#Polio eradication in @CDCMMWR: Are we finally on the cusp of that elusive dream?

Note: This was cross-posted to my own blog.


I came across a very encouraging article in last week’s MMWR (the CDC’s Morbidity and Mortality Weekly Report) this morning about polio eradication. After several reappearances in 2013, cases are down again this year and, if things continue to go well, the end may be in sight:

Four of six WHO regions have been certified as free of indigenous WPV, and endemic transmission of WPV continued in only three countries in 2014. In 2013, the global polio eradication effort suffered setbacks with outbreaks in the Horn of Africa, Central Africa, and the Middle East; however, significant progress was made in 2014 in response to all three outbreaks. Nonetheless, the affected regions remain vulnerable to WPV re-importation from endemic areas and to low-level, undetected WPV circulation. Continued response activities are needed in these regions to further strengthen AFP surveillance and eliminate immunity gaps through high-quality SIAs and strong routine immunization programs.

Progress in Nigeria since 2012 has brought the goal of interrupting the last known chains of indigenous WPV transmission in Africa within reach. Elimination of all poliovirus transmission in Nigeria in the near term is feasible, through intensified efforts to 1) interrupt cVDPV2 transmission, 2) strengthen routine immunization services, and 3) increase access to children in insecure areas. Similar efforts should be implemented in all countries in Africa, where 9 months have passed without a reported WPV case, and 6 months have passed since the last reported cVDPV2 case.

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Number of cases of wild poliovirus type 1 in countries with recent polio outbreaks, by territory* — January 1, 2013–March 30, 2015

*Central Africa (Cameroon and Equatorial Guinea), Horn of Africa (Ethiopia and Somalia), and Middle East (Iraq and Syria).

The eradication push has suffered major blows in the last two years. In 2013, after six years of being polio-free, a major outbreak in Somalia contributed more polio cases to the year’s tally than the rest of the world combined; meanwhile, the virus made its way back into Syria that same fall after a 14-year hiatus. Luckily, extraordinary efforts in the midst of conflict zones on the part of health workers were able to beat the virus back to the heart of the fight – the final three countries in which it remains endemic.

Number of cases of wild poliovirus type 1 among countries with endemic poliovirus transmission, by country — January 1, 2013–March 30, 2015
Number of cases of wild poliovirus type 1 among countries with endemic poliovirus transmission, by country — January 1, 2013–March 30, 2015

Most (86%) WPV cases in Afghanistan in 2014 resulted from importation from Pakistan; however, the detection of orphan viruses highlights the need to strengthen the quality of both polio vaccination and AFP surveillance (10). Efforts are also needed to increase population immunity by intensifying routine polio immunization activities to ensure high coverage among infants with at least 3 OPV doses.

Recent challenges to the secure operation and public acceptance of the polio eradication program in Pakistan are unprecedented (10). Although poliovirus transmission has been concentrated primarily in the FATA region of northwest Pakistan, transmission has continued in the greater Karachi area, and WPV cases have been reported from all major Pakistan provinces. Successful efforts to enhance security to protect health workers and increase public demand for vaccination are urgently needed.

The recent gains in control and elimination of poliovirus transmission globally must be maintained and built upon through innovative strategies to access populations during SIAs in areas with complex security and political challenges, improve AFP surveillance, and strengthen routine immunization. With the progress achieved in 2014 to interrupt endemic WPV transmission in Nigeria and polio outbreaks in Africa and the Middle East, permanent interruption of global poliovirus transmission appears possible in the near future, provided that similar progress can be made in Afghanistan and Pakistan; progress there would also reduce the risk for future importation-related outbreaks in polio-free countries.

While there have been several cases of circulating vaccine-derived poliovirus in northern Nigeria, the fact that no wild poliovirus has been seen in the country since last July is extremely encouraging – eradication in Africa may be in sight. The final stronghold will be Pakistan and Afghanistan (primarily its regions that border Pakistan) – where, as the global health community has discussed ad nauseum, militants take advantage of the lack of public trust in eradication owing to bad intelligence schemes, among other things.

Obviously, it is still too early to tell. Gaps in surveillance mean incomplete data; there are most likely more cases that have not been reported. Furthermore, ongoing conflict (not to mention the recent Ebola outbreak) has left the health systems of many countries devastated, so vulnerabilities are everywhere. Nevertheless, with continued dedication (and a little luck), we may very well get there. Here’s hoping.

Remembering My Aunt, Dr. Ameyo Adadevoh, Who Stopped Ebola in Nigeria

This blog post originally appeared on the Management Sciences for Health (MSH) blog and was authored by Video Editor Niniola Soleye. This reposting does not convey an endorsement of MSH from the IH Section.

