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Surveillance for Health Care Access and Health Services Use, Adults Aged 18–64 Years — Behavioral Risk Factor Surveillance System, United States, 2014 | MMWR

Surveillance for Health Care Access and Health Services Use, Adults Aged 18–64 Years — Behavioral Risk Factor Surveillance System, United States, 2014 | MMWR



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MMWR Surveillance Summaries
Vol. 66, No. SS-7
February 24, 2017



Surveillance for Health Care Access and Health Services Use, Adults Aged 1864 Years — Behavioral Risk Factor Surveillance System, United States, 2014



Catherine A. Okoro, PhD1; Guixiang Zhao, MD, PhD1; Jared B. Fox, PhD2; Paul I. Eke, PhD3; Kurt J. Greenlund, PhD3; Machell Town, PhD1 (View author affiliations)
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Abstract

Problem/Condition: As a result of the 2010 Patient Protection and Affordable Care Act, millions of U.S. adults attained health insurance coverage. However, millions of adults remain uninsured or underinsured. Compared with adults without barriers to health care, adults who lack health insurance coverage, have coverage gaps, or skip or delay care because of limited personal finances might face increased risk for poor physical and mental health and premature mortality.
Period Covered: 2014.
Description of System: The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, landline- and cellular-telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. Data are collected from states, the District of Columbia, and participating U.S. territories on health risk behaviors, chronic health conditions, health care access, and use of clinical preventive services (CPS). An optional Health Care Access module was included in the 2014 BRFSS.
This report summarizes 2014 BRFSS data from all 50 states and the District of Columbia on health care access and use of selected CPS recommended by the U.S. Preventive Services Task Force or the Advisory Committee on Immunization Practices among working-aged adults (aged 18–64 years), by state, state Medicaid expansion status, expanded geographic region, and federal poverty level (FPL). This report also provides analysis of primary type of health insurance coverage at the time of interview, continuity of health insurance coverage during the preceding 12 months, and other health care access measures (i.e., unmet health care need because of cost, unmet prescription need because of cost, medical debt [medical bills being paid off over time], number of health care visits during the preceding year, and satisfaction with received health care) from 43 states that included questions from the optional BRFSS Health Care Access module.
Results: In 2014, health insurance coverage and other health care access measures varied substantially by state, state Medicaid expansion status, expanded geographic region (i.e., states categorized geographically into nine regions), and FPL category. The following proportions refer to the range of estimated prevalence for health insurance and other health care access measures by examined geographical unit (unless otherwise specified), as reported by respondents. Among adults with health insurance coverage, the range was 70.8%–94.5% for states, 78.8%–94.5% for Medicaid expansion states, 70.8%–89.1% for nonexpansion states, 73.3%–91.0% for expanded geographic regions, and 64.2%–95.8% for FPL categories. Among adults who had a usual source of health care, the range was 57.2%–86.6% for states, 57.2%–86.6% for Medicaid expansion states, 61.8%–83.9% for nonexpansion states, 64.4%–83.6% for expanded geographic regions, and 61.0%–81.6% for FPL categories. Among adults who received a routine checkup, the range was 52.1%–75.5% for states, 56.0%–75.5% for Medicaid expansion states, 52.1%–71.1% for nonexpansion states, 56.8%–70.2% for expanded geographic regions, and 59.9%–69.2% for FPL categories. Among adults who had unmet health care need because of cost, the range was 8.0%–23.1% for states, 8.0%–21.9% for Medicaid expansion states, 11.9%–23.1% for nonexpansion states, 11.6%–20.3% for expanded geographic regions, and 5.3%–32.9% for FPL categories. Estimated prevalence of cancer screenings, influenza vaccination, and having ever been tested for human immunodeficiency virus also varied by state, state Medicaid expansion status, expanded geographic region, and FPL category.
The prevalence of insurance coverage varied by approximately 25 percentage points among racial/ethnic groups (range: 63.9% among Hispanics to 88.4% among non-Hispanic Asians) and by approximately 32 percentage points by FPL category (range: 64.2% among adults with household income <100% of FPL to 95.8% among adults with household income >400% of FPL). The prevalence of unmet health care need because of cost varied by nearly 14 percentage points among racial/ethnic groups (range: 11.3% among non-Hispanic Asians to 25.0% among Hispanics), by approximately 17 percentage points among adults with and without disabilities (30.8% versus 13.7%), and by approximately 28 percentage points by FPL category (range: 5.3% among adults with household income >400% of FPL to 32.9% among adults with household income <100% of FPL).
Among the 43 states that included questions from the optional module, a majority of adults reported private health insurance coverage (63.4%), followed by public health plan coverage (19.4%) and no primary source of insurance (17.1%). Financial barriers to health care (unmet health care need because of cost, unmet prescribed medication need because of cost, and medical bills being paid off over time [medical debt]) were typically lower among adults in Medicaid expansion states than those in nonexpansion states regardless of source of insurance. Approximately 75.6% of adults reported being continuously insured during the preceding 12 months, 12.9% reported a gap in coverage, and 11.5% reported being uninsured during the preceding 12 months. The largest proportion of adults reported ≥3 visits to a health care professional during the preceding 12 months (47.3%), followed by 1–2 visits (37.1%), and no health care visits (15.6%). Adults in expansion and nonexpansion states reported similar levels of satisfaction with received health care by primary source of health insurance coverage and by continuity of health insurance coverage during the preceding 12 months.
Interpretation: This report presents for the first time estimates of population-based health care access and use of CPS among adults aged 18–64 years. The findings in this report indicate substantial variations in health insurance coverage; other health care access measures; and use of CPS by state, state Medicaid expansion status, expanded geographic region, and FPL category. In 2014, health insurance coverage, having a usual source of care, having a routine checkup, and not experiencing unmet health care need because of cost were higher among adults living below the poverty level (i.e., household income <100% of FPL) in states that expanded Medicaid than in states that did not. Similarly, estimates of breast and cervical cancer screening and influenza vaccination were higher among adults living below the poverty level in states that expanded Medicaid than in states that did not. These disparities might be due to larger differences to begin with, decreased disparities in Medicaid expansion states versus nonexpansion states, or increased disparities in nonexpansion states.
Public Health Action: BRFSS data from 2014 can be used as a baseline by which to assess and monitor changes that might occur after 2014 resulting from programs and policies designed to increase access to health care, reduce health disparities, and improve the health of the adult population. Post-2014 changes in health care access, such as source of health insurance coverage, attainment and continuity of coverage, financial barriers, preventive care services, and health outcomes, can be monitored using these baseline estimates.

