Nature
Volume 511 Number 7509 pp263-376 17 July 2014
http://www.nature.com/nature/current_issue.html
Editorial
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Within reach – A redoubling of efforts should swiftly eradicate polio from its last strongholds.
16 July 2014
The global effort to eradicate poliomyelitis has been spectacularly successful, eliminating 99% of cases in its 26-year history. But that progress has begun to unravel in the past 18 months, with outbreaks in east and west Africa and in the Middle East. The lesson is clear: as long as the virus is allowed to persist in the three countries in which it remains endemic — Pakistan, Afghanistan and Nigeria — exports of the disease will continue to affect other countries. A determined effort is needed to eradicate the virus from these endemic countries, and fast.
The worsening situation meant that in May, the World Health Organization (WHO) declared polio a public-health emergency of international concern. This allowed it to impose a requirement that all travellers entering or leaving Pakistan, Cameroon, Syria and Equatorial Guinea — the countries currently exporting polio — must have up-to-date polio vaccinations. And it strongly recommended the same for other nations with ongoing polio outbreaks. The WHO also requires the governments of affected countries to declare that polio constitutes a national public-health emergency.
It is too soon to tell how well countries will enforce the travel restrictions or how effective they will be. But the WHO’s declaration has another, and arguably more important, potential impact. It has greatly heightened public and political awareness of the global polio threat. The move could yet shame those nations with weak control efforts into doing better. Ultimately, political will, through every level of government right down to the local level, is crucial if eradication efforts are to succeed.
The setbacks have reignited scepticism among some critics of the multibillion-dollar global effort, which has repeatedly missed its own deadlines for worldwide eradication — the first such deadline was set for 2000. But this must not obscure the fact that impressive gains have been made, so much so that at the end of 2012, global polio eradication truly seemed within reach. It is important to turn the current situation around quickly, consolidate those gains, and condemn polio to the history books.
There is cause for optimism. In Afghanistan, the virus has been wiped out from many areas where it was previously rampant, with cases now restricted mostly to the northeast, where polio is imported from across the border with Pakistan. Afghanistan is expected to become polio-free perhaps as soon as year’s end. Nigeria has also improved its eradication efforts, resulting in a sharp drop in case numbers. Eradication there is in sight, although a current worsening of the country’s political and security tensions risks undoing the progress. Pakistan, despite a lacklustre control effort, has also shrunk the geographical range of the virus.
The global-eradication effort — despite some shortcomings — has a good track record of successfully fighting sporadic flare-ups. There is every reason to believe that the current spate of outbreaks will be contained (although war-torn Syria could remain problematic).
The big challenge is to conquer the virus in the endemic countries that are fuelling exports of the disease — and above all in Pakistan. A report released in May by the Independent Monitoring Board of the Global Polio Eradication Initiative puts it bluntly: “Pakistan’s situation is dire. Its program is years behind the other endemic countries.” Unless matters change, the report concludes, the country is “firmly on track to be the last polio-endemic country in the world”.
That damning indictment needs to be heard and responded to at every level of Pakistani society. The country faces many obstacles — but so too did the other countries that nonetheless have succeeded in eradicating polio. There is no excuse for Pakistan not to do so. Its government must pull out all the stops to act swiftly and decisively. As the report rightfully argues, ultimate responsibility for Pakistan’s bungled polio efforts lies with its authorities: “If the country’s leaders were to truly and wholly take on the mission of wiping polio from their borders, what now seems to some an impossible dream would fast become reality.”
Another barrier to eradication is societal resistance to vaccination, rooted, for example, in local distrust of immunization campaigns and unfounded concerns that it conflicts with religious beliefs. Polio has spread to Waziristan in northern Pakistan, a stronghold of the Taliban, who have banned vaccinations. Vaccinators have also been murdered.
In the past few months, international Islamic scholars and bodies — including the newly formed Islamic Advisory Group on Polio Eradication — have to their credit spoken out to condemn attacks on polio workers, and to emphasize that polio vaccination is compatible with Islam, denouncing those who claim otherwise. Resistance and suspicion of vaccines will always be present, but religious leaders can help by reiterating these messages to local populations.
