ES depends on appropriate selection of sampling sites, which is difficult in low-income countries with informal sewage networks.


We measured ES site and sample characteristics in Nigeria during June 2018–May 2019, including sewage physicochemical properties, using a water-quality probe, flow volume, catchment population, and local facilities such as hospitals, schools, and transit hubs. We used mixed-effects logistic regression and machine learning (random forests) to investigate their association with enterovirus isolation (poliovirus and nonpolio enteroviruses) as an indicator of surveillance sensitivity.


Four quarterly visits were made to 78 ES sites in 21 states of Nigeria, and ES site characteristic data were matched to 1345 samples with an average enterovirus prevalence among sites of 68% (range, 9%–100%). A larger estimated catchment population, high total dissolved solids, and higher pH were associated with enterovirus detection. A random forests model predicted “good” sites (enterovirus prevalence >70%) from measured site characteristics with out-of-sample sensitivity and specificity of 75%.


Simple measurement of sewage properties and catchment population estimation could improve ES site selection and increase surveillance sensitivity.

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