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  1. Fulltext Viral Aetiology of Acute Flaccid Paralysis Surveillance Cases, before and after Vaccine Policy Change from Oral Polio Vaccine to Inactivated Polio Vaccine
    Saraswathy Subramaniam TS, Apandi MA, Jahis R, Samsudin MS, Saat Z
    J Trop Med, 2014;2014:814908.
    PMID: 24772175 DOI: 10.1155/2014/814908
    Since 1992, surveillance for acute flaccid paralysis (AFP) cases was introduced in Malaysia along with the establishment of the National Poliovirus Laboratory at the Institute for Medical Research. In 2008, the Ministry of Health, Malaysia, approved a vaccine policy change from oral polio vaccine to inactivated polio vaccine (IPV). Eight states started using IPV in the Expanded Immunization Programme, followed by the remaining states in January 2010. The objective of this study was to determine the viral aetiology of AFP cases below 15 years of age, before and after vaccine policy change from oral polio vaccine to inactivated polio vaccine. One hundred and seventy-nine enteroviruses were isolated from the 3394 stool specimens investigated between 1992 and December 2012. Fifty-six out of 107 virus isolates were polioviruses and the remaining were non-polio enteroviruses. Since 2009 after the sequential introduction of IPV in the childhood immunization programme, no Sabin polioviruses were isolated from AFP cases. In 2012, the laboratory AFP surveillance was supplemented with environmental surveillance with sewage sampling. Thirteen Sabin polioviruses were also isolated from sewage in the same year, but no vaccine-derived poliovirus was detected during this period.
    Matched MeSH terms: Poliovirus Vaccine, Inactivated; Poliovirus Vaccine, Oral; Poliovirus
  2. Fulltext Circulating vaccine-derived poliovirus: a menace to the end game of polio eradication
    Ming LC, Hussain Z, Yeoh SF, Koh D, Lee KS
    Global Health, 2020 07 16;16(1):63.
    PMID: 32677974 DOI: 10.1186/s12992-020-00594-z
    The World Health Organisation Western Pacific Region countries were declared free of polio in 2000 until a polio outbreak involving 305 cases occurred in Indonesia in 2006. It was not until 2014 that the World Health Organisation South East Asia region was officially declared polio-free again. However, in February 2019, the Global Polio Eradication Initiative announced a new circulating vaccine-derived poliovirus outbreak in the Papua province of Indonesia. To make matter worse, the outbreak responses were tardy and led to transmission among migrating communities to other cities. The pressing regional issues of polio outbreak caused by circulating vaccine-derived poliovirus and use of oral polio vaccine have not been well presented. Our letter highlighted the suboptimal outbreak responses as well as the necessity of cross-border vaccination to curb continued poliovirus transmission.
    Matched MeSH terms: Poliovirus Vaccine, Oral; Poliovirus; Poliovirus Vaccines
  3. Fulltext Concurrent outbreaks of circulating vaccine-derived poliovirus types 1 and 2 affecting the Republic of the Philippines and Malaysia, 2019-2021
    Snider CJ, Boualam L, Tallis G, Takashima Y, Abeyasinghe R, Lo YR, et al.
    Vaccine, 2023 Apr 06;41 Suppl 1:A58-A69.
    PMID: 35337673 DOI: 10.1016/j.vaccine.2022.02.022
    Concurrent outbreaks of circulating vaccine-derived poliovirus serotypes 1 and 2 (cVDPV1, cVDPV2) were confirmed in the Republic of the Philippines in September 2019 and were subsequently confirmed in Malaysia by early 2020. There is continuous population subgroup movement in specific geographies between the two countries. Outbreak response efforts focused on sequential supplemental immunization activities with monovalent Sabin strain oral poliovirus vaccine type 2 (mOPV2) and bivalent oral poliovirus vaccines (bOPV, containing Sabin strain types 1 and 3) as well as activities to enhance poliovirus surveillance sensitivity to detect virus circulation. A total of six cVDPV1 cases, 13 cVDPV2 cases, and one immunodeficiency-associated vaccine-derived poliovirus type 2 case were detected, and there were 35 cVDPV1 and 31 cVDPV2 isolates from environmental surveillance sewage collection sites. No further cVDPV1 or cVDPV2 have been detected in either country since March 2020. Response efforts in both countries encountered challenges, particularly those caused by the global COVID-19 pandemic. Important lessons were identified and could be useful for other countries that experience outbreaks of concurrent cVDPV serotypes.