QuickStats: Age-Adjusted Percentage of Adults Aged ≥65 Years, by Number of 10 Selected Diagnosed Chronic Conditions and Poverty Status — National Health Interview Survey, 2013–2015 | MMWR

QuickStats: Age-Adjusted Percentage of Adults Aged ≥65 Years, by Number of 10 Selected Diagnosed Chronic Conditions and Poverty Status — National Health Interview Survey, 2013–2015 | MMWR

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MMWR Weekly
Vol. 66, No. 7
February 24, 2017

QuickStats: Age-Adjusted Percentage* of Adults Aged ≥65 Years, by Number of 10 Selected Diagnosed Chronic Conditions§and Poverty Status — National Health Interview Survey, 2013–2015

* With error bars indicating 95% confidence intervals.
 Estimates are based on household interviews of a sample of the noninstitutionalized U.S. civilian population and are derived from the National Health Interview Survey Sample Adult component. Percentages were age- adjusted to the projected 2000 U.S. population as the standard population, using three age groups: 65–74, 75–84, and ≥85 years.
§ Respondents were asked about the following 10 selected chronic conditions: hypertension, coronary heart disease, stroke, diabetes, cancer, arthritis, hepatitis, chronic obstructive pulmonary disease (COPD), weak or failing kidneys during the past 12 months, and current asthma. COPD was defined as ever having COPD or emphysema or having chronic bronchitis during the past 12 months. Unless a time frame was noted, chronic conditions were based on the respondents reporting ever being told by a doctor or other health professional that they had the condition.
 Poverty status is based on family income and family size using the U.S. Census Bureau poverty thresholds. Family income was imputed where missing.
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For the period 2013–2015, 13% of adults aged ≥65 years reported having none of 10 selected diagnosed chronic conditions; 25% had one, 46% had two or three, and 16% had four or more of the conditions. No differences by poverty status were observed among those who reported having two or three conditions, but those in the lowest income group (<100% of the poverty threshold) were less likely to have none or only one of the chronic conditions compared with those in the highest income group (≥400% of the poverty threshold). Those in the lowest income group also were more likely to have four or more conditions when compared with those in the highest income group (21% compared with 12%).
Source: National Health Interview Survey, 2013–2015. https://www.cdc.gov/nchs/nhis.htm.
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Reported by: Ellen A. Kramarow, PhD, ekramarow@cdc.gov, 301-458-4325; Yelena Gorina, MPH, MS.
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Suggested citation for this article: QuickStats: Age-Adjusted Percentage of Adults Aged ≥65 Years, by Number of 10 Selected Diagnosed Chronic Conditions and Poverty Status — National Health Interview Survey, 2013–2015. MMWR Morb Mortal Wkly Rep 2017;66:197. DOI: http://dx.doi.org/10.15585/mmwr.mm6607a6.

