Polio eradication in Syria

The Lancet Infectious Diseases
Jul 2014 Volume 14 Number 7 p533 – 656
http://www.thelancet.com/journals/laninf/issue/current

Comment
Polio eradication in Syria
Balsam Ahmad a, Sanjoy Bhattacharya b

The negative public health effects of the Syrian conflict were dramatically underlined by confirmation of a polio cluster in the northeastern rebel-held city of Deir al-Zour in October, 2013. The re-emergence of polio, 14 years after a WHO Eastern Mediterranean Regional Certification Commission certified the country to be rid of naturally occurring poliovirus, has caused vigorous discussion. Accusations and counter-accusations have flowed, with the Syrian health authorities and WHO’s networks coming under scrutiny. Several commentators queried the effectiveness of the so-called Early Warning Alert and Response System that was established in September, 2012, by the Syrian Ministry of Health with technical support from WHO.1 Others argue that the early warning system has succeeded in tackling the consequences of local polio outbreaks.2 Parallel systems of reporting and immunisation have been created in opposition-held governorates, and are reportedly supported, financially and technically, by the US Centers for Disease Control and Prevention.3

Questions have been raised about the transparency and impartiality of WHO and its ability to ensure the vaccination of all children, irrespective of their location inside Syria.1, 3 WHO’s representatives have not remained silent through these interactions. They have provided explanations as to why the Syrian polio outbreak was confirmed as late as October, 2013, when a case was identified as early as July of that year.4 WHO sources acknowledged that the current polio outbreak in Syria had been one of the biggest challenges facing the global eradication initiative.4 The organisation, unsurprisingly, has associated itself with efforts to counter the issue, such as initiation of vaccination campaigns in Syria and across the borders. WHO has also engaged itself with recent negotiations intended to strengthen cross-party cooperation for tackling of the polio outbreak. This approach is most notable in relation to the recent declaration made by the First Global Islamic Advisory Group Meeting on Polio Eradication, held in Jeddah, Saudi Arabia, on Feb 26—27, 2014. The gathering issued an appeal that every community, government, civil society, and religious organisation should ensure that all children benefit from access to the polio vaccine.5 The collaborations underpinning the event are noteworthy; it was organized by Al Azhar Sharif, the International Islamic Fiqh Academy, the Organization of Islamic Cooperation, the Islamic Development Bank, WHO, and UNICEF.

However, there are further issues to consider. For instance, the polio outbreak in Syria might be attributable to trends that predate the civil war. In a letter published in The Lancet, Sahloul and colleagues1 assessed WHO figures about routine polio immunisations and noted that vaccination coverage in rebel areas had been below accepted standards in the past. In a media report, WHO has acknowledged that Deir al-Zour had been excluded from a mass vaccination campaign associated with the Global Polio Eradication Initiative in 2012 because of the relocation of most of its residents to other areas.6 These trends raise deeper questions about the collection, analysis, dissemination, and use of data relating to the presence and transmission of polio in Syria (and elsewhere) by the Global Polio Eradication Initiative and WHO. How has the search for poliovirus been done? Have researchers relied too long on intermittent and incomplete data collection, with relatively uninformed projections made about the regression of polio incidence and the scale of the dangers from the disease? The definition of the basis for the certification of polio eradication has not remained stable since the Global Polio Eradication Initiative was launched in 1988. Even the choice of polio as an eradicable disease has been questioned.7 Robust data collection and attendant certification processes are of utmost importance. These measures, necessarily, require impartiality and transparency, the lack of any conflicts of interest, and the absence of interference from governments or funders. The case of Syria seems to suggest that such high standards have generally been rare. The dream of global polio eradication will remain a chimera until reliable frameworks for immunisation and evaluation are put in place.
We declare no competing interests.
References
1 Sahloul Z, Coutts A, Fouad FM, et al. Health response system for Syria: beyond official narrative. Lancet 2014; 383: 407. Full Text | PDF(91KB) | PubMed
2 Muhjazi G, Bashour H, Abourshaid N, Laham H. An early warning and response system for Syria. Lancet 2013; 382: 2066. Full Text | PDF(50KB) | PubMed
3 Coutts A, Fouad MF. Response to Syria’s health crisis—poor and uncoordinated. Lancet 2013; 381: 2242-2243. Full Text | PDF(1493KB) | PubMed
4 Aylward RB, Alwan A. Polio in Syria. Lancet 2014; 383: 489-491. Full Text | PDF(364KB) | PubMed
5 First Global Islamic Advisory Group Meeting on Polio Eradication. Final communiqué. http://www.polioeradication.org/Portals/0/Document/Resources/Declaration_Resolution/Jeddah_Declaration_EN.pdf. (accessed June 3, 2014).
6 WHO Regional Office for the Eastern Mediterranean. Measles and polio vaccination campaign targets 2.5 million children in the Syrian Arab Republic, 6 December 2012. http://www.emro.who.int/media/news/vaccination-campaign-syria.html. (accessed March 26, 2014).
7 Muraskin W. Polio eradication was an ideological project. BMJ 2012; 345: e8545. PubMed
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This timely dengue early warning permits the Ministry of Health and local authorities to implement appropriate, city-specific mitigation and control actions ahead of the World Cup.