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        "titulo" => "Par&#225;lisis fl&#225;cida aguda y enterovirus en Espa&#241;a&#46; Resultados de la vigilancia en 2019"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Detection of enterovirus in cases of acute flaccid paralysis &#40;AFP&#41; adequately reported and studied per epidemiological week&#46; Spain&#44; 2015-2019&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Since the Global Polio Eradication Initiative &#40;GPEI&#41; was launched in 1988&#44; global polio cases have been reduced by more than 99&#37;&#46; Five of the six WHO regions have already achieved the goal of interrupting the transmission of wild poliovirus &#40;WPV&#41;&#58; the Americas &#40;1994&#41;&#44; the Western Pacific &#40;2000&#41;&#44; Europe &#40;2002&#41;&#44; South-East Asia &#40;2014&#41; and Africa &#40;2020&#41;&#46; Afghanistan and Pakistan are currently the only two countries considered polio-endemic<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Of the three WPV&#44; two have already been declared eradicated&#58; WPV type 2 &#40;WPV2&#41; in 2015 and WPV type 3 &#40;WPV3&#41; in October 2019 &#40;no detections since 2012&#41;&#46; Along with WPV&#44; there are vaccine-derived polioviruses &#40;VDPV&#41; circulating in the world that originate in areas where the oral polio vaccine &#40;OPV&#41; is still used and that remain in circulation due to population immunity failures&#46; Most polio produced by VDPV is associated with the PV type 2 vaccine&#44; and therefore eliminating the type 2 component of OPV and replacing the trivalent oral vaccine with a bivalent oral vaccine was a priority objective of the WHO&#46; Global replacement took place in April 2016<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and was the first step towards eliminating the use of attenuated polio vaccines worldwide&#46; The trivalent oral vaccine is no longer used in either routine vaccination or vaccination campaigns&#59; monovalent type 2 vaccine is available for control of outbreaks&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">WHO&#47;Europe publishes an annual report on the polio situation in the European Region prepared by the Regional Commission for the Certification of Poliovirus Eradication &#40;RCC&#41;&#46; This commission assesses the risk of importation and circulation of WPV or the emergence of a VDPV in the region&#46; The level of risk is established according to the quality of the surveillance system&#44; the level of immunity of the population and the preparedness of the countries for controlling an outbreak&#46; In the annual report for 2019&#44; and after reviewing the reports sent by the National Certification Commission &#40;NCC&#41; of each country&#44; the RCC concluded that there had been no transmission of WPV or VDPV in the European Region in 2018&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The RCC warned that Bosnia and Herzegovina&#44; Romania and Ukraine remain at high risk of an outbreak following introduction of a PV&#44; due to low population immunity and weak surveillance systems&#46; In addition&#44; 21 of the 53 countries in the Region &#40;40&#37;&#41; were classified as at intermediate risk&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In Europe&#44; there is concern about the increase in VDPV cases and the increased detection of WPV1 in wastewater in several areas of the world&#44; and it is therefore stressed that member countries must maintain high vaccination coverage&#46; Countries are also called upon to establish national action plans for importation of WPV or the emergence of a VDPV and to carry out simulations to test their response capacity if a PV is detected in their territory &#40;Polio Outbreak Simulation Exercise &#91;POSE&#93;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In terms of the type of vaccine administered&#44; most countries in the Region &#40;35&#47;53&#41; use the inactivated polio vaccine &#40;IPV&#41; exclusively&#44; and the rest &#40;18&#41; combine it with bivalent OPV&#46; The introduction of IPV in some countries has been delayed due to global supply constraints&#44; but the availability of these vaccines is improving and the use of OPV will be gradually eliminated throughout the region&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In Spain&#44; OPV was replaced by the inactivated vaccine in 2004&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Regarding the containment of PV in laboratories&#44; the RCC considers it urgent that the so-called poliovirus essential facilities be certified&#44; and that they be established only in countries or regions where it is strictly necessary to retain the virus&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Spain has not requested certification in this regard&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In 2019 the independent Global Commission for Certification of Poliomyelitis Eradication &#40;GCC&#41; took advantage of World Polio Day&#44; 23 October&#44; to declare that WPV type 3 had been eradicated worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This is an