WHO declares polio a public health emergency
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3124 (Published 06 May 2014) Cite this as: BMJ 2014;348:g3124
All rapid responses
Dear Editors,
Millions of Greeks are completely uninsured.
Poverty leads parents to neglect indispensable vaccinations! [3][4][5][6][7]
Indebted public hospitals do not have funds to provide vaccinations to every child in Greece. [2]
Exceptional funding is necessary to prevent dangerous outbreaks of infective diseases among Greek children. [1]
Evidently, no vaccinations are performed for hundreds of thousands of children in Greece.
Tens of thousands of immigrants from polio endemic areas enter Greece every month.
References
[1] http://www.ekathimerini.com/4dcgi/_w_articles_wsite1_1_13/05/2013_498434
[2] http://www.bmj.com/content/342/bmj.d200?tab=responses
[3] http://www.vaccinestoday.eu/vaccines/greek-crisis-children-missing-vacci...
[4] http://www.euractiv.com/health/doctors-thousands-children-greec-news-532216
[5] http://www.enetenglish.gr/?i=news.en.society&id=1658
[6] http://www.euronews.com/2012/03/30/greeks-who-cannot-pay-for-children-s-...
[7] http://greece.greekreporter.com/2013/12/05/thousands-of-children-in-gree...
Competing interests: No competing interests
I appreciate the effort of the author to summarize the challenges to polio eradication in Pakistan. However, one issue that will remain a challenge to polio eradication is the change in the public attitude toward vaccination programs. Most of the people have lost trust in the polio campaign. They still believe that it’s a CIA plot against their children and their communities. Before the CIA fake polio campaign, in some parts of Pakistan it was believed that “polio vaccination is the western conspiracy against Pakistan and to make our children sterile” and it is not from a HALAL source. I have no doubt in saying that after the CIA intentional mistake, these beliefs are further confirmed and will hinder WHO's aim to save children in Pakistan. In addition to polio eradication it will be a big challenge for WHO and others to gain back the confidence of the people of Pakistan.
Competing interests: No competing interests
Clusters of unvaccinated (eventually temporal) exist everywhere. The epidemic potential is exacerbated by the reduction of herd immunity due to IPV vaccination. Israel policy (revaccinate all subiects that received only IPV) must be taken as an example in all European countries. In general it is crucial to come back to the original criterion to declare a country free from polio: efficient active surveillance system for AFP; more than 95% vaccination cover at district level, not only at regional or national level, ascertained through sampling surveys with 95% respondence without sostitution; periodical environment investigations.
Competing interests: No competing interests
After swine flu debacle, now the polio ‘prevention’ debacle.
Anderson et al. (1951. Poliomyelitis occurring after antigen injections (Pediatrics; 7(6): 741-759) wrote, “During the last year several investigators have reported the occurrence poliomyelitis within a few weeks after injection of some antigen. Martin in England noted 25 cases in which paralysis of as single limb occurred within 28 days of injection of antigen into that limb, and two cases following penicillin injections. In Australia, McCloskey, during a study of the 1949 outbreak, recorded 38 cases that developed within 30 days of an antigen injection, finding an association between the site of paralysis and that of the recently antecedent injection. His findings, suggested a greater association with pertussis vaccine than with other antigens.
Geffen, studying the 1949 poliomyelitis cases in London, observed 30 patients who had received an antigen within four weeks, noting also that the paralysis involved especially the extremity into which the injection had been given.”
Peterson et al. (1955) reported on vaccination induced poliomyelitis in Idaho as part of the Salk vaccine trial (Vaccination-induced poliomyelitis in Idaho. Preliminary report of experience with Salk poliomyelitis vaccine. JAMA; 159 (4): 241-244).
The Cutter laboratories were accused of distributing vaccines containing live polioviruses, however vaccines produced by other manufacturers also caused paralysis (Nathanson and Langmuir 1963. The Cutter incident: poliomyelitis following formaldehyde-inactivated poliovirus vaccination in the United States during the spring of 1955 III. Am. J Hyg; 78: 61-81).
Wyatt (1981) summarised cases of provocation poliomyelitis caused by multiple injections in his article “Provocation poliomyelitis: neglected clinical observations from 1914 to 1950” (Bull Hist Med; 55: 543-557).
Wyatt et al. (1992) and Wyatt (1993) warned against the unnecessary injections causing paralytic poliomyelitis in India (Trans Roy SocTrop Med Hyg; 86: 546-549 and Lancet 341: 61-62, respectively).
Sutter et al. (1992) published an article “Attributable risk of DTP (Diphtheria and Tetanus toxoids and Pertussis toxoid vaccine injection in provoking paralytic poliomyelitis during a large outbreak in Oman”. (J Infec Dis; 165: 444-449).
