Recently I wrote two sentences in preparing a post I never published called “Counterintuitive Econundrums.” Reading them back, I realize they contain roughly the content value of a paragraph each. They’re not perfect sentences, but their advantages over the paragraphs they represent make them excellent models of writing that earns better grades.
An econundrum—combining the words “ecology” and “conundrum”—is a counterintuitive example of a supposed bit of “green” technology or practice that turns out to be less ecologically friendly than it seems.
My favorite econundrums puncture the inflated claims of greenness too often made by commercial operations determined to sell us something they pretend has big environmental advantages.
This sentence packs a lot of material and delivers it in a steady stream that needs no punctuation. Commalessness is not a requirement of good writing, but sentences that charge resolutely toward their conclusion without deviating can gain a lot of momentum and arrive like a freight train. Let’s unpack the sentence into its component claims. Here’s the paragraph the sentence replaces:
Commercial operations are in business to sell us something. Because they know a large percentage of consumers are more likely to buy something that is kind to the environment than a similar but planet-killing product, they promote their products as green. Often they exaggerate the environmental friendliness of their products to trick us into making purchases that don’t really benefit the planet. Econondrums sometimes puncture the inflated claims of the companies that exaggerate their environmental benefits. Those are my favorite econonundrums.
Electric cars make me furious, for example, because their manufacturers pretend exhaust pipe emissions are the only measure of a car’s environmental impact, conveniently ignoring the damage done to the planet to produce the electricity in the first place, a huge percentage of which is lost to transmission before it ever starts the car.
The sentence is a little long and might be better phrased, but as it stands it’s certainly not as clumsy at the version it represents, which takes way too much space to spell out the same claims:
Electric car manufacturers claim that their cars cause less environmental damage than cars that burn gasoline. They support that claim by measuring the amount of environmentally-damaging exhaust that gasoline engines emit when they’re driven. While they are correct in saying their cars don’t emit gasses, they are wrong to claim that exhaust gasses are the only way to measure environmental impact. The electricity required to power their cars is not environmentally clean because it can’t be produced in the first place without damaging the planet in some way; what’s more, a huge percentage of the electricity generated at power plants is lost in the miles of transmission wires from the plant to the charging station before it ever gets into the car. Therefore, claims that electric cars are cleaner than gasoline engine vehicles make me furious.
I invite you to respond here if this is helpful, or if you feel the need for additional samples, better models, or even revised versions of your own paragraphs before or after you’ve posted them. If I can model better writing for you, I’ll be happy to try.
Whenever possible, I will provide models of the type of work this course is designed to produce. Today, I offer a draft of my own White Paper on the hypothesis that despite tremendous investment and goodwill from hopeful eradicators, we may never be free of polio.
Work in Progress
Like all research documents, the White Paper is a work in progress. It’s not intended to be a polished work product. I will continue to work on it during the semester, with the help of your feedback, and add to it (or delete sections that turn out to be irrelevant) as I modify my hypothesis in search of a thesis I can prove.
We write to find out what we believe.
The truth is, we don’t have a thought in our heads. We receive impressions, we experience sensations, our instincts control the momentary notions that flit across our consciousness: none of that adds up to actual ideas.
I believe you know what’s in my head. It’s ___________________ or __________________, or _______________ eating _________________.
When we write, or speak, we are forced to organize the chaos in our heads to communicate the patterns of our impressions in a comprehensible fashion. In other words, we don’t have ideas until we express them.
The process contains an imaginary step.
There is no value in “thinking about my sources.” Because thinking occurs only during writing, it’s useless to separate the composition process into stages that don’t involve writing, such as:
Thinking about my topic.
Thinking about sources.
Writing about sources as I read them.
Organizing my thoughts into patterns.
Writing a disorganized essay.
Revising for organization.