Pakistan’s situation is exacerbated by the Taliban’s stubborn blocking of polio vaccinations, ostensibly in opposition to US drone strikes. But polio has no religion. It respects no political affiliation. For the benefit of all, every effort must be made to overcome residual resistance to vaccination and to root out the virus from its last strongholds.
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Nature | Comment
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Infectious disease: Polio eradication hinges on child health in Pakistan
Zulfiqar Ahmed Bhutta
16 July 2014
Boosting basic medical services and routine immunizations — not travel vaccinations — is the key to ending polio worldwide, says Zulfiqar Ahmed Bhutta.
Until about a year ago, a world free of poliomyelitis seemed to be imminent. In 1988, about 350,000 people in 125 countries became paralysed by the virus. Last year, only 406 cases were reported, with 160 of them in just a few areas of the three countries where polio remains endemic: Afghanistan, Nigeria and Pakistan. In April 2013, charities and governments pledged US$4 billion to a six-year plan developed by the World Health Organization (WHO) to eradicate polio. In March, after India had gone three years with no new cases, the WHO certified its southeast Asia region (which does not include Afghanistan and Pakistan) as polio-free.
But in May, the WHO declared polio an international public-health emergency, particularly because of the high risk of international spread from Pakistan, Cameroon and Syria (see go.nature.com/7z3efj). Disrupted vaccination programmes in war-torn places are partly to blame.
Confronted by this, the WHO took an unprecedented step: it called for mandatory polio vaccination for everyone travelling to or from Pakistan, Syria and Cameroon, and encouraged travel vaccinations for Afghanistan, Nigeria and others1. Formal international travel restrictions for Pakistan began on 1 June. Analyses in the past few years show2 that symptom-free adults transmit polio at surprisingly high rates. However, computer modelling described3 earlier this month suggests that immunizing adults to control an outbreak is less effective than previously believed.
In my view, vaccinating travellers will be ineffective and it could make polio harder to eliminate in the poor and conflict-ridden parts of Pakistan. It is largely here that the final battle to eradicate polio from the world will be won or lost.
Cases of polio in Pakistan increased from 18 in the first six months of 2013 to 88 in the first half of 2014 (ref. 4). Of these, 75% were in the regions known as the Federally Administered Tribal Areas (FATA) in the northwest (see ‘Dangerous rebound’). Here, access for polio-vaccination teams is severely restricted by conflict and insecurity.
Since mid-June, the situation has worsened. In the wake of government military action against Taliban insurgents, more than 800,000 people from Waziristan in the FATA have been displaced to neighbouring parts of Pakistan and Afghanistan. Instead of focusing on the vaccination of international travellers, Pakistan, the WHO and immunization services should provide immediate health care to displaced families and others in these high-risk areas.
Precious doses
Federal and provincial governments in Pakistan have scrambled to set up vaccination points at all ports and airports, and at more than 130 public hospitals. The government of Punjab, Pakistan’s richest and most populous province, also rushed to impose vaccination requirements for the main routes of entry. The federal government made polio vaccination mandatory at major entry and exit points in the FATA, especially in North Waziristan, although much of the long, troubled border with Afghanistan is unpatrolled.
Official sources estimate that more than 10 million doses are needed just for the air travellers entering or exiting Pakistan each year, including the roughly 7 million Pakistani citizens who work overseas, mostly as labourers in the Middle East. The donor community has provided 200,000 doses of injectable polio vaccine for refugees, but no further financial support has been pledged for more doses or for trained staff to perform vaccinations and issue certificates to adult travellers at public hospitals.
So far, the only service offered for free to travellers is the oral vaccine from the supplies of national polio programmes. (Some 300 million doses of oral polio vaccine, mostly furnished by the United Nations children’s charity UNICEF, are needed annually to vaccinate young children in Pakistan.) Pakistan’s army requested 60,000 doses of inactivated injectable polio vaccine as a priority for its troops. Adults must buy this type of vaccine privately at a cost of $4.30 per dose — a huge expense in an area where the average monthly income is about $100. Newspapers report that getting a vaccination certificate is as difficult and expensive as getting a visa. An industry of fake certification could emerge.