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L to R: MSH staffer Niniola Soleye and her aunt, Dr. Ameyo Adadevoh 

My aunt, Dr. Ameyo Adadevoh, identified and contained the first case of Ebola in Nigeria.  She paid with her life because the health system was not ready to deal with Ebola.  The system has since caught up, and is today a model for other countries.  But the loss of such a gifted doctor and family anchor is incalculable.

Ebola arrived in Nigeria at a time when doctors at all federal government hospitals were on a labor strike (my aunt worked in a private hospital).  After ongoing negotiations with the government failed to meet their demands, the doctors – desperate to see significant changes in the health system and seeking improved salaries, positions, and titles – reached their breaking point.  So they went on an indefinite strike.

Patrick Sawyer – the index case – left quarantine in Liberia and collapsed at the airport in Lagos, Nigeria.  He was trying to travel to a meeting of the Economic Community of West African States (ECOWAS) in Calabar, Nigeria.

When he arrived at my aunt’s hospital, another doctor diagnosed him with malaria.  My aunt first encountered him during her ward round the following day and once she saw him she suspected Ebola even though she had never seen an Ebola patient before.  She questioned him and he denied being near anyone suffering from the virus but she immediately contacted the Lagos State and Federal Ministries of Health and got him tested.  While waiting for the test results to come back, the pressure on my aunt began.  Liberian government officials (and the patient himself) insisted that she discharge him so he could attend the ECOWAS conference.  She held her ground and resisted his release.  They even threatened to sue her for a violation of human rights (holding him against his will) but she remained steadfast for the greater public good.  Though she didn’t have the proper protective gear or protocols, she created an isolation area in her hospital to continue his treatment and protect her staff.  The patient couldn’t be moved because there was no isolation facility available in Nigeria at the time —the infectious diseases hospital in Lagos wasn’t functional.

The test results came back.  Patrick Sawyer’s Ebola diagnosis was confirmed, and he died in her hospital.

My aunt became ill ten days later and was taken to a makeshift isolation ward that had been set up for all the Ebola cases in the infectious diseases hospital.  The conditions of the facility were so poor that she and other patients were eventually moved to a former tuberculosis ward that had been donated by the USG.

Between the doctors’ strike and the lack of preparedness, the Ebola outbreak in Nigeria could have been a thousand times worse.  My aunt’s actions helped prevent a major spread of the virus across the country.  Because she raised the necessary red flags quickly and refused to discharge the patient, all Ebola cases in Nigeria can be traced to a single path of transmission originating with the index case. That’s no small feat in a country of more than 170 million people.

The events leading to my aunt’s death were a clear result of the larger health system troubles in Nigeria.  That said, today, Nigeria is Ebola-free.  In fact, other countries – including the US – are now looking to Nigeria to share best practices for the response and containment of Ebola.  This demonstrates that the health system eventually did catch up to Ebola, but the response was too late for my aunt and several others who were on the front lines.  If the index patient had ended up in another hospital under the care of another doctor, the delayed response from the health system may have been much more costly.

There are so many lessons to learn from the current Ebola outbreak in West Africa.  For me, the most obvious one is the importance of health system strengthening as a means to not only improve overall quality and access for all, but also to give countries the ability to properly respond to unexpected health challenges like Ebola.  If any of the affected countries had stronger health systems before this outbreak, the number of fatalities would have been significantly reduced.  We must learn from this outbreak and focus on health system strengthening as a crucial part of the rebuilding process.

One of the biggest challenges in the Ebola current outbreak is a shortage of health workers.  The high fatality rates in this Ebola outbreak reflect that.  Health workers at all levels of a health system need to be properly supported, incentivized, and protected.  They shouldn’t have to go on strike in order to improve their health systems so they can provide higher quality care.  My aunt and the more than 200 other health workers in West Africa who also lost their lives in the battle against Ebola shouldn’t die in vain.

I’m so proud that MSH is developing a solid short-term and long-term response to the Ebola outbreak in West Africa.  As part of my role at MSH, I’m supporting the Ebola response team and I see that as my way of continuing my aunt’s legacy through my job and helping to prevent other families from experiencing what my family has gone through in the last two months.

For me, the inability of the Nigerian health system to adequately prepare and quickly respond to the Ebola outbreak was an agonizing, first-hand example of the need for MSH and it reinforced the importance of the work we do.  My aunt’s death is still very painful but it comforts me to know that I am part of an organization that’s truly committed to saving lives (in everyday practice, not just in theory) and is dedicated enough to step into a crisis situation and mobilize the expertise and resources that are so desperately needed.