important milestone in the effort to rid the world of all poliovirus strains and to ensure that no child&#44; anywhere in the world&#44; is paralysed by the polio virus&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In 2019&#44; a total of 176 cases of paralytic polio caused by WPV were reported worldwide&#44; compared to 33 reported in 2018 &#40;83&#46;7 per cent increase&#41;&#46; All cases were due to WPV1 and occurred in Afghanistan &#40;147&#41; and Pakistan &#40;29&#41;&#46; Three hundred and sixty-seven cases produced by circulating VDPV were also reported&#44; mainly in Angola &#40;130&#41;&#44; DR Congo &#40;88&#41;&#44; Pakistan &#40;22&#41;&#44; Central African Republic &#40;21&#41;&#44; Nigeria and Ghana &#40;18 each&#41;&#44; Philippines &#40;15&#41;&#44; Ethiopia &#40;12&#41; and Chad &#40;10&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Maintaining a polio-free territory and preventing the reintroduction of the virus requires high vaccination coverage in all population groups and geographical levels and an active poliovirus surveillance system&#46; Since the certification of the European Region of the WHO as &#39;polio-free&#39;&#44; each Member State must establish a national plan to maintain elimination status&#46; The cornerstone of PV surveillance is AFP surveillance&#44; which is syndromic surveillance&#46; However&#44; in non-endemic countries that also have quality health services&#44; the WHO accepts alternative laboratory surveillance systems&#44; such as enterovirus &#40;EV&#41; surveillance on clinical samples and environmental PV surveillance&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In Spain&#44; the first action plan for the eradication of polio was established in 1998&#44; with the creation of the Acute Flaccid Paralysis &#40;AFP&#41; Surveillance System and the EV surveillance system&#46; The Plan was updated in 2016<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> following WHO recommendations and guidelines&#44; including guidelines for EV surveillance in the laboratory<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and for environmental surveillance of PV<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and the response document to an outbreak of PV&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The plan contains four priority areas of intervention&#58; the vaccination programme&#44; PV surveillance &#40;AFP and EV surveillance&#41;&#44; the response plan to detection of a PV and the containment of PV in laboratories&#46; Surveillance starts with the urgent notification of any case of AFP in children under 15 years of age&#44; which triggers a process of epidemiological&#44; clinical and laboratory investigation to confirm or exclude it as a polio case&#44; classify it appropriately and&#44; if necessary&#44; rapidly implement intervention measures&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In Spain&#44; national coverage with three doses of vaccine administered in the first year of life &#40;basic series&#41; has exceeded 95&#37; since 1996 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The objective of this paper is to describe the results and quality of the polio and AFP surveillance systems and of complementary EV and environmental surveillance in Spain in 2019&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Method</span><p id="par0060" class="elsevierStylePara elsevierViewall">In Spain&#44; PV surveillance is carried out through surveillance of polio cases&#44; with the notification and investigation of suspected polio in persons of any age and of any AFP in a child under 15 years of age&#46; Case surveillance is complemented by EV surveillance and environmental surveillance&#46; The aim of the latter is to demonstrate the absence of circulating PV among EV identified in clinical samples from patients with clinical pictures other than AFP&#44; and in wastewater&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">A clinically suspected case of polio or AFP is reported from the hospital where the case is identified to the corresponding epidemiological surveillance unit&#46; Case definition&#58; a person of any age where polio is suspected by a physician&#44; or a person under 15 years of age with AFP&#46; AFP syndrome is characterized by acute onset of paralysis in one or more limbs with absence or decrease of tendon reflexes in the affected limbs&#44; without sensory or cognitive loss and without other apparent cause&#46; A case of AFP with fever that occurs in a child who has received less than three doses of polio vaccine&#44; comes from a polio-endemic area&#44; or belongs to a high-risk group &#40;e&#46;g&#46;&#44; immunosuppressed&#41; is considered a priority case for investigation&#46; AFP cases of any age clinically suspected to be polio cases are also <span class="elsevierStyleItalic">considered</span> a priority&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The National Poliovirus Laboratory &#40;LNP&#41; of the National Centre for Microbiology &#40;CNM&#41; coordinates the virological study of AFP with three autonomous communities - Canary Islands&#44; Catalonia&#44; and