    Matched MeSH terms: Poliovirus Vaccine, Oral/adverse effects; Poliovirus*
  4. Poliomyelitis vaccination benefits--versus risk
    Assaad F
    Dev. Biol. Stand., 1979;43:141-50.
    PMID: 520666
    Paralytic poliomyelitis is a constantly rising problem in the developing world. It may take an insiduous endemic "infantile paralysis" behaviour exacting a high toll in the first few years of life, as in Ghana or Burma but on the other hand it may take the form of sudden extensive outbreaks of paralytic disease as in Argentina, Mexico or Malaysia. The developed world has controlled the disease by effectively immunizing a very high proportion of their populations, but those who have not been vaccinated are at risk even in countries with very high coverage, as has been noted in the Netherlands, Sweden, United States of America, etc. There is no reason to have a crippled paralytic child (or adult). Both the live and killed vaccines have been repeatedly shown to be safe and effective. The minute risk incidental to vaccination is more than one hundredfold smaller than the risk from the disease, not only in the developing world but in the developed world as well. Therefore, the question of which vaccine to use is of far less relevance than of how to increase effective coverage with any available vaccine. This does not mean that vaccine control should be relaxed. A health respect should be maintained for the polioviruses used as vaccine sources and great care must be exercised by those undertaking the manufacture or the administration of vaccine.
    Matched MeSH terms: Poliovirus Vaccine, Inactivated/adverse effects; Poliovirus Vaccine, Inactivated/therapeutic use*; Poliovirus Vaccine, Oral/adverse effects; Poliovirus Vaccine, Oral/therapeutic use*
  5. Fulltext Polio vaccination in Pakistan: by force or by volition?
    Khan TM, Chiau LM
    Lancet, 2015 Oct 31;386(10005):1733.
    PMID: 26545429 DOI: 10.1016/S0140-6736(15)00689-3
    Matched MeSH terms: Poliovirus Vaccines*
  6. Fulltext Polio vaccination in Pakistan
    Khan MU, Ahmad A
    Lancet, 2015 Jul 25;386(9991):337.
    PMID: 26227462 DOI: 10.1016/S0140-6736(15)61405-2
    Matched MeSH terms: Poliovirus Vaccines*
  7. Influence of immunization schedule on immunization coverage
    Chen ST
    J Trop Med Hyg, 1989 Dec;92(6):386-90.
    PMID: 2607571
    The infant immunization coverage for triple antigen (DPT) from 1968 and trivalent oral polio vaccine (TOPV) from 1972 to 1985 for Peninsular Malaysia are presented. It shows that immunization coverage improved when the recommended age for first dose of DPT was changed from the fourth to the second month of life in 1972 and declined when the recommended age for the first dose of DPT and TOPV was revised again from the second to the third month of life in 1980. The advantages of immunizing children early in life are discussed.
    Matched MeSH terms: Poliovirus Vaccine, Inactivated/administration & dosage*
  8. Fulltext Parents' and healthcare professionals' perception toward the introduction of a new fully liquid hexavalent vaccine in the Malaysian national immunization program: a cross-sectional study instrument development and its application
    Al Bashir L, Ismail A, Aljunid SM
    Front Immunol, 2023;14:1052450.
