Jul 3, 2012

Ending polio, one type at a time

Countries have endorsed a plan for the polio endgame, one that hinges on making inactivated polio vaccine more affordable for low- and middle-income countries. Patrick Adams reports.

A mother takes her child for vaccination in Kwara State, Nigeria, one of the few countries in which polio is still endemic
WHO/Thomas Moran
A mother takes her child for vaccination in Kwara State, Nigeria, one of the few countries in which polio is still endemic
In 2000, the polio eradication campaign seemed to be nearing its end. Wild type 2 poliovirus had been stamped out worldwide the previous year, while poliovirus types 1 and 3 had been confined to a few hundred cases. But then, the virus did something the experts didn’t expect.
Somewhere on the island of Hispaniola in the Caribbean a child developed paralysis as a result of the live poliovirus used to make the vaccine. Cases of vaccine-associated polio paralysis had been known for many years, but were – and still are – extremely rare. But what was alarming about this case was that the vaccine-derived virus had spread similar to a wild virus, and was causing an outbreak.
Twenty-one children in the Dominican Republic and Haiti that make up Hispaniola became paralysed and two died before the outbreak could be quelled by mass vaccination campaigns. The episode revealed a troubling new possibility: that the vaccine of choice in most countries, the trivalent oral polio vaccine, could itself lead to new polio outbreaks.
Although such outbreaks have occurred in 16 countries since the Hispaniola outbreak, they are extremely rare, given the 10 billion doses or more of oral polio vaccine administered to 2.5 billion children.
For officials at the World Health Organization (WHO) the eradication puzzle had suddenly become more complex.
“We realized that not only would we have to eradicate the wild poliovirus but we would also have to eradicate the vaccine-derived virus as well,” says Bruce Aylward, Assistant Director-General for Polio, Emergencies and Country Collaboration at WHO, one of the four spearheading partners in the Global Polio Eradication Initiative (GPEI) along with Rotary International, the US Centers for Disease Control and Prevention and UNICEF.
“So we had this big new problem and we had to come up with a whole new solution. It’s been quite a ride,” Aylward says.
Since then, Aylward and his colleagues have been developing that “new solution”: a plan to take the world from eradicating the wild poliovirus to ensuring the polio endgame will achieve a world free of all polio-paralysis, be it from wild- or vaccine-derived polio. If successful, polio would become the second infectious disease to be wiped out after smallpox was eradicated in the 1970s.
Governments and their partners have invested some US$ 9 billion in 25 years of polio eradication efforts, according to the Global Polio Eradication Initiative, but the world is only expected to realize a return on this investment – estimated at a minimum direct savings of US$ 40–50 billion by 2035, in low-middle-income and low-income countries – if the three remaining endemic countries: Afghanistan, Nigeria and Pakistan, eliminate the disease, while the rest of the world remains polio-free, according to a study published in Vaccine 2010.
While vaccination efforts are most intense in these three countries, all countries need to maintain high immunization coverage with their polio vaccination programmes as they all face the risk of re-infection as long as cases are still occurring somewhere in the world.
This year the World Health Assembly, which governs WHO and the Global Polio Eradication Initiative, endorsed the plan for the polio eradication endgame, declaring the completion of polio eradication a “programmatic emergency for global public health” and calling on countries to provide funding.
WHO Director-General Dr Margaret Chan told the Assembly that polio eradication was “at a tipping point between success and failure,” highlighting the funding gap of US$ 945 million until the end of 2013 (against a US$ 2.19 billion budget for that period). This year alone, the cash shortage has led to a reduction in mass vaccination activities in 24 high-risk countries, putting millions of children at risk.
The polio eradication endgame plan is to switch from the trivalent oral polio vaccine, currently the vaccine of choice in most countries, to two vaccines: a new bivalent oral polio vaccine for routine immunization backed up by judicious use of inactivated polio vaccine (IPV).