Andalusia - which have laboratories for the virological study of stool samples in patients with AFP&#46; Samples from the other communities are carried out in the LNP&#46; The technique of choice for the virological study of stool samples from AFP cases&#44; and the only one accepted so far by WHO-Europe&#44; is virus cell culture &#40;in RD and L20B cell lines&#44; the latter specific for PV&#41;&#46; Although progress is being made in the standardisation of PCR techniques for the direct detection of PV&#44; the results of these techniques are not yet accepted as definitive for ruling out the presence of PV in faeces&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">&#34;Zero-case&#34; monthly reporting is to monitor the quality of AFP surveillance&#46; Before making a notification&#44; epidemiologists ask hospitals in the autonomous community to scan the paediatric and neurological services to identify possible recent unreported cases of AFP&#46; If a case is identified&#44; it will be reported and investigated in the laboratory&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">As a disease subject to an eradication plan&#44; any case declared to the AFP Surveillance System is immediately reported to WHO&#47;Europe&#44; who also require the <span class="elsevierStyleItalic">annual evaluation</span> of the system through a set of indicators&#46; The main quality indicators are the <span class="elsevierStyleItalic">AFP reporting rate</span> and the <span class="elsevierStyleItalic">percentage of cases</span> where <span class="elsevierStyleItalic">adequate clinical samples</span> have been taken&#46; The product of these is the <span class="elsevierStyleItalic">surveillance index</span>&#44; which summarizes the quality of the system and must be &#8805;&#46;80&#46; Other indicators that measure the quality of surveillance are the timeliness of reporting &#40;percentage of AFP cases notified in the first 7 days after onset of paralysis&#41;&#44; the timeliness of investigation &#40;percentage of cases investigated in the 48&#8239;h following reporting&#41; and the follow-up rate &#40;percentage of cases with clinical follow-up of the progression of paralysis&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In Spain&#44; EV surveillance in syndromes other than AFP was introduced in 1998 as complementary to AFP surveillance&#46; EV surveillance is voluntary and is not established throughout the national territory&#46; The Laboratory Network of EV surveillance currently comprises the LNP and laboratories of 9 hospitals &#40;the 3 autonomous laboratories of the AFP network&#58; Andalusia &#91;HUVN&#93;&#44; Canary Islands &#91;HUGC-Dr Negrin&#93; and Catalonia &#91;HSCSP&#93;&#59; and 7 non-autonomous laboratories in Barcelona &#91;HSJD&#93;&#44; Saragossa &#91;HUMS&#93;&#44; Bilbao &#91;HUC&#93;&#44; Pamplona &#91;CHN&#93;&#44; Murcia &#91;HCUVA&#93;&#44; Vigo &#91;HM&#93; and Madrid &#91;HU La Paz&#93;&#41;&#46; The LNP coordinates the network to collect information on EV detected in clinical samples from patients of any age admitted with conditions other than AFP&#44; to confirm the absence of circulating PV among the EV identified&#46; The clinical pictures included in EV surveillance are mainly&#58; meningitis and encephalitis&#44; respiratory infections&#44; fever without focus in young children&#44; hand&#44; foot&#44; and mouth disease &#40;HFMD&#41; or other type of exanthema&#44; myocarditis&#44; and neonatal sepsis&#46; Currently&#44; the methods used by the laboratories of the surveillance network to detect EV in clinical samples are based on molecular genome amplification techniques &#40;PCR&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Environmental surveillance is a complementary surveillance system in wastewater in non-endemic areas at risk of importation&#46; In Spain&#44; environmental surveillance is only carried out in certain geographical areas with the aim of maintaining the necessary infrastructures and methodologies should they need to be applied in the event of PV detection or circulation alert at any point in the national territory&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0095" class="elsevierStylePara elsevierViewall">In 2019&#44; no suspected polio was reported&#44; 38 cases of AFP were reported&#44; and 412 faeces samples and 7329 non-faeces clinical samples were studied in EV surveillance&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Thirty-eight cases of AFP were reported compared to 69 expected cases &#40;the WHO estimates an incidence of 1 case of AFP per 100&#44;000 children under 15 years&#41;&#46; Only 5 autonomous communities reported several cases equal or higher than the expected&#46; The reporting rate was &#46;55 per 100&#44;000 under 15 years &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#59; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; similar to 2018 &#40;&#46;58&#47;100&#44;000&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Of the cases&#44; 32&#46;0&#37; &#40;26&#41; were girls&#46; Most &#40;78&#46;9 per cent&#41; were 4 years old or older&#46; All but one had received at