    PMID: 37180162 DOI: 10.3389/fimmu.2023.1052450
    A newly developed fully liquid hexavalent vaccine that comprises six antigens for Diphtheria, Tetanus, acellular Pertussis, Inactivated Poliomyelitis, Haemophilus Influenza type b., and Hepatitis B, is proposed to be introduced in the Malaysian national immunization program, instead of the non-fully liquid pentavalent vaccine and monovalent Hepatitis B vaccine that is currently employed in the immunization schedule. Although the introduction of new vaccines is a necessary intervention, it still needs to be accepted by parents and healthcare professionals. Hence, this study aimed to develop three structured questionnaires and to investigate the participants' perception and acceptability toward the incorporation of the new fully liquid hexavalent vaccine. A cross-sectional study was conducted among a sample of 346 parents, 100 nurses, and 50 physicians attending twenty-two primary health care centers in the states of Selangor and the Federal Territory of Kuala Lumpur and Putrajaya during 2019-2020. The study found that Cronbach's alpha coefficients for the study instruments ranged from 0.825 to 0.918. Principal components analysis produced a good fit with KMO>0.6. For the parents' perception questionnaire, the only extracted factor explained 73.9 % of the total variance; for the nurses' perception toward a non-fully and fully liquid combined vaccine, there was a sole extracted factor that explained 65.2 % and 79.2% of the total variance, respectively. Whereas for the physicians' perception, there was one factor extracted that explains 71.8 % of the total variance. The median score for all the questionnaire items ranged from 4 to 5 (Q1 and Q3 vary between 3-5). Parents' ethnicity was significantly associated (P-value ≤ 0.05) with the perception that the new hexavalent vaccine would reduce their transportation expenses. Moreover, a significant association (P-value ≤ 0.05) was found between physicians' age and the perception of the hexavalent vaccine's ability to decrease patient overcrowding in primary healthcare centers. The instruments used in this study were valid and reliable. Parents of Malay ethnicity were the most concerned about transportation expenses since they have the lowest income and are more concentrated in rural areas compared to other races. Younger physicians were concerned about reducing patient crowding and hence reducing their workload and burnout.
    Matched MeSH terms: Poliovirus Vaccine, Inactivated*
  9. Fulltext Laboratory acute flaccid paralysis surveillance in Malaysia: a decade of commitment to the WHO global polio eradication initiative
    Saraswathy TS, Khairullah NS, Sinniah M, Fauziah MK, Apandi MY, Shamsuddin M
    Southeast Asian J Trop Med Public Health, 2004 Jun;35(2):421-4.
    PMID: 15691149
    The Institute for Medical Research, Malaysia, was designated the National Reference Laboratory for Poliomyelitis Eradication (NRLPE) in 1992. Since then, our Polio Laboratory has collaborated actively with the Disease Control Division, Ministry of Health (MOH), Malaysia and WHO towards achieving polio eradication. Since 1992, the NRLPE has investigated 1,063 stool specimens from 641 acute flaccidparalysis (AFP) cases. One hundred and one enteroviruses were isolated from these specimens. Positive cell cultures were confirmed by microneutralization assay using standard WHO antisera. All enterovirus isolates were sent to the Victorian Infectious Disease Reference Laboratory in Melbourne, Australia, for further identification and poliovirus intratypic differentiation. Thirty-one out of these 101 virus isolates (30%) were polioviruses (PV) and the remaining 70 (70%) were non-polio enteroviruses (NPEV) which included coxsackie B viruses, echoviruses and enterovirus 71. Three of the poliovirus isolates were wild-type polioviruses isolated in 1992 which were the last wild-type polioviruses isolated in Malaysia. The rest were vaccine-related Sabin-like strains. Monthly reports of the virological investigation of AFP cases are sent to WHO and to the MOH, AFP control committee. The NRLPE continues to play an integral role in AFP surveillance and is committed to the WHO's goal of global polio eradication by the year 2005.
    Matched MeSH terms: Poliovirus Vaccine, Oral/administration & dosage; Poliovirus/isolation & purification*
  10. Enterovirus survey before and after poliomyelitis vaccination in Kuala Lumpur, Malaysia
    Tan DS, Lam SK
    Southeast Asian J Trop Med Public Health, 1978 Sep;9(3):301-7.
    PMID: 219550
    Stool samples from healthy children mainly of the low income group aged 0 to 7 years of age from five Maternal and Child Health Centres in Kuala Lumpur were obtained for isolation of enteroviruses. The specimens were collected before and after the mass vaccination given in the face of polio type 1 epidemic which started in October, 1971. The prevelance rate of enteroviruses was 11.9% (3.0% polioviruses, 8.9% non-polio enteroviruses) before the vaccination and essentially the same after. Coxsackie A viruses predominated over the other enteroviruses in the pre- and post-vaccination phases. The highest isolation rate of enteroviruses was observed in children 0 to 2 years age. No significant differences in distribution by sex, race and month were noted. A sharp fall in the prevalence rates of total enteroviruses and polioviruses was noted shortly after the mass vaccination campaign However, the rates reverted to the pre-vaccination state during the next successive years.
