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Poliomyelitis
Eradication
Field Guide
Third Edition

Scientific and Technical Publication No. 607

PAN AMERICAN HEALTH ORGANIZATION
Pan American Sanitary Bureau, Regional Office of the
WORLD HEALTH ORGANIZATION
525 Twenty-third Street, N.W.
Washington, D.C. 20037
www.paho.org

2006
 Also published in Spanish (2005) with the title: Erradicación de la poliomielitis: guía práctica.
(ISBN 92 75 31607 4)

PAHO HQ Library Cataloguing-in-Publication Data

Pan American Health Organization

Poliomyelitis Eradication. Field Guide.
Washington, D.C.: PAHO, © 2006.
(Scientific and Technical Publication No. 607)

ISBN 92 75 11607 5

I. Title II. Series

1. POLIOMYELITIS - prevention & control
2. POLIOMYELITIS - epidemiology
3. EPIDEMIOLOGIC SURVEILLANCE
4. MASS VACCINATION
5. POLIOVIRUS VACCINES
6. GUIDEBOOKS [PUBLICATION TYPE]

NLM WC556

This guide was prepared by the Immunization Unit of the Pan American Health Organization.

Cover photos: Pan American Health Organization

The Pan American Health Organization welcomes requests for permission to reproduce or
translate its publications, in part or in full. Applications and inquiries should be addressed to the
Publications Program, Pan American Health Organization, Washington, D.C., U.S.A., which will
be glad to provide the latest information on any changes made to the text, plans for new editions,
and reprints and translations already available.

© Pan American Health Organization, 2006

Publications of the Pan American Health Organization enjoy copyright protection in accor-
dance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights are
reserved.
The designations employed and the presentation of the material in this publication do not
imply the expression of any opinion whatsoever on the part of the Secretariat of the Pan Ameri-
can Health Organization concerning the status of any country, territory, city, or area or of its
authorities, or concerning the delimitation of its frontiers or boundaries.
The mention of specific companies or of certain manufacturers’ products does not imply that
they are endorsed or recommended by the Pan American Health Organization in preference to
others of a similar nature that are not mentioned. Errors and omissions excepted, the names of
proprietary products are distinguished by initial capital letters.
CONTENTS

About the Immunization Field Guides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2. Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2.1 Infectious Agent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2.2 Distribution and Frequency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2.3 Transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2.4 Reservoir . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2.5 Incubation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2.6 Immunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2.7 Changes in Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

3. Clinical Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3.1 Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3.2 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3.3 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
3.4 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
3.5 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

4. Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
4.1 Immunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
4.2 Vaccination Schedule, Contraindications, and Adverse Events . . . . . . . . . 9
4.3 Dosage and Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
4.4 Cold Chain and Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
4.5 Vaccine Efficacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

5. Immunization Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
5.1 Routine Immunization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
5.2 Mass Campaigns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

iii
iv „ PAN AMERICAN HEALTH ORGANIZATION

5.3 Coverage of At-Risk Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

5.4 Missed Vaccination Opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

6. Epidemiologic Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
6.1 Case Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
6.2 Detection and Notification of Probable Cases . . . . . . . . . . . . . . . . . . . . . 17
6.3 Case Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
6.4 Laboratory Confirmation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
6.5 Monitoring and Feedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
6.6 Surveillance Indicators for Acute Flaccid Paralysis . . . . . . . . . . . . . . . . . . 27
6.7 Response to Outbreaks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
6.8 Information and Data Analysis Systems . . . . . . . . . . . . . . . . . . . . . . . . . . 30

7. Certification of Polio Eradication in the Americas . . . . . . . . . . . . . . . . 33

8. The Final Phase of Global Eradication of Poliomyelitis . . . . . . . . . . . . 34

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Annexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Annex 1. Poliomyelitis outbreak caused by vaccine-derived virus in Haiti
and the Dominican Republic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Annex 2. Distribution of diagnoses for discarded cases of acute flaccid
paralysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Annex 3. Description of differential diagnosis of poliomyelitis . . . . . . . . . . 46
Annex 4. Refrigerator record form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Annex 5. Immunization coverage of < 1-year-old children . . . . . . . . . . . . . 52
Annex 6. Coverage of 1-year-old population with at least three doses
of OPV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Annex 7. Acute flaccid paralysis case investigation form . . . . . . . . . . . . . . . 54
Annex 8. Line-listing of probable cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Annex 9. Polio outbreak control measures—summary form . . . . . . . . . . . . 58
Annex 10. Specimen tracking form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Annex 11. Polio Weekly Bulletin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Annex 12. Laboratory line-listing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
 POLIOMYELITIS ERADICATION FIELD GUIDE „ v

Annex 13. Guidelines for laboratories within a network . . . . . . . . . . . . . . . . 63

Annex 14. Mop-up worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Annex 15. Mop-up vaccination form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Annex 16. Weekly reporting monitor form . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Annex 17. Summary of weekly reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Annex 18. Key surveillance indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Annex 19. Active search for cases of paralysis . . . . . . . . . . . . . . . . . . . . . . . . 70
Annex 20. Sample presentation on surveillance of acute flaccid paralysis . . 74

Tables
Table 1. Criteria for the differential diagnosis of poliomyelitis . . . . . . . . . . 7
Table 2. Specimens for poliovirus detection . . . . . . . . . . . . . . . . . . . . . . . . 22
Table 3. Rate of reported cases of acute flaccid paralysis per 100,000
population under 15 years of age, by department
(fictitious data) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Figures
Figure 1. OPV3 coverage and incidence of poliomyelitis in the Region
of the Americas, 1969–2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x
Figure 2. Polio cases in the Americas, 1985 . . . . . . . . . . . . . . . . . . . . . . . . . ix
Figure 3. Areas in Haiti and the Dominican Republic with confirmed cases
of polio, 2000–2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x
Figure 4. Wild poliovirus, 2004–2005 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Figure 5. Spread of wild poliovirus, 2004–2005 . . . . . . . . . . . . . . . . . . . . . . 3
Figure 6. Pathogenesis and clinical course of acute poliomyelitis . . . . . . . . . 5
Figure 7. Vaccine efficacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Figure 8. Map displaying OPV coverage by municipality in children less
than 1 year of age. January–December 2003 (fictitious) . . . . . . . . 13
Figure 9. Investigation of a probable case of poliomyelitis . . . . . . . . . . . . . . 17
Figure 10. Case investigation decision tree . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Figure 11. Packaging for virological specimens . . . . . . . . . . . . . . . . . . . . . . . 24
Figure 12. Polio reference laboratory network in the Americas . . . . . . . . . . 26
Figure 13. Progress of polio eradication, 1988 and 2004 . . . . . . . . . . . . . . . 34
Figure 14. Outbreaks caused by circulating vaccine-derived
poliovirus (cVDPV) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
ABOUT THE IMMUNIZATION FIELD GUIDES

The Expanded Program on Immunization is viewed as one of the most successful

public health experiences in the Americas because it has played a pivotal role in
reducing infant mortality from vaccine-preventable diseases in the Region. In fact,
since the program was launched the countries stopped the transmission of wild
poliovirus in the Region in 1991 and interrupted indigenous measles transmission in
November 2002; they also are making significant gains in the battle to eliminate
rubella and congenital rubella syndrome. In addition, national immunization pro-
grams are undertaking extraordinary efforts to identify at-risk populations and over-
come inequities in vaccination. To maintain these advances and to cope with new
challenges, such as the introduction of new vaccines, partnerships will have to be
strengthened among governments, donor agencies, the private sector, scientific
associations, and society as a whole.
To this end, PAHO is promoting the best technical quality by issuing these practi-
cal field guides, which have been prepared by the Immunization Unit in the Family
and Community Health Area. The most recent techniques presented in the field
guides, coupled with useful illustrations, will help health workers in their efforts to
control, eliminate, or eradicate diseases such as poliomyelitis, neonatal tetanus, yel-
low fever, diphtheria, pertussis, tetanus, Haemophilus influenzae type b infections, hep-
atitis B, measles, and rubella. The field guides also include standardized methods
and procedures for conducting epidemiologic surveillance and maintaining an up-
to-date information system that makes it possible to take timely and effective deci-
sions.
These field guides are based on the latest scientific information and they bring
together the experience of prominent health professionals in the field. As a result,
they are particularly suitable for promoting strategies that have already proven to be
effective. The strengthening of prevention activities, the reduction of health
inequities, and the promotion of technical expertise in vaccination services were the
principles that guided the preparation of the guides.
The Expanded Program on Immunization, a joint effort of all the countries of the
Americas, effectively contributes to the attainment of the Millennium Development
Goals.

Dr. Mirta Roses Periago

Director
Pan American Health Organization

vii
PREFACE

This Poliomyelitis Eradication Field Guide presents information and strategies that
health workers in the Americas should be familiar with in order to keep the hemi-
sphere polio-free. Perhaps a more appropriate title would be “Field Guide for the
Maintenance of Polio Eradication,” since the last case of this disease caused by wild
poliovirus in the Region was detected in 1991 (see Figure 1). In 1994, the Interna-
tional Commission for the Certification of Poliomyelitis Eradication in the Americas
(ICCPE) reviewed the evidence available in all the countries and territories of the
hemisphere and concluded that the indigenous circulation of wild poliovirus in the
Americas had been interrupted. As can be seen in Figure 2, this goal was achieved in
a continent where endemic poliomyelitis was present in most countries.
The strategies that allowed the eradi-
cation of polio in the Americas are the Figure 1. OPV3 coverage and incidence of poliomyelitis in the
Region of the Americas, 1969–2003
same as those currently being used
globally, and are essentially the same 7,000 100
90
strategies that will make it possible to 6,000
80
keep countries disease-free. They con- 5,000 70
Notified cases

Coverage (%)
sist in reaching and maintaining high 60
4,000
levels of vaccination coverage (through 50
3,000
vaccination campaigns, if necessary) 40

and ensuring adequate epidemiologic 2,000 30

20
surveillance, which in the present con- 1,000
10
text means the immediate investigation 0 0
69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03
of cases and aggressive control of out-
breaks (see Figure 2). Cases Coverage

These are the same strategies that Type 1 vaccine-derived poliovirus (VDPV) in 2000 and 2001: 21 cases
Note: Coverage data are for children under 1 year of age.
were applied to combat the polio out- Source: PAHO, Family and Community Health, Immunization Unit.
break that occurred in the Dominican
Republic and Haiti in 2000 and 2001 (see Figure 3). This outbreak, which was caused
by a virus derived from the Sabin vaccine itself, showed that reversion of the vaccine
virus to neurovirulence is a constant threat unless countries ensure adequate vaccina-
tion coverage. It also showed that surveillance for flaccid paralysis should be main-
tained at an optimal level, not only during eradication efforts but also afterwards.
Finally, it demonstrated that the vaccination strategies used during the eradication
campaign continue to be valid. The outbreak was controlled using live attenuated oral
poliovirus (OPV) vaccine. Given the importance of this outbreak for countries that
have already eradicated poliomyelitis, details of the outbreak are provided in Annex 1.

ix
x „ PAN AMERICAN HEALTH ORGANIZATION

Figure 2. Polio cases in the Americas, 1985

1 point = 1 case
Source: Pan American Health Organization, Family and Community Health,
Immunization Unit.

Figure 3. Areas in Haiti and the Dominican Republic with confirmed cases of polio,
2000–2001

Gonaïves Santiago
Concepción
de la Vega San Francisco de Macorís
HAITI San Juan de la Maguana
Port-au-Prínce Santo Domingo

DOMINICAN REPUBLIC

= Areas with confirmed cases

Source: PAHO, Family and Community Health, Immunization Unit, PESS/HVP. Data through 30 May 2001.
1. INTRODUCTION
1.1 Background
On 14 May 1985, the Director of the Pan American Health Organization (PAHO)
announced the goal of eradicating wild poliovirus in the Americas. At the XXXI Meet-
ing of the PAHO Directing Council in September 1985, the Member Governments
unanimously approved a resolution to adopt this goal. When the ICCPE met in
1994, poliovirus had not been detected in the Americas for three years, despite
intensive surveillance by more than 21,000 health units that submitted weekly
reports and the investigation of over 3,800 probable cases, which on close study
were discarded as not being poliomyelitis. The eradication effort also dramatically
strengthened vaccination services for other preventable diseases included in the
Expanded Program on Immunization (EPI).
A number of public and private agencies joined forces with PAHO to achieve the
eradication goal, including the United Nations Children’s Fund (UNICEF), the Inter-
American Development Bank (IDB), the United States Agency for International
Development (USAID), the United States Centers for Disease Control and Preven-
tion (CDC), the Canadian Public Health Association (CPHA), Rotary International,
and others.

2. EPIDEMIOLOGY
2.1 Infectious Agent
The poliovirus is an enterovirus, and it has three antigenic types: 1, 2, and 3.
Although all three types can lead to paralysis, type 1 is most frequently responsible,
type 3 plays a lesser role, and type 2 is only rarely involved. Most epidemics are
caused by type 1. Cases associated with the vaccine, which contains all three types,
are usually caused by types 2 or 3.
Poliovirus derived from the Sabin vaccine, which has caused outbreaks in the
Dominican Republic, Egypt, Haiti, Madagascar, and the Philippines, is a virus that
has mutated from the original Sabin strain by more than 1% and reverted to neurovir-
ulence. Two types of vaccine-derived poliovirus (VDPV) have been recognized: iVDPV
(i stands for immunodeficient), which is isolated from immunodeficient individuals,
and cVDPV (c stands for circulating), which is isolated from outbreaks and shown to
have the same epidemiological and biological characteristics as the wild viruses.
2.2 Distribution and Frequency
Poliomyelitis existed worldwide before the eradication initiative was undertaken,
first in the Americas and then globally. At the time of writing this field guide (Sep-

1
2 „ PAN AMERICAN HEALTH ORGANIZATION

tember 2005), three Regions of the world were certified as free from the indigenous
circulation of the wild poliovirus: the Region of the Americas in 1994, the Eastern
Pacific in 2000, and Europe in 2002. The transmission of the wild virus only persists
in 10 countries of the world, four of which (Indonesia, Nigeria, Sudan, and Yemen)
accounted for 91% of the cases reported during 2005. The annual number of cases
of polio reported was 719 in 2000 (in 23 countries), 483 in 2001 (in 15 countries),
1,918 in 2002 (in 9 countries), 784 in 2003 (in 15 countries), 1,255 in 2004 (in 18
countries), and 1,469 in 2005 (16 countries) (see Figure 4). The dramatic increase
in cases in 2004 was due to the fact that Nigeria interrupted its national vaccination
campaigns, which caused not only an increase in the number of cases in that coun-
try, but also led to the emergence of cases in countries that previously had eliminat-
ed polio but that had pockets of susceptibles, such as Botswana, Ethiopia, Guinea,
Mali, Saudi Arabia, and Sudan (see Figure 5). This experience reveals the risk of
imported cases to countries and regions of the currently polio-free world. It also
highlights the importance of maintaining high immunization coverage, conducting
national immunization days, sustaining good epidemiologic surveillance of acute
flaccid paralysis, and taking measures to contain wild poliovirus in laboratories.
2.3 Transmission
Fecal-oral transmission of the poliovirus is the predominant mode in the developing
countries where sanitation is poor, whereas oral-pharyngeal transmission is more
likely to predominate in industrialized countries and also during outbreaks. One
week after onset, little virus remains in the throat, but it continues to be shed in
stools for six to eight weeks. Cases are probably most infectious during the first few
days before and after the onset of symptoms.
2.4 Reservoir
Humans are the only reservoir of poliovirus, and infection is spread from person to
person. Given the large number of inapparent infections, it is sometimes difficult
to find the source of a case. A long-term carrier state is not known to occur, except
for rare cases in which the virus has been isolated repeatedly and over long periods
in immunodeficient individuals. Those cases have not been associated with polio
outbreaks.
2.5 Incubation
On average, the incubation period from exposure to the virus to the onset of the first
symptoms is 7 to 10 days, with an overall range of 4 to 40 days. The initial illness is
followed by a few days relatively free of symptoms before the onset of paralysis.
 POLIOMYELITIS ERADICATION FIELD GUIDE „ 3

Figure 4. Wild poliovirus, 2004–2005

* This excludes virus detected by

Wild poliovirus type 1
environmental surveillance and
Wild poliovirus type 3
vaccine-derived poliovirus.
Wild poliovirus types 1 and 3
Countries with endemic poliomyelitis
Countries with reestablished transmission
Case or outbreak following importation
Source: World Health Organization, September 2005.

