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The inactivated polio vaccine (IPV, or Salk) contains trivalent fully inactivated virus, administered by injection. This vaccine cannot induce VAPP nor do cVDPV strains arise from it, but it likewise cannot induce contact immunity and thus must be administered to every individual. Added to this are greater logistical challenges. Though a single dose is sufficient for protection, administration requires medically trained vaccinators armed with single-use needles and syringes. Taken together, these factors result in substantially higher delivery costs.[22] Original protocols involved intramuscular injection in the arm or leg, but recently subcutaneous injection using a lower dose (so-called fractional-dose IPV, fIPV) has been found to be effective, lowering costs and also allowing for more convenient and cost-effective delivery systems.[23][24] The use of IPV results in serum immunity, but no intestinal immunity arises. As a consequence, vaccinated individuals are protected from contracting polio, but their intestinal mucosa may still be infected and serve as a reservoir for the excretion of live virus. For this reason, IPV is ineffective at halting ongoing outbreaks of WPV or cVDPV, but it has become the vaccine of choice for industrialized, polio-free countries.[22]

While vaccination has played an instrumental role in the reduction of polio cases worldwide, the use of attenuated virus in the oral vaccine carries with it an inherent risk. The oral vaccine is a powerful tool in fighting polio in part because of its person-to-person transmission and resulting contact immunity. However, under conditions of long-term circulation in undervaccinated populations, the virus can accumulate mutations that reverse the attenuation and result in vaccine virus strains that themselves cause polio. As a result of such circulating vaccine-derived poliovirus (cVDPV) strains, polio outbreaks have periodically recurred in regions that have long been free of the wild virus, but where vaccination rates have fallen. Oral vaccines can also give rise to persistent infection in immunodeficient individuals, with the virus eventually mutating into a more virulent immunodeficiency-associated vaccine-derived poliovirus (iVDPV). In particular, the type 2 strain seems prone to reversions, so in 2016 the eradication effort abandoned the trivalent oral vaccine containing attenuated strains of all three virus types and replaced it with a bivalent oral vaccine lacking the type 2 virus, while a separate monovalent type 2 vaccine (mOPV2) was to be used only to target existing cVDPV2 outbreaks. Further, a novel oral vaccine targeting type 2 (nOPV2) that has been genetically stabilized to make it less prone to give rise to circulating vaccine-derived strains is now in limited use.[32][21] Eradication efforts will eventually require all oral vaccination to be discontinued in favor of the use of injectable vaccines. These vaccines are more expensive and more difficult to deliver, and they lack the ability to induce contact immunity because they contain only killed virus, but they likewise are incapable of giving rise to vaccine-derived viral strains.[33][34]

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In 1995, Operation MECACAR (Mediterranean, Caucasus, Central Asian Republics, and Russia) was launched; National Immunization Days were coordinated in 19 European and Mediterranean countries.[83] In 1998, Melik Minas of Turkey became the last case of polio reported in Europe.[84] In 1997, Mum Chanty of Cambodia became the last person to contract polio in the Indo-West Pacific region.[85] In 2000, the Western Pacific Region (including China) was certified polio-free.[85]

By 2001, 575 million children (almost one-tenth the world's population) had received some two billion doses of oral polio vaccine.[87] The World Health Organization announced that Europe was polio-free on 21 June 2002, in the Copenhagen Glyptotek.[88]

In August 2003, rumors spread in some states in Nigeria, especially Kano, that the vaccine caused sterility in girls. This resulted in the suspension of immunization efforts in the state, causing a dramatic rise in polio rates in the already endemic country.[90] On 30 June 2004, the WHO announced that after a 10-month ban on polio vaccinations, Kano had pledged to restart the campaign in early July. During the ban the virus spread across Nigeria and into 12 neighboring countries that had previously been polio-free.[79] By 2006, this ban would be blamed for 1,500 children being paralyzed and had cost $450 million for emergency activities. In addition to the rumors of sterility and the ban by Nigeria's Kano state, civil war and internal strife in Sudan and Côte d'Ivoire have complicated WHO's polio eradication goal. In 2004, almost two-thirds of all the polio cases in the world occurred in Nigeria (760 out of 1,170 total).[citation needed]

