#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.

Exitus Acta Probat: Negotiating humanitarian access

As I write a commentary about how the CIA’s attempt to locate Osama bin Laden under the cover of a hepatitis vaccination drive endangered the polio eradication effort (and vacciation efforts everywhere), I realize that I am beating a dead horse (so to speak). The collective global health and development community has complained about how ill-advised and irresponsible the plot was until it was blue in the face. We all understand the ramifications; we all shake our heads in unison when reports of health workers being attacked roll in. I saw no point in hashing it out again.

That is, until I shared my views with my non-professional network on Facebook.

Those of you who are more avid Facebookers know that in addition to it being a place to share pictures of new babies, social antics, culinary ventures, and personal details that no one really wants to know, it is a space for people to air out their political and religious beliefs, and to comment (and flame) others’ similar beliefs. Election season can be particularly miserable. While I refrain from doing this most of the time, I will occasionally share stories on things that I find interesting or (in this case) frustrating. In response to this article on the consequences of the CIA’s scheme, I got the following comment:

I fail to see what the CIA has to do with polio. It’s the Taliban that is attacking workers and keeping the vaccine from getting to people.

On the surface, my friend’s comment is true: it is the Taliban, not the CIA, that is attacking health workers and reversing out progress toward polio eradication. But the fact of the matter is that public health and humanitarian workers will always have to work around unsavory characters to reach those most in need. That is why the medical workers are negotiating with the Assad’s government to gain access to the wounded in Syria; it is why health providers worked with al-Shabaab and local warlords in Somalia; it is why midwives work through armed rebel groups to educate ethnic minority communities in Burma. Though affected by all of it, people’s health goes beyond foreign policy, diplomatic relations, and political stalemates. Whether an area is controlled by government forces, extremist groups, or local warlords, its people – and in the case of polio, most critically, its children – will get sick if they can’t access disease prevention. More importantly still, if health workers lose access to these vulnerable populations, progress made in containing disease will be lost – and they can spread even further. Letting up the pressure of polio vaccinations in Pakistan has allowed the virus to rear its ugly head in China and, more recently, Egypt.

After some discussion, he conceded that I had a point. Now I just wish that Obama would do the same and ban the CIA from implementing this kinds of bad ideas to gather intelligence. Bad guys come and go, but negotiating with them to obtain humanitarian access is a reality that will never go away.

WHO Video: Dr Bruce Aylward interview regarding attacks on health workers in Pakistan

During the week of 18 December 2012, at least six people working on a polio vaccination campaign have been reported shot dead in several locations in Pakistan – Gadap, Landi, Baldia and Orangi towns of Karachi city, Sindh Province and Peshawar, Khyber Pakhtunkhwa Province. Those killed were among thousands who work selflessly across Pakistan to eradicate polio.

The Government of Pakistan and the affected provinces temporarily suspended the vaccination campaign due to concerns over safety of health workers.

Such attacks deprive Pakistan’s most vulnerable populations — especially children — of basic life-saving health interventions. of the children of Pakistan.

Polio is a highly infectious disease caused by a virus that can cause permanent paralysis in a matter of hours. Safe and effective vaccines protect children from the disease. Currently the disease remains endemic in only three countries: Afghanistan, Nigeria and Pakistan.

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