least three doses of polio vaccine &#40;97&#46;4&#37;&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Regarding the signs and symptoms suggestive of polio&#44; 28&#46;9&#37; &#40;11&#41; of the cases presented fever at onset of paralysis&#44; in 44&#46;7&#37; &#40;17&#41; paralysis progressed rapidly &#40;&#60;11 days&#41; and in 15&#46;8&#37; &#40;6 cases&#41; paralysis was asymmetrical&#46; In most cases the paralysis affected the limbs &#40;spinal&#58; 89&#46;5&#37;&#59; 34 cases&#41;&#46; Two cases were also reported with limb&#47;facial involvement&#44; spinal&#47;bulbar and facial &#40;one case each&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In all cases a definitive clinical diagnosis was achieved&#44; which was mostly Guillain-Barr&#233; syndrome&#47;Polyradiculoneuritis &#40;33&#59; 86&#46;8&#37;&#41;&#46; Three cases &#40;7&#46;9&#37;&#41; of transverse myelitis were also diagnosed and 2 cases were classified as &#34;Other neuropathies&#47;systemic diseases&#34;&#46; In 2019 there was only one loss to follow-up&#59; 63&#46;2&#37; &#40;24&#41; of the cases did not present residual paralysis 60 days after onset of paralysis&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Laboratory results</span><p id="par0120" class="elsevierStylePara elsevierViewall">At least one stool sample was taken in 34 cases of AFP &#40;89&#46;5&#37;&#41; and in 29 &#40;76&#46;3&#37;&#41; two samples were taken&#46; All 63 samples processed were negative for PV by both cell culture and PCR&#46; Sample collection is considered timely and adequate when at least two samples are taken at least 24&#8239;h apart&#44; within 14 days of onset of paralysis&#46; In 26 cases &#40;68&#46;4&#37;&#41; one sample was collected in time and in 19 cases &#40;50&#46;0&#37;&#41; two samples were collected &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#59; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">The cases of AFP accumulated in the first half of the year&#44; although with no clear seasonal pattern &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">The presence of EV was confirmed in 4 cases of AFP&#44; which represents 11&#46;7&#37; of the cases with laboratory study &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; EV was detected by PCR&#44; and not by cell culture&#44; in a total of 6 stool samples from the 4 cases&#46; Not all the EVs could be characterised&#46; EV-D68 was identified in a stool sample from one case&#44; 3 EVs of species A &#40;in 1 and 2 stools from 2 different cases&#41; and finally&#44; in the 2 samples from another case&#44; the EVs were found to be rhinoviruses &#40;rhinoviruses also belong to the genus <span class="elsevierStyleItalic">Enterovirus</span>&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Evaluation of the quality of the surveillance system for acute flaccid paralysis</span><p id="par0135" class="elsevierStylePara elsevierViewall">Throughout 2019&#44; most communities carried out monthly &#34;zero-case&#34; reporting&#58; 71&#46;5&#37; of the expected notifications &#40;163&#47;228&#41; were received&#44; 59&#46;2&#37; &#40;135&#47;228&#41; of them on time &#40;in the first week of the following month&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">En 2019 the AFP notification rate was &#46;55 per 100&#44;000 and two &#8220;adequate&#8221; faeces samples were collected in 50&#46;0&#37;&#44; both below the target set by the WHO&#46; The surveillance index&#44; product of the above&#44; was &#46;28&#44; far from the quality standard of at least &#46;80 set by the WHO&#59; the index figure in 2019 is like that of other years in the series &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a> and <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">In 2019 the timeliness of case reporting was 68&#46;4&#37;&#46; If the date of hospital admission - which better reflects the time from when the health system knows about the case until it is reported - is considered for calculating the indicator instead of the date of paralysis onset&#44; the percentage of timely reporting rises to 73&#46;7&#37;&#44; which is close to the target set by the WHO &#40;&#8805;80&#37;&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Of the cases&#44; 81&#46;6&#37; were investigated in the 48&#8239;h after they were reported and 97&#46;4&#37; were adequately followed up on progression of paralysis&#46; This indicates that once cases enter the system they are studied appropriately&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Sample submission and processing times in the laboratory generally meet the quality standards set by the WHO&#59; the target for detection of non-polio EV in the stool samples studied is exceeded &#40;WHO target of at least 10&#37; and EV detection rate in 2019 of 11&#46;7&#37;&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">APF is a syndrome requiring hospital admission&#46; A search of hospital records of hospitalisations that meet the clinical definition of AFP estimates the burden of AFP disease in a territory and enables the thoroughness of the surveillance system to be monitored&#46; A search of the