First used in Afghanistan in 2009, the bivalent oral polio vaccine is at least 30% more effective than the old trivalent oral polio vaccine against polioviruses types 1 and 3 and does not contain live type 2 poliovirus that caused most of the outbreaks of circulating vaccine-derived poliovirus since the first outbreak in Hispaniola.
Bivalent vaccines protect against two serotypes of a disease, trivalent vaccines against three. In the case of polio, although there are three types of the poliovirus, it is the type 2 component in the trivalent oral polio vaccine has caused more than 80% of cases of vaccine-derived polioviruses that have caused outbreaks and so removing the type 2 component from the vaccine is vital to success.
And that is where IPV comes in. IPV, which is administered through injection, provides immunity to all three types of poliovirus but, unlike the oral vaccine, does not cause vaccine-derived polio because the virus used in its manufacture is dead.
Unlike the oral vaccine, however, IPV does not invoke intestinal immunity needed to stop transmission. So a child who receives only IPV won’t develop polio, but could excrete the virus perpetuating its circulation. That’s why a combination of both the bivalent oral vaccine and IPV is now necessary.
The Global Polio Laboratory Network, consisting of a network of 145 WHO-accredited laboratories worldwide, analyses specimens from acute flaccid paralysis (AFP) cases and characterizes poliovirus isolates. In 2011, more than 200 000 specimens were analysed by the GPLN
The Global Polio Laboratory Network, consisting of a network of 145 WHO-accredited laboratories worldwide, analyses specimens from acute flaccid paralysis (AFP) cases and characterizes poliovirus isolates. In 2011, more than 200 000 specimens were analysed by the GPLN
“IPV would serve as a kind of insurance policy by boosting children’s immunity to type 2 and would have the added advantage of also boosting types 1 and 3 immunity and, thereby, accelerating the removal of those last wild polioviruses,” says WHO’s Roland Sutter, coordinator of the Research and Product Development Team of the Global Polio Eradication Initiative.
This two-prong strategy, involving the bivalent oral polio vaccine and IPV, Aylward and Sutter believe, will succeed in eliminating the main risk due to the type 2 virus. After the eradication of all remaining strains of wild poliovirus transmission, countries could stop using the bivalent oral polio vaccine, eliminating any residual remaining risks associated with the type 1 and 3 components contained in that vaccine.
The chief hurdle to this plan is cost. At a minimum of US$ 3 a dose, IPV is far too costly for the low-income countries that might need it most. So the fear when developing the plan was that, in the unlikely event that a type 2 vaccine-derived poliovirus did emerge during or immediately after the switch, children with immunity only to types 1 and 3 wouldn’t be protected as countries would not be able to afford IPV.
The challenge, then, was to find a way to use IPV in a significantly less expensive but yet sufficiently effective way. And Aylward knew that wouldn’t be easy. “If you’re a manufacturer, there isn't a great incentive to find ways to make your product more cheaply available,” he says. “We sometimes had to push hard.”
Eventually, in 2010, WHO experts collaborated with researchers in Cuba and Oman, among other countries, to look at four possible scenarios to reduce the cost of IPV use: reducing the number of doses, using a fractional (1/5th) dose, increasing the interval between doses and producing the vaccine in resource-limited settings. “All of this work was driven by a developing country need for a cheap solution to this circulating vaccine-derived poliovirus problem”, says Aylward, “and the really exciting thing is that most of this research took place in developing countries.”
Moreover, he says, the results were far better than expected. “Will one-fifth of a dose work?” he says. “Yes, just as well as a full dose for boosting. Will two doses work as well as four doses? Yes, if you give them four months apart. Can you make an affordable IPV product in a low-income country? Well, it turns out you probably can. These were all big surprises for many working in immunization.”
“What we need now is for manufacturers to agree to produce intra-dermal fractional dose IPV, and for licensing bodies to rapidly examine whether this potential solution can undergo fast-track licensing – given the strong public health imperative – so that we have it within a year,” says Aylward. But for all of the promising data, that has yet to happen.
“The A380 is on the runway, but we haven’t gotten it up in the air yet. And that requires a lot of people cooperating.”