Figure 5. Spread of wild poliovirus, 2004–2005

18 polio-free countries had imported

cases. Endemic transmission was
reestablished in six of these countries.
This corresponds to data collected
between June 2004 and May 2005.

Source: World Health Organization, May 2005.

4 „ PAN AMERICAN HEALTH ORGANIZATION

2.6 Immunity
All unimmunized persons are susceptible to poliomyelitis. Epidemiologic evidence
shows that infants born to mothers with antibodies are protected naturally against
paralytic disease for a few weeks. Immunity is acquired through infection with the
wild virus and through immunization. Immunity following natural infection (includ-
ing inapparent and mild infections) or administration of a complete series of live
oral polio vaccine (OPV) results in both humoral and local intestinal cellular
responses. Such immunity is thought to be lifelong and can serve to block infection
with subsequent wild viruses, thereby interrupting the chain of transmission. The
inactivated poliovirus vaccine (IPV) confers humoral immunity but relatively less
intestinal immunity. Thus, vaccination with IPV does not provide resistance to car-
riage and spread of the wild virus in the community. There is believed to be little or
no cross-immunity between the poliovirus types.
2.7 Changes in Epidemiology
The Global Polio Eradication Initiative has significantly reduced the number of cas-
es in the world, from an estimated 350,000 in 1988 to only 1,469 reported as of
November 2005. The disease continues to follow the same epidemiologic pattern
that it had when incidence was high: it particularly affects poorer, non-immune pop-
ulations and retains the same epidemiological characteristics. On the other hand,
the emergence of outbreaks caused by vaccine-derived virus is a relatively recent phe-
nomenon that bears out the importance of achieving global eradication as soon as
possible.

3. CLINICAL ASPECTS
3.1 Pathogenesis
The mouth is the usual site of entry, and the virus first multiplies in the lymph nodes
of the pharynx and the gastrointestinal tract. It is usually present in the pharynx and
in the stool before the onset of paralytic illness. Once the virus has entered the body,
it invades local lymphoid tissue, enters the bloodstream, and then may invade cer-
tain types of nerve cells. As it multiplies intracellularly, the virus may damage or
destroy the nerve cells completely.
3.2 Clinical Features
For reporting purposes, surveillance is chiefly concerned with identifying paralytic
cases. Many people infected with the wild poliovirus have only a mild illness that
cannot be distinguished clinically from illnesses due to a large number of other caus-
es. Symptoms associated with these minor illnesses include mild fever, muscular
 POLIOMYELITIS ERADICATION FIELD GUIDE „ 5

pain, headache, nausea, vomiting, stiffness in the neck and back, and, less frequent-
ly, signs of aseptic (nonbacterial) meningitis. Inapparent (subclinical) infections are
common: depending on the strain of poliovirus, the ratio between subclinical and
clinical infections is estimated to range between 100:1 and 1,000:1 (see Figure 6).
Older children and adults run a greater risk of developing paralytic illness. The
case-fatality rate ranges between 2% and 20% among persons who do develop the
paralytic form of the disease. However, if there is bulbar or respiratory involvement,
the case-fatality rate may be as high as 40%. Most deaths occur within the first week
following the onset of paralysis.
3.3 Differential Diagnosis
Every case of acute flaccid paralysis (AFP) in persons under 15 years old that is clear-
ly not due to severe trauma should be investigated. If there is a strong suspicion of
polio in persons over 15 years of age, such cases should also be thoroughly investigated.

Figure 6. Pathogenesis and clinical course of acute poliomyelitis

PATHOGENESIS Days after exposure
0 5 10 15 20
Mild illness Major illness
Percentage of all

<1% Frank cases

infections

4%–8% Abortive cases

90%–95% Inapparent cases

Virus present in:

Blood
Throat
Feces May persist 17 weeks
Antibody present:
Neutralizing Persists for life
Complement fixing Usually disappears after 1 year
Source: Adapted from Paul JR, Epidemiology of Poliomyelitis, WHO Monograph No. 26, 1955.

CLINICAL COURSE
HEADACHE (SEVERE)
HEADACHE VOMITING
SYMPTOMS
AND SIGNS

SORE THROAT STIFF NECK AND BACK

NORMAL SYMPTOM-FREE STIFF HAMSTRINGS
PAIN IN LIMBS
ANOREXIA
VOMITING PARALYSIS
TEMPERATURE

103
102
101
100
99
98 Days after exposure
Cerebrospinal fluid (CSF) 0 5 10 15 20 25
Cells o ++ ++ + + o
Elevated protein o +- + ++ ++ +
Source: Horstmann DM, “Clinical aspects of acute poliomyelitis,” American Journal of Medicine, 6(5), 598; copyright 1949, with the authorization of Excerpta Medica, Inc.
6 „ PAN AMERICAN HEALTH ORGANIZATION

It is difficult to confirm paralytic poliomyelitis in the acute phase based on clini-

cal symptoms and signs alone, since a large number of other diseases and condi-
tions may cause similar symptoms. Laboratory confirmation is therefore critical to
the final diagnosis. The two diseases most frequently confused with polio are Guil-
lain-Barré syndrome (GBS) and transverse myelitis (see Table 1).
Other conditions that may present symptoms similar to those of paralytic
poliomyelitis include traumatic neuritis, certain tumors, and, less frequently,
meningitis/encephalitis, as well as illnesses produced by a variety of toxins. The
most prominent difference between poliomyelitis and other causes of AFP is that
for polio the paralytic sequelae are generally severe and permanent, whereas with
other causes, the paralysis tends to resolve or improve within 60 days of onset. A
record should be kept of the definitive diagnosis corresponding to all discarded
cases of AFP (Annex 2). For a more detailed discussion of the differential diagno-
sis of poliomyelitis, see Annex 3.

When paralysis due to poliomyelitis occurs:

• It is typically flaccid (the muscles are not stiff or spastic).

• Patients usually have problems standing and walking.
• It is commonly preceded by symptoms of a minor illness, such as sore throat, headache, backache, fever,
vomiting, etc.
• Paralysis develops rapidly, usually within four days.
• Fever is usually present at onset of paralysis.
• Most patients have limited or no sensory loss (for example, they will feel a needle prick). This sign may be
difficult to determine in children.
• The legs are more commonly involved than the arms, and the large muscle groups are at greater risk than
the small groups. The proximal muscles of the extremities tend to be more involved than the distal ones.
• It is asymmetric (not affecting both sides equally). Although any combination of limbs may be paralyzed,
the most typical pattern is involvement of one leg only, and, less often, one arm. It is less common for
both legs or both arms to be affected. Quadriplegia is rare in infants.
• Sequelae tend to last longer than 60 days after onset.

3.4 Complications
The complications are essentially related to the severity of the illness. Some people
with paralytic poliomyelitis manage to recover partially or completely, but the large
majority of patients have permanent sequelae in the form of paralysis of the affect-
ed members. Those who experience muscle weakness or paralysis for over 12
months will usually have permanent residual paralysis.
During the acute phase, the most severe complication is bulbospinal paralysis,
which gives rise to paralysis of the respiratory muscles. The case-fatality rate for par-
alytic poliomyelitis is usually 2% to 5% in children and 15% to 30% in adults
 POLIOMYELITIS ERADICATION FIELD GUIDE „ 7

Table 1. Criteria for the differential diagnosis of poliomyelitis

Polio Guillain-Barré syndrome Traumatic neuritis Transverse myelitis

Time from onset of paralysis Usually from two to three From hours to 10 days From hours to four days From hours to four days
to full progression days

Fever Fever with onset of paralysis, Not common Commonly present before, during, Rarely present
usually disappearing within and after flaccid paralysis
three to four days

Flaccid paralysis Acute, asymmetrical, Generally acute, symmetrical, and Asymmetrical, acute, usually Acute, lower limbs
principally proximal (upper distal (lower part of arms and affecting only one limb affected symmetrically
part of arms and legs) legs)

Muscle tone Reduced or absent in the Reduced or absent Reduced or absent in the Deduced in lower limbs
affected limb affected limb

Deep-tendon reflexes Decreased or absent Absent Decreased or absent Absent in lower limbs

Sensation, pain Sensation usually normal; Cramps, tingling, reduced Pain in buttocks, reduced sensation Anesthesia of lower
severe myalgia, backache sensation on palms and soles to cold and heat limbs with sensory
perception

Cranial nerve involvement Only when bulbar Often present, low and high: Absent Absent
involvement is present Miller/Fisher variant

Respiratory insufficiency Only when bulbar In severe cases, complicated by Absent Often thoracic paralysis,
involvement is present bacterial pneumonia with sensory perception

Autonomic signs & symptoms Rare Frequent blood pressure Hypothermia in affected limb Present
alterations, sweating, blushing,
body temperature fluctuations

Cerebrospinal fluid Inflammatory High protein content with Normal Normal or mild increase
relatively few cells in cells

Bladder dysfunction Absent Transient Never Present

Nerve conduction velocity at 3 Abnormal: anterior horn cell Abnormal: Abnormal: axonal damage Normal or abnormal,
weeks disease (normal during the demyelinization no diagnostic value
first 2 weeks)

Sequelae at 3 months up to 1 year Severe, asymmetrical atrophy; Symmetrical atrophy of peroneal Moderate atrophy, only in affected Atrophy, flaccid diplegia
skeletal deformities appear muscles (outer side of leg) lower limb years later
later

Source: Alcalá H, Olivé J-M, de Quadros C. “The Diagnosis of Polio and Other Acute Flaccid Paralyses: A Neurological Approach.” Document presented at the Ninth Meet-
ing of the Technical Advisory Group on Vaccine-preventable Diseases, held in Guatemala City, Guatemala, 12–15 March 1991. (Doc. EPI/TAG/91-10).
8 „ PAN AMERICAN HEALTH ORGANIZATION

(depending on the patient’s age). This figure increases from 25% to 75% when there
is bulbar involvement.
3.5 Treatment
There is no specific treatment for poliomyelitis. During the acute phase, the only
medical care is life support to preserve vital functions. Once the acute stage has
passed, physical therapy and other measures that facilitate the recovery of move-
ment and locomotion are helpful.

4. VACCINES
There are two types of polio vaccine: (1) trivalent oral (live, attenuated) polio vac-
cine (OPV) and (2) inactivated or killed polio vaccine (IPV). This guide provides
more detail on the use of the Sabin oral vaccine (OPV) because it is recommended
by the Technical Advisory Group of the PAHO Immunization Program, and it has
been and continues to be used in global campaigns to eradicate poliomyelitis.
The Sabin OPV vaccine is prepared using strains of different live viruses that have
been attenuated for oral administration. Because it is replicative, it is the vaccine
that more closely simulates the natural infection process. Also, it stimulates the pro-
duction of secretory IgA antibodies and circulating IgGs. Today the trivalent form is
used throughout the world (although it should be noted that vaccines have been
made using a single virus type, ranging in color from pale yellow to light pink). Since
the vaccine virus is live and the preparation is administered orally, imitating the nat-
ural route of infection, it also can be transmitted from a vaccinated person to close
contacts who have not been immunized. Its circulation interrupts transmission of
the wild virus by displacing it. This effect is greater if the vaccine is administered to
entire communities on national immunization days.
OPV is usually provided in vials of 10 or 20 doses using a dropper. Each dose, usu-
ally two drops, contains:

• Poliovirus I 1,000,000 infective units

• Poliovirus II 100,000 infective units
• Poliovirus III 600,000 infective units

The vaccine contains small traces of streptomycin and neomycin, and it has no
preservatives. The use of a live poliovirus vaccine spreads the vaccine viruses in the
environment, resulting in transmission of the virus to other individuals, both vacci-
nated and unvaccinated.
The IPV, or Salk-type vaccine, is non-replicative. It is made with inactivated or
killed viruses and inoculated either subcutaneously or intramuscularly. The virus is
not shed in stools, and it does not colonize lymphoid tissue in the throat. The vac-
 POLIOMYELITIS ERADICATION FIELD GUIDE „ 9

cine stimulates the production of circulating antibodies and suppresses pharyngeal

excretion of the virus, but it does not prevent intestinal infection; consequently, it
has not been used in the polio eradication campaign. It is available in monovalent
form or combined with other vaccines, such as triple diphtheria, pertussis, tetanus
(DPT), hepatitis B, or Haemophilus influenzae type b (Hib).
4.1 Immunity
Under ideal conditions, a primary series of three doses of OPV produces seroconver-
sion to all three virus types in over 90% of vaccine recipients, and it is thought to
have clinical efficacy of nearly 100%. Three properly spaced doses of OPV should
confer long-term immunity. In some countries, especially in tropical climates, there
have been reports of insufficient serologic response to OPV. This result may be due
to interruptions in the cold chain, interference due to intestinal infection with other
enteroviruses, or the presence of diarrhea that causes excretion of the virus before it
can attach to the mucosal cells.
4.2 Vaccination Schedule, Contraindications, and Adverse Events
Although the schedule may vary in some countries, in routine circumstances it is rec-
ommended to give three doses of trivalent OPV at four-to eight-week intervals start-
ing at 6 weeks of age or 2 months, if so specified in the national immunization
schedule. A dose at birth is highly recommended in endemic areas, although it is not
counted as part of the primary series and is referred to as “OPV zero.” In the case of
intervals between doses that are longer than the recommended four to eight weeks,
it is not necessary to restart the schedule. Polio vaccine may be given simultaneous-
ly with any other childhood immunization.
There are no contraindications to vaccination with OPV. Although diarrhea is not a
contraindication, a dose administered to a child with diarrhea should not be counted
as part of the series, which should be completed as soon as the diarrhea has passed.
On rare occasions, OPV has been associated with paralysis in vaccine recipients
or their contacts. In the United States, the overall frequency of OPV vaccine-associ-
ated paralysis is 1 case in 2.6 million doses distributed. The relative frequency of
paralysis varies depending on the number of doses received in the series. For recipi-
ents of the first dose, the frequency is 1 case in every 1.4 million doses, while for sub-
sequent doses the frequency is 1 case in every 27.2 million doses.
In countries where human immunodeficiency virus (HIV) is widespread, children
should be immunized following the regular schedule, using antigens provided by the
Expanded Program on Immunization. This recommendation also applies to persons
with HIV infection. Unvaccinated individuals with clinical (symptomatic) AIDS living
in countries where poliomyelitis still poses a serious threat should also receive OPV
according to the regular established schedule. In this regard it should be noted that
10 „ PAN AMERICAN HEALTH ORGANIZATION

the American Academy of Pediatrics recommends the use of IPV (inactivated polio
vaccine) for patients with immunodeficiencies. It should be made clear that these
patients cannot be guaranteed an adequate immune response from the IPV.
4.3 Dosage and Administration
The basic schedule calls for three doses of OPV, given either at 6, 10, and 14 weeks
of age or at 2, 4, and 6 months. In areas where polio is still endemic, a dose for new-
borns is also recommended. OPV should be administered orally (that is, directly in
the mouth). Each dose consists of two drops of live oral poliovirus vaccine (the man-
ufacturer’s instructions should be reviewed). It is given by drops in the child’s
mouth, making sure that the dropper does not contaminate the mucosa; if the child
spits out the vaccine, he or she should be vaccinated again.