Spanish National Health System&#8217;s Hospital Discharge Records &#40;RAE-CMBD&#41; is carried out annually&#44; identifying hospital discharges that are clinically compatible with AFP in children under 15 years of age&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In accordance with ICD 10 diagnostic codes A80&#46;39 &#40;Other types of acute paralytic poliomyelitis&#41;&#44; G61&#46;0 &#40;Guillain-Barr&#233; syndrome-GBS&#41;&#44; G95&#46;9 &#40;Disease of spinal cord&#44; unspecified&#41; and G60&#46;9 &#40;Hereditary and idiopathic neuropathy&#44; unspecified&#41;&#44; through an active search in the RAE-CMBD&#44; the epidemiological surveillance services of the autonomous communities detect cases compatible with the definition of AFP&#46; Due to the special epidemiological situation produced by the SARS-CoV-2 pandemic&#44; only 8 of the 19 autonomous communities and cities have been able to provide this data&#44; and therefore this indicator has not been considered for 2019&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Complementary enterovirus surveillance</span><p id="par0170" class="elsevierStylePara elsevierViewall">In the Network of EV Surveillance Laboratories in 2019&#44; an overall total of 7741 clinical samples were studied and an EV was identified in 5&#46;5&#37; &#40;427&#41;&#46; The samples studied were 412 faeces and 7329 non-faeces &#40;primarily CSF&#44; serum&#44; or respiratory samples&#41; for EV diagnosis&#46; In 75 and 352 samples&#44; respectively&#44; the diagnosis was positive&#44; which means a yield of 18&#37; for faeces and 5&#37; for other samples&#46; In addition&#44; throughout 2019 the Enterovirus Unit of the CNM received EV positive samples from other microbiology laboratories outside the network for EV genotyping&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Overall&#44; the CNM received 521 clinical samples in which an EV had been identified &#40;96 stool samples and 425 from other clinical samples&#41;&#46; The samples came primarily from patients with meningitis &#40;22&#37;&#41;&#44; encephalitis &#40;10&#37;&#41;&#44; febrile syndrome &#40;34&#37;&#41;&#44; respiratory disorders &#40;16&#37;&#41; or with mucocutaneous infections &#40;BMS or exanthema&#44; 9&#37;&#41;&#46; Most of the EV positive samples &#40;84&#37;&#59; 439&#41; came from paediatric patients &#40;&#60;15 years&#41;&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Of the total of 521&#8239;EV positive samples received&#44; 404 &#40;78&#46;0&#37;&#41; could be genotyped&#46; The most frequently identified serotype was echovirus &#40;E&#41;-7 &#40;13&#37;&#41;&#44; followed by E-30 &#40;12&#37;&#41;&#44; E-11 &#40;9&#37;&#41;&#44; coxsackievirus &#40;CV&#41;-A6 &#40;8&#37;&#41; and E-13 &#40;8&#37;&#41;&#44; CV-B1 &#40;7&#37;&#41; and E-6 &#40;6&#37;&#41;&#46; EV-A71 was detected in 2&#37; of the typed EVs and EV-D68 only in one case of PFA&#46; In all cases&#44; the presence of PV was ruled out&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Finally&#44; through the EV surveillance system PVDV types 1 and 3 were identified in an adult diagnosed with severe immunosuppression but without symptoms of polio&#46; Following the epidemiological and laboratory investigation&#44; the most likely hypothesis was that the patient acquired the vaccine strains through close contact with a person who arrived in Spain in 2017 and who had been vaccinated with the bivalent oral vaccine when they left their country of origin&#46; Due to their immunosuppression status&#44; the patient had not been able to eliminate the viruses&#44; which arose from VDPV&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The risk assessment concluded that the risk for reintroducing poliovirus associated with this chronic excretory iVDPV &#40;immunodeficiency-associated vaccine-derived poliovirus infection&#41; was very low&#46; The conclusion was since there was no evidence that the virus had been transmitted between contacts&#44; that it had been a casual finding in the patient with no association with polio cases and that surveillance&#44; control and prevention measures had been strengthened to detect PV circulation early and respond to any situation&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Environmental surveillance of poliovirus</span><p id="par0190" class="elsevierStylePara elsevierViewall">In 2019&#44; environmental surveillance covered a population of 3&#44;842&#44;000 people&#46; In the LNP&#44; 16 wastewater samples were studied&#44; 4 of which were positive for EV &#40;25&#37;&#41;&#44; and although they could not be genotyped&#44; they were confirmed to be EV of species A&#44; thus ruling out the presence of PV&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0195" class="elsevierStylePara elsevierViewall">The results of AFP and EV surveillance show that there were no cases of polio and no circulation of PV&#44; indicating that Spain was &#34;polio-free&#34; in 2019&#46; The AFP surveillance system was established in Spain in 1998 as a key part of the polio eradication plan&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> The system is well established