    Matched MeSH terms: Poliovirus Vaccine, Oral/immunology*; Poliovirus/isolation & purification
  11. The value of potency testing of poliomyelitis and measles vaccines as an integral part of cold chain surveillance
    Saraswathy TS, Sinniah M, Lee WS, Lee PC
    Southeast Asian J Trop Med Public Health, 1993 Jun;24(2):265-8.
    PMID: 8266228
    The Virology Division in the Institute for Medical Research, Kuala Lumpur, Malaysia performs potency tests on oral polio vaccines and live attenuated measles vaccines. Since these potency tests were introduced in 1981 a total of 752 tests have been performed on vaccine samples from peripheral immunization centers. Of 165 representative vaccine samples sent for potency evaluation after a cold chain breakdown 154 (87%) passed minimum potency requirements recommended for immunization of infants. In the absence of potency evaluation, those vaccines exposed to temperatures higher than the recommended storage range would be discarded, perhaps resulting in unnecessary wastage and economic loss. Results of the vaccine potency evaluation has enabled health authorities to indirectly monitor cold chain efficiency and ensure the high quality of viral vaccines used in our childhood immunization program.
    Matched MeSH terms: Poliovirus Vaccine, Oral/immunology*; Poliovirus Vaccine, Oral/standards
  12. Poliomyelitis in Malaysia - a case of underdiagnosis?
    Hussain Imam Muhammad Ismail
    Malaysian Journal of Child Health, 1992;4(1):23-26.
    MyJurnal
    The last confirmed case of poliomyelitis in West Malaysia was in 1986', and over the past few years, we have condescendingly associated polio with other developing countries. Recently, 2 children with acute flaccid paralysis (AFP) were confirmed as cases of poliomyelitis due to a wild strain of the virus. This implies a failure of the immunisation programme to contain the spread of the wild virus (Hall). However, if we look at the WHO standard case definition of polio virus infection (appendix 1) it is possible that we could have missed a few cases over the last 6 years. At this juncture a brief clinical summary of the 2 cases and a discussion of the differential diagnosis may be useful. (Copied from article).
    Matched MeSH terms: Poliovirus
  13. Fulltext Knowledge, attitudes and perceptions towards polio immunization among residents of two highly affected regions of Pakistan
    Khan MU, Ahmad A, Aqeel T, Salman S, Ibrahim Q, Idrees J, et al.
    BMC Public Health, 2015;15:1100.
    PMID: 26541976 DOI: 10.1186/s12889-015-2471-1
    Despite the efforts of national and international organizations, polio has not been eradicated from Pakistan. The prevalence of polio in Pakistan is exceptional in global context. Quetta and Peshawar divisions are amongst the most affected regions hit by polio in Pakistan. This study was carried out to assess the knowledge, attitudes and perceptions towards polio immunization among residents of Quetta and Peshawar divisions in Pakistan.
    Matched MeSH terms: Poliovirus Vaccines*
  14. Enough With Polio: It's Measles' Turn Now in Pakistan
    Rehman IU, Khan TM
    Disaster Med Public Health Prep, 2016 08;10(4):539-40.
    PMID: 27263952 DOI: 10.1017/dmp.2016.91
    Matched MeSH terms: Poliovirus Vaccines/administration & dosage*
  15. Fulltext Milestone of polio Environmental Surveillance in Malaysia conjoining with the Polio Global Eradication Initiative
    Kamal Haikal Mat Rabi, Amry Khursany Ismail, Mohd Samsul Samsuddin, Manisha Zauri Abdul Wahid, Zarina Mohd Zamawi, Ravindran Thayan
    Malaysian Journal of Medicine and Health Sciences, 2019;15(106):78-78.