Errata: Vol. 66, No. SS-5 | MMWR

Errata: Vol. 66, No. SS-5 | MMWR

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MMWR Weekly
Vol. 66, No. 7
February 24, 2017



Errata: Vol. 66, No. SS-5



In the Surveillance Summary “Health-Related Behaviors by Urban-Rural County Classification — United States, 2013,” errors occurred in Table 1 and Table 2. On page 5, in Table 1, under the Micropolitan column, the 95% CI values should have been (75.7–77.3) for the current nonsmoking row and (29.8–31.4) for the maintaining normal body weight row; under the Noncore column, the 95% CI values should have been (74.0–75.9) for the current nonsmoking row, (28.0–29.8) for the maintaining body weight row, and (45.7–47.7) for the meeting aerobic physical activity recommendations row. On page 6, in Table 2, errors occurred in footnotes and the table is reprinted below.
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Return to your place in the textTABLE 2Prevalence of reporting four or five health-related behaviors* among adults aged ≥18 years, by urban-rural status and selected demographic characteristics§ — Behavioral Risk Factor Surveillance System, United States, 2013

Announcement: World Birth Defects Day — March 3, 2017 | MMWR

Announcement: World Birth Defects Day — March 3, 2017 | MMWR

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MMWR Weekly
Vol. 66, No. 7
February 24, 2017



Announcement: World Birth Defects Day — March 3, 2017



Every year, approximately 3%–6% of infants worldwide are born with a serious birth defect (15). Birth defects can affect an infant regardless of birthplace, race, or ethnicity. In many countries, birth defects are among the leading causes of death for infants and young children (6). Those who survive and live with these conditions are at an increased risk for lifelong disabilities.
During the past year, birth defects have received increased attention, as researchers at CDC and worldwide have been studying the relationship between Zika virus disease and congenital Zika syndrome (7). The Zika virus disease outbreak and its effect on birth defects have highlighted the need for and benefits of international collaboration and communication about birth defects prevention.
To further raise awareness about birth defects, 33 countries joined to support World Birth Defects Day in 2016 (8). On March 3, 2016, social media presence of the hashtag #WorldBDDay reached nearly 4.8 million persons around the world.
For World Birth Defects Day 2017, the same group of partners has reconvened and invited others to join them to continue to bring attention to this global public health issue. The goals for 2017 are to raise awareness about birth defects, reduce stigma, and increase opportunities for prevention by 1) increasing the number of birth defects surveillance programs globally, 2) improving existing birth defects surveillance programs, 3) improving access to care, and 4) continuing research on the causes of birth defects.
CDC invites other organizations around the world to participate in World Birth Defects Day 2017 by sharing stories and information about birth defects using the hashtag #WorldBDDay.
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References

  1. CDC. Update on overall prevalence of major birth defects—Atlanta, Georgia, 1978–2005. MMWR Morb Mortal Wkly Rep 2008;57:1–5. PubMed
  2. Christianson A, Howson CP, Modell B. March of Dimes: global report on birth defects. The hidden toll of dying and disabled children. White Plains, NY: March of Dimes Birth Defects Foundation; 2006. http://www.marchofdimes.org/materials/global-report-on-birth-defects-the-hidden-toll-of-dying-and-disabled-children-full-report.pdf
  3. Dolk H, Loane M, Garne E. The prevalence of congenital anomalies in Europe. In: Posada de la Paz M, Groft SC, eds. Rare diseases epidemiology. Dordrecht: Springer Netherlands; 2010:349–64.
  4. Egbe AC. Birth defects in the newborn population: race and ethnicity. Pediatr Neonatol 2015;56:183–8. CrossRef PubMed
  5. Kim MA, Yee NH, Choi JS, Choi JY, Seo K. Prevalence of birth defects in Korean livebirths, 2005–2006. J Korean Med Sci 2012;27:1233–40. CrossRef PubMed
  6. World Health Organization. Congenital anomalies. Geneva, Switzerland: World Health Organization; 2015. http://www.who.int/mediacentre/factsheets/fs370
  7. Moore CA, Staples JE, Dobyns WB, et al. Characterizing the pattern of anomalies in congenital Zika syndrome for pediatric clinicians. JAMA Pediatr; 2016. Epub November 3, 2016.
  8. International Clearinghouse for Birth Defects Surveillance and Research. World Birth Defects Day. Rome, Italy: International Clearinghouse for Birth Defects Surveillance and Research; 2016. http://www.icbdsr.org/index.php/?option=com_content&view=article&id=299&Itemid=977
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Suggested citation for this article: Announcement. World Birth Defects Day — March 3, 2017. MMWR Morb Mortal Wkly Rep 2017;66:195. DOI: http://dx.doi.org/10.15585/mmwr6607a4