There is no precedent to predict how well these travel restrictions will work. I travelled out of Karachi airport on 6 and 15 June. Although vaccination counters had been set up, I saw no queues of travellers waiting to receive polio vaccines, and no one asked me for a vaccination card at any of the multiple checkpoints. Furthermore, polio transmission from Pakistan to Afghanistan occurs mostly across an unregulated border.
Meanwhile, Pakistan’s efforts to vaccinate young children have fallen behind. Some of the blame can be pinned on the ill-planned abolition of its ministry of health in 2011 and the subsequent devolution of health services to the provinces. Although the ministry was reinstated last year and federal polio efforts are now back in operation, they are still weak.
That said, Pakistan deserves much more credit than it has received for its past work to eradicate polio, especially in its troubled tribal regions: it has staged more than 130 national and regional polio-immunization efforts since it began house-to-house vaccination campaigns in 2000.
But the emphasis on polio, to the neglect of other health services, has long fuelled beliefs that polio immunization is an external initiative operating for outsiders’ benefit. Anti-Western sentiment has led to repeated attacks on polio-eradication workers, volunteers and security personnel; more than 80 have been killed since December 2012. This year, polio teams have been hit by roadside bombs and by gunmen on motorcycles. In March, a Pakistani polio worker was kidnapped and shot.
Resistance to polio campaigns is more entrenched and violent in Pakistan than in most other countries. Disastrously, mobile-vaccination teams came under more suspicion than ever5 after it emerged that the US Central Intelligence Agency had staged a fake hepatitis B vaccination project in the Pakistani city of Abbottabad in 2011 to try to trace Osama bin Laden.
Although international Islamic scholars have spoken up for polio eradication, support for it from local religious and society leaders on the ground has been, at best, lukewarm. In the 1980s and 90s, warring factions in Latin America and in Africa agreed to ‘days of tranquility’ to permit mass polio immunizations. In Pakistan, by contrast, a handful of Taliban leaders in the tribal areas of North Waziristan and the Khyber Agency have, since mid-2012, denied entry to vaccination teams as a protest against US drone strikes.
Pakistani army moved to provide security to vaccination teams in the FATA, but it has not offered support to other mainstream health workers. This and the hastily imposed travel regulations will only give credence to claims that polio eradication is part of a foreign agenda.
Prescription package
Providing polio vaccines as part of a package of health services is a better way to engage local communities and religious leaders than through a narrow, polio-specific programme. Nigeria and Afghanistan have made remarkable progress in reaching difficult populations in this way, and cases dropped by about 60% in both nations from 2012 to 20134. The Taliban do not actively keep children from being immunized for measles or from receiving care for diarrhoea or malnutrition.
Currently, Pakistan has one of the highest rates of child mortality in south Asia6. Children face much bigger health threats than polio. But immunization services for major childhood diseases such as diphtheria, tetanus and measles remain plagued with inefficiencies, poor oversight and a shortage of resources.
Full immunization rates for children in the country were last year estimated at 54% with wide variations across the country7, compared to more than 95% in nearby Bangladesh. The figures for Pakistan may even be an overestimate: the survey excluded the FATA and vulnerable populations in mega-cities. In a household survey conducted this year, my colleagues and I found that 25% of children under five years in the urban slums of Karachi were not vaccinated for any childhood disease; the same was true for 64% of children in a relatively peaceful district of the FATA.
The time to act is now. The military offensive in North Waziristan has, paradoxically, opened up opportunities to provide health services to children from the FATA through care for displaced families. This could contribute to building community support and to re-establish the rule of law in conflict-ridden areas once people return. Ongoing support will be necessary to eradicate polio: children require multiple doses of vaccine to build immunity.
I fervently hope that the government and concerned agencies will devote their energies to scaling up full immunization efforts in these displaced and marginal populations, rather than diverting resources to international travellers. This is a chance to eradicate polio from the planet.
vaccines and global health :: ethics and policy 