    MyJurnal
    Introduction: Poliomyelitis is an incapacitating and highly infectious disease which effect mostly young children. It is caused by one of the three serotypes of polioviruses (PV) and transmitted through faecal-oral route hence making the disease quite pertinent to the lower and middle class society or under-immunized population. This surveillance is one of the strategy included by WHO in the “Eradication, Integration and Certification: The Endgame Strategy 2019-2023” as a supplement to AFP surveillance by which it could be more sensitive to detect low circulation of WPV and circulating vaccine derived poliovirus (cVDPV). Methods: Routine collection and testing of representative environmental surveillance are carried out in the National Polio Laboratory. The specimens are collected from designated locations draining target populations at increased risk of poliovirus transmission using the grab method once a month and processed according to WHO standard protocol. Polioviruses were identified by real time reverse transcriptase polymerase chain reaction (rRT-PCR) for intratypic differentiation (ITD) and vaccine derived poliovirus (VDPV) whereas non-polio enteroviruses (NPEVs) were identified by PCR and sequencing. Results: From 2012 to 2019, results showed various isolation of PVs and NPEVs. A total of 12 sewage disposal plants located in urban highly populated areas in Kuala Lumpur (3), Selangor (5), Sabah (3 ) and Negeri Sembilan (1) were investigated. A total of 22 Sabin-like PVs were isolated consisting of 3 PV1, 8 PV2 and 11 PV3 thus indicated that in Malaysia even though PVs were existed in environment, but all of them were Sabin-Like viruses and no evidence of imported WPV or VDPV in the sampling sites. Conclusion: Even though Malaysia has been declared as WPV free country in 2000, Environmental Surveillance is very important and crucial in detecting the introduction and silent circulation of WPV and cVDPV before the virus reaches the community.
    Matched MeSH terms: Poliovirus; Poliovirus Vaccines
  16. Molecular epidemiology of wild poliovirus type 1 in Europe, the Middle East, and the Indian subcontinent
    Mulders MN, Lipskaya GY, van der Avoort HG, Koopmans MP, Kew OM, van Loon AM
    J Infect Dis, 1995 Jun;171(6):1399-405.
    PMID: 7769273
    The genomic relationships of wild poliovirus type 1 strains recently isolated in Europe, the Middle East, and the Indian subcontinent was analyzed by automated amplicon sequencing of the VP1/2A junction region of the genome. Four major genotypes of poliovirus type 1 were found to circulate. Two genotypes were found predominantly in Eastern Europe, one of these in the Caucasian Region and the other in countries bordering the Black Sea. A third genotype circulated mainly in Egypt. The fourth and largest genotype circulated in the largest geographic area. Strains belonging to this genotype could be found in countries as far apart as Malaysia and Ukraine. Considerable genetic variation was observed among strains isolated in Egypt, Pakistan, and India, where poliovirus is endemic. Strains belonging to all four genotypes circulated in Pakistan. Data confirm the extent of poliovirus circulation in certain regions, stressing the need for intensification of vaccination in these regions.
    Matched MeSH terms: Poliovirus/genetics*
  17. Final stages of poliomyelitis eradication--Western Pacific Region, 1997-1998
    Centers for Disease Control and Prevention (CDC)
    MMWR Morb Mortal Wkly Rep, 1999 Jan 22;48(2):29-33.
    PMID: 9933126
    In 1988, the World Health Assembly resolved to eradicate poliomyelitis globally by 2000. A plan of action for polio eradication in the Western Pacific Region (WPR) by 1995 was adopted in 1990. The plan was based on routine and supplemental vaccination activities with oral poliovirus vaccine (OPV) and acute flaccid paralysis (AFP) surveillance in the eight countries where polio was endemic (Cambodia, China, Laos, Malaysia, Mongolia, Papua New Guinea, Philippines, and Vietnam). Regionwide, the number of reported polio cases decreased from approximately 6000 in 1990 to zero in 1998. This report describes the extensive efforts to eliminate the last chains of poliovirus transmission in the Mekong River area.
    Matched MeSH terms: Poliovirus Vaccine, Inactivated/administration & dosage
  18. Fulltext Recovery of poliovirus from cut surface of stored fresh papaya fruit
    Lee ASC, Yap KL
    Southeast Asian J Trop Med Public Health, 1999 Jun;30(2):280-3.
    PMID: 10774695
    Poliovirus kept on the cut surfaces of fully ripe papaya cubes placed in an ice box showed a sharp and significant reduction in the recovery of infectious virus about 15 minutes after exposure. Thereafter, a very gradual decrease ensued and infectious residual virus was detected up to the end of the 6-hour exposure period. Papaya cubes washed or kept overnight before virus inoculation, and from less ripe fruits produced a similar survival pattern. A very small proportion of the inoculum was recovered from the mashed content of the inoculated papaya cubes thus suggesting that most of the non-recovered virus particles were inactivated. The results suggest that the importance of poliovirus-contaminated cut papayas as a transmission vehicle for the virus is greatly reduced by the rapid decline in the infectivity of a large proportion of the virus soon after contamination. Nevertheless, the potential to transmit remains as a small residual pool of infectious poliovirus is able to survive for a relatively long period.