Thinking doesn’t occur during the reading process. We only react, mostly arguing with the text. We begin thinking when we begin writing. Step 5 by itself is a waste of time. Step 6, because it involves writing, is incredibly valuable. It puts the sources to use before we’re even certain what our thesis will be. Step 7 by itself is imaginary. The time to write about sources is while we’re reading them; the time to organize our thoughts is after we’ve written our first draft.
Writing is Thinking
The most effective technique, instead, and the one we’ll use in this class, is to write as a way of having ideas and clarifying our arguments.
Collect a Source
Write about that Source
Collect New Sources Suggested by a Developing Hypothesis
Write about those Sources
Repeat Beyond what is Needed
Write a first draft that is way too long.
Edit and organize into Persuasive Essay
Cutting, not writing, is the last step.
When we finish organizing, we’ll have too much material for a narrow thesis. The last step will be to eliminate non-essential material and edit our language for brevity and clarity, to prove one thing well instead of waving vaguely at everything.
Today, I’ll talk you through my sample White Paper to demonstrate the range of material that a straightforward thesis can accommodate. Next, I’ll have you collect and write about several sources. Once you begin to develop a strong hypothesis, you’ll produce some sample opening paragraphs like the one below, and others.
Working Hypothesis 1
Eradication is possible and highly desirable even if to accomplish it we need to be slightly unscrupulous.
Which Practice Openings support this thesis?
Working Hypothesis 2
The world is too fragmented and mistrustful to ever join in a truly global effort, even to eradicate a dreaded disease.
Which Practice Openings support this thesis?
Why We Will Always Have Polio
For practice, we can try several ways to open.
A good way to decide how the process is going is to experiment with radically different openings. As we try on several, one or more will suggest themselves as the most likely thesis, or the one we can most effectively argue and support.
A Practice Opening
Children are the saddest casualties, and too often the most vulnerable.As recently as 2014, in the latest catastrophe to spin out of the death fest in Syria, the local polio outbreak spread to Iraq. Despite what the New York Times called “an ambitious Middle East inoculation effort,” the conditions of war, including tens of thousands of internal refugees huddled in unclean camps, once again catapulted the insidious virus across international borders to threaten mostly the vulnerable children, this time in Iraq.
[Doesn’t actually have a thesis.]
[Need numbers on childhood infections to support this claim.] [Note for further research: are children actually physically more vulnerable to the virus than adults? Or does their behavior, not their biology, make them easier to infect?]
A Practice Opening
The virus that causes polio thrives during conflict and mayhem. Repeatedly over the last half century, whenever mankind has come close to banishing the disease forever, human misadventures have invited it back. Certainly in times of war, but even during peace, we have failed to accomplish the ultimate eradication we seek. Nations [sects? religious factions?] are less cooperative now than in 1977, when we eradicated smallpox once and forever, and banished that dreaded disease from our planet.
SELF-CRITIQUE [Still just a suggestion. Doesn’t actually claim that we’ll never eradicate polio.]
A Practice Opening
This generation is not ready to eradicate polio.An editorial in the journal Lancet, September 2006, relates the sad history of polio vaccination campaigns thwarted by distrust in the very communities they are meant to protect. Fear in poor countries that mass vaccination is a conspiracy by the developing world has for years complicated the efforts of volunteers to conduct the one-day mass immunization efforts that have been the most effective part of the World Health Organization’s program. Even when funding, volunteers, and sufficient doses have been present, the trust of the poor and often suspicious residents of vulnerable countries has been absent.
But the developing world has no monopoly on ignorance, willfulness, and distrust.
[In March, 2015, Time magazine, using data provided by the New York Times, reports that “measles has made a comeback, at least in New York City, where as many as 19 cases have been confirmed.”]
Update with more current source for 2015 Disneyland outbreak.
The small number of cases, for measles or for polio, is never a reason for complacency. For decades, childhood measles cases in the US, a triumphant result of universal vaccination, numbered zero. Said Time in 2014: “The emergence of these diseases—especially measles—is alarming, and mostly due to parents in the U.S. not vaccinating their kids.”