According to Strebel et al. (1994. Paralytic poliomyelitis in Romania, 1984-1992. Am J Epidemiology; 140 (12: 111-124)) although poliomyelitis due to wild virus had virtually disappeared from Romania (no cases reported between 1984-1989), the vaccine-associated paralytic poliomyelitis (VAPP) was reported at very high rates for over two decades. The overall risk of VAPP in Romania was up to 17 times higher than the reported risk in the USA.
In November 1990, to decrease the risk of VAPP, Romania imported OPV produced by “Western European manufacturer”. The risk of VAPP continued unabated with that vaccine.
Paralysis continued developing after both injectable and oral polio vaccines worldwide.
No surprise that the most recent mass polio vaccination programs fuelled by Bill and Melinda Gates Foundation resulted in increased cases of VAPP.
Two Indian paediatricians, Drs Vashisht and Pulliel (Department of Paediatrics of St Stephens Hospital in Delhi) noted another major ethical issue raised by the campaign: the failure to thoroughly investigate the increased incidence “of non-polio acute flaccid paralysis (NPAFP)” in areas where many doses of vaccine were used, while noting that these cases are clinically indistinguishable from polio paralysis and twice as deadly. They also noted that while India was declared polio-free in 2011, at the same time there were 47,500 cases of NPAFP, which increased in direct proportion to the number of polio vaccine doses received. Independent studies showed that children identified with NPAFP “were at more than twice the risk of dying than those with wild polio infection”.
According to their report, nationally, the NPAFP rate is now twelve times higher than expected. In the states of Uttar Pradesh and Bihar – which have pulse polio vaccination every month – the NPAFP rate is 25 and 35 fold higher than the international norms (Ramesh Shankar, Mumbai 2012).
Ron Law (Assaulting alternative medicine: worthwhile or witch hunt? BMJ.com 10 March 2012) addressed the polio situation in India: eradication has been achieved by re-naming the disease. Poliomyelitis paralysis which occurs even after 30+ vaccination doses, is now called acute flaccid paralysis (AFP) or polio-like paralysis; hardly a great success of vaccination or comfort to the parents of the more than 60 000 affected children.
Earlier redefinition of poliomyelitis had been introduced in the US: a disease with residual paralysis which resolves within 60 days changed into a disease with residual paralysis which persists for more than 60 days. Cases of paralysis which resolve within 60 days (99% of cases) are diagnosed as viral or aseptic meningitis.
According to MMWR (1997; 32[29]: 384-385), there are 30 000 to 50 000 cases of viral/aseptic meningitis per year in the US. Considering that in the pre-vaccine era the vast majority (99%) of the reported cases were non-paralytic (corresponding to aseptic or viral meningitis), vaccination has actually increased the incidence of poliomyelitis. Before mass vaccination there were a few hundred or few thousand cases of polio in some outbreaks, while now it is up to 50 000 cases every year. Figure 1 in Schonberger et al. (1984. Control of poliomyelitis in the United States. Rev infect Dis; 6 (Suppl 2: S424-S426) shows the steady downward trend in the incidence of poliomyelitis stopping, and indeed increasing, when DPT and P vaccination became mandatory in the US in the mid-seventies.
The experience in northern Namibia showed that with no polio vaccination children developed natural immunity to the wild polio virus without developing paralysis (Biellik et al. 1994. Poliomyelitis in Namibia. Lancet 344: 1776).
The vaccine viruses inactivation by a 14-day treatment with 1:4000 formaldehyde solution is the subject to asymptotic factor making the inactivation incomplete (Gerber et al. 1961. Inactivation of vacuolating virus (SV 40) by formaldehyde, Proc Soc Exp Biol & Med; 108: 205-209), and, Fenner (1962. The reactivation of animal viruses. BMJ; July 21: 135-142), also reversible.
Evans et al. (1985. Nature ; 314: 548-550) demonstrated “Increased neurovirulence associated with a single nucleotide change in a noncoding region of the Sabin type 3 poliovirus genome”.
The solution is in the name: stop VAPP (vaccine-associated paralytic poliomyelitis).
Competing interests: No competing interests
The campaign against Polio has had serious setback since the CIA set up a bogus immunization Program in Islamabad, Pakistan to snare Osama Bin laden. Polio Workers have been targeted since.
As far as I know WHO has not protested to the US Govt. and asked it to shoulder the damaging consequences of its Intelligence Agency.
Unless that happens I do not hold much hope for any progress in that Campaign.
Competing interests: No competing interests
RED FLAGS in the ENDLESS ENDGAME
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The four millenia old Egyptian stele (presently in Copenhagen)clealy depicts a youth with a withered right lower limb, characeristic of an antecedent polio.Polio is an ageless disease that affected all ages.It was ubiquitous.
In our life time,a dramatic reduction of the incidence of polio was achieved.The key was polio vaccine and its universal acceptance. Buoyed by the success,in 1988 a Global Polio Eradication Program was initiated by the World Health Organisation in partnership with the United Nations International Childrens Emergency Fund, Rotary International and the Center for Disease Control.
The dream was for an end game.