Notes from the Field: Francisella tularensis Type B Infection from a Fish Hook Injury — Minnesota, 2016 | MMWR

Notes from the Field: Francisella tularensis Type B Infection from a Fish Hook Injury — Minnesota, 2016 | MMWR

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MMWR Weekly
Vol. 66, No. 7
February 24, 2017



Notes from the Field: Francisella tularensis Type B Infection from a Fish Hook Injury — Minnesota, 2016



Tory Whitten, MPH1; Jenna Bjork, DVM1; Dave Neitzel, MS1; Kirk Smith, DVM1; Maureen Sullivan, MPH2; Joni Scheftel, DVM1 (View author affiliations)
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On June 27, 2016, the Minnesota Department of Health (MDH) Public Health Laboratory (PHL) was notified of a suspected Francisella tularensis isolate cultured at a hospital laboratory. The isolate was confirmed as F. tularensis type B at MDH PHL by reverse transcription–polymerase chain reaction, culture, and direct fluorescent antibody testing. Francisella tularensis subspecies tularensis (type A) and holarctica (type B) bacteria are the causative agents of tularemia.
MDH initiated an epidemiologic investigation to identify potential exposure sources and risks to additional persons. The case occurred in an immunocompetent white, non-Hispanic woman aged 67 years from Sherburne County, Minnesota. On June 18, she was fishing on a freshwater lake in northeastern South Dakota. While removing a hook from a fish, the hook penetrated the pulp of the patient’s left middle finger. On June 21, she developed pain and swelling at the site of the puncture and was seen at an urgent care center where she received an injection of ceftriaxone and was prescribed oral cephalexin. The pain and swelling did not improve, and she was seen by her primary care provider the next day. Because of concern about a possible joint infection, the patient was referred to an orthopedic specialist, who saw her on June 23, at which time an enlarged, tender left axillary lymph node was noted. The orthopedist drained the finger wound, collected a swab of cloudy, nonpurulent fluid for culture, and changed the patient’s antibiotic to ciprofloxacin. After MDH PHL confirmed tularemia on June 28, the patient was seen again by the orthopedist; by this time she had developed an eschar-like ulcer. An infectious disease consultation was obtained, ciprofloxacin was discontinued, and a treatment course of doxycycline was initiated and ultimately continued for 5 weeks. As of July 8, the lymphadenopathy had resolved and the ulcerated wound was improving. MDH epidemiologists shared exposure information with the South Dakota Department of Health; no other cases of tularemia were reported from this area of South Dakota in 2016 (South Dakota Department of Health, personal communication, January 4, 2017).
Tularemia can cause a wide range of symptoms in humans, depending upon the route of inoculation. The infection is often characterized by fever, lymphadenopathy, and an ulcer at the site of cutaneous inoculation. Type A is frequently associated with lagomorphs (hares, rabbits, and pikas), and type B is frequently associated with rodents and aquatic environments. Type A is often considered more virulent to humans than is type B, but subtypes exist that are associated with varying degrees of severity (1,2). Exposure routes include animal contact, arthropod (ticks and biting flies) bites, and exposure to natural waters (15). During 1994–2015, 10 tularemia cases were confirmed in Minnesota residents; five were caused by F. tularensis type B (MDH, unpublished data, 2009–2015) (5).
Although tularemia is rarely diagnosed in Minnesota, there has been one other culture-confirmed case of a tularemia type B wound infection that resulted after lake water exposure of a superficial cut, sustained while shaving (MDH, unpublished data, 2012). Inoculation by fish hook represents a novel exposure to F. tularensis. This and the previous Minnesota case highlight the significance of freshwater exposure in cases of tularemia, the importance of obtaining a thorough exposure history, and the importance of obtaining wound cultures, especially when wound infections do not respond to empiric antibiotic therapy. Prompt diagnosis and initiation of appropriate antibiotics, consistent with current practice guidelines, can prevent serious illness in tularemia cases (6).
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Acknowledgment