A Practice Opening
The proof that we will never eradicate polio from earth was evident at Disneyland in January, 2015.A measles outbreak there quickly spread, sickening 137 in California, and migrated to eight states and Canada. A single park visitor returned to Quebec and sparked an outbreak there that sickened 150 members of a religious group that shuns vaccination. Measles was banished from the US generations ago by the simple process of vaccinating children, but we have become complacent. Parents who thought they had little to fear have increasingly declined to vaccinate against a disease they haven’t experienced, creating the perfect conditions for measles to return.
A Practice Opening
To rid the world of polio forever, we will have to paralyze 250 children. The tragic truth of our effort to eradicate polio using the most common and cost-effective vaccination technique (OPV) is that it paralyzes approximately one child in every 3 million inoculated. The cost of not vaccinating, of course, would be catastrophically higher, but we must nonetheless admit that we will be sacrificing some of the world’s children to achieve the goal of eliminating polio from the planet.
A Practice Opening
If we ever banish polio from the planet, the heroes of that accomplishment will be thousands of volunteers who inoculate millions of children on a single historic day.
At first, the campaign to rid the world of a disease that has left some 10 million to 20 million people paralyzed did not seem to be making an impact. But in 1995, WHO and its partner, the United Nations Children’s Fund (UNICEF), adopted the new strategy of blitzing the entire child population of a country in a single day. In 1996, such National Immunization Days vaccinated more than 420 million children–almost two-thirds of the world’s children under five–against polio. These dramatic campaigns captured the imagination of the world and have even persuaded hardened fighters in war-torn countries such as Afghanistan, Sudan, and Sri Lanka to stop fighting for a day so that their children can be immunized.
2014 Syrian Outbreak
[Sections like these, which might look like data dumps, are always purposeful summaries. The process of making our readings our own begins here, with the paraphrasing and shaping of source material into language that owes much to the original, but which can safely be called our own.]
The transmission of polio, a highly contagious disease that primarily afflicts children younger than 5 and can lead to partial and sometimes fatal paralysis, reflects one of the most insidious effects of the three-year-old Syria conflict, which has sent millions of refugees across the country’s borders and severely undermined its public health system.
For Iraq, the outbreak is the first time in 14 years that polio has appeared; the disease was absent even during the 2003-2011 war that began with the American-led invasion to topple Saddam Hussein.
World Health Organization officials said the first Iraqi polio case, that of a 6-month-old boy in Baghdad, was confirmed on March 30 by Iraq’s Ministry of Health and had the same genetic fingerprint as the virus that paralyzed 27 children in eastern Syria in October — both having originated in Pakistan, one of the few countries in the world where polio has not been eradicated. The Polio Global Eradication Initiative, a partnership that includes the W.H.O., reported two new Syria caseslast week — in Aleppo and Hama, far from the original outbreak area.
Christopher Maher, the eastern Mediterranean manager of the W.H.O.’s Polio Eradication and Emergency Support unit, said that Iraqi officials had been immunizing children protectively since the Syria outbreak began, and that in light of the first confirmed case in their home country they were now expediting another scheduled round of vaccinations.
“At the moment, they’re madly preparing their response plan,” Mr. Maher said in a telephone interview. It takes multiple rounds of vaccine, taken orally, to immunize a child.
Iraq has an estimated five million children under the age of 5. While estimates vary on the number of infections for every confirmed case, and not all children develop symptoms, Mr. Maher said, “in all likelihood it would be dozens — you’ve got to assume there’s some extension of the transmission.”
The W.H.O. and UNICEF said in ajoint statementon Sunday that Iraq’s expedited polio response was part of a broader vaccination effort in the region, with the goal of reaching more than 20 million children this week. Lebanon and Turkey will participate later this month, and Jordan and the Palestinian territories will be part of future vaccination rounds, said Juliette S. Touma, a spokeswoman for UNICEF’s regional office in Amman, Jordan.