4.4 Cold Chain and Supply

OPV is one of the most heat-sensitive vaccines in common use. It can be stored for
up to 1 year, and it should be kept frozen whenever possible. Otherwise, at the local
level it should always be kept at temperatures no higher than 8 °C (i.e., from 0 °C to
+8 °C). In regional facilities at the central level it is recommended to store the vac-
cine at –15 °C to –25 °C.
Sealed vials of polio vaccine can be kept at 0 °C to 8 °C for up to six months, and
they can be thawed and refrozen without damage. However, the EPI recommends
that they be stored for a maximum of three to six months in regional facilities, and
for one to three months at facilities at the local level.
Vials of polio vaccine that have been transferred from the refrigerator to a vaccine
carrier for local outreach activities (e.g., for use at mobile clinics or in house-to-house
vaccination) should be discarded at the end of the day if they were opened.
Unopened vials should be returned to the refrigerator and used as soon as possible.
Annex 4 shows a sample of a form that can be used to record temperature and oth-
er basic aspects of refrigerator maintenance in order to ensure proper conservation
of the vaccines.

4.5 Vaccine Efficacy

Since no vaccine is 100% effective, not all persons given polio vaccine are necessari-
ly protected against the disease. The best way to determine whether the number of
vaccine recipients who develop poliomyelitis is too high is to calculate the vaccine’s
efficacy. Low efficacy (for example, less than 80%) may indicate that there are prob-
lems with the cold chain, the manufacturing process, application techniques, or use
of vaccine lots of different origin that affect the vaccine’s protective capacity.
There are several ways to calculate vaccine efficacy, including the use of coverage
 POLIOMYELITIS ERADICATION FIELD GUIDE „ 11

data and the investigation of outbreaks using case-control studies. These methods
are too detailed to describe here. A preliminary assessment is outlined below to
quickly determine whether the efficacy is within expected limits.
Vaccine efficacy can be estimated if the two fol-
lowing variables are known: (1) the proportion of Figure 7. Vaccine efficacy
cases occurring in vaccinated individuals (PCV) 100 100
and (2) the proportion of the at-risk population 90 90
Y
that is vaccinated (PPV). The curves in Figure 7
80 80
X

Percentage of cases vaccinated (PCV)

indicate theoretical vaccine efficacy levels based
70 70
on these two variables (PCV and PPV). In this
60 58,8% 60
example, the proportion of cases with three or 58.8%
50 EFICACIA DE LA VACUNA
VACCINE EFFICACY(%)(%) 40
40 50
50 60
60 70
7080
80 90909595 50
more doses of polio vaccine (PCV) is 58.8%.
Based on prior coverage estimates, the at-risk 40 40

population (children under 5 years of age) that 30 30

was vaccinated (PPV) was 75%. Figure 7 shows 20 88% 20
the intersection of these two values (point x). 10 75% 88% 10
Since x is to the left of the 60% curve, vaccine effi-
0 0
cacy in this case is estimated to be less than 60%. 0 10 20 30 40 50 60 70 80 90 100
In another example with the same percentage of Percentage of population vaccinated (PPV)

individuals receiving three or more doses of vac- Source: Orenstein WA et al., “Field evaluation of vaccine efficacy” Bull WHO 1985; 63(6):
1055–1068.
cine (PCV = 58.8%) but a higher proportion of
individuals vaccinated (PPV = 88%), the intersection of these values on the graph
(point y) is located to the right of the 80% curve, indicating vaccine efficacy that is
higher than 80%. This method does not give precise estimates of vaccine efficacy,
but it does provide a rough guide as to whether further evaluation is necessary.
The efficacy of routine immunization activities can be monitored by monthly
reviews of the vaccination records of the 1-year-old population (12 to 23 months of
age) to determine whether or not the children were fully immunized by the end of
their first year of life. Reasons for noncompliance with the vaccination schedule
should be identified and strategies should be adjusted accordingly (see Annexes 5
and 6).

5. IMMUNIZATION ACTIVITIES
5.1 Routine Immunization
Systematic or routine immunization is conducted by the permanent health services
on an ongoing basis. The objective is to ensure that all new cohorts entering the pop-
ulation are immunized as early as possible to prevent pockets of susceptibles from
developing. The success of routine immunization depends on the following:
12 „ PAN AMERICAN HEALTH ORGANIZATION

• Integration of immunization within routine health services delivery;

• Activities aimed at reducing missed opportunities;
• Improved outreach activities conducted by the health services;
• A high level of cooperation between the health services and the community in
finding the most effective means of reaching groups that are in remote areas
or are less receptive to immunization.

5.2 Mass Campaigns

Conducting national immunization days is an integral part of the strategy, and with-
out such campaigns polio cannot be eradicated. Widespread vaccination produces
extensive dissemination of the vaccine virus, which competes with the wild virus and
can quickly interrupt its transmission. Such campaigns are intended to supplement
routine immunization programs and can be held at the local or national level.
During these mass campaigns a single dose of trivalent OPV should be given,
regardless of immunization status. Two vaccination rounds should be conducted
each year, allowing an interval of at least four weeks and no more than eight weeks.
Although the experience in Latin America has shown that in general it is sufficient to
conduct two well-executed vaccination campaigns, elsewhere in the world (especial-
ly in Asia), in densely populated countries with poor health conditions and with very
low coverage, it is necessary to carry out several national immunization days before
managing to interrupt the circulation of the wild poliovirus. Children who have
missed another vaccination (for example, measles) should be referred to the nearest
health center for additional immunization if the missing vaccination cannot be giv-
en at the time of the polio campaign for logistical reasons. The opportunity should
also be taken to offer other health services, such as the provision of vitamin A or par-
asiticides, health education, and case referral.
Countries that have failed to interrupt transmission, that are still experiencing cov-
erage deficits, or that are facing a reduction in coverage should consider holding
more immunization days. The aim is to vaccinate as many children under 5 years of
age (including newborns) as possible, regardless of their previous vaccination histo-
ry. The simultaneous administration of multiple antigens (including tetanus toxoid
for women of childbearing age who live in high-risk areas) is encouraged.
The most effective immunization campaigns are organized at the national level,
thus enabling many resources (educational, military, religious, private enterprise,
and community) to be mobilized nationwide for one to three days (in remote areas,
the campaign may need to last as long as one week). Such campaigns should be con-
ducted at least twice each year, and not less than four to six weeks apart, or two
months apart at a maximum. This approach aims at 100% coverage of the under-5-
year-old population in the target area of the campaign (see Figure 8).
 POLIOMYELITIS ERADICATION FIELD GUIDE „ 13

The participation of local community leaders is key to the success of the cam-
paign. Mass media attention needs to be focused on the event. The decentralization
of financial resources for direct administration by health officials at the lowest level
of the health system is essential, so that the funds are closest to where the expendi-
tures will take place. Logistic, geographic, or demographic factors may prompt
some countries to conduct immunization days in smaller geopolitical units, such as
single provinces or regions.

Figure 8. Map displaying OPV coverage by municipality in children less than 1 year of
age. January–December 2003 (fictitious)

Municipalities with 90% or more coverage

Municipalities with 80%–89% coverage
Municipalities with 50%–79% coverage
Municipalities with coverage below 50%

5.3 Coverage of at-risk Groups

During the organization of these immunization days, special attention needs to be
paid to areas and municipalities where coverage rates are below the national aver-
age. This is particularly true in areas with deficient health services, and where addi-
tional human and logistical resources may need to be allocated. Furthermore, in the
periods between immunization days, special programs should be organized in those
areas where coverage continues to be low.
The groups at special risk for infection tend to be found in localities or municipal-
ities that have been defined as “at risk” by surveillance and other indicators. Accord-
ingly, target areas should be identified for “mop-up” vaccination campaigns and,
within these areas, a specific number of households should be visited. The following
criteria are generally used to define areas in need of mop-up vaccination:

• Detection of an imported case;

• Deficient surveillance information;
14 „ PAN AMERICAN HEALTH ORGANIZATION

• Poor vaccination coverage;

• Low economic status;
• Limited access to health services;
• Urban areas with a large poor population, particularly one that is transient;
• Areas of heavy migration across borders.

During “Vaccination Week in the Americas,” each country in the region carries out
promotion, vaccination, and health services delivery to groups selected in relation to
their levels of risk. This is an example of the concerted way in which countries can
carry out health interventions to reduce inequity and protect their communities.
These continent-wide campaigns were launched in 2003 and reach nearly 40 million
people annually.
5.4 Missed Vaccination Opportunities
An opportunity for immunization is considered missed when a person who is eligi-
ble for it and who has no contraindication to immunization visits a health service
and does not receive all the needed vaccines. Missed opportunities mainly occur in
two settings: during visits for preventive services, including other vaccinations, and
during visits for curative services. In both settings, eliminating missed opportunities
can raise coverage levels in a population.
Studies of missed opportunities for immunization indicate a continuing need to
ensure that health personnel know about the limited contraindications for adminis-
tering vaccines and do not impose unwarranted barriers to immunization. Neces-
sary steps should be taken to ensure that vaccines are offered to all women and chil-
dren every time they have contact with the health system. Rates of missed opportu-
nities are generally highest in children under 1 year of age, who are the primary tar-
gets of vaccination programs. Opportunities for immunization are missed for the
following reasons:

• False contraindications, such as fever, diarrhea, vomiting, colds, and cough-

ing, are the major causes of missed opportunities. Despite the fact that
national program standards are clear on the definition of contraindications,
health workers often fail to vaccinate because of erroneous beliefs. For exam-
ple, they may believe that vaccination would produce adverse reactions or
exacerbate a problem, would be inadequate, or would not be absorbed by
the body. Contrary to common beliefs, malnutrition is not a contraindication
to vaccination.
• The attitude of many health services providers is another major cause of
missed opportunities. They might fail to mention vaccination during routine
 POLIOMYELITIS ERADICATION FIELD GUIDE „ 15

patient visits, might not offer it, or might not ask their patients about their
vaccination status. Some health workers avoid offering vaccination in order to
economize on biologicals, since they are reluctant to open a multidose vial of
vaccine for a single child.
• Inadequate supply and distribution of vaccines.
• Another cause of failure to vaccinate relates to lack of organization and avail-
ability of services. Problems often cited include waiting to gather a large num-
ber of children before starting to vaccinate, providing services during limited
hours or on limited days, or scheduling only specific days of the week or
month for vaccinations.

Following are some approaches for reducing missed opportunities:

• Develop in-service training programs for all professional and technical health per-
sonnel to ensure that they are up to date on national immunization standards
and prepared to help change attitudes about false contraindications.
• Arrange for meetings and visit operations and personnel on-site to review the
performance of the programs and to discuss with health workers alternatives
that will allow them to take advantage of every vaccination opportunity.

To reduce missed opportunities for vaccination, health services should:

1. Check the vaccination status of all persons seeking services at health facilities, regardless of their
reason for attendance. Patients should be encouraged to bring their vaccination card every time they
visit a health center, and any vaccination that is missing should be given immediately.
2. Carry out routine health and vaccination education activities in waiting rooms and emergency
rooms, as well as for hospitalized patients.
3. Offer all vaccines on a daily basis. Do not hesitate to open a vial even when only a few children will
be vaccinated. Vaccinate all children in need of immunization, whether or not they are ill.
4. Set up convenient vaccination posts with extended hours of operation.

Program managers should:

1. Ensure an adequate stock of biologicals and supplies.
2. Decentralize immunizations to the health units or areas.
3. Evaluate activities being carried out to reduce missed opportunities for vaccination.

Communities should:
1. Increase awareness and inform parents about the need for vaccination.
2. Get private health providers involved.
3. Develop a training program for community leaders.
4. Carry out activities with the mass media to promote immunization.
5. Link the provision of other services (such as milk or food supplements) to the presentation of an up-
to-date vaccination card.
16 „ PAN AMERICAN HEALTH ORGANIZATION

6. EPIDEMIOLOGIC SURVEILLANCE
6.1 Case Definitions
For purposes of the polio eradication program, the Technical Advisory Group on
Polio Eradication has adopted the following case definitions (see also Figure 9):
Probable case
A probable case is any case of acute flaccid paralysis in a person under 15 years of
age for any reason other than severe trauma, or paralytic illness in a person of any
age in whom polio is suspected.
Confirmed case
A confirmed case is acute flaccid paralytic illness, with or without residual paraly-
sis, associated with the isolation of wild poliovirus (or circulating vaccine-derived
poliovirus—cVDPV).
Polio-compatible case
A polio-compatible case is a case in which a stool sample was not collected within
15 days of the onset of paralysis and the patient also presents an acute paralytic ill-
ness with polio-compatible residual paralysis at 60 days, or death takes place, or the
case is lost to follow-up. If epidemiologic surveillance is adequate, the proportion
of these cases should be small.
Vaccine-associated case
A vaccine-associated case is acute paralytic illness in which the vaccine virus is
believed to be the cause of the disease. Vaccine-associated cases should be distin-
guished from those caused by wild poliovirus or circulating vaccine-derived
poliovirus. In order to classify a case as vaccine-associated, the following criteria
must be met:

• It must be a typical clinical case of poliomyelitis (including sequelae);

• OPV must have been received between 4 and 40 days prior to onset of the
paralysis;
• The vaccine virus must have been isolated from a stool sample; and
• The dose in question should preferably be the first one administered in a
series (see Section 4.2).

