title: The recent outbreaks and reemergence of poliovirus in war and conflict-affected areas.
abstract: BACKGROUND
  Poliomyelitis is a highly infectious disease caused by poliovirus, which becomes difficult to manage/eradicate in politically unstable areas. The objectives of this study were to determine the movement and management of such polio outbreaks in endemic countries and countries with reoccurring cases of polio and to determine the effect of political instability on polio eradication.
  
  
  METHODS
  In this study, the extent of polio outbreaks was examined and modeled using statistical methodologies and mapped with GIS software. Data on polio cases and immunization were collected for countries with polio cases for the period 2011 to 2014. Weekly data from the Global Polio Eradication Initiative were collected for selected countries. The recent virus origin and current movement was mapped using GIS. Correlations between immunization rates, the Global Peace Index (GPI), and other indicators of a country's political stability with polio outbreaks were determined. Data were analyzed using SAS 9.4 and ArcGIS 10.
  
  
  RESULTS
  For several reasons, Pakistan remains highly vulnerable to new incidences of polio (306 cases in 2014). Overall immunization rates showed a steady decline over time in selected countries. Countries with polio cases were shown to have high rates of infant mortality, and their GPI ranked between 2.0 and 3.3; displaced populations, level of violent crime rating, and political instability also were ranked high for several countries.
  
  
  CONCLUSIONS
  Polio was shown to be high in areas with increased conflict and instability. Displaced populations living in hard-to-reach areas may lack access to proper vaccination and health care. Wars and conflict have also resulted in the reemergence of polio in otherwise polio-free countries.
authors.affiliation: Department of Biology/Environmental Science, Jackson State University, 1400 JR, Lynch Street, JSU Box 18540, Jackson, MS 39207, USA.
authors.forename: Luma
authors.initials: L
authors.lastname: Akil
authors.affiliation: Department of Biology/Environmental Science, Jackson State University, 1400 JR, Lynch Street, JSU Box 18540, Jackson, MS 39207, USA. Electronic address: Hafiz.a.ahmad@jsums.edu.
authors.forename: H Anwar
authors.initials: HA
authors.lastname: Ahmad
mesh_terms: D000349:Africa / Q000453:epidemiology; D004196:Disease Outbreaks / Q000517:prevention & control; D005260:Female; D014943:Global Health; D006801:Humans; D015994:Incidence; D007223:Infant; D008297:Male; D008877:Middle East / Q000453:epidemiology; D011051:Poliomyelitis / Q000453:epidemiology* / Q000517:prevention & control; D017955:Poliovirus / Q000302:isolation & purification / Q000502:physiology; D011055:Poliovirus Vaccine, Oral / Q000008:administration & dosage; D011159:Population Surveillance; D014611:Vaccination; D014857:Warfare
chemical_list: D011055:Poliovirus Vaccine, Oral
keywords: GIS; Polio vaccination; Poliomyelitis; War zones