An undreamt of an opposition emerged.The slogans screamed :" the vaccine is a poison "," it sterilises men and women ", "a conspiracy to reduce the poor ", " there is pork in it! " etc. Formidable forces flooded the field- an unexpected nightmare !
Sensitive, delicate,transparent counselling may win the day for a polioless tomorrow.
Competing interests: House Officer (1962),Polio Unit, Lady Ridgeway Childrens Hospital, Colombo, Sri Lanka.
Failure of polio eradication in conflict areas: another perspective
This communication is with reference to the recent publication of Gulland in BMJ.1 There is no doubt that the prime responsibility of polio eradication lies with government authorities. However, in addition to administrative shortcomings, there are also socio-political factors which play a major role in contributing to the failure of polio eradication in the aforementioned countries, especially Pakistan. The difficulties in vaccinating children from these regions is not easily appreciated by anyone living in the developed world. It should be noted that more than 90% of polio cases have been identified in federally-administered tribal areas (FATA), the Khyber-Pakhtunkhuwa (KPK) province and some well-defined pockets of Karachi.2 Interestingly, most of the identified cases are of Pashtun ethnicity; even those living in Karachi have their roots in FATA or KPK province.3 Refusal to be vaccinated by the families has been identified as a major reason why polio eradication programs have failed in these areas. It is important to consider the reasons behind this unwillingness to be vaccinated. Recently, Murakami et al (2014) have shown that in a large area of KPK province, the prime reasons for refusing vaccination are based on religious beliefs and opposition by the local religious leaders.4 The role of religious anti-western and anti-immunisation campaigners in opposing the efforts of national and international agencies has been highly significant.5 Villagers, especially in the affected areas, are constantly preached to and warned that these vaccinations are anti-Islamic. But, more importantly, the grave security situation and attacks on polio workers and their security personnel are primarily responsible for the failures in the immunisation programs. More than 40 polio workers and security personnel have been killed since December 2012.6
It can be argued that educating the masses and overcoming hostility as well as improving the law and order situation is the responsibility of the government in order to ensure an effective immunisation campaign against polio. However, the considerable problems the Pakistani authorities face is compounded by the actions of foreign powers outside of its control. This is illustrated by the collateral damage that was done following a fake vaccination campaign organised by the CIA during the hunt for Osama bin Laden in 2011. This event resulted in a deep suspicion of vaccination personnel, resulting in a backlash and militant attacks against them, as well as providing more ammunition for anti-vaccination campaigners. The situation was very well highlighted by the deans of 12 US medical colleges who sent a letter of complaint to President Obama on January 13, 2014 demanding a ban on these covert operations which jeopardize world health.7 This was subsequently acknowledged by the Obama administration which announced a ban on fake vaccination campaigns from now on.
With these background facts, let us analyse that will the recommendation of WHO for mandatory vaccinations of travellers be sufficient to address this global issue. This exercise will surely affect the global spread of disease from the endemic areas to some extent. But it still will not help in eradicating the disease from these areas, which will continue to be a concern for the whole world. The issue can only be resolved through combined efforts of health and political leadership; local as well as international. The global powers and WHO have a moral imperative in coming up with a better solution in delivering pathogen eradication programs, particularly in conflict areas. Otherwise this recent recommendation would be just to quarantine the countries and regions as "Red Zones" without achieving the prime objective of making this world polio-free.
Dileep Kumar Rohra, PhD
College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
Correspondence: Dileep Kumar Rohra, Department of Pharmacology,
College of Medicine, Alfaisal University, P.O Box 50927, Riyadh 11533, Saudi Arabia
E mail: drohra@alfaisal.edu
References:
1. Gulland A. WHO declares polio a public health emergency. BMJ 2014;348:g3124.
2. Endpolio Pakistan. Polio facts. Status as of May 2014. http://www.endpolio.com.pk/polio-in-pakistan (accessed on May 27, 2014).
3. WHO. Polio eradication efforts not reaching most vulnerable. http://www.who.int/mediacentre/news/notes/2012/polio_20121101/en/ (accessed on May 29, 2014).
4. Murakami H, Kobayashi M, Hachiya M, Khan ZS, Hassan SQ, Sakurada S. Refusal of oral polio vaccine in northwestern Pakistan: a qualitative and quantitative study. Vaccine 2014; 32:1382-7.
5. Sheikh A, Iqbal B, Ehtamam A, Rahim M, Shaikh HA, Usmani HA, Nasir J, Ali S, Zaki M, Wahab TA, Wasim W, Aftab AA. Reasons for non-vaccination in pediatric patients visiting tertiary care centers in a polio-prone country. Arch Public Health 2013; 71:19 (doi:10.1186/0778-7367-71-19).
6. Gulland A. Three more polio workers are killed in Pakistan. BMJ 2014;348:g1208.
7. http://www.jhsph.edu/news/news-releases/2013/Klag%20letter%20to%20Presid... (accessed on May 30, 2014).
Competing interests: No competing interests