In this classification, the word “associated” should be emphasized, since the

definitive causal relationship can only be established by isolating the virus from the
site of the lesion.
 POLIOMYELITIS ERADICATION FIELD GUIDE „ 17

Discarded case
A discarded case is a case of acute paralytic illness for which an adequate stool sam-
ple was obtained within two weeks after onset of paralysis and was negative for
poliovirus. Small amounts of the original specimen should be kept in the laborato-
ry for future reference. In the case of a patient who presents residual paralysis at 60
days, has died, or has been lost to follow-up, aliquots of the specimens should be
examined in two additional network laboratories using appropriate techniques to
ensure the accuracy of this classification. If the specimens were adequate and the
results are all negative, the case should be discarded.
6.2 Detection and Notification of Probable Cases

Detection of probable cases should be done mainly through health services that are
linked to surveillance systems. At the same time, active searches should be carried

Figure 9. Investigation of a probable case of poliomyelitis

Probable case of acute

flaccid paralysis

Yes Trauma or No
tumor?

Yes Adequate No
sample?

No Wild virus Yes No Yes

Died or lost to
isolated? follow-up?

No Yes
Sequelae?

Discarded Confirmed Compatible

Investigation
completed
18 „ PAN AMERICAN HEALTH ORGANIZATION

out; the support of community leaders is essential for these activities. All health serv-
ices personnel should know the definition of a probable case of poliomyelitis and, if
such cases are found, they should immediately submit a report to the next higher lev-
el and institute control measures, including the collection of stool samples from the
patient.
Every country should have a system for reporting probable cases of acute flaccid
paralysis. Within this system, health centers report the presence or absence of cases
once a week to the next higher level. Door-to-door or community-wide searches are
an effective way to find additional cases once an initial case is found, or to investigate
districts or municipalities where the health centers have not reported a case in a long
time, particularly in areas where persons with illness are not likely to seek medical
care.
If a polio outbreak is suspected in a community, a list should be drawn up of all
churches, preschool centers, schools, hospitals, clinics, pharmacies, and rehabilita-
tion facilities in the affected area. A minimum of one visit should be made to each
site, but weekly contact is encouraged, depending on the extent of the outbreak and
the personnel available (volunteers can be used). During the first visit, the health
workers should be asked if any case of paralytic illness has been seen or diagnosed
within the last six months. If such cases occurred, the health worker’s immediate
superior responsible for the center or the coordinator of epidemiologic surveillance
should be notified immediately, and the patient’s medical record must be reviewed
to determine if there is any possibility that the case was polio. If there is this possi-
bility, the patient’s home should be visited next.
In health centers that serve larger populations, contacts may also include select-
ed medical professionals such as neurologists and pediatricians. Efforts to identify
additional cases should extend well beyond the neighborhood or community in
which the probable case was found. Because the Region of the Americas has been
free of wild poliovirus since 1991, every probable case of polio should trigger imme-
diate notification, the collection of stool samples from the patient, and an investi-
gation that will confirm the presence or absence of other cases in the community.

6.3 Case Investigation

All reported cases of AFP should be investigated within 48 hours of being reported.
Outbreak control should begin as soon as one or more of these cases fit the defini-
tion of a probable case—that is, AFP is observed and no other cause of the paralysis
can be determined. The outbreak should be publicized and immunization activities
set up immediately so that transmission can be stopped. Mop-up operations should
be initiated to obtain the most effective results as quickly as possible. At the same
time, it is important to intensify surveillance in order to find additional cases.
 POLIOMYELITIS ERADICATION FIELD GUIDE „ 19

Health authorities at all levels and in neighboring jurisdictions should be

informed and become involved in all aspects of outbreak control. If a probable case
has traveled or had close contact with individuals from other parts of the country in
the 40 days prior to the onset of paralysis, the regional or district-level surveillance
coordinators in those areas should be notified immediately. When appropriate, oth-
er countries should be notified as well. The public should also be informed through
the mass media.
For each probable case, the patient's home should be visited and a case investi-
gation form completed (see Annex 7). Also, a line-listing of probable AFP cases
should be maintained (see Annex 8). In addition, it should be determined whether
other AFP cases have turned up in any places visited by the patient during the month
prior to onset of paralysis, such as a preschool center or school, or another town or
village. For cases from rural areas, the investigator should check the nearest large
urban center or other sites such as a marketplace or tourist centers that might be a
reservoir. All investigations should be the responsibility of specially trained epidemi-
ologists who work for state or national agencies. The following sections outline the
required measures in the investigation of probable cases.
A decision should be made to classify a case as either AFP or as “discarded” with-
in 48 hours of notification. The definitions given earlier in this chapter (Section 6.1)
should be followed strictly, regardless of vaccination history or the opinion of
attending clinicians.
Probable cases (AFP)
After a case is classified as “probable,” the following actions should be taken (see
Figure 10):

• Collect all available demographic and clinical information on the case (see
Annexes 7 and 9);
• Fill out the Line-Listing of Probable Cases (AFP) (see Annex 8);
• Immediately collect a stool sample from the patient. The epidemiologist in
charge of the investigation should determine whether samples should be tak-
en from individuals who were in contact with the initial case. Samples from
contacts are not routinely collected. If it is decided to collect samples from con-
tacts, they should be taken from children under 5 years of age who did not
receive the oral polio vaccine within the last 30 days. A date and place must be
set for further follow-up in order to: (1) collect additional stool samples, if nec-
essary, and (2) determine whether residual paralysis is present after 60 days;
• Inform surveillance site coordinators in the surrounding areas that a case of
AFP has been identified;
 20 „ PAN AMERICAN HEALTH ORGANIZATION

• If the onset of paralysis occurred less than six months earlier, initiate an inves-
tigation in the community to identify additional cases and institute wide-
spread control measures regardless of coverage levels; and
• If the onset of paralysis occurred more than six months earlier, start mop-up
vaccination activities as soon as the low transmission season begins.

Figure 10. Case investigation decision tree

PROBABLE CASE

Yes Yes No

To begin community control measures:

Continue investigation to • Visit home/neighborhood
determine final classification • Start immunization activities
1) Decide:
1) Fill out investigation form and line- • Who to vaccinate (target age group)
listing as data become available. • When to vaccinate
2) Collect 1 stool specimen from the • Where to vaccinate (including door-to-door)
patient; collect specimens from 5 2) Notify national surveillance coordinator and discuss control strategy
contacts (only if the epidemiologist 3) Notify community leaders and surveillance coordinators in other areas
so indicates). 4) Review polio vaccination coverage data on children under 5 years old in
3) Arrange for follow-up to determine affected and surrounding areas
clinical outcome. 5) Search for additional cases in a wide geographic area. Inquire about any
cases that may have occurred in the last six months:
• Visit schools, churches, etc.
• Visit medical care facilities
• Meet with community leaders
• Conduct door-to-door searches
6) Increase surveillance for the following 6–12 months:
• Complete line-listing of all cases
• Submit a case investigation form to the surveillance coordinator

Confirmed or polio-compatible
case

No
Yes Was another cause confirmed?

Yes No Discarded case

Report to the surveillance
No additional investigation required
coordinator
 POLIOMYELITIS ERADICATION FIELD GUIDE „ 21

Case-finding during an outbreak. In the Americas, where poliomyelitis has already

been eliminated, the presence of a single confirmed case of the disease constitutes
an outbreak. To detect additional cases, procedures similar to those described else-
where in this chapter should be used, and the support of community leaders should
be enlisted.
Target group for vaccination in the event of a polio outbreak. In general, children under 5
years of age should receive the highest priority. However, if cases occur in children 5
years of age or older, the older children should be vaccinated as well. All should
receive a single dose followed by a second dose four to six weeks later, irrespective
of documented polio vaccine history.
Concept of high-risk communities. Each case of paralysis probably represents 100 to
1,000 infected people. Consequently, it is likely that the virus may have spread
beyond the local area in which the case resides. It has been shown that mass immu-
nization programs with OPV quickly interrupt the transmission of poliovirus. Thus,
immunization activities should cover a wide geographic area, particularly if there is
any doubt about the quality of surveillance or the data on vaccine coverage. Adja-
cent areas may have coverage levels similar to that of the affected village or city, or
there may be frequent or large-scale population movements. If so, vaccination cam-
paigns may need to be conducted in those areas as well. Such immunization activi-
ties should be organized promptly and publicized extensively.
6.4 Laboratory Confirmation
The laboratory plays a critical role in surveillance, since eradication focuses on elim-
inating the wild poliovirus itself and not just the clinically apparent disease. Viral cul-
ture of stool specimens collected from both AFP cases and their contacts is the most
sensitive and effective way to rule out transmission of either wild poliovirus or vac-
cine-derived virus (see Table 2). Since it is impossible to be sure that a patient will
be available for follow-up, clinical information and specimens should be taken dur-
ing the first consultation.
To ensure that stools from cases and contacts (if collection of the latter has been
indicated) are tested without delay, and to solve any other problems, there should
be good communication and coordination between the epidemiologist and the
virologist. For probable cases, all available specimens from both the probable cases
and contacts should be examined.
Type of specimen
Although the following list includes all types of specimens that could be used for lab-
oratory diagnosis, for purposes of AFP surveillance it is recommended that only
ONE stool specimen be taken from the patient as soon as it is determined that it is
a probable case.
 22 „ PAN AMERICAN HEALTH ORGANIZATION

Table 2. Specimens for poliovirus detection

Feces Autopsy material

(tissue and intestinal contents)
When to collect As early as possible in the course of the illness; collect one Within 24 hours of death.
sample each from cases and contacts (if so indicated).

Collection technique Use a clean, empty container to collect 8 g of feces Avoid contamination of nervous system tissue with intestinal
(approximately the size of two thumbs). contents. Tissues should be collected using sterilized
instruments and placed in individual, sterile containers. Use
separate instruments and containers for different tissue
types.
Storage If possible, keep specimens refrigerated from the time of Keep specimens refrigerated from the time of collection.
collection.

Labeling Label all specimens clearly with name of case or contact, case Label all specimens clearly with name of case or contact,
number, date of collection, and date of onset of paralysis. case number, date of collection, and date of onset of
paralysis.

Shipping of specimens Ship specimens wrapped in a well-sealed plastic sack in a Ship specimens wrapped in a well-sealed plastic sack in a
thermos or cooler with ice. Use dry ice if available. Include thermos or cooler with ice. Dry ice is strongly recommended.
appropriate laboratory slips, and inform laboratory when Include appropriate laboratory slips, and inform laboratory
specimen will arrive. when specimen will arrive.

Type of exam Virus isolation and characterization. Virus isolation.

Interpretation of results If poliovirus is isolated, it must be characterized as being Isolation of poliovirus from central nervous system tissue
either a “wild” or “vaccine-derived” strain. Absence of virus confirms poliovirus infection.
does not rule out the possibility of poliomyelitis.

Stool. The virus can usually be found in feces from 72 hours to six weeks after infec-
tion, with the highest probability during the first two weeks after onset of paralysis.
Cerebrospinal fluid (CSF). It is not likely to yield virus, and therefore its collection is
not recommended.
Throat. It is not likely to yield virus, and therefore specimen collection from this site
is not recommended.
Blood. It is not likely to yield virus, and current serologic tests cannot differentiate
between wild and vaccine-derived virus strains. Experience has shown that for
polio, interpretation of serologic data can often be misleading. Therefore, collec-
tion of blood specimens is not recommended.

If a probable case dies, a definite diagnosis of polio can be made or rejected by

examining the spinal cord. It is important that a qualified and experienced pathol-
ogist do the examination and that a specimen be sent directly to a reference labora-
tory so that efforts can be made to culture for poliovirus.
 POLIOMYELITIS ERADICATION FIELD GUIDE „ 23

Specimen collection
Probable case. One stool sample should be collected from probable cases within
two weeks of the onset of paralysis.
Probable case, patient has died. Specimens should be collected from intestinal con-
tents or nearly formed stools; tissue (medulla, spinal cord) and serum may also be
collected as soon as possible after death. These specimens will be sent to the labo-
ratory, where they should be cultured and undergo polymerase chain reaction (PCR)
and histopathologic analysis. A section of nerve from the affected limb should also
be obtained.
Contacts. When so indicated by the epidemiologist, stool specimens should be col-
lected from five or more contacts who are under 5 years of age and who have not
received oral polio vaccine within the last 30 days. The epidemiologist will usually
give instructions to collect specimens from contacts when the probable case has
clinical or epidemiological manifestations suggesting that it is a true case of
poliomyelitis (high fever, asymmetrical acute flaccid paralysis, etc.), or when there is
more than one probable case in the community.
If the probable case is seen later than 14 days after the onset of paralysis, and is
clinically compatible with polio, special studies will be needed in addition to analy-
sis of the stool specimen. Such studies may include community surveys to collect
stool specimens from 50 to 100 of the patient’s contacts and neighbors who are
under the age of 5 and who have not been vaccinated within the previous 30 days.
At least 8 g of specimen (about the size of two thumbs) should be collected direct-
ly in the container that will be sent to the laboratory. Rectal swabs are not recom-
mended, although rectal tubes may be used in special circumstances.
Storage and shipment of specimens
Stool specimens should be kept cold if they are to remain in adequate condition for
reliable testing when they arrive at the laboratory (see Figure 11). The best way to
keep them cold is with dry ice; when dry ice is unavailable, ice packs are recommend-
ed. Dry ice requires special handling, so it should be ensured that any box contain-
ing dry ice is hermetically sealed.
The person responsible for shipping should make sure that there is sufficient
quantity of the stool specimen and ice. In addition, the shipper should telephone
and send a fax to the receiver, and should ensure that the appropriate forms are
included with the shipment. Upon delivery, the receiver should inform the shipper of
the date and time the specimens were received and their condition. If possible, this
verification should take place within 48 hours, so that arrangements can be made
to collect additional specimens if necessary.
 24 „ PAN AMERICAN HEALTH ORGANIZATION

Figure 11. Packaging for virological specimens

Labeled, screw-capped vial containing the specimen.

Absorbent material—e.g., tissue paper or absorbent cotton wool sufficient to

absorb all the specimen should leakage occur.

Plastic bag; heat-sealed or taped closed (do not staple).

Shock-absorbent padding—e.g., loosely packed paper or absorbent cotton

wool.

Rigid, waterproof outer container. Case investigation form and lab slip
should be placed inside this container. Use tight-fighting lid—e.g.,
screw-on or push-on type. Apply tape or metal clips over lid to secure.

Ice-filled, insulated container (maintain at 0–8 ° C).

When specimens are sent by messenger service or hand-delivered, the carrier

should be advised of the contents and special handling requirements of the package,
as well as the importance of delivering the samples directly and immediately. The
delivery service should inform the shipper when delivery has been successfully com-
pleted.
The following information should be provided for all specimens:

• Collection date,
• Case identification number,
• Health jurisdiction,
• Hospital/clinic,
• Key clinical information, and
• Vaccination history and date of last OPV dose.

Quality control of specimen collection

Ongoing evaluation of the quality of stool specimen collection, transportation, and
storage is a crucial component of the program. Laboratories in the network should
 POLIOMYELITIS ERADICATION FIELD GUIDE „ 25

be evaluated annually to ensure the quality of specimen processing. Specific forms

should accompany each specimen to assist in the collection of critical monitoring in-
formation (see Annex 10). A detailed record of the condition in which each specimen
is received should be kept by both the receiving laboratory and the central laborato-
ry in each country, so that those responsible for sending the specimen will receive
feedback about the quality of the shipment.
The laboratory should note:

• The adequacy of packaging for the specimen;

• The type of specimen;
• Whether the specimen was sufficient (8 g);
• Whether ice was still present when the specimen arrived;
• Whether the package was correctly identified.