Emergency Preparedness and Response Laboratory staff members, Public Health Laboratory Division, Minnesota Department of Health.
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Corresponding author: Tory Whitten, tory.whitten@state.mn.us, 651-201-5654.
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1Infectious Disease Epidemiology, Prevention, and Control Division, Minnesota Department of Health; 2Public Health Laboratory Division, Minnesota Department of Health.
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References

  1. Kugeler KJ, Mead PS, Janusz AM, et al. Molecular epidemiology of Francisella tularensis in the United States. Clin Infect Dis 2009;48:863–70. CrossRef PubMed
  2. Keim P, Johansson A, Wagner DM. Molecular epidemiology, evolution, and ecology of Francisella. Ann N Y Acad Sci 2007;1105:30–66. CrossRef PubMed
  3. Whitehouse CA, Kesterson KE, Duncan DD, Eshoo MW, Wolcott M. Identification and characterization of Francisella species from natural warm springs in Utah, USA. Lett Appl Microbiol 2012;54:313–24. CrossRef PubMed
  4. Guerpillon B, Boibieux A, Guenne C, et al. Keep an ear out for Francisella tularensis: otomastoiditis cases after canyoneering. Front Med (Lausanne) 2016;3:9. PubMed
  5. Scheftel JM, Griffith JM, Leppke BA, Pantlin GC, Snippes PM, Wünschmann A. Tularaemia in Minnesota: case report and brief epidemiology. Zoonoses Public Health 2010;57:e165–9.CrossRef PubMed
  6. Stevens DL, Bisno AL, Chambers HF, et al. ; Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014;59:e10–52. CrossRef PubMed
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Suggested citation for this article: Whitten T, Bjork J, Neitzel D, Smith K, Sullivan M, Scheftel J. Notes from the Field: Francisella tularensis Type B Infection from a Fish Hook Injury — Minnesota, 2016. MMWR Morb Mortal Wkly Rep 2017;66:194. DOI: http://dx.doi.org/10.15585/mmwr.mm6607a3.

Continued Endemic Wild Poliovirus Transmission in Security-Compromised Areas — Nigeria, 2016 | MMWR

Continued Endemic Wild Poliovirus Transmission in Security-Compromised Areas — Nigeria, 2016 | MMWR

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MMWR Weekly
Vol. 66, No. 7
February 24, 2017




Continued Endemic Wild Poliovirus Transmission in Security-Compromised Areas — Nigeria, 2016





Chimeremma Nnadi, MD, PhD1; Eunice Damisa, MPH2; Lisa Esapa, MPH1; Fiona Braka, MBBS3; Ndadilnasiya Waziri, DVM4; Anisur Siddique, MD4; Jaume Jorba, PhD5; Gatei wa; Nganda, DVM1; Chima Ohuabunwo, MD1; Omotayo Bolu, MD1; Eric Wiesen, MS1; Usman Adamu, MBBS2(View author affiliations)
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Summary

What is already known about this topic?

In August 2015, 1 year after the last known case of wild poliovirus (WPV) infection was reported in Nigeria in July 2014, the World Health Organization removed Nigeria from the list of endemic countries because of the high likelihood that endemic WPV circulation had been interrupted in Nigeria. However, Borno State in northeastern Nigeria has experienced years of armed insurgency, which has hampered implementation of effective polio eradication activities.
What is added by this report?

During August and September 2016, four WPV cases and one circulating vaccine-derived poliovirus (cVDPV) isolate were reported in accessible areas of Borno State. Analysis of the WPV isolates showed limited genetic relationship, indicating prolonged undetected transmission. In response, regionally synchronized supplementary immunization activities were conducted in five Lake Chad basin countries, and >30 million children in 18 northern states in Nigeria were vaccinated. Additional measures to strengthen polio surveillance quality were implemented in accessible areas of Borno State. Ongoing conflict-related insecurity continues to restrict polio workers’ access to populations in insurgent-held areas.
What are the implications for public health practice?