in all autonomous communities and although no cases or circulation of PV have been identified&#44; the reporting and laboratory study of paralysis cases in paediatric patients admitted to hospital is maintained&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Over the years&#44; there has been a downward trend in case reporting&#44; except in 2016 when it recovered significantly to the 2005 rate&#44; possibly due to the increase in circulation of other EVs such as EV-D68 and EV-A71&#44; which are also associated with AFP symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> In 2019&#44; 14 autonomous communities reported one or more cases&#59; in most patients stool samples were collected and studied and cell culture ruled out the presence of PV in all of them&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Surveillance of AFP&#44; in addition to providing evidence that PV is not circulating in a territory&#44; allows the epidemiology of this syndrome in children to be characterised&#58; age of presentation&#44; seasonality and geographical distribution&#44; clinical diagnoses and progression of paralysis&#46; Investigating cases in the laboratory&#44; as well as ruling out PV&#44; enables other EV to be identified that can cause severe neurological disease&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In 2019&#44; paralysis occurred mainly in children over the age of 4 years &#40;78&#46;9&#37;&#41; unlike the historical series &#40;1998&#8211;2015&#41; in which most cases are younger children&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> What remains is the pattern of the clinical profile&#44; with a majority of diagnoses of GBS and other polyradiculoneuritis or transverse myelitis&#44; and with a third of patients showing residual sequelae within 60 days of onset of paralysis&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">The surveillance rate&#44; as an indicator of the quality of surveillance&#44; is like other years in the series&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">EV infections are more frequent in the paediatric population&#44; and although most are asymptomatic&#44; they can infect different organs and produce a wide range of diseases according to the type of cells affected&#58; respiratory&#44; neurological&#44; mucocutaneous diseases&#44; myocarditis&#44; or neonatal sepsis&#46; The CNS is frequently infected by EVs&#59; the PVs were the first EVs identified as causing paralytic polio&#46; Other EVs also cause severe neurological disease&#44; ranging from aseptic meningitis &#40;in fact&#44; EVs are the main cause&#41;&#44; encephalitis&#44; encephalomyelitis&#44; rhombencephalitis&#44; AFP or bulbar involvement&#44; which can lead to cardiorespiratory failure and death&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Non-polio EVs are detected with variable frequency in clinical samples from children with AFP&#46; One of the quality objectives set by the WHO in the surveillance of AFP is that at least 10 per cent of stool samples studied should be found to have an EV&#46; In our historical series the percentage of samples in which an EV is identified is very variable&#44; with years when none is identified &#40;2009 and 2014&#41; and others when an EV is detected in more than 15&#37; of AFP cases &#40;16&#46;1&#37; in 2010 and 45&#46;1&#37; in 2016&#41;&#44; <span class="elsevierStyleSup">11&#8211;13</span> which is explained by the epidemic circulation of the different non-polio EVs&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Throughout the years of surveillance&#44; the most frequent EVs detected in AFP cases were of species B&#44; although in recent years EVs of species A have also been found&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> EV surveillance was established as complementary surveillance within polio eradication plans&#44; with the aim of monitoring PV circulation in countries considered to be &#39;polio-free&#39;&#46; Now that polio eradication is near&#44; the WHO wants to build on the systems already in place and jointly strengthen EV and environmental surveillance worldwide to rule out the presence of PV&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">EV surveillance has been strengthened in Spain in recent years&#44; with the addition of new laboratories to the Surveillance Laboratory Network&#46; Currently&#44; 10 hospital laboratories located in 9 autonomous communities participate in surveillance&#44; sending samples and clinical and epidemiological information to the LNP&#46; Other laboratories send samples for genotyping through the Microbiological Surveillance Programme &#40;CNM&#41;&#44; although as they do not belong to the network&#44; the samples received do not always have the clinical data&#46; The aim is for the network of laboratories to grow and cover the entire country&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">The identification of VDPV in an immunosuppressed patient with no symptoms compatible with polio has highlighted the quality of surveillance systems&#44; high standards of environmental sanitation&#44; adequate vaccination coverage