New vaccine to be introduced in the polio endgame

He’s going to need a new vaccine in the freezer

The Global Polio Eradication Initiative’s draft plans for a polio endgame that will continue till end 2018 involves a shift from the current trivalent oral polio vaccine (tOPV) to a combination of an injectable inactivated vaccine (IPV) and bi-valent oral vaccine.

The GPEI’s strategy has two prongs- ending wild polio virus transmission in the areas it still exists in Afghanistan, Pakistan and Nigeria by the end of 2014 and a parallel effort to remove the vaccine derived polio viruses created by the reversion of vaccine derived strains to neuro-virulence.

This two pronged strategy removes an often artificial distinction the polio campaign had maintained between polio caused by the wild, or naturally occurring virus, and paralytic polio caused by vaccine derived viruses. Eradication had tended to be defined as an end to transmission of wild polio virus.  But paralytic polio will continue as long as polio viruses derived from the attenuated Sabin strains circulate in human populations. Once a vaccine derived virus reverts to a virulent form after mutating in the human intestine and then circulates from person to person, there is no difference in the severity of the disease that is caused.

Nigeria has had an on-going outbreak of polio caused by a vaccine derived virus since 2005. The Democratic Republic of Congo, Somalia and Yemen, which are free of wild polio virus, have reported cases of polio caused by the vaccine from immunisation campaigns.

The majority of these cases are caused by the component in the trivalent vaccine that is meant to protect against type 2 wild polio virus infection.  It has been known for more at least a decade now that the vaccine virus can cause disease, and it would be necessary to introduce the inactivated polio vaccine into the campaign at some stage.  The high cost of IPV, and perhaps a reluctance to muddy the waters by discussing changes in strategy and the introduction of a new vaccine has meant that the public and volunteers on the ground are largely unaware of what is going to be required in the years ahead.

A key step is going to be preparing with governments and other stake holders for the introduction of at least one dose of an inactivated polio vaccine as part of routine childhood immunisation.  At the same time, the cost of IPV needs to be brought down to below US$ 1 a dose, perhaps by using fractional dose intradermal injections rather than intramuscular injection.

One welcome feature of the draft strategy is the GPEI’s expressed desire to work closely with routine immunisation programmes and also integrate the polio eradication campaign better with the Global Vaccine Action Plan  and contribute to specific GVAP objectives.

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New deadline for polio programme

End 2014 appears to be the new date that the global polio eradication programme plans for ending wild polio virus transmission globally, pushing back by two years an existing end 2012 deadline.  The  2012 deadline (or milestone as it is described) is unrealistic, given the vigorous circulation of the polio virus in northern Nigeria, and its continued entrenchment in pockets of Afghanistan and Pakistan, and it was only a matter of time before a new date was set.

The polio programme is working on an “Endgame strategic plan” setting out a new schedule for eradicating wild polio virus, and ending the risk of vaccine derived polio, which grows with the continued use of the oral polio vaccine that the polio eradication campaign has depended on.

The draft has not been made  public yet, but a summary is available in a report from the polio eradication campaign  to the Independent Monitoring Board that oversees and advises the programme. If transmission of the wild virus is stopped in 2014, it will take another four years till the end of 2018 for global certification of eradication. Funding of around US $ 5.5 billion will also be required for the 2013-2015 period.

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Disease eradication is a high stakes venture

ImageEradicating a disease is a bit like landing a man on the moon, or, as the Austrian daredevil Felix Baumgartner recently did, parachuting down to the earth from the edge of space and living to tell the tale: it’s a risky venture requiring single minded determination to succeed, technical expertise, generous funding and a huge helping of luck.

The global campaign to eradicate polio will require all of this if it is to succeed. The polio virus remains stubbornly entrenched in pockets of Nigeria, Pakistan and Afghanistan and the campaign is set to miss an end 2012 deadline of deadline to end transmission of the wild, or natural polio virus globally.

Eradication campaigns are the most ambitious and technically complex of global health programmes. Consider what polio eradication involves. It aims to wipe off the face of the earth the virus that causes polio . This virus is one of the most basic forms of existence on earth: a sliver of RNA encased in a protein coat, visible only through powerful electron microscopes. This speck of genetic material has to be hunted down and driven to extinction. Because it can only reproduce in human beings, if enough humans are immune to it, the virus will eventually find no place to reproduce and die out. The polio campaign’s strategy is to build enough population immunity through large scale immunization campaigns to drive the virus to extinction. But with hundreds of thousands of non-immune children born every minute in countries where the polio virus still exists, this is not an easy task.

Eradication campaigns also have to be time bound: they are expensive, high intensity public health programmes that only make sense if they meet their goals within a defined time. If they drag on too long, they pull resources away from other public health priorities.

The campaign missed its original target of 2000 and it would take a miracle for it to meet its current end 2012 deadline. What will happen after that? Will funding keep coming if there are no tangible signs of progress in these countries? Or will the polio campaign go the way of the vast majority of disease eradication campaigns that the world has seen. Ambitious programmes to eradicate malaria and yellow fever which had to be shelved when it was found that the technical knowledge of the disease that the campaign had been based on, proved to be faulty.  Smallpox has been the only successful eradication campaign so far.  Will polio eradication go the way of malaria and yellow fever, or will it prove to be successful like smallpox?