Although the areas that are insurgent-held have diminished over the last year, about 40% of communities in Borno State remain inaccessible. Response to the detection of WPV and cVDPV was highly successful in accessible areas. Increasing polio vaccination coverage and improving surveillance quality among cohorts of unimmunized and underimmunized populations is a critical public health need in Borno and the Lake Chad region.


Chimeremma Nnadi, MD, PhD1; Eunice Damisa, MPH2; Lisa Esapa, MPH1; Fiona Braka, MBBS3; Ndadilnasiya Waziri, DVM4; Anisur Siddique, MD4; Jaume Jorba, PhD5; Gatei wa; Nganda, DVM1; Chima Ohuabunwo, MD1; Omotayo Bolu, MD1; Eric Wiesen, MS1; Usman Adamu, MBBS2(View author affiliations)
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On August 10, 2016, 2 years after the most recent wild poliovirus (WPV) case was reported in Nigeria (in July 2014) (1), two WPV cases were reported in the northeastern state of Borno, which has been severely affected by insurgency-related insecurity since 2013. On September 9 and 26, 2016, two additional WPV cases were reported in Borno in children whose families migrated from security-compromised, inaccessible areas of the state. All four cases were WPV serotype 1 (WPV1), with genetic differences indicating prolonged undetected transmission. A large-scale emergency response plan was developed and implemented. The plan initially called for vaccination of 815,791 children during August 15–18 in five local government areas (LGAs) in the immediate vicinity of the first two WPV cases. Subsequently, the plan was expanded to regionally synchronized supplementary immunization activities (SIAs), conducted during August 27–December 6 in five Lake Chad basin countries at increased risk for national and regional WPV1 transmission (Cameroon, Central African Republic, Chad, Niger, and Nigeria). In addition, retrospective searches for missed cases of acute flaccid paralysis (AFP), enhanced environmental surveillance for polioviruses, and polio surveillance system reviews were conducted. Prolonged undetected WPV1 transmission in Borno State is a consequence of low population immunity and severe surveillance limitations associated with insurgency-related insecurity and highlights the risk for local and international WPV spread (2). Increasing polio vaccination coverage and implementing high-quality polio surveillance, especially among populations in newly secured and difficult-to-access areas in Borno and other Lake Chad basin areas are urgently needed.
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Security Situation

Borno shares boundaries with Adamawa, Gombe, and Yobe states in Nigeria, and international boundaries with Cameroon, Chad, and Niger (Figure 1). Years of armed insurgency in Borno has led to destruction of the health care delivery infrastructure, including nearly two thirds of health facilities in the state. During the last 2 years, approximately half of all settlements in the state were inaccessible for implementation of effective polio eradication activities, including high-quality surveillance and immunization activities. An estimated 2.1 million internally displaced persons (IDPs) have sought shelter in formal and informal camp settings, as well as in communities in Borno and other Nigerian states (3). In addition, conflict-driven insecurity has led to the forced displacement of 200,000 refugees across international boundaries. Because of the prevailing humanitarian situation in Borno and other northeastern Nigeria states, in August 2016, the World Health Organization (WHO) declared a Grade 3 emergency in the region, indicating a substantial public health event requiring a major international response (4,5). Efforts by the Nigeria military have resulted in improved accessibility in Borno during the last year, although assessments in November 2016 indicate that 39% of settlements are still inaccessible because of insurgency-related insecurity (Figure 2).
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WPV Case Investigations and Response Plan

The first WPV case reported was in a child aged 23 months in Gwoza LGA, and the second was in a child aged 24 months from Jere LGA. Dates of paralysis onset were reported as July 4 and 13, 2016, respectively. The third and fourth cases were in two children aged 23 and 21 months from Monguno LGA, with respective dates of paralysis onset of August 6 and 21, 2016. Additional investigation identified an isolate of circulating vaccine-derived type 2 poliovirus (cVDPV2) in a healthy contact, aged 6 years, of one of the polio patients from Monguno LGA. cVDPVs are genetic variants of the oral vaccine virus that emerge and can cause paralysis indistinguishable from WPV disease in unimmunized or underimmunized populations (6). Laboratory analysis of the four WPV isolates showed limited genetic relationship among isolated viral strains; the closest known genetic link was to a virus last identified in Borno in 2013, indicating distinct and prolonged periods of undetected transmission (7). The cVDPV2 isolate was 37 nucleotides different from Sabin 2 and 25 nucleotides different from the closest match, also signifying prolonged undetected circulation. This was the second cVDPV2 isolate identified in Borno in 2016; the first isolate was from an environmental sample collected in March 2016 in Maiduguri LGA which had prompted SIAs with monovalent oral poliovirus vaccine type 2 (mOPV2) in May, June, and July (2).
In collaboration with Global Polio Eradication Initiative partners, health authorities in four other Lake Chad basin countries and staff members from the Nigeria Polio Emergency Operations Center planned and implemented a large-scale regional response during August–December 2016. The response included SIAs to vaccinate children against WPV1 and cVDPV2, intensified surveillance for AFP cases, and enhanced environmental surveillance (8). In addition, a review of polio surveillance activities in the region was conducted.
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Supplementary Immunization Activities