Results of the laboratory analysis

It is important that the status and results of the tests on the samples be conveyed
back to the individuals who requested them as soon as possible. Initial laboratory
results should be reported within 28 days of receipt of the specimens.
Isolation of poliovirus
Failure to isolate poliovirus from a stool specimen does not rule out the diagnosis of
poliomyelitis. Many factors can influence the results, including intermittent shed-
ding of the virus in stool, insufficient material collected, collection of the specimen
too late in the course of the illness, inadequate storage and shipping of specimens,
and problems with laboratory technique. The proportion of specimens from which
enteroviruses were isolated should be reported, since this figure is an indirect indi-
cator of specimen quality. In tropical areas, at least 10% of the specimens can be
expected to yield enteroviruses.
Characterization of poliovirus
All polioviruses isolated from the stools of patients with acute flaccid paralysis or
from their contacts should be characterized. This characterization determines
whether the virus is “wild” or “vaccine-like.” The initial identifications are confirmed
by polymerase chain reaction (PCR) analysis using primer sets specific to each vac-
cine strain and to the predominant wild polioviruses indigenous to the region. Wild
viruses identified using this procedure should be further characterized by partial
nucleotide sequencing of the virus genomes, which reveals the genetic relationships
between virus isolates. Given that poliovirus genomes evolve rapidly during replica-
tion in humans, the proximity of epidemiological links between cases may be esti-
mated by analyzing the nucleotide sequence relationships in the genomes of the iso-
 26 „ PAN AMERICAN HEALTH ORGANIZATION

lated viruses. Sequence information is also used in the systematic design of nucleic
acid probes and in the initiation of RNA segments for PCR. This further characteri-
zation also makes it possible to know if it is a vaccine virus or one derived from the
Sabin vaccine.
Laboratory network
Poliomyelitis is not clinically distinctive and may be confused with other causes of
flaccid paralysis. Surveillance systems, therefore, need laboratory support in order
to confirm or rule out poliovirus as the cause of a case of acute flaccid paralysis.
Techniques for analyzing stool specimens, isolating poliovirus, and differentiating
between vaccine-derived virus and wild poliovirus must be standardized, and the
quality of procedures must be monitored.
PAHO has sponsored the formation of a laboratory network (see Figure 12) to ana-
lyze stool specimens for poliovirus. Several of the more sophisticated (level 3) labs per-
form intratypic differentiation tests for
Figure 12. Polio reference laboratory network in the Americas poliovirus, and the results are published in
the Polio Weekly Bulletin of the Pan American
Health Organization (see Annex 11). It is
important for the laboratories to provide
regular updates of their findings so that the
epidemiologic surveillance system can
monitor the status of all stool specimens
collected from AFP patients.
CDC The network serves to enhance labora-
(United States) Virus isolation and characterization
Intratypic differentiation
tory performance by developing new tech-
nologies and analytic approaches, by pro-
INDRE
(Mexico) viding training, and by maintaining strong
INCAP collaboration among laboratories. Net-
CAREC (English-speaking Caribbean)
(Guatemala)
INS
INH (Venezuela) work representatives should be encour-
(Colombia) CHAGAS (Brazil) aged to meet regularly to discuss the eval-
uation of testing methods, interpretation
LACEN (Brazil)
of findings, implementation of new tech-
nologies, network resource and training
FIOCRUZ (Brazil)
needs, and ways to improve network per-
formance, particularly in the area of
MALBRAN (Argentina) research. The laboratories need to com-
municate their requirements regarding
timely collection, storage, and appropri-
ate means of shipping clinical specimens.
 POLIOMYELITIS ERADICATION FIELD GUIDE „ 27

Maintenance of a central database that summarizes laboratory information on

each case and contact (Annex 12) is critical, as is dissemination of this information
among the participants. Quality control of laboratories includes: annual accredita-
tion; site visits to evaluate operations; testing of each laboratory with a panel of
specimens known to the sender but not to the laboratory; and analysis of the time
taken to report initial results of whether or not poliovirus was isolated, including the
time taken to identify and report the type of virus isolated (vaccine-derived, wild,
type 1, 2, or 3); among other requirements (see Annex 13).
6.5 Monitoring and Feedback
Information dissemination
At the country level, a bulletin should be distributed to all those involved in surveil-
lance and eradication to provide results on reported and confirmed cases. In addi-
tion, the bulletin should indicate the number of units reporting each week (includ-
ing negative reporting). Information should also be included about the current epi-
demiological status of polio and other EPI target diseases. Polio update bulletins
should be distributed on a weekly or monthly basis to all health care workers, other
health service providers, and members of the community at large.
6.6 Surveillance Indicators for Acute Flaccid Paralysis
The following indicators should be evaluated and reported on a routine basis:
Surveillance
1. Percentages of reporting sites that submit reports every week: At least 80% of the sites
should submit weekly reports, even in the absence of cases.
2. Sensitivity of surveillance: It should be expected that in a given year at least 1 case
of acute flaccid paralysis will be detected in every 100,000 children under 15
years of age. Each country’s monitoring data should be reviewed to ascertain
whether or not the territorial units (states, provinces, departments) are com-
plying with their annual guidelines. This indicator is particularly helpful in
detecting “silent” areas (i.e., those that have failed to follow the indicated
guidelines), and it will be used to adopt the corrective measures called for by
the review. The review should not be limited to verifying whether a jurisdiction
has followed established reporting guidelines, since data attributed to that
jurisdiction may be coming from a large referral hospital that is actually
reporting cases from elsewhere. In such cases it will then have to be deter-
mined whether a consultation occurred in a patient’s place of origin and
whether the relevant health facility reported the case. Cases should be
assigned to the jurisdiction in which the patient resided for the last 45 days
prior to onset of paralysis. Table 3 gives an example of the type of line-listing
 28 „ PAN AMERICAN HEALTH ORGANIZATION

the country should prepare in order to determine the rate of AFP in its respec-
tive territorial jurisdictions.
3. Interval between case onset and notification: At least 80% of all cases should be
detected and reported within 14 days of the onset of paralysis.
Investigation
1. Interval between notification of a probable case and investigation: 100% of the cases
should have been investigated within 48 hours of notification.
2. Stool specimen from probable cases: For at least 80% of the AFP cases, a stool
specimen should have been obtained within 14 days of the onset of paralysis.
3. Interval between specimen collection
and receipt in the laboratory: 100%
Table 3. Rate of reported cases of acute flaccid paralysis
per 100,000 population under 15 years of age, of the specimens should be
by department (fictitious data) received by the laboratory within
YEAR 3 days.
DEPARTMENT 2000 2001 2002 2003 4. Case follow-up: At least 80% of all
Akron 4.10 7.50 2.00 0.70 probable cases should be fol-
Antigua 0.30 1.50 1.00 1.50 lowed up within 60 days of
Cárdenas 0.60 0.00 0.00 0.00
paralysis onset to determine
Chattanooga 0.40 0.40 0.40 0.00
whether or not there is residual
Coronado 5.70 0.90 1.80 0.90
paralysis.
Evansville 1.90 1.90 0.70 0.60
Huila 2.30 0.00 1.10 1.10 5. Case investigation form: 100% of the
Jacksonville 3.20 1.70 0.70 0.70 cases should have a completed
La Unión 0.00 0.60 1.21 0.60 investigation form with demo-
Lowell 0.40 0.80 0.40 0.00 graphic, clinical, and laboratory
Mangas 4.10 2.10 2.10 1.00 information.
Ogden 0.20 1.60 3.30 1.40 6. Critical clinical variables: The med-
Providence 1.10 1.10 0.40 1.50
ical records for 100% of the cas-
San Juan 4.70 2.20 2.20 0.70
es should contain the following
San Marco 2.40 1.50 1.50 1.00
variables: date of paralysis
Savannah 0.30 0.30 0.60 0.00
onset; time or period of progres-
Shreveport 10.90 0.00 0.00 0.00
sion of paralysis; presence of
Somerville 10.90 0.00 4.40 0.00
Spokane 1.60 1.60 0.00 0.00
fever at onset of paralysis; resid-
Tampa 1.80 0.40 1.10 0.40 ual paralysis 60 days after onset;
Toledo 0.70 0.50 0.70 0.50 atrophy at 60 days; location of
Waterbury 1.10 0.00 1.60 0.00 paralysis (proximal or distal,
Yonkers 1.80 1.80 0.00 0.00 symmetrical or asymmetrical);
Youngstown 0.00 0.00 2.00 2.00 and final diagnosis.
AVERAGE 1.77 1.15 1.11 1.06
 POLIOMYELITIS ERADICATION FIELD GUIDE „ 29

Laboratory
1. Condition of specimens: 100% of the specimens received should have proper epi-
demiological data, be correctly packaged, and be surrounded by ice.
2. Interval between receipt of specimen and report of results: 100% of the findings should
be communicated to the sender within 28 days of receipt of the specimen.
3. Recovery of virus: Enterovirus should be recovered in at least 10% of the stools
processed.
Control
1. Control measures must be instituted for 90% of all cases classified.

6.7 Response to Outbreaks

Outbreak management
When it is decided that outbreak control is necessary, certain information should
be gathered and a plan of required actions adopted. The decision to adopt meas-
ures to combat an outbreak should be based on epidemiologic analysis (which at
that point may, but need not, include laboratory results). Although it is difficult to
list all the criteria that need to be met in order to start taking action against an out-
break, this decision may be made if one or more of the following conditions are
present:

• A case of AFP in which the wild virus has been isolated;

• Cases of AFP that seem to be epidemiologically connected with no obvious
external cause (for example, poisoning from organophosphorus compounds);
• Cases of AFP with the clinical characteristics of polio;
• Detection of wild poliovirus or vaccine-derived virus in neighboring areas or
countries; and
• Low vaccination coverage.

The following factors, among others, need to be taken into account when man-
aging an outbreak:

• Population data: Obtain the most recent data on population size and distribu-
tion.
• What’s been done: List any measures already taken.
• Case review: List cases reported in the area in the last six months. Construct an
epidemic curve.
• Coverage rates: Obtain existing coverage data, including official estimates.
30 „ PAN AMERICAN HEALTH ORGANIZATION

• Spot map: On a map, use pins or a pen to mark the location of cases and areas
targeted for vaccination.
• Resources: Determine what resources are available at all levels (transportation,
vaccine, cold chain materials, etc.). Field personnel to assist in outbreak con-
trol should include teams from other programs, district staff, medical and
nursing students, interpreters, and drivers. Arrange for transportation and pay-
ment of travel advances.
• Coordination: Inform appropriate health and community authorities when and
where the team will be arriving and ask that specific health system staff and com-
munity representatives be present.
• Supplies: Organize necessary supplies to take to the outbreak area:
— Adequate supply of OPV vaccine for estimated target population;
— Cold chain materials: ice packs, portable refrigerators/cold boxes, vac-
cine shipping containers, vaccine control cards, thermometers. Deter-
mine whether refrigerators for the ice packs are locally available or need
to be brought (e.g., a kerosene refrigerator);
— Adequate supply of forms: line-listings for probable cases and laborato-
ry information, AFP case investigation forms (Annex 7), summary of out-
break control measures (Annex 9), and mop-up work tally sheets (Annex-
es 14 and 15).
• Outbreak monitoring: Information on cases, immunization activities, and villages
visited needs to be updated continuously and monitored during an outbreak.
This information on control measures should be kept on a form that can be
quickly summarized, such as the one shown in Annex 9. Outbreak contain-
ment will have been successful if no additional cases are reported one month
after the second round of immunizations. At that time, special reviews and
checks should be made to ensure that no new cases have occurred.

6.8 Information and Data Analysis Systems

An important component of a successful polio eradication program is a well-devel-
oped information system—one that provides program managers and health workers
with the necessary information to take appropriate action. Information from the
disease surveillance system is used to prepare regular summary reports. These
reports should be distributed to the personnel responsible for acting on specific
problems. All surveillance information should be standardized, that is, it should
include the same type of data elements.
 POLIOMYELITIS ERADICATION FIELD GUIDE „ 31

Data collection
The system, whether it is manual or computerized, consists of two main elements:
Case tracking and data collection
At the national and regional levels of a country, there should be a system that is
capable of tracking reported AFP cases until they are either confirmed or discard-
ed. Such a system should incorporate the following:

• A uniform case identification number;

• A standardized case investigation form;
• The basic demographic data on each case;
• The basic clinical data on each case;
• The recording and monitoring of laboratory specimens from the time they
are obtained until the final results are received.

Reporting units
At the national and the regional levels of a country there should be a system to
keep track of reporting units. These units may be a geographic jurisdiction (such
as a county, district, or municipality), or a health facility such as a hospital or pri-
vate clinic. The critical data to be monitored for each of these units are prompt-
ness of reporting (on-time or late) and frequency of reporting.
Computerization
In the Americas, a computer-based system known as the Polio Eradication Surveil-
lance System (PESS) has been used to process the above-mentioned information for
all countries in the Region. The database is menu-driven, which allows users who
have limited computer ability to operate the program. This system has helped to cre-
ate a standard set of variables that allows comparisons over time within countries
and between countries. The standardization of surveillance data is fundamental.
Work is under way on a new system that will handle this information more expedi-
tiously and in real time.
Analysis
Initially, analysis should focus on data related to vaccination coverage and the
degree of compliance with epidemiologic surveillance indicators. Once this part is
done, more attention can be given to the time, place, and characteristics of AFP
cases; the search for information pointing to the existence of cases that are clus-
tered either geographically or in time periods; the presence of characteristics that
might more closely meet the definition of clinical poliomyelitis; the predominance
of AFP cases in immunized or unimmunized children; the ages of any such children;
32 „ PAN AMERICAN HEALTH ORGANIZATION

the presence of sequelae in these cases; etc. Polio-compatible cases should also be
studied.
The structure of the case investigation forms and line-listings should be analyzed
in order to gain an overview of the cases and to determine whether the standards for
reporting and investigation are being met (see Annexes 16, 17, and 18). The follow-
ing information should be analyzed:

Stool samples. In order to confirm poliomyelitis, it is essential to collect a stool

sample from the patient within 14 days after onset of paralysis, as well as at least
five samples from contacts (if so instructed by the epidemiologist).

Clinical data. It is equally critical to determine the presence of clinical risk factors for
poliomyelitis, such as fever at onset of paralysis, rapid progression of paralysis, and
residual paralysis after 60 days.