In 2006, only four countries in the world (Nigeria, India, Pakistan, and Afghanistan) were reported to have endemic polio. Cases in other countries are attributed to importation. A total of 1,997 cases worldwide were reported in 2006; of these the majority (1,869 cases) occurred in countries with endemic polio.[92] Nigeria accounted for the majority of cases (1,122 cases) but India reported more than ten times more cases in 2006 than in 2005 (676 cases, or 30% of worldwide cases). Pakistan and Afghanistan reported 40 and 31 cases respectively in 2006. Polio re-surfaced in Bangladesh after nearly six years of absence with 18 new cases reported. "Our country is not safe, as neighbours India and Pakistan are not polio free", declared Health Minister ASM Matiur Rahman.[97] (See: Map of reported polio cases in 2006)

In 2014, there were 359 reported cases of wild poliomyelitis, spread over twelve countries. Pakistan had the most with 306, an increase from 93 in 2013, which was blamed on Al Qaeda and Taliban militants preventing aid workers from vaccinating children in rural regions of the country.[112][113] On 27 March 2014, the WHO announced the eradication of poliomyelitis in the South-East Asia Region, in which the WHO includes eleven countries: Bangladesh, Bhutan, North Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste.[114] With the addition of this region, the proportion of world population living in polio-free regions reached 80%.[114] The last case of wild polio in the South-East Asia Region was reported in India on 13 January 2011.[115]

Laos was declared free of cVDPV1 in March,[59][131] but three distinct cVDPV2 outbreaks occurred in the Democratic Republic of the Congo, one of them of recent origin, the other two having circulated undetected for more than a year. Together they caused 20 cases by year's end.[132][133][134][135] In Syria, a large outbreak began at Mayadin, Deir ez-Zor Governorate, a center of fighting in the Syrian Civil War, and also spreading to neighboring districts saw 74 confirmed cases from a viral strain that had circulated undetected for about two years.[136][137] Circulation of multiple genetic lines of cVDPV2 was also detected in Banadir province, Somalia, but no infected individuals were identified.[138] WHO's Strategic Advisory Group of Experts on Immunization recommended that cVDPV2 suppression be prioritized over targeting WPV1,[139] and according to protocol OPV2 is restricted to this purpose.

In June, Nigeria was removed from the list of countries with endemic wild poliovirus, leaving only Pakistan and Afghanistan.[178] Two months later, the Africa Regional Certification Commission, an independent body appointed by the World Health Organization, declared the African continent free of wild poliovirus.[4] This certification came after extensive assessments of the certifications of National Polio Certification Commissions (NCCs)[179] and confirmation that at least 95% of Africa's population had been immunised.[4] WHO Director-General Tedros Adhanom called it a "great day... but not the end of polio",[180] as there remain major continuing outbreaks of the vaccine derived poliovirus in West Africa and Ethiopia in addition to wild cases in Afghanistan and Pakistan.[172]

Almost 700 cases caused by cVDPV2 were detected in 2021 in 22 countries, over half occurring in Nigeria. Other countries with cVDPV2 cases include Afghanistan, Benin, Burkina Faso, Cameroon, Congo, the DRC, Eritrea, Ethiopia, Guinea, Guinea-Bissau, Liberia, Mozambique, Niger, Pakistan, Senegal, Sierra Leone, Somalia, South Sudan, Tajikistan, Ukraine, and Yemen, with the virus found in environmental samples or in those from symptom-free people in several additional African and Asian nations without reported cases.[171] An analysis of cVDPV2 strains from 2020 and the first half of 2021 attributed them to 38 distinct emergences, representing a mix of novel strains and previously detected strains that continued to circulate, while several previously circulating strains were no longer found.[186] For cVDPV1, 13 cases had been identified in Madagascar and 3 in Yemen. The only instances of cVDPV3 detected in the year were a single environmental sample from China and several from Israel and the adjacent occupied territories.[171][186] 2ff7e9595c