and the capacity to detect and respond to PV-related events in our country&#46; National protocols should be kept up to date in line with WHO recommendations for responding to notification of a polio event or outbreak&#46; As long as there are still polio cases in the world&#44; efforts in health care and public health services must be maintained to identify any importation of a poliovirus&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">The WHO&#39;s declaration of the elimination of WPV3 globally has been a milestone on the road towards polio eradication&#46; Even so&#44; the global situation remains a cause for concern&#44; particularly the increase in reported outbreaks of VDPV &#40;mainly type 2&#41; in several countries in Africa and South-East Asia&#44; which highlight failures in the immunity of populations and the need to stop using the current OPVs&#46; In fact&#44; new&#44; more genetically stable&#44; vaccines attenuated against PV2 &#40;nOPV2&#41; that prevent the development of VDPV are expected to be in use in the most affected countries by 2021&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">The current COVID-19 pandemic also represents a critical moment in the progress of polio eradication and the control of other vaccine-preventable diseases&#46; The WHO has recommended the temporary suspension of vaccination campaigns in areas without active outbreaks&#44; as this activity is incompatible with recommendations on social distancing&#46; Countries are asked to prioritise routine vaccination of children to maintain coverage and to maintain&#44; where possible&#44; surveillance activities to monitor developments&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Funding</span><p id="par0245" class="elsevierStylePara elsevierViewall">This research study has received no specific grants from funding agencies in the public&#44; commercial&#44; or non-profit sectors&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interests</span><p id="par0250" class="elsevierStylePara elsevierViewall">N&#46; Torner declares that she is a member of the magazine&#39;s editorial team&#46; The other authors have no conflict of interests to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">The Acute Flaccid Paralysis &#40;AFP&#41; and Enterovirus &#40;EV&#41; Surveillance systems are key to achieving the eradication of poliomyelitis worldwide&#46; Among others&#44; they allow detecting the reintroduction of poliovirus &#40;PV&#41; from endemic areas&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Analysis of the results of the protocol for the surveillance of AFPs and EVs in 2019 and the standard quality index established by the World Health Organization&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">38 cases of AFP were reported&#44; -notification rate of 0&#46;55 &#47; 100&#44;000&#8239;&#60;&#8239;15 years- and adequate collection of clinical samples was achieved in 50&#37; of the cases&#46; The quality of AFP surveillance is summarized in the Surveillance Index&#44; which in 2019 was 0&#46;28 away from the 0&#46;80 established as the standard by WHO&#46; EV were detected in 11&#46;7&#37; of AFPs and in 5&#46;5&#37; of other syndromes &#40;meningitis&#44; mucocutaneous and respiratory&#41;&#44; the predominant types were E-7&#44; E-30&#44; E-11&#44; CV-A6 and E -13&#46; A case of VDPV without polio clinical presentation in an immunosupressed adult was detected&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conlusions</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">As long as there is circulation of poliovirus in the world&#44; it is necessary to keep the surveillance systems of EV -polio and nonpolio- active&#44; reinforcing the collection and processing of samples to detect the unexpected circulation of these viruses in time&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Los sistemas de Vigilancia de Par&#225;lisis Fl&#225;cida Aguda &#40;PFA&#41; y Enterovirus &#40;EV&#41; son clave para lograr la erradicaci&#243;n de la poliomielitis en todo el mundo&#46; Entre otras&#44; permiten detectar la reintroducci&#243;n de poliovirus &#40;PV&#41; desde zonas end&#233;micas&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis de los resultados del protocolo para la vigilancia de las PFAs y EV en 2019 y el &#237;ndice de calidad est&#225;ndar establecido por la Organizaci&#243;n Mundial de la Salud&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">En Espa&#241;a en 2019 se notificaron 38 casos de PFA&#44;-tasa de notificaci&#243;n de 0&#46;55&#47;100&#44;000&#8239;&#60;&#8239;15 a&#241;os- y la recogida adecuada de muestras cl&#237;nicas se consigui&#243; en el 50&#37; de los casos&#46; La calidad de la vigilancia de PFA se resume en el &#205;ndice de Vigilancia&#44; que en 2019 fue de 0&#44;28 alejado del 0&#44;80 establecido como est&#225;ndar por OMS&#46; Se detectaron EV en 11&#44;7&#37; de los casos de PFA y en 5&#44;5&#37; de casos con otros s&#237;ndromes &#40;meningitis e infecciones muco-cut&#225;neas y respiratorias&#41; y los tipos que circularon m&#225;s frecuentemente fueron E-7&#44; E-30&#44; E-11&#44; CV-A6 y E-13&#46; Se