Age. The age distribution of cases is useful for establishing which age groups to tar-
get in the vaccination campaign. In the Americas, the great majority of cases have
been seen in children under 6 years of age.
Geographic location. Cases should be plotted on a map and this information
should be compared with coverage data and surveillance reporting sites. These
maps can be useful for coordinating activities (for example, locations for adminis-
tering vaccinations).
Source of notification. This information will help determine whether improvements
are needed in the notification process for surveillance. For example, if cases are
being reported only from rehabilitation centers, then additional sources from clinics
and hospitals may be required.
Rate of acute flaccid paralysis. The effectiveness of the surveillance program can be
judged by the rate of AFP cases. The surveillance program should find at least 1 case
in every 100,000 children under 15 years of age.
Vaccination history of cases. Accurate information on the vaccination history of per-
sons with poliomyelitis is essential for evaluating vaccine efficacy and possible cold
chain problems.
Virus typing. Ultimately, the results of genomic sequencing will be useful in deter-
mining whether an outbreak was caused by the circulation of indigenous poliovirus
or by a vaccine-derived or imported strain. Urgent control measures should be tak-
en in the area that is the source of the identified virus.

Annex 20 provides examples of how to organize and present this information on

AFP surveillance and to facilitate the assessment of an immunization program.
 POLIOMYELITIS ERADICATION FIELD GUIDE „ 33

7. CERTIFICATION OF POLIO ERADICATION

IN THE AMERICAS
On 6 July 1990, delegates to the first meeting of the International Commission for
the Certification of Poliomyelitis Eradication in the Americas (ICCPE) established
preliminary criteria for certifying countries as free of poliomyelitis. National com-
missions in each country were formed that would be responsible for reviewing and
supervising pre-certification activities, and it was decided that the countries should
prepare national reports to present to the ICCPE. In these reports they would doc-
ument: (1) the quality of surveillance for AFP; (2) surveillance for wild poliovirus; (3)
active AFP case-finding in areas of poor surveillance (Annex 19); and (4) the imple-
mentation of mass vaccination campaigns in high-risk areas.

The ICCPE sought to accomplish the following:

• Verify the absence of virologically confirmed indigenous poliomyelitis cases in

the Americas for a period of at least three years under adequate AFP surveil-
lance conditions;
• Confirm the absence of detectable wild polioviruses in designated communi-
ties by testing stool samples of healthy children and, where appropriate, by
testing wastewater from high-risk populations;
• Obtain an on-site evaluation by national certification commissions;
• Institute appropriate measures to deal with imported cases.

As already mentioned, in 1994 the ICCPE concluded that the Region of the Amer-
icas was free from indigenous circulation of wild poliovirus. However, the fact that
polio eradication in the Americas has been certified does not mean that the children
of this hemisphere are not at risk of contracting the disease. At the time this Guide
was prepared, poliomyelitis continued to be endemic in many countries of the
world, and imported cases constitute a threat for those that have already eliminat-
ed the disease. There is also the possibility that the vaccine-derived virus can be rein-
troduced in municipalities, departments, provinces, or countries with low vaccina-
tion coverage, as occurred in Haiti and the Dominican Republic in 2000 and 2001.
In order to detect an outbreak in a timely manner, and guarantee that the children
of the Americas will remain protected, the countries of the Region should maintain
vaccination coverage levels of 95% or higher in all their municipalities, and continue
to comply with the surveillance indicators for acute flaccid paralysis.
 34 „ PAN AMERICAN HEALTH ORGANIZATION

8. THE FINAL PHASE OF GLOBAL ERADICATION

OF POLIOMYELITIS
The enormous progress made by the worldwide initiative for poliomyelitis eradication
is clearly illustrated in Figure 13, which shows that the annual number of cases
decreased from nearly 350,000 in 1988 to 1,266 in 2004. This significant achievement
also reveals some of the risks the world faces at this stage, considering that the only
previous experience in this regard has been the global eradication of smallpox. The
Region of the Americas was certified polio-free in 1994 (the last case associated with
wild poliovirus was reported in Peru in 1991).
Once the indigenous circulation of the wild poliovirus has ended in a country, con-
tinent, or in the world, there is still the risk of the occurrence of polio cases from a
virus derived from the oral vaccine that has mutated after circulating in the popula-
tion (cVDPV), or from a chronic excretor of the virus (iVDPV), as well as cases caused
by wild poliovirus that has been released accidentally or intentionally from a labora-
tory where it was stored. There is also the risk of cases of paralysis associated with

Figure 13. Progress of polio eradication, 1988 and 2004

In 1988, there were 350,000 cases in 125 countries.

In 2004, there were 1,266 cases in 18 countries.

Endemic countries in 2004.

Source: World Health Organization.
 Another Random Document on
Scribd Without Any Related Topics
without power or influence. The English government soon perceived
its error, and wished to correct it, and thenceforth the
misunderstandings commenced between the colonies and the
mother country, in which the latter increased their resistance, in
proportion as the demands of the former were augmented.
The privileges of the different powers were soon entirely
confounded. The governor was invested by the crown with the right
of erecting courts and nominating judges; privileges which were
vividly contested by the people, who claimed them as legislative
prerogatives. Notwithstanding the multifarious encroachments of the
crown, the colony, even when most actively opposing them,
remained still attached to the mother country, and willingly aided
her in the colonial war she had to sustain against France in 1744.
After this war, which had alternately been renewed and suspended
during sixteen years, with various successes and reverses, and which
finally terminated in the ruin of the French colonies, the colonists
hoped that the gratitude of England for the services they had
rendered, would assure them thenceforth the enjoyment of their
rights and liberties, acquired by every kind of sacrifice; but scarcely
had two years elapsed after the establishment of peace, before all
their hopes were blighted.
England at that time triumphed by land and sea; her commercial
preponderance was felt in all parts of the world, and aroused the
envy of all European nations. But this glory with which she was
intoxicated, was not acquired without waste of treasure, and the
contracting of immense debts. To pay these debts, and re-establish
her finances, new sources of revenue were to be created, and her
attention was turned towards her colonies.
The colonies had made an immense profit by their West India
trade, and by the aid of a good administration had found means to
form a sinking fund, which enabled them to pay their debts, and
successively to increase their importations of English manufactures.
The cupidity of the crown was excited by this prosperity, and from
that moment ministerial adroitness was exercised in nothing but
varying the means of extracting money from the colonists. The
commanders on the coasts were converted into harsh excisemen,
charged to repress unlawful commerce, and prevent smuggling.
These commanders, assured of impunity, since they were only to be
tried by the courts of Great Britain, were not backward in making
illegal seizures, for their own profit. The import duties were raised to
the highest pitch, and these duties were made exclusively payable in
gold or silver, which rendered the paper money circulated among the
colonists of no value. In short, the new system introduced by the
English minister, became as tyrannical as ruinous, because at the
moment enormous duties were imposed, it annihilated the means of
paying them. Emboldened by the forbearance of the colonists, the
British government knew not where to stop, and in the year 1765, the
oppressive law called the stamp act was passed, which ordered, that
for the future all contracts, wills, deeds, &c. should be drawn on
stamp paper, under penalty of being rendered null, and imposed a
tax on this paper, destined to pay the expenses of the last American
war. This law produced universal exasperation, as soon as it was
made known; it became the subject of conversation and discussion in
all public and private societies; every one looked to the past, and
recapitulated with bitterness the outrages perpetrated by England,
and from that moment, it may be said, the revolutionary fire was
kindled. From supplications and remonstrances, to which the
colonists had hitherto confined themselves, they advanced to threats;
the people of Massachusetts especially, expressed their resentment
forcibly. It was at the instigation of this state, that a congress formed
of deputies from many provinces, assembled at New York, on the 7th
of October. This Congress, composed of men respectable for their
characters and information, and which eventually served as the
model of the Congress that so gloriously conducted the war of the
revolution, published an energetic declaration of the rights of the
colonies; a view of the oppressions of England; a petition to the king,
and a memorial to parliament. These acts of Congress produced an
effect upon parliament, which was augmented by the presence and
writings of Benjamin Franklin, who was then in London, and had
been called before the house of Commons to be examined relative to
the complaints of his fellow citizens. He presented himself with
characteristic modesty, and a republican simplicity, which was
singularly in contrast with the insolent splendor of the minions of
power, who attended his examination in crowds, in hopes of seeing
him humbled, whom they regarded as a rebel, for presuming to
speak of the rights of man in the presence of royalty. His calm
answers and profound arguments produced a great impression upon
the assembly, causing the promoters of the stamp act to reconsider
the matter, and determined them to withdraw this monument of
their ignorance and tyranny.
In proportion to the height the indignation of the Americans had
been raised by the passage of the stamp act, was their joy on hearing
of its repeal. The British government however, did not profit by this
return of public feeling to a milder mood; not only were all the
odious restrictions upon the colonial commerce continued, but the
stamp act was followed by an equally intolerable duty upon the
paper, tea, glass and colours imported by the colonists from England.
But the preamble to this act was most especially grevious to the
colonists; as it announced that the product of these new taxes should
be placed at the disposal of parliament, to defray the expenses of the
colonial administration, and particularly to pay the salaries of the
governors and judges, who would thereby be rendered independent
of the provincial Legislatures and made dependent upon the
ministry. A permanent administration to superintend these taxes
was created by parliament and established at Boston. The people of
Massachusetts could not be deceived as to the views of the ministry;
accustomed for a long time to discuss and manage their own affairs
they resolved not voluntarily to submit to the disgrace of being
governed by an unlawful authority, appointed at a distance of more
than 3,000 miles. The representative assembly was then convened,
and protested against the taxes and the use to be made of them; and
they addressed a circular to the other provincial assemblies, in
which, after recapitulating their privileges, and the oppressions of
England, they conclude by asking for their co-operation in resisting a
tyranny which daily pressed with increased weight upon the colonies.
This step was treated as infamous and rebellious by the servants of
the crown, who redoubled their vexations. Two English regiments
arrived, which being refused quarters in the city, by the council,
landed under protection of their ships, with fixed bayonets and two
pieces of cannon, and established their guard-house in front of the
state house, which was thus turned into a barrack. The city was
thenceforth in the power of the military, who scoured the streets,
insulting the citizens, disturbing their rest or business, and
interrupting even their religious exercises by the continual noise of
their martial music.
 Under these circumstances the assembly was convoked at Boston,
but did not meet, declaring that they did not feel at liberty in
presence of an armed force; the session was consequently removed to
Cambridge, where the governor had the impudence to present
himself and demand funds to pay the troops; which being refused,
the assembly was dissolved.
However, a change in the English ministry had determined
parliament to suppress all the duties except that on tea; but this
apparent return to a system of moderation in no way appeased the
resentment of the citizens of Massachusetts, who saw nothing but
caprice in the measure, or a new method employed by parliament to
establish its right of interference in colonial affairs; and they
determined not to abandon the contested point.
A circumstance soon after occurred in Boston, which might have
been followed by the most serious consequences. The English
soldiers accustomed to regard the citizens as rebels, treated them
with severity; and the citizens irritated by their incessant ill
treatment, cherished a violent hatred against the troops, allowing no
opportunity of expressing their dislike to escape. On the 5th of
March, 1770, a detachment under command of Captain Preston was
insulted by some boys, who, it is said, pelted them with snow balls,
and abused them. Blinded by resentment, the soldiers charged and
fired upon the crowd, wounding five dangerously, others slightly,
and killing three outright. The citizens immediately flew to arms, and
but for the intervention of the governor and magistrates, Preston and
his men would have been exterminated. The troop were arrested and
tried, but such was the feeling of justice that animated the
inhabitants of Boston, that the jurors, convinced that the soldiers
had been provoked, entirely acquitted them.
This event convinced the popular party that an open struggle with
the mother country was unavoidable, and that they must prepare for
it. In consequence, secret committees of correspondence were
organized, in order to regulate the measures that would soon have to
be adopted. The utility of this organization, then called the league
and covenant, soon became apparent.
From the time the tax on tea was established, the Bostonians
resolved to relinquish its use, rather than receive it from the English,
and thenceforward the East India company received no more orders.
The company, however sorry for the loss of their market, determined
to send several cargoes of tea to their agents in Boston who would
pay the duties and thus avoid the difficulty. But scarcely was the
arrival of these cargoes known, before the public agitation became
great. The next morning the following hand bill was widely circulated
through the city.

“Friends, brethren, fellow citizens!

“The accursed tea sent to this port by the East India company has arrived.
The hour of destruction, or of vigorous resistance to the machinations of tyranny
has struck. All those who love their country, who are jealous of their own
happiness and who wish to deserve well of posterity, are invited to assemble at
Faneuil Hall, to day at 9 o’clock (the bells will then ring) to concert a determined
resistance to this destructive and infamous measure of the administration.
Boston 29th. Nov. 1773.”