México a la vanguardia en el Síndrome de Post Polio

Jun 29, 2012

Religious resistance to the polio vaccine

In DR Congo, communications efforts are turning back religious resistance to the polio vaccine

By Natacha Ikoli
KINSHASA, Democratic Republic of the Congo, 27 June 2012 – Though polio has been eradicated from much of the world, it remains a tragic reality in the Democratic Republic of the Congo (DRC), where transmission of the virus was re-established in 2006. Since 2010, it has affected nearly 200 people.
UNICEF correspondent Natacha Ikoli reports on efforts to promote polio vaccination among religious communities opposed to the vaccine in the Democratic Republic of the Congo.
With the support of UNICEF, the World Health Organization (WHO) and their partners, the country initiated emergency action plans to address the situation through immunization campaigns and public health programmes.
Yet in spite of multiple countrywide polio vaccination drives in 2011, wild poliovirus remains a threat, in part because some parents continue to refuse to vaccinate their children. Many resisters are fearful of rumors about the vaccine’s side effects or distrust health provider, and in some provinces, parents decline to vaccinate their children out of religious beliefs.

Religious resistance
While Christianity is the predominant religion in the country, many still follow traditional religions, and numerous groups merge Christian tenets with traditional beliefs. Some of these groups strongly resist immunization.
© UNICEF video
A polio vaccination campaign in the Democratic Republic of the Congo. Though polio has been eradicated from much of the world, it remains a tragic reality in DRC.
Such religious resistance to immunization is notable in Nyunzu, a remote, hard-to-reach area. In Mukwaka, on the outskirts of Nyunzu, spiritual leader Marco Kiabuta strongly discourages his followers from using modern health care.
“When there’s a health issue, first and foremost you’ve got to call on the village wise men who will pray over the ill,” he said. In explaining this position, Mr. Kiabuta points to the bible he carries with him at all times. Adherents who don’t improve with prayer are allowed to seek assistance from a doctor, but they often decline certain treatments.
“We refuse to be treated for a disease we don’t recognize,” he said.
Ending vaccine refusal
Those refusing vaccination are only a small segment of Nyunzu’s population, said Mr. Abderrahmane Bocar, an immunization specialist with UNICEF. But it is a wide window of opportunity for poliovirus to enter the community and thrive.
© UNICEF video
A polio vaccination campaign in the Democratic Republic of the Congo. Polio remains a threat in the country in part because some parents continue to refuse to vaccinate their children.
In remote areas, said Dr. Isaac Mpambu Malanda, a health zone director, people often attribute polio disease to evil spirits. Yet communication and education efforts can have a tremendous impact.
Reaching out to representatives of resistant groups and to community members can dispel negative ideas about the oral polio vaccine. Identifying resistant groups and engaging them in frequent dialogues can prompt them to change their ideas about vaccination and life-saving health care.
In Bas-Congo province, where Dr. Malanda operates, four groups refused vaccination in early 2011. Today, thanks to intense communication efforts, only one religious group continues to stand firm against the polio vaccine.

More than 500,000 children across Mauritania

In Mauritania, healthcare campaign aims to save children from preventable diseases

© UNICEF Mauritania/2012
A girl holds her sister and her sister's vaccination certificate in a poor suburb of Nouakchott, Mauritania.
By Fadila Hamidi and Anthea Moore
M’BOUT and NOUAKCHOTT, Mauritania, 28 June 2012 – More than 500,000 children across Mauritania have benefited from a two-month campaign organized by the Ministry of Health, with support from UNICEF and the World Health Organization (WHO), that provided an integrated package of immunizations (including measles and polio vaccinations) and vitamin A supplementation for all Mauritanian children under 5 years old.
This preventative care is essential to building resilience in Mauritania’s children, who are highly vulnerable to malnutrition and illness this year due to the Sahel nutrition crisis, which currently affects 700,000 people in the country.
Expanding life-saving care

Immunizations were undertaken at health centres and specially designated sites in urban centres. Some 1,000 health workers went door-to-door, providing oral doses of vitamin A and deworming medicine, from remote desert communities to the shanty settlements around the capital Nouakchott. In addition, more than 1,000 community outreach events promoted hand-washing with soap, birth registration and positive parenting practices.
The campaign, part of the second African Immunization Week, was launched on 28 April at the opening of a new health centre in M’Bout. Officials from the Government of Mauritania, the WHO, Counterpart International and UNICEF were welcomed with traditional music, singing and dancing as the community celebrated the prospect of improved health care.
© UNICEF Mauritania/2012
UNICEF Representative in Mauritania Lucia Elmi administers a vitamin A supplement to a child during the country's two-month health campaign.
Fatou Mint Samba, 27, attended the opening of the health centre with her youngest son Abbass, who is 7 months old, and her mother Dola Mint Masa, who laughed and said she is too old to remember her age.
Many women like Ms. Mint Samba brought their children to the health centre to receive vaccinations and vitamin supplements. They were also eager to learn more about immunization and to receive insecticide-impregnated mosquito nets to protect against malaria-carrying mosquitoes.
Ms. Mint Masa lost a 5-year-old niece to measles, and has since been a strong community advocate for improved health care. “Last year there was a measles epidemic in this area. I went from door-to-door telling people to have their children vaccinated. I did this because I remember the death of my niece eight years ago,” she said.
“Many of the diseases that existed during my childhood don’t exist here anymore because of vaccination,” she added.
© UNICEF Mauritania/2012
Children attend the opening of a new medical centre in M'Bout, Mauritania.
Communities central to change
Preventative public health measures like immunization are both life-saving and cost-effective.
The logistical challenges of reaching remote communities in sparsely populated Mauritania are immense. And yet, excluding the cost of the vaccines and supplements, delivering this integrated package cost just 40 cents per child.
These services are particularly important during the current nutrition crisis, as malnutrition and childhood illnesses can create a vicious cycle, each increasing children’s vulnerability to the other.
After the official opening of the health centre, a radio programme was broadcast from a nearby tent. The presenter asked women from the community questions about immunization and awarded prizes for correct answers. The exchanges were accompanied by smiles, laughter and more music, signs that positive change is being embraced in the community, and that community members are proud to be at the centre of that change.
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