detect&#243; la excreci&#243;n de un poliovirus derivado de vacuna &#40;PVDV&#41; en un paciente adulto inmunodeprimido sin cl&#237;nica de poliomielitis&#46; Los resultados muestran que no hubo casos ni circulaci&#243;n de poliovirus salvaje y que se pudo detectar un PVDV&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Mientras haya circulaci&#243;n de poliovirus en el mundo&#44; es necesario mantener activos los sistemas de vigilancia de EV -polio y no polio- reforzando la recogida y el procesamiento de muestras para detectar a tiempo la circulaci&#243;n inesperada de dichos virus&#46;</p></span>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Autonomous community&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Population &#60;15 years&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Expected cases&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reported cases&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Rate &#47;100&#44;000&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Andalusia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;326&#44;088&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Aragon&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">185&#44;764&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Asturias&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">111&#44;087&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Balearic Islands&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">176&#44;510&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Canary Islands&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">288&#44;663&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Cantabria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">76&#44;521&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Castilla-La Mancha&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">305&#44;368&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Castilla y Le&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">285&#44;325&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Catalonia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;169&#44;615&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Valencian C&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">736&#44;642&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Extremadura&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">144&#44;094&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Galicia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">318&#44;284&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Madrid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;024&#44;440&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#46;10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Murcia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">254&#44;099&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Navarra&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">100&#44;599&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Basque Country&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">304&#44;246&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">La Rioja&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">45&#44;302&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ceuta&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Melilla&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#44;773&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#44;889&#44;437&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2521643.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Expected and reported cases&#44; and acute flaccid paralysis &#40;AFP&#41; reporting rates per 100&#44;000 inhabitants under 15 years of age&#44; by autonomous community&#46; Spain&#44; 2019&#46;</p>"
        ]
      ]
      6 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0035"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Acute Flaccid Paralysis Surveillance System&#46; National Centre of Epidemiology&#46; ISCIII&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Indicator&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">WHO target&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2018&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AFP reporting rate &#40;cases &#47;100&#44;000 inhab&#46;&#8239;&#60;&#8239;15 years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#37; AFP with 1 stool sample &#8804;14 days from onset of paralysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;80&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">83&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">81&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">91&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">68&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#37; AFP with 2 stool samples &#8804;14 days from onset of paralysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">56&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">56&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">56&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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