The citizens eagerly responded to this patriotic call. The concourse

was so great that the Hall could not contain the people, and they
were obliged to adjourn to a more ample space; the discussions
which were commenced and continued at this meeting prevented any
resolution from being adopted on that day. The meeting adjourned
until next day, and 500 persons under command of Capt. Proctor
were appointed to watch that the tea should not be landed during the
night. The meeting of the 30th. was still more numerous, and the
ardor of the citizens was farther augmented by the governor’s
proclamation, which commanded them to renounce their projected
resistance to the law, and to disperse on peril of their lives. The
governor’s orders were treated with universal contempt, and the
meeting calmly proceeded to draft several propositions which were
accepted, and it was decided, that those who had used the tea
without reflection since the tax was laid, should be censured, and
that those who received it for the future should be declared enemies
to their country. The members of the assembly pledged themselves
by oath, to support the different resolutions with their lives and
fortunes; after which they voted thanks to their neighbours of the
vicinity of Boston for the promptness with which they had joined
them, and also to Jonah Williams for the manner in which he had
acted as moderator. After appointing a committee to hasten the
departure of the tea ships, the meeting adjourned. Many days were
spent in negotiation between the committee and the authorities
without producing the departure of the vessels.
On the 15th of December, a more numerous meeting of citizens
than had yet been collected, occurred; more than two thousand
persons from the country were present. Samuel Philips Savage, of
Weston, was chosen moderator, and Mr. Rotch, owner of one of the
vessels, was cited before the meeting to account for her remaining in
port, and declared that the collector of the customs had refused to
clear her. He was directed to have her ready to sail that day, at his
own risk and peril, to protest immediately against the custom house,
and to address the governor directly for a clearance. The meeting was
about to adjourn until the next day, but Josiah Quincy, Jr. an
influential member of the popular party, endowed with great energy
of character, detained his fellow citizens and reminded them of their
pledge in the city to sustain all their resolutions at peril of their lives
and fortunes. At a quarter past six Mr. Rotch returned. The
governor’s answer was, that for the honour of the laws, and the
respect due to the king, he would not allow the ships to depart, until
all formalities should be freely and fully concluded by the custom
house. This answer produced much commotion in the meeting.
Immediately a man who was in the gallery dressed in the costume of
a Mohawk Indian, uttered a war whoop, which was re-echoed by
about thirty persons at the door, dressed in the same manner, when
the meeting was dissolved as if by enchantment. The crowd hastened
towards the harbor. The men disguised as Indians, rushed on board
the tea ships, and in less than two hours, all the tea chests were
broken open and thrown into the sea; every thing else on board was
left untouched; and after this expedition, the multitude withdrew
silently and in order. This scene occurred in presence of several
vessels of war, and as it were under the eyes and guns of the garrison
of the fort, without the government attempting to make the least
resistance, so grand and so imposing is the anger of a people who
throw off the shackles of tyranny.
The names of the citizens disguised as Indians were never made
known; several of them are said to be still living, and enjoy with
modesty the happiness of having struck the first blow which shook
the royal power on the American continent.
The national pride of Great Britain, became indignant at the news
of this resistance, which was called an outrage against the royal
majesty. The governor and governed, all uttered the same cry,
vengeance! war! against the rebel colonists; and this cry was followed
by a host of laws, each more tyrannical than the other, by the aid of
which they hoped to alarm and reduce the province of
Massachusetts. The port of Boston was interdicted for an unlimited
time; the provincial charter was destroyed; the citizens were torn
from their natural jurisdiction; the appointment of magistrates was
placed at the special pleasure of the crown, which also arrogated to
itself the right of billeting its soldiers in the houses of the citizens.
Far from being disheartened or intimidated by the audacious folly of
the English government, the inhabitants of Massachusetts redoubled
their activity. A new assembly of the people was convoked at Boston
in which an appeal was made to God and the world, against the
tyranny and oppression of England. An exhortation was addressed to
the other colonies, beseeching them to unite with Massachusetts for
the maintenance and defence of their common liberties. The other
colonies were not regardless of this appeal, and many of the
legislatures declared that the first of June, upon which the port of
Boston was shut up, should be ranked among unfortunate days, and
the bells on that day were muffled and tolled; the people in crowds
attended the churches, and sought the protection of the Deity against
those who meditated civil war, and the destruction of their liberties.
The assembly of Massachusetts adjourned to meet at Salem, but
Governor Gage, prevented the meeting. The members of assembly
formed themselves into a private society, under the name of the
League, in which they reciprocally pledged themselves, before God,
to suspend all relations with Great Britain, until her unjust laws
should be repealed. The governor declared this league to be criminal,
and contrary to the rights of the king, and this declaration was in
turn treated as tyrannical, since it opposed the people in attending to
their own especial interests; and the indignant people, after forcing
the crown magistrates to resign their functions, swore no longer to
obey any other authorities than those of their own creation, and to
recognize no other law than the ancient laws of the colony.
 The suspension of all commerce soon plunged the inhabitants of
Boston into the deepest distress; their necessities daily multiplied
and were felt with increased severity, yet no one thought of
compounding with tyranny. In spite of the injunctions of the English
government, the citizens of Marblehead and Salem hastened to
alleviate the sufferings of their Boston brethren; they furnished them
with provisions and money; offered them the free use of their ports,
wharves and warehouses, for the renewal of their commerce, which
could no longer be carried on at home, yet without which it was
almost impossible for them to subsist. Encouraged by these
evidences of the approbation of their compatriots, the Bostonians
were confirmed in their resolution of maintaining the justice of their
cause by force of arms. They began immediately to make
preparations; companies of minute men were organized in the city
and throughout the province. At the first sound of the first call of the
league, or the first report of a new outrage by the English, these
minute men were to take up arms and attack the aggressors wherever
to be met with. Magazines of arms and ammunition were collected
with address and activity. For several months, about thirty young
mechanics had formed a volunteer company for the purpose of
watching the movements of the English and informing their fellow
citizens; towards the spring of 1775 they increased their activity, and
every night patroled the streets two by two. About midnight on the
15th of April, they observed that all the boats were launched and
ready astern of the ships of war, and that the grenadiers and light
infantry were making preparations, they gave immediate notice of
this to Dr. Warren, who despatched a messenger forthwith to John
Hancock and Samuel Adams with the news, they having left the city
to avoid being arrested by the governor, who, it was reported, had
issued orders to that effect. On the 18th additional indications of
some projected movement were perceived. The Light infantry and
grenadiers were concentrated upon the common, and at 10 o’clock at
night, 800 men under command of Colonel Smith embarked, and
landed at Lechmere point, near Cambridge, whence, after receiving a
day’s rations, they marched at midnight. This expedition was
destined to destroy the magazines established by the league at
Concord. The secrecy observed in the camp, and the silence
maintained during the march, led the English to believe that no one
in Boston suspected their departure. They pressed forward by
moonlight, and arrived at Lexington by daylight, six miles from
Concord. But the calm which had previously existed, was now
interrupted by the beating of drums through the country, which
seemed to call the inhabitants to arms, and a company of about sixty
Americans suddenly appeared before them. The English immediately
halted, closed up their ranks, and loaded their arms: the Lexington
company did the same, and were ordered not to abandon the ground
without orders, nor to be the first to fire. Scarcely were these
arrangements made, when Major Pitcairn, commanding the British
advanced guard, came forward and cried out in an insolent voice,
“throw down your arms and disperse, you rebel scoundrels.” This
audacious summons was not answered, and Pitcairn ordered his
troops to fire: they eagerly obeyed, and eight hundred Englishmen
were not ashamed to utter shouts of joy in commencing so unequal a
combat, in which sixty citizens offered with devotion their lives as a
sacrifice in the holy cause of their country.
The Americans received the first fire with firmness; one of them
seeing a friend fall at his side, cried out “you shall be revenged,” fired
upon the English, and the war of independence was begun. But the
Americans could not long sustain themselves against so unequal a
force. They abandoned the ground, leaving eight killed and several
wounded, around whom the British proudly defiled, insulting them
with shouts of victory.
Having reposed for some time after this terrible battle, the fierce
defenders of the crown marched for Concord, where they arrived at
nine o’clock. They found the inhabitants in great agitation, but still
ignorant of the assassination of their fellow citizens at Lexington. A
company of citizens occupied the bridge, and this time the British
fired without any summons to surrender: the citizens of Concord
warmly returned their first fire, killing some soldiers and officers of
the king, after which, too weak to sustain a battle, they dispersed and
abandoned the magazines to the English, which they destroyed in a
few hours.
The alarm was soon spread throughout the country; the tocsin
called to arms all who were able to bear them, and in a short time the
English found themselves so surrounded, that they began to feel that
their retreat would not be so easy as their two victories. From
Concord to Lexington their march was nothing better than a
disorderly flight; the well sustained and well directed fire of the
rebels, who were concealed along their route, in the barns, gardens,
behind the trees and in the ditches, did not allow them to halt a
moment to defend themselves. At Lexington they were met by Lord
Percy, who at the head of six companies of infantry, a corps of
marines, and two companies of artillery, which came in time to
prevent their entire destruction, but not to save them from disgrace.
Notwithstanding this reinforcement, they still reached Charlestown
with great difficulty, where they passed the night under the
protection of the guns of the ships; the next morning they re-entered
Boston, after having lost in this sad expedition, nearly two hundred
men, in killed and wounded.
It would be difficult to depict the astonishment and humiliation of
the English, at finding themselves thus driven back by the rebels, and
blockaded in their entrenchments by an undisciplined multitude.
The royal army, however, was speedily reinforced by 12,000 men
from England, commanded by General Burgoyne, Clinton and Howe.
General Gage resolved to strike a great blow against the spirit of
insurrection, in order to wipe off the disgrace of the rout at
Lexington; he commenced by a proclamation in which he announced
the vigorous enforcement of martial law, and promised entire pardon
to all those who laid down their arms. Samuel Adams and John
Hancock had the honour of being excepted from this general
amnesty. This distinction was in fact well merited by their ardent
love of liberty, their intelligence, patriotic virtues, and the immense
influence they exercised over the minds of the people.
This proclamation was received as all the promises and threats of
despotism should be; it was entirely disregarded; and the people
closed up their ranks.
While the English army remained shut up in Boston, and upon the
narrow tongue of land, which unites the city with the continent,
30,000 Americans kept them rigorously blockaded. Their right was
in front on the Dedham road, their centre at Cambridge, and their
left wing especially composed of Massachusetts troops, rested upon
Charlestown, a village separated from Boston by a narrow stream,
traversed by a bridge. The English general resolved to escape by this
bridge, from his unfortunate position; but the Americans suspected
his plan, and hastened to prevent its execution. During the night, a
thousand men under the command of Colonel Prescott established
and entrenched themselves upon Breed’s Hill, a small eminence,
which commanded the city of Boston, and the Charlestown bridge.
When the British at day-break discovered the redoubt, which Colonel
Prescott’s little troop had thrown up with so much diligence, they
attempted but in vain to destroy it; General Gage then thought it
highly important to the safety of his army, that the Americans should
be dislodged from this commanding position, and made his
arrangements accordingly. Major general Howe at the head of ten
companies of grenadiers, ten companies of infantry, and some field
pieces, landed at Moreton point, and formed his troops in line of
battle; but perceiving that the Americans were not intimidated by
this hostile demonstration, he thought it advisable to wait for a
reinforcement, which he immediately demanded from Boston. This
delay gave the Americans time to receive additional troops, which
were led by General Warren, and to complete their plan of defence.
The English began this attack by burning Charlestown; in a few
minutes this village containing more than five hundred wooden
buildings was devoured by the flames.
The inhabitants of Boston, and the reserve of the English army
were gazing from the amphitheatre formed by the heights of the city,
with equal anxiety upon the dreadful battle, with the results of which
the destinies of each were equally connected.
On the 17th of June 1775, at one o’clock, the English army moved
slowly to the fight, with shouldered arms, exhibiting that calmness,
which is inspired by a long habit of military discipline. The
Americans awaited them firmly, with the coolness and resolution
that is always imparted by love of liberty. The English had already
approached within thirty yards of the entrenchments, without a
single gun being fired to break the ominous silence, under which
their movements were made, when suddenly they received a volley of
musketry so fatally aimed that their ranks were disordered, broken,
and flying in confusion towards the shore, leaving behind them a
great number of their officers killed and wounded. A second attack
was followed by a similar result, and even at this time the English
soldiers were thrown into such a panic that many of them sought
refuge in the boats. Their officers could neither check their flight nor
rally them except by resorting to the severest measures. Finally, a
third attack, supported by some pieces of artillery, aided by the fire
of several ships, and two floating batteries, was completely
successful. The Americans, forced from their entrenchments, still
defended themselves for a considerable time, fighting hand to hand,
and giving blows with the butts of their guns in return for the
enemy’s charges with the bayonet. Their retreat was more calm and
regular than could have been anticipated from inexperienced militia.
In this last attack, the royal troops showed great intrepidity, and a
courage worthy of a better cause. They lost nearly 1,100 men killed
and wounded, among which were more than 90 officers. The patriot
army, which fought for a long time under cover, did not lose 500
men, but had to lament the death of one of its most estimable
commanders, general Warren.
The English paid too dearly for this victory to follow up its
advantages; they were on that day contented with the possession of
the bloody field of battle.
The useless burning of Charlestown, which preceded the battle,
was regarded by the Americans, as an act of the most shameful
barbarity, and excited a general sentiment of horror and indignation.
It was at Charlestown, that the English after their rout at Lexington
had found succour for their wounded, and the most generous
hospitality was displayed towards their stragglers. The loss of the
position on Bunker’s Hill, did not prevent the Americans from
keeping the royal army closely blockaded in Boston. The forces of the
besiegers were daily augmented, and on the 2d of June, general
Washington, in the name of the Congress assembled at Philadelphia,
took the command. Nothing of importance, however was undertaken
against the city during the rest of the year. The approach of winter
rendered the condition of the besieged dreadful; the cold was
extreme and fuel was deficient; the English could not obtain it but at
the expense of the inhabitants whose houses were demolished for the
sake of the wood. The situation of the inhabitants deeply affected
Washington, who wished to profit by several days of severe frost,
which would have allowed him to cross upon the ice, to make a
general attack: but this plan was unanimously opposed by his council
of war.
About the end of April 1776, having received some reinforcements,
he resolved to occupy the heights of Dorchester, whence it would be
easy to annoy the ships in the harbour and even the garrison in the
town. He hoped moreover that this movement, by drawing the
enemy from his inaction, would give an opportunity of bringing him
to a general engagement, and he took his measures with great skill,
to derive all possible advantage therefrom. The occupation of the
heights of Dorchester was effected on the night of the 2d March, with
so much activity, that at day-break the besieged beheld the
Americans established and capable of sustaining an attack in their
new position.
General Howe immediately perceived the critical situation into
which he was thrown by this bold movement of the Americans, and
after several fruitless attempts to dislodge them, he determined to
evacuate Boston, while the sea still remained open to him. On the
17th of March he embarked with all his army, and his rear-guard
might have heard the shouts of joy with which the triumphal entry of
Washington was hailed in the city.
From that time, Boston, which is justly distinguished by the
glorious title of Cradle of the Revolution, ceased to be the theatre of
war. The town and province were forever freed from the presence of
the enemies of liberty; but the citizens of Massachusetts did not
display less ardour in the achievement of the great work, the
liberation of the colonies; their contingents to the continental army
were always furnished with exactness, and their troops sustained to
the end of the war, their admirable reputation for courage and
patriotism.
The news of peace arrived at Boston on the 23d April, 1783, and
diffused among the people the most exhilarating joy; the entire
abolition of negro slavery was proclaimed, and commerce and
industry, under the protection of freedom, appeared with renewed
lustre.
The state of Massachusetts since that epoch has constantly
increased in wealth and happiness; it has regulated and determined
its boundaries in a friendly manner with its neighbours, and at
present it is bounded north by the states of Vermont and New
Hampshire; east by the Ocean; south by the states of Rhode Island
and Connecticut; and west by the state of New York. The face of the
soil is infinitely varied, and its coasts are richly furnished with
convenient bays, which are adorned with a great number of small
islands. The soil of the sea board is generally arid, but the lands of
the interior are very productive, and cultivated in such a manner as
to impart to the whole country the appearance of a smiling garden.
Elegant country houses, fine villages and large towns, amply attest
the numbers of the population, in fact about 530,000 souls occupy a
surface of 7,800 square miles. In 1790 the population was only
370,787 souls; this increase is certainly very rapid, but we shall find
much more astonishing changes in the new states.
65,000 persons are employed in agriculture. 36,000 in the various
manufactories of cotton, wool, cloth, glassware, paper, soap, in the
foundries, &c.; and about 14,000 in commerce. A considerable
number are also engaged in the fisheries, but of the exact amount we
have been unable to procure information; however, this sketch will
suffice to show to what degree public industry is carried in this state;
for if we subtract the individuals employed in the various offices of
government in public instruction, or engaged in particular business,
such as carpenters, masons, tailors, &c. and then remove from the
sum total of the population children still unfit for labor, and the aged
who are disabled by their infirmities, we shall see how small a
number of idle persons belong to this state. From this active industry
a degree of general domestic comfort is produced, which strikes
Europeans with astonishment when they first visit this country.
The general welfare of the people, contributes to augment between
all classes, that equality which the constitution establishes between
individuals, in the eye of the law. At church on Sunday, and at public
meetings, it is impossible to distinguish by his dress, and it might
almost be added, by his manners, an artisan, from what is called a
gentleman, in society: the multiplicity of schools, and the right
which every man enjoys of attending to public affairs, diffuses among
this class of Americans a knowledge and a correctness of judgment,
which would be sought in vain in the middle classes of France. In
Boston, what is called the best society, that is, companies of literary
men, rich merchants, government officers, and professional men,
offer the surprising contrast of a rare degree of information, with
great simplicity of manners. The excessive severity of character
which distinguished the first settlers of New England, is gradually
becoming effaced by communication with other people, and
especially by the introduction of religious toleration; the rigorism of
the puritans has given place to a mild harmony between the
numerous sects, which are not only numerous in New England, but
the whole Union. But it must not be supposed, however, that
indifference has succeeded to fervor; religious exercises are observed
with scrupulous exactitude; and it would be difficult to find in Boston
a pleasure house open on Sunday. The chains which were formerly
stretched across the streets during divine service, are gradually
disappearing. The government never interferes in any way in
religious matters; the pastors of the different congregations are paid
by their parishioners, and if an especial respect be publicly paid to
those who frequent the churches, those who never attend them are
never persecuted. Finally, there is but one remaining trace of the
religious tyranny of the first settlers, and unfortunately that trace
occurs in the state constitution. The 1st article of the 6th chapter,
excludes from the offices of government all candidates who are not
christians, and who will not swear that they are convinced of its
truth.—“I, A. B. do declare that I believe the christian religion, and
have a firm persuasion of its truth.”
We can scarcely comprehend how, in a society so free and
enlightened, where the progress of philosophy is every day evident,
the state still can continue to refuse the services of a virtuous man,
because the individual may be a Jew or a Mussulman.
 CHAPTER IV.