Following notification of the first two WPV cases, outbreak response vaccination using bivalent oral poliovirus vaccine (bOPV) (containing types 1 and 3 OPV) were conducted during August 15–18, 2016, in Jere and Gwoza LGAs and in three additional LGAs with substantial IDP populations. Five rounds of regionally synchronized SIAs also were implemented, targeting children aged <5 years in five Lake Chad basin countries (Cameroon, Central African Republic, Chad, Niger, and Nigeria) at risk for poliovirus transmission because of large population movements. SIA quality was evaluated using lot quality assurance sampling (LQAS) methodology. Overall, approximately 30 million children in 18 Northern Nigeria states were vaccinated with bOPV. In addition, one dose of inactivated polio vaccine (IPV) was administered to children in Borno State to boost immunity (Table). A separate outbreak response to the cVDPV2 detected in Monguno LGA was conducted using mOPV2 during December 2016 and January 2017.
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Poliovirus Surveillance

AFP surveillance. In 2016, a total of 614 AFP cases were reported in Borno State, a 73% increase from 354 reported cases in 2015. Improvements in AFP reporting in 2016 can be attributed to increased surveillance activity in the wake of the March 2016 cVDPV isolation, as well as improving access to populations in previously inaccessible areas of the state.
Environmental surveillance. Following the reported WPV circulation in Borno, the number of environmental sampling sites in Borno was increased from four to six. In March 2016, the frequency of sample collection at existing sites in Maiduguri (the Borno State capital) was increased from monthly to weekly following the reported cVDPV2 isolation (2). No positive WPV or cVDPV isolate has been reported from any of the sites since April 2016.
Surveillance reviews. Two surveillance reviews were conducted as part of the response to assess and develop recommendations to improve weaknesses in surveillance that could account for the prolonged undetected transmission indicated by genetic sequence analyses of isolates from reported WPV1 cases. A key finding was the limited ability to conduct systematic high-quality surveillance in security-compromised areas of Borno State, which adversely affected case detection and reporting. In addition, serious surveillance performance limitations were identified, including inconsistent AFP case reporting in some fully accessible areas. Measures were recommended to strengthen surveillance activities at the national and subnational levels, including the development of protocols for improved identification of the location of cases among IDPs.
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Discussion