The polio eradication campaign argues that all that is required is a greater effort by the governments of Nigeria, Pakistan and Afghanistan to implement their polio immunization campaigns more effectively so that large numbers of children are not missed.

But it is more than a question of greater effort. Disease control and eradication programmes are not merely about health: they are also about politics and governance. Health and politics are intertwined, and global disease eradication campaigns are where the global and the local meet and often clash.

One reason Afghanistan, Pakistan and Nigeria are struggling is because the polio campaign has become enmeshed in the geopolitical fault lines of the post 9/11 world.  In all three countries, the polio campaign is seen by Islamic militants and clerics as a proxy for western interests. In Pakistan, tribal leaders in North Waziristan have banned polio immunization teams from entering the province in protest against US drone attacks against suspected Taliban targets.  The use by the CIA of a Pakistani doctor to get intelligence on Osama Bin Laden through the guise of a hepatitis B vaccination campaign threw a cloud of suspicion over all international immunization campaigns.

In Afghanistan  many parts of the 13 districts in the southern part of the country where polio persists are no go areas for polio vaccination teams. The polio campaign hopes that importance of eradicating disease will triumph over politics and vaccination teams will be allowed to work in the midst of conflict.

This could happen, but it does not mean that local communities will embrace the idea of polio vaccination. Polio is not a major public health issue in the countries it exists in . Malaria, measles, diarrheal diseases, lower respiratory tract infections and malnutrition are the major causes of illness and death in children. Yet when their children suffer from these common illnesses, people often need to travel long distances and pay money to get medical care.  In contrast, vaccination against polio is delivered to their doors free.  This raises suspicion and anger: why has polio been give such priority, and if it is possible to deliver polio vaccine like this, why can’t other more urgent health care also be brought to people’s door steps?

Issues like this tend to be dismissed by the polio campaign as stemming from ignorance, and elaborate communication campaigns have devised to get people to accept polio immunization. But those who refuse polio vaccination for their children  are not ignorant; they are pointing to the gap between their health priorities and health priorities set at the global level by international organisations. Polio has been difficult to eradicate partly because of this gap between local and global priorities.  A key lesson for the future global health programmes is to find ways to reduce this democratic deficit between what people in developing countries feel their health greatest health needs are, and the kind of programmes that are developed at the global level by the WHO and international donor agencies.

( An earlier version of this article appeared in The Hindu http://www.thehindu.com/opinion/op-ed/polio-endgame-not-immune-to-politics/article4028364.ece)

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White people in Nigeria

In my more than five  decades, I have never been described as a white man. But in Nigeria, that is what I am.  As hordes of children trail after me in a village in Kano district , one of the adults explains their excitement: “they have never seen a white person come to the village before.”

When I attempt to order an African dish at my hotel in Abuja, the waitress tries to dissuade me: “White people like you will not like it.”  I order it anyway. The salad of beans that I have ordered is rubbery and soaked in palm oil and chilli. “ I told you, white people cannot eat this food,” she declares as she clears my uneaten plate.

Anyone who is not black African is white, and the rest of the UNICEF polio communication team I have been travelling with: Fa Andriamsinoro, from Madagascar, and Panchanan Acharr, from Orissa in India are also given similar racial makeovers.  Fa at first attempts to explain that he is African, and that Madagascar is part of Africa. He is greeted with disbelief, and eventually gives up trying to explain. Panchanan finds it amusing and laughs loudly.

Panchanan(centre) and Fa from UNICEF

The polio eradication programme in Northern Nigeria is full of similar “white” men and women from India, all veterans of the successful Indian polio programme. In Kano state, Mary Mendes and Deepali Sharma are consultants overseeing the social mobilization work for UNICEF.

Deepali Sharma and  Mary Mendes(centre)

The WHO has seven Indian doctors in the state providing expertise to the local authorities. This Indian contribution is one of the untold stories of the polio programme.

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On the polio trail

I’ve spent four days on the road in Kano in Northern Nigeria acompanying UNICEF teams, travelling from idyllic rural settlements surrounded by fields of maize to squalid urban slums where children run and play alongside open  drains and mounds of garbage. If the global polio programme is to succeed in stamping out the disease, this is the landscape where a public health miracle must occur.

Teams of vaccinators, young women in traditional headscarves, lugging plastic carrier cases of vaccine have been trudging along dusty roads, knocking on doors and trying to squeeze drops of vaccine into the mouths of children. Often the doors they knock on are slammed shut and the vaccinators shooed away.

Who are these people coming to vaccinate my child?

Why should anyone refuse a free vaccine that can could save their children from a potentially crippling disease? Ignorance and lack of education are usually blamed for refusal. But the people of Kano are not stupid. They would not have survived harsh conditions of poverty had they been. Rather, the reasons reflect the complex social and political realities which shape health. To begin with, nothing in Kano is free, and so a vaccine delivered free to the door, by a government that has done little in other areas of health, arouses suspicion. Particularly when polio is rare compared to the other diseases that afflict children in the area: malaria, measles, respiratory disease and chronic malnutrition, which together are responsible for the majority of deaths of children under five.