Let’s Get Ethical: Giving Untested Experimental Drugs to Ebola Patients

West Africa is in the throes of the worst Ebola outbreak to date. Ebola virus disease, the hemorrhagic fever caused by the Ebola virus, has been seen in small but often deadly outbreaks in tropical sub-saharan Africa since its discovery in 1976. Though researchers are fairly certainly that it is transmitted through bush meat, and fruit bats are suspected, no animal species has been confirmed as a reservoir. Combined with the fact that the virus is highly contagious and so often deadly (usually because there is little to no medical infrastructure in areas where outbreaks occur), it is the source of international fascination and fear. It is the perfect plot device for outbreak movies and sensational media reports – a mysterious ailment from the heart of darkness that could rear its ugly head in our packed population centers at any moment.

Although it’s not quite as scary as movies like “Outbreak” would have you believe, the havoc that it is currently wreaking in West Africa is most definitely real. The most recent update from WHO puts the death count at 932 and the number of cases (both suspected and confirmed) at over 1,700. Guinea, Liberia, and Sierra Leone have been battling the virus since the spring, and last week it made its way to Nigeria and there was even a suspected death in Saudi Arabia. We all know that international air travel means that these types of illnesses are only a plane ride, which raises the question of why we haven’t made more progress in developing a vaccine or treatment for such a devastating disease.

Frankly, most global health and development professionals know the answer – if the only market for potential drugs is among the poor in central Africa, commercial drug companies won’t exactly be lining up to put money into the research:

The factor preventing such trials in humans, though, has been cost, said Dr. Daniel Bausch, an associate professor of tropical medicine at the Tulane University School of Public Health who is currently stationed at the U.S. Naval Medical Research Unit 6 in Lima, Peru.

That’s because, while the National Institutes of Health and the U.S. government often fund the early animal safety and efficacy testing of a vaccine, pharmaceutical companies typically fund the human clinical trials to take a drug or vaccine to market.

“When you have a population or situation with Ebola where it only sporadically occurs, and it occurs really in the world’s poorest populations, it’s not exactly an attractive candidate for the pharmaceutical industry on the economic side,” Bausch said.

That all changed, however, when two American aid workers who were treating Ebola patients in Liberia fell ill with the virus themselves. Dr. Kent Brantly, a doctor working with Samaritan’s Purse, and Nancy Writebol, a nurse employed by Service in Mission, are now all over U.S. and global headlines as the first Westerners to contract the virus – and, because of their privileged status, as the first people to receive an experimental treatment in the early stages of development before being flown back to Emory for medical care (despite objections from Donald Trump and Ann Coulter).

Though several people have raised objections to bringing Americans back stateside for treatment (particularly at what it probably cost), Emory is probably the safest and best-equipped facility to treat and contain the patients. Samaritan’s Purse is footing the bill for transporting them, so no government funds are being used. Bringing them back to the states for treatment is not so much of an issue, in my opinion – but using an experimental drug which is untested in humans is another matter.

At first glance, an outbreak of a disease with a high fatality rate (usually 40-70%) and no cure seems like the perfect situation to bypass the standard drug testing and approval process, which can take several years. However, it is the recklessness generated by precisely this type of desperate situation that raises ethical dilemmas. Does informed consent really count when patients are panicked at the prospect of imminent death? What if the drug is administered to the afflicted on a large scale and turns out to be toxic, or causes long-term disability? Who determines which patients to prioritize and how to protect those most vulnerable – such as children or pregnant women – who may react very differently to the drug?

Additionally, the fact that the drug has only been given to the two Westerners raises a very different, but equally important, problem. The international community has struggled for years to bring critical medicines to populations with the greatest need, who are simultaneously the least able to afford them. The fact that this experimental treatment was given to two aid workers – who, unlike their patients, have the support of large and wealthy organizations and will be more able to access the needed high-quality supportive care than their own patients – raises some disturbing questions.

The WHO has announced that it will convene a panel of medical ethicists to discuss and provide guidance on the issue. The pharmaceutical companies that develop and manufacture the drug are, naturally, chomping at the bit to get a large production run funded in order to provide ZMapp, the experimental serum, to a large number of Ebola patients. It is unclear how the global health community will move forward. But perhaps it can serve as a lesson to the pharmaceutical industry to take a more active interest in developing therapies for diseases that may not seem lucrative at first glance. Perhaps then we’ll be prepared for an unexpected multi-country outbreak – instead of having to scale up an untested drug developed by a tiny biopharmaceutical.