The recent finding of prolonged undetected WPV circulation in Borno State highlights key challenges facing polio eradication efforts in Nigeria and globally. Although the large-scale outbreak response SIA and surveillance activities conducted in the Lake Chad basin region were considered successful, conflict-related inaccessibility might continue to limit surveillance and immunization activities, raising concerns about further undetected WPV and cVDPV transmission. To reduce the potential for persistent virus transmission, it is important to increase polio surveillance quality and vaccination coverage among cohorts of persons in unimmunized and underimmunized populations, prioritizing persons living in recently accessible areas, IDP camps, and refugee communities.
As has been observed in Afghanistan and Pakistan, the two other countries that have not yet interrupted endemic WPV transmission, insurgency-related insecurity can restrict access to populations in conflict settings, potentially imposing limits on implementation of polio eradication activities, including high-quality immunization and surveillance activities (9,10). In Borno State, the restriction of the implementation of polio eradication activities in insurgent-held areas has been absolute: no polio eradication activities occurred in those areas. Despite multiple SIA rounds conducted in accessible areas of Borno State prior to August 2016 for which all children were eligible, two of the four children with WPV had never received polio vaccine, and the other two did not complete the polio vaccination series. This finding validates longstanding concerns about WPV circulation among populations that have become susceptible because of the inability to reach and fully vaccinate children in security-compromised areas. Although recent gains made by the Nigerian military have led to an increase in the number of areas now accessible to polio eradication activities, approximately 40% of settlement communities in Borno State are still classified as fully inaccessible. Unless a substantial proportion of children in these settlement communities are reached and vaccinated, it will be difficult to interrupt WPV transmission in the inaccessible areas of Borno State.
Large population migration to and from refugee and IDP camps and communities has occurred across Nigeria and other Lake Chad basin countries (3), increasing the potential for WPV transmission in settings far removed from the conflict. For this reason, immediate steps were taken to increase polio vaccination coverage in large areas of the Lake Chad region. The risk for outbreaks among IDPs in camps and host communities across the region remains, because of the continued migration of potentially infected and underimmunized persons from the security-compromised areas of Borno State.
Armed conflict limits the implementation of high-quality surveillance activities. The current polio surveillance system in Borno State has identified WPV cases, but exclusively in accessible areas of the state. The continued insurgency-related access limitation in a number of subdistricts in Borno State means that the risk for undetected transmission in these communities might persist until secure access becomes feasible. In addition, the recent findings of prolonged undetected WPV circulation in Borno State, along with other deficiencies highlighted in recent surveillance reviews, underscore the need for improved surveillance in areas that have become accessible. Regular and rigorous supervision, evaluations, and reviews focused on surveillance performance at the subdistrict level are urgently needed.
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Corresponding author: Chimeremma Nnadi, cnnadi@cdc.gov, 404-553-7641.
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1Global Immunization Division, CDC; 2National Polio Emergency Operations Center, National Primary Health Care Development Agency, Abuja Nigeria; 3Expanded Program on Immunization, World Health Organization, Nigeria Country Office; 4National Stop Transmission of Polio Program, Africa Field Epidemiology Network, Nigeria Country Office; United Nations Children’s Fund, Nigeria Country Office; 5Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC.
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References

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Return to your place in the textFIGURE 1Location of wild poliovirus (WPV) isolates and circulating vaccine-derived type 2 poliovirus (cVDPV2) isolate identified in the local government areas of Jere, Gwoza, and Monguno — Borno State, Nigeria, 2016
Abbreviation: CAR = Central African Republic.
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Return to your place in the textFIGURE 2Security-related accessibility classifications within the 27 local government areas* — Borno State, Nigeria, May and November 2016
*Accessible population and settlement data for house-to-house and special vaccination teams.
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Return to your place in the textTABLEPolio outbreak response supplementary immunization activity dates, antigen types, target areas, number of children vaccinated, and reported lot quality assurance sampling (LQAS) results — Nigeria, August 2016–January 2017
Activity datesVaccine typeTarget areaNo. of children vaccinatedPercentage of LGAs achieving ≥90% on LQAS*
August 15–18, 2016bOPVFive Borno LGAs815,791100
August 27–30, 2016bOPVZone 1§5,787,17771
September, 17–20, 2016bOPVZone 230,466,28271
IPVBorno State1,523,98150
October 15–18, 2016bOPVZone 231,422,23786
November 12–15, 2016bOPVZone 232,563,31180
December 3–6, 2016bOPVZone 232,449,57685
December 16–19, 2016mOPV-2Zone 1 plus Bauchi and Sokoto states**9,977,37790
January 28–31, 2017mOPV-2Zone 2Not availableNot available
Abbreviations: bOPV = bivalent (types 1 and 3) oral poliovirus vaccine; IPV = inactivated polio vaccine; LGA = local government area; mOPV-2 = monovalent (type 2) poliovirus vaccine.
* ≥90% coverage achievement pass mark on LQAS set by Nigeria polio Emergency Operations Center.
 Immediate outbreak response in the Borno LGAs of Bama, Gwoza, Jere, and Maiduguri Municipal Council, and one accessible ward in Mafa.
§ Zone 1 = Adamawa, Borno, Gombe, Taraba, and Yobe states.
 Zone 2 = Abuja Federal Capital Territory, Adamawa, Bauchi, Borno, Gombe, Jigawa, Kaduna, Kano, Katsina, Kebbi, Kwara, Nasarawa, Niger, Plateau, Sokoto, Taraba, Yobe, and Zamfara states.
** Bauchi and Sokoto states were included as target areas because of increased risk profiles.
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Suggested citation for this article: Nnadi C, Damisa E, Esapa L, et al. Continued Endemic Wild Poliovirus Transmission in Security-Compromised Areas — Nigeria, 2016. MMWR Morb Mortal Wkly Rep 2017;66:190–193. DOI: http://dx.doi.org/10.15585/mmwr.mm6607a2.