This is an area with chronically poor government services, where the nearest health centre is a run down building several kilometres away with no doctor and few medicines. So, the appearance of a vaccinator or local health worker at the door is also an opportunity for people to vent their grievance at the lack of health facilities, and demand better health care in return for accepting the vaccine.

The polio campaign is also hostage to Nigeria’s religious and ethnic divisions, in particular the divide between the Christian and animist south, and the Muslim north. A few days before the recent polio immunization campaign by President Goodluck Jonathan, a southerner and Christian, made a speech on the need for family planning. Some in the north interpreted the polio drops as part of a plot by the south to reduce fertility. In 2003, the then governor of Kano suspended polio immunization amidst doubts that it was a plot by the west against Muslims in revenge for the 9/11 attacks.

Added to this, is the fact of a underfunded and underperforming local government system, which has the main responsibility for delivering polio vaccine.

Can it be done? The government of Nigeria now sees it as a matter of national pride: Nigeria is only one of three countries ( Afghanistan and Pakistan are the others) where polio is still endemic. “We don’t want to be one of only three countries”, as senior health official told me. “We have to finish the job. The Gates Foundation, UNICEF, WHO, the US CDC and other international donors are pouring large amounts of money into polio eradication in Nigeria.

Fatima, a newly recruited UNICEF community mobiliser, in Bebeji, Kano.

New systems, including teams of community mobilisers that UNICEF has put in place, as well as consultants and supervisors in high risk districts, as well as pressure from the federal and state governments on local governments might help to swing the tide. The polio peak season has begun with the rains that have been hitting Kano and other parts of Northern Nigeria. The number of polio cases this year, is higher than at the same time last year. The signs are not good, but with luck and effort, anything is possible.

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Off to Nigeria

I leave  tomorrow on  a ten day journey  that will take me to Kano in northern Nigeria, one of the last few pockets in the world where polio still exists.  The people of Kano, as well as their neighbours in the northern  Nigerian states of Borno, Sokoto, Zamfara and Kebi are less that enthusiastic about the  polio immunisation campaign, and have resisted getting their children vaccinated. A lack of trust in western medicine, puzzlement about why polio is given priority over more urgent health needs, and lingering religous doubts- the same set of factors that are at work in Pakistan and Afghanistan, two other countries where polio persists, have combined to make polio eradication an uphill task. In addition, the polio campaign faces obstacles  ranging from the Boko Haram, to the elusive nomadic tribes that that flit across borders eluding vaccination teams.

The good folk at the UNICEF polio campaign in Nigeria have  allowed me to accompany them to Kano for an immunisation campaign, and I am curious about what I will see. I’m particularly intrigued by the clash between the global and the local that the polio campaign ( as well as global health campaigns in general) embodies. What happens when sophisticated global health programmes, managed from places like Geneva, descend on communities that are as far from the centres of global power as they can possibly be?  How do people respond to outsiders knocking on their door and asking to put strange drops in their children’s mouths?

What motivates underpaid and overworked vaccinators to knock on countless doors to try and persuade reluctant parents to immunise their children?

A lot has been written about the polio programme from the perspective of the  experts who run and manage the programme and decide who needs to be vaccinated, and when and where this should happen. But I want to look at it from the other end of the telescope, and see what sense all of this makes to the ordinary people for whose benefit these programmes are carried out.

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Coercion is unethical

Coercion has often been a  dark side  of the history of public health. During the campaign to eradicate small pox,  there were cases of villagers in India and Bangladesh being pulled out of their homes to be vaccinated. If they ran away, they were chased down and forcibly vaccinated. This raised little outcry internationally because these were poor uneducated villagers at the bottom of the global pyramid of power and wealth. It is difficult of conceive of people in the west being forcibly vaccinated.

The same thing appears to be happening again with the polio campaign. The Daily Trust newspaper in Nigeria has reported that parents in Kebbi state in Northwestern Nigeria have been threatened with arrest, and on occassion detained until they allowed their children to be immunised.

Arrests—detention for only hours until parents release their children for vaccination— have been a means of dealing with habitual noncompliance in parts of the state for several past rounds of vaccination, often with tacit approval from authorities and the traditional council,” the newspaper reported.

In the Democratic Repubic of Congo, UNICEF has reported that parents from all provinces except Kinshasa and Katanga have reported coercion by vaccination teams.

As international pressure grows on countries like Nigeria, Pakistan and Afganistan to eliminate the polio or risk becoming international pariahs, these governments in turn will cut corners to ensure that vaccination targets are met.

It is upto the Global Polio Programme partners- WHO, UNICEF,  the US CDC, Rotary International and the Bill and Melinda Gates Foundation, as well as the Independent Monitoring Board of the polio programme to ensure that ethical, non -coercive means are used to achieve a polio free world.  The means are as important as the ends.

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