    Matched MeSH terms: Poliovirus/growth & development*
  19. Fulltext Poliomyelitis and measles serosurvey in northern Malaysia
    Saraswathy TS, Sinniah M, Lee WS, Lye MS, Choo KE, Jusoh H
    Southeast Asian J Trop Med Public Health, 1994 Sep;25(3):565-8.
    PMID: 7777927
    In 1990 the Institute for Medical Research carried out a serosurvey in the state of Kelantan to study the age stratified immune prevalence rates for measles and poliomyelitis. Our findings indicate that 981 out of 1,097 (89%) of the population screened had measles antibodies and more than 90% (366 out of 400) had antibodies to all three serotypes of poliovirus. The susceptible group for measles was infants below one year of age, of whom 53.3% (8/15) did not have measles antibody. Of 400 subjects, 125 (31.3%) who were either incompletely vaccinated or had not been vaccinated against poliomyelitis, had polio neutralizing antibodies to all three poliovirus serotypes, suggesting herd immunity in the population. No high risk age group could be identified for poliomyelitis.
    Matched MeSH terms: Poliovirus/immunology
  20. Fulltext Economic impact of switching from partially combined vaccine "Pentaxim® and hepatitis B" to fully combined vaccine "Hexaxim®" in the Malaysian National Immunization Program
    Aljunid SM, Al Bashir L, Ismail AB, Aizuddin AN, Rashid SAZA, Nur AM
    BMC Health Serv Res, 2022 Jan 05;22(1):34.
    PMID: 34986870 DOI: 10.1186/s12913-021-07428-7
    BACKGROUND: The decision to implement new vaccines should be supported by public health and economic evaluations. Therefore, this study was primarily designed to evaluate the economic impact of switching from partially combined vaccine (Pentaxim® plus hepatitis B) to fully combined vaccine (Hexaxim®) in the Malaysian National Immunization Program (NIP) and to investigate healthcare professionals (HCPs)' and parents'/caregivers' perceptions.

    METHODS: In this economic evaluation study, 22 primary healthcare centers were randomly selected in Malaysia between December 2019 and July 2020. The baseline immunization schedule includes switching from Pentaxim® (four doses) and hepatitis B (three doses) to Hexaxim® (four doses), whereas the alternative scheme includes switching from Pentaxim® (four doses) and hepatitis B (three doses) to Hexaxim® (four doses) and hepatitis B (one dose) administered at birth. Direct medical costs were extracted using a costing questionnaire and an observational time and motion chart. Direct non-medical (cost for transportation) and indirect costs (loss of productivity) were derived from parents'/caregivers' questionnaire. Also, HCPs' and parent's/caregivers' perceptions were investigated using structured questionnaires.

    RESULTS: The cost per dose of Pentaxim® plus hepatitis B vs. Hexaxim® for the baseline scheme was Malaysian ringgit (RM) 31.90 (7.7 United States dollar [USD]) vs. 17.10 (4.1 USD) for direct medical cost, RM 54.40 (13.1 USD) vs. RM 27.20 (6.6 USD) for direct non-medical cost, RM 221.33 (53.3 USD) vs. RM 110.66 (26.7 USD) for indirect cost, and RM 307.63 (74.2 USD) vs. RM 155.00 (37.4 USD) for societal (total) cost. A similar trend was observed for the alternative scheme. Compared with Pentaxim® plus hepatitis B, total cost savings per dose of Hexaxim® were RM 137.20 (33.1 USD) and RM 104.70 (25.2 USD) in the baseline and alternative scheme, respectively. Eighty-four percent of physicians and 95% of nurses supported the use of Hexaxim® in the NIP. The majority of parents/caregivers had a positive perception regarding Hexaxim® vaccine in various aspects.

    CONCLUSIONS: Incorporation of Hexaxim® within Malaysian NIP is highly recommended because the use of Hexaxim® has demonstrated substantial direct and indirect cost savings for healthcare providers and parents/caregivers with a high percentage of positive perceptions, compared with Pentaxim® plus hepatitis B.

    TRIAL REGISTRATION: Not applicable.

    Matched MeSH terms: Poliovirus Vaccine, Inactivated
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