Global Health Weekly News Round-Up

From December 4 to 10, the US Centers for Disease and Control (CDC) celebrated National Influenza Vaccination Week (NIVW). It was an effort to spread the message of the importance of continuing flu vaccination through the holiday season and beyond. (Source: http://www.cdc.gov/Features/FightTheFlu/?s_cid=fb1293)

On December 10, 2011, Human Rights Day was observed . (Source: http://www.un.org/en/events/humanrightsday/2011/index.shtml)

Politics and Policies

Programs

Research

Diseases and Disasters

These headlines were compiled by Vani Nanda, MPH Candidate at West Chester University PA.

Global Health News Last Week

May 12 was International Nurses Day.
USAID’s Frontlines magazine is running an exclusive interview with Dr.

Margaret Chan, the WHO Director-General, in which she discusses current global health priorities and systems strengthening.

Peoples-uni, an open-access education initiative, offers open-access resource and online learning materials for capacity-building in low- and middle-income countries.

POLICY

  • Excessive bleeding following childbirth is the leading cause of maternal deaths in the developing world, but the World Health Organization (WHO) has now approved the use of misoprostol, a drug that considerably reduces this risk.
  • Shanghai’s health authority and local hospitals are seeking to reduce the rate of births by cesarean section this year after a recent report showed that far more Shanghai women are undergoing the procedure than is recommended by the World Health Organization (WHO).
  • For the fifth time, at next week’s WHO General Assembly, countries will debate whether or not to destroy the last two known stockpiles of smallpox.
  • The Director General of Nigeria’s drug and food regulator, Dr. Paul Orhii, was in London last week where he lodged a strong case before members states of the World Health Assembly to institute a legal platform to combat the spread of counterfeit drugs.

PROGRAMS

  • Humanosphere’s Tom Paulson writes that funding for childhood vaccinations is not keeping up with the need and is struggling to compete with more high-profile priorities.
  • The phenomenon of “poverty tourism” – in which charities and aid organizations take donors on trips to “experience poverty” and meet their beneficiary – is coming under increased scrutiny and generating controversy.
  • John Donnelly, writing in GlobalPost, characterizes the Obama Administration’s Global Health Initiative as off to “a slow, stumbling start” in a short series called “Healing the World.”
  • Last Wednesday, the WHO launched a campaign to reduce the huge but largely unrecognized burden of traffic deaths and injuries over the next decade.

RESEARCH

  • An HIV-positive person who takes anti-retroviral drugs after diagnosis, rather than when their health declines, can cut the risk of spreading the virus to uninfected partners by 96%, according to a study.
  • New research has revealed that a bacteria present in the gut of mosquitos may be another tool to fight the spread of malaria.
  • An experimental drug helped monkeys with a form of the Aids virus control the infection for more than a year, suggesting it may lead to a vaccine for people, or even a cure.
  • A study by US scientists, published in the American Journal of Public Health, found that 400,000 females aged 15-49 were raped over a 12-month period in the DRC 2006 and 2007. That comes out to an average of 48 women and girls being raped every hour.
  • A new report by MSF argues that switching from using quinine to artesunate to treat malaria could save up to 200,000 lives a year.
  • A US study has suggested that homosexual men are more likely to have had cancer than heterosexual men.
  • According to the findings of the last Pakistan Demographic and Health Survey, getting pregnant soon after childbearing, miscarriage or abortion places mothers and newborns at a higher risk of health complications or even death.
  • Results announced today by the United States National Institutes of Health show that if an HIV-positive person adheres to an effective antiretroviral therapy regimen, the risk of transmitting the virus to their uninfected sexual partner can be reduced by 96%.

DISEASES AND DISASTERS

  • According to statistics released by the National Coordinator of the Nigeria’s National Malaria Control Program (NMCP), Dr. Babajide Coker, Nigeria contributes a quarter of the malaria burden in Africa, and a staggering 90 per cent of its citizens are at risk for contracting the disease.
  • Johnson & Johnson’s recalled at least 11,700 bottles of HIV/AIDS drug Prezista in several countries, after discovering trace amounts of a chemical emitting offensive odors in five batches of products sold in the U.K., Ireland, Germany, Austria and Canada.
  • In China, around 1.5 million people require organ transplants, but just 10,000 receive them each year, as few Chinese agree to donate their organs upon death. Illegal organ traffickers have stepped in to fill that gap.

TOTALLY UNRELATED TO ANYTHING ELSE: Princess Beatrice’s atrocious weird attention-grabbing hat, worn to the royal wedding, is now being auctioned on eBay for UNICEF and Children in Crisis. Um, yay?