Camp of Savin Hill. Visit to John Adams: review of the regulations of the
Massachusetts militia.

On the 28th of August general Lafayette was invited by the

governor to visit the camp at Savin Hill, a few miles from Boston; he
accepted the invitation, and we arrived there at noon. Savin Hill is a
very picturesque situation on the borders of the sea, where during
the fine season the volunteer militia companies of Boston go
successively to pass some days in camp, for the purpose of military
exercise. On our arrival we found them under arms. The young
officer in command came to receive the general, and after a brief
address he returned to the head of his troops, which manœuvred
with much precision. After various movements of infantry, the
artillery commenced firing at a mark. Most of the shots were fired
with great skill, at a target floated at a sufficient distance on the
water. The artillerists invited the general to aim one of their pieces,
which he did, and his shot knocked the target in pieces. This
successful shot, which no one expected from a man of his age,
procured him the applauses of all the young soldiers, and of the
ladies who usually visit the camp to see their brothers and husbands,
but on this occasion had flocked in greater numbers to see Lafayette.
The guns of the artillerists attracted our attention from the
moment of our arrival; after the exercises were finished I approached
to examine them more attentively, and was considerably surprised to
recognize our French models, which were perfectly imitated. From
the officers who observed the interest with which we examined these
pieces, we learned that this improvement was owing to general
Henry Lallemand, who was forced by the proscriptions of 1815 to
seek a refuge in the United States, where he died in 1823, universally
esteemed and regretted. The militia of Massachusetts are indebted to
him for great improvements in their artillery; and he has left a
treatise on the subject, in three volumes, in which, it is true, he has
only reproduced in part the regulations already known and practised
in France, but which he has admirably adapted to the use of those for
whom he wrote. He married in Philadelphia the niece of a French
gentleman, who during 50 years residence in that city, had by his
success in commerce, amassed one of the largest fortunes in the
United States. The situation of general Lallemand, however, was not
improved by this marriage, as he died poor. His amiable and
interesting widow, with her only daughter, continues to reside at
Philadelphia, under the protection of her uncle.
After visiting the camp at Savin Hill, the governor took us to dine
at his country seat; whence we returned to attend a brilliant ball,
which Mr. Lloyd, senator of the United States, gave to general
Lafayette.
John Adams, whose name is so gloriously connected with all the
great epochs of the American revolution, and who had the honour of
succeeding Washington in the first magistracy of the republic, was
then detained at his retreat by the weight of eighty-nine years.
Lafayette who had been acquainted previously, and even maintained
a strict friendship with him, was unwilling to depart without paying
him a visit: a feeling of delicacy, easy to be understood, made him
wish that this visit should be unattended by any of that triumphal
pomp, by which his slightest movements had been accompanied. In
consequence, he set out in a carriage, merely accompanied by two
gentlemen of the city, and followed by his son and myself. We arrived
about two o’clock at Quincy. Our carriages stopped at the door of a
very simple small house, built of wood and brick, and but one story
high. I was somewhat astonished to learn that this was the residence
of an Ex-President of the United States. We found the venerable
John Adams in the midst of his family. He received and welcomed us
with touching kindness: the sight of his ancient friend imparted a
pleasure and satisfaction, which appeared to renew his youth. During
the whole of dinner time, he kept up the conversation with an ease
and readiness of memory, which made us forget his 89 years.
The long life of John Adams has been exclusively devoted to the
service of his country and liberty, which from his youth he
passionately loved.
He was born at Quincy, the 19th October, 1735, and studied at
Cambridge, which he left in 1755, to take charge of a grammar school
at Worcester, where, at the same time, he applied himself to the
study of the law, under James Putnam. In 1758, he was admitted to
the bar. In 1770 he was chosen as a representative of the town of
Boston, in the Assembly of Massachusetts. When the quarrels
between the English soldiers and the citizens of Massachusetts
became sanguinary, he showed his full strength of character, by
defending captain Preston and his soldiers, for firing on the people;
in this defence he was assisted by Josiah Quincy, jr. and S. Blowers.
He was unwilling that the love of liberty should transcend the love of
justice, and his eloquence secured the safety of those unfortunates,
who were in fact nothing but the blind and ignorant instruments of
English tyranny.
In 1774, he was elected a member of the Council of Massachusetts,
but the political opinions which he had already expressed openly and
energetically on numerous occasions, caused him to be rejected by
governor Gage. A few months afterwards, he was sent to the
Continental Congress, where he proved one of the most ardent and
skilful defenders of liberty.
In 1776, he was appointed, together with Jefferson, each to draw
up a Declaration of Independence. Jefferson’s address was preferred
by Congress, as is known, but Adams’s, on account of his eloquence
and patriotism, was not the less regarded as the soul and fire of that
immortal assembly. Shortly after he was sent with Dr. Franklin and
Edward Rutlege, to treat with Lord Howe for the pacification of the
colonies.
In 1777, he was appointed commissioner to the court of France, in
place of Silas Deane. In April 1779, Congress having censured all the
other European commissioners, made an honourable exception of
John Adams. On his return from Europe, the same year, he was
elected a member of the Convention assembled to revise the
Constitution of Massachusetts. In the month of August of the same
year, he was sent to Europe with power to treat for a general peace.
In December, 1780, Congress voted him public thanks for the
services he had rendered in Europe. In 1781, he concluded with the
provinces of Holland a treaty very advantageous to his country.
 In 1785, he was sent as minister plenipotentiary to England. It was
during this honourable mission, that he published, in 1787, at
London, his learned summary of all the ancient and modern
constitutions, under the title of Defence of the American
Constitutions. This profoundly erudite work, in which the author in
several passages appeared to indicate his predilections for English
constitutions, drew forth vigorous attacks from a large number of
patriotic writers, and particularly from Philip Livingston, then
governor of New Jersey, who opposed him in an excellent work,
which he published under the title of Examination of the English
Constitution.
Recalled from England at his own request, he was received with
the thanks of his fellow-citizens and of Congress. In 1789, after the
adoption of the new constitution, John Adams was elected Vice-
President of the United States, and remained in this honourable
situation during the eight years of the presidency of Washington,
whose confidence in his talents and patriotism was unbounded.
In 1797, he was himself elected to the Chief Magistracy of the
republic, to succeed Washington, who refused a third election.
Circumstances were then very difficult. The French revolution, which
at first received the general approbation of the United States, had at
that time become, through the intrigues of royalists and foreigners,
an object of horror, even to its warmest partizans. The French
question agitated all minds, and had become the subject of vivid
discussion, and sometimes of violent attacks, between the two
parties called Federal and Democrat. The ill-managed attempts of
our diplomatic agents in the United States, to profit by these
divisions, alarmed President Adams, and induced him to propose to
Congress, as a measure of security, the suppression of the act of
habeas corpus. This proposition was too directly opposed to the
sentiments of liberty, entertained by the American people, not to be
rejected with force, and I may say even with indignation. The House
of Representatives would not even discuss the bill, and the
popularity of John Adams received at that time such a shock, that at
the expiration of the fourth year of his administration, he was not re-
elected.
In 1801, he retired to his dwelling at Quincy; his fellow-citizens
soon forgot the cause of his retreat, and only remembered the great
and numerous services he rendered to his country during his long
career. The governorship of Massachusetts was offered him, and
some time afterwards he was invited to preside over the committee
appointed to revise the constitution of the state. But he began to feel
the necessity of repose; he thanked them, and concluded by praying
the theologians, philosophers, and politicians, to let him die in peace.
Notwithstanding this refusal, he had not become insensible to the
great interests of the country, and when she was menaced in 1811 by
the odious vexations of England, his patriotic voice was heard from
the bosom of his retreat, declaring that the national honour could
only be maintained by war. His eloquence was re-animated in a letter
which he wrote to rally to this sentiment, those whom party spirit
had most widely separated. In short, he so generously sacrificed his
private opinions to the dangers of the moment, that his most ardent
adversaries could not withhold the expression of their admiration
and gratitude.
At the moment of our visit, although he could not go out of his
chamber, could scarcely raise himself from his chair, and his hands
were unable to convey the food to his mouth without the pious
assistance of his children or grand-children, his heart and head felt
not less ardour for every thing good. The affairs of his country
afforded him the most pleasant occupation. He frequently repeated
the greatness of the joy which he derived from the gratitude of his
fellow-citizens towards Lafayette. We left him, filled with admiration
at the courage with which he supported the pains and infirmities
which the lapse of nearly a century had necessarily accumulated
upon him.
A grand review had been ordered and prepared for the 30th, in the
morning the troops from the environs of Boston arrived under
command of general Appleton, those of the city had pitched their
tents upon the common, in front of the capitol on the preceding
evening, and on rising we were struck with the appearance of this
extemporaneous camp. At noon, about 8,000 men were drawn up in
line of battle, on this vast parade: a great concourse of ladies adorned
all the windows which overlooked the ground, or filled the
surrounding walks. A few moments after general Lafayette presented
himself, accompanied by the governor and his staff, before the line,
where he was received by the acclamations of the troops, to which
martial music and the shouts of the spectators responded. After
passing in front of the ranks of these young soldier-citizens, whose
equipments and appearance might charm even eyes accustomed to
the regularity of hired European troops, the general was conducted
to the most elevated point of the parade, to behold the military
movements which were to follow. We did not discover in the
handling of their arms, that minute precision to which European
officers attach so ridiculous an importance, and which is only
acquired by reducing a soldier to the sad condition of a puppet, for,
at least, four hours a day; but we were forced to admire the
promptitude of the charges, and the union and vivacity of the firing.
Beyond doubt, the movements of the line were somewhat defective
as to calmness and precision; but it was impossible, I believe, to
execute with greater rapidity and intelligence all the movements of
light troops. This sort of service appears to be very consonant to the
American character; it is also well suited to troops more particularly
called to the defence of situations where all the resources are known
to them, and which are particularly favourable to a war of detail. This
sort of sham battle, which was performed before our eyes, lasted
nearly three hours, and interested us exceedingly; when it was ended
we went under an immense tent, where the principal citizens to the
number of 1200, were collected at table to receive the adieus of
Lafayette, who was to quit the city on the next morning. In the centre
of the table, and in front of the places we were to occupy, stood a
large silver basin, filled with fragments of arms or projectiles,
military buttons, &c. collected on Bunker’s Hill a long time after the
battle of the 17th June. The governor had the goodness to offer us
some of these fragments; for my part, I gratefully accepted a button,
upon which, notwithstanding the rust that covered it, could readily
be distinguished the number, 42; it is known that this number is one
of those which suffered most severely in attacking the American
entrenchments. The care with which the Americans preserve and
revere all the monuments of the revolution is very remarkable; every
thing which recalls this glorious epoch, is to them a precious relic,
which they regard almost with religious reverence. This sort of
devotion is praiseworthy, since it contributes to feed the sacred fire
of love of liberty, by which they are animated. It is worth quite as
much, I believe, as that profound veneration which we have in
Europe for the ribbands conferred by power.
 During the review I remarked with surprise the variety of
uniforms; in the numerous companies that defiled before us, scarcely
could I find two companies somewhat similar in this respect. Some
were clothed with a luxury that was very little adapted to war; while
those from the country, were on the contrary so simply clad, that
they had nothing military about them but the cartridge box and
musket. This difference was explained to me by the formation of
volunteer companies. These are composed of young men, who, from
being friends or neighbours, organize under the authority of the
governor, a peculiar company; the colour and fashion of their
uniform is decided by common consent; they elect their own officers,
and choose the name of their corps. Thus organized and constituted,
they remain always subject to the general regulations by which all the
militia are governed, but they meet much more frequently for the
purpose of military exercise; as most of these young men are
sufficiently well off, they can afford to expend something upon a
brilliant dress, and hence the variety of their uniforms. If from this
slight rivalry in elegance, between the volunteer companies, great
emulation in service ensues, as the officers suppose who had the
kindness to give me some information on these points, it is
unquestionably an advantage; but is it not to be feared that this
advantage may be attended by serious inconveniences? May not the
embroidery and plumes which at present serve to distinguish one
company from another, hereafter be used to distinguish the son of a
rich merchant from a mere mechanic? and will not this distinction
between the rich and poor militiaman open the door to the
aristocracy of wealth, which is not less an enemy to equality than the
aristocracy of parchments? I am aware that American manners and
institutions diminish this danger; but ought a danger to be
disregarded because it is still distant?
The existence, organization, duties, and basis of the discipline of
the militia throughout the Union, are determined by general laws
emanating from congress. However, as differences of situation or
manners which distinguish the aspect of the various states
composing the great federation require modifications in the
application of these laws, each state regulates for itself the formation
of militia corps, their especial discipline, the appointment of officers,
&c. &c. taking care, however, not to depart from the general
principles established by congress.
 As all the particular regulations of the States differ somewhat from
each other, and it would, moreover, be too tedious to describe them
all in detail, it may suffice to satisfy the reader’s curiosity that we
present in this place a sketch of the regulations of the Massachusetts
militia.
The law of the Congress of the United States, calls into the ranks,
all citizens capable of bearing arms from the age of eighteen to forty-
five, inclusively; the law of Massachusetts makes an exception in
favour of the individuals hereafter designated: the lieutenant
governor of the state; members of the executive council; judges of the
supreme court, the inferior courts and their clerks; members of the
legislature; justices of the peace; all officers employed in the registry
of deeds, &c.; the attorney general, the solicitor general; secretary
and treasurer of state and their clerks; sheriffs; teachers of public
schools; the ministers of all religious sects, without distinction; all
civil officers appointed by the United States, and finally the Quakers,
when they present a certificate signed by one or two of their elders,
stating that the bearer is actually one of their society, and is
conscientiously scrupulous of bearing arms. Nevertheless, all the
individuals above excepted from militia duty, are obliged from the
age of 18 to 45, to keep in the house, and to present at each annual
review, the arms and equipments of war prescribed by the laws of the
United States: they must, moreover, pay two dollars a year, which are
placed in the treasury of the town or district, to be employed in
arming and equipping poor citizens unable to furnish their own
accoutrements.
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