“The recent detection of a polio case in Iraq after a 14-year absence is a reminder of the risk currently facing children throughout the region,” Maria Calivis, the UNICEF regional director for the Middle East and North Africa, said in the statement. “It is now even more imperative to boost routine immunizations to reach every child multiple times and do whatever we can to vaccinate children we could not reach in previous rounds.”
The statement acknowledged that the effort had “yet to reach especially vulnerable groups such as children who are on the move fleeing violence from Syria or those living in the midst of active conflict.”
Tragic Evidence of Insurmountable Opposition
Some rights advocates and public health experts have criticized the W.H.O. and other United Nations agencies for adopting an accommodating policy toward President Bashar al-Assad of Syria, who they contend has deliberately withheld inoculations against polio and other contagious diseases to insurgent-controlled areas.
Dr. Annie Sparrow, a pediatrician and deputy director of human rights at the Icahn School of Medicine at Mount Sinai in New York, said in a study published in February that the polio outbreak in Syria was far more widespread than just the cases reported by the W.H.O. The health organization has disputed her findings.
Dr. Sparrow said in a telephone interview on Monday that the most recent polio news from Iraq and Syria was both expected and alarming. “It should signal an absolute failure of the global eradication effort,” she said.
Mr. Assad’s forces, she said, “have been bombing the heck out of the people of Aleppo instead of vaccinating them, which is what they should be doing.”
While Mr. Maher said the spread to Iraq was not in itself surprising, health officials were uncertain about its precise path to Baghdad, where the victim had no obvious contact with possible carriers from Syria, most of them refugees concentrated near Iraq’s border with Syria.
“It’s great if you have clear-cut chain of transmission so you can easily see how this would happen — maybe a refugee child,” he said. “But where you would expect to see the virus would have been in the northwest, and not down in Baghdad.”
At the same time, he said, the confirmed case reflected the ability of the polio virus to find vulnerable victims, touching a child who had been part of “a pocket of under-immunized children in the community.”
Ms. Touma said the inoculation effort in Syria had made progress but was still failing to regularly reach an estimated 323,000 Syrian children at the highest risk of contracting polio, in areas of fighting or restricted access.
“The trick with polio is that we can’t give up, we have to do multiple inoculations continuously and as wide as possible,” she said.
Dangers of Measles
According to the CDC, for every 1,000 children who get the measles, one or two will die. Currently, public-health workers are worried about the situation in New York, but just in the past three months, there have been reported cases of the disease in Massachusetts, Illinois and California. The CDC reports that from Jan. 1 to Feb. 28, 2014, 54 people in the U.S. have reported being infected with measles. On average, there are about 60 cases reported in the U.S. every year. Most people in the U.S. are vaccinated against the measles, but since measles is still around in other countries, those who travel outside of the U.S. can contract it if they are not vaccinated. New York City has not been able to confirm the source of the disease.
How and Why of Polio
[consolidated encyclopedia information] Polio (short for poliomyelitis) is an infectious disease that rarely kills but cripples about 1 in 200 of its victims. The virus invades the nervous system and can lead to irreversible paralysis in just hours. Adults fight off the infection more effectively than children, most often children younger than five. There is no cure, but there have been safe and effective vaccines for more than 50 years. By their nature, vaccines need only be administered once to be effective for a lifetime, so the strategy to eliminate polio once and for all from the planet is to vaccinate every child until transmission stops. If the world can be made polio-free for a moment, it will remain polio-free forever.
The virus enters the body through the mouth, multiplies in the intestine, and is passed to others through the feces; therefore, it ravages particularly countries with poor sanitation and hygiene. Children not well toilet-trained are a danger, but even flies can passively pass the virus from feces to food. A single case of polio, if it fails to migrate to other vulnerable children, can die out in that community forever. Complicating matters, most infected individuals show no symptoms and can silently pass the virus on unwittingly until it dies out in their bodies naturally. Therefore, a single reported case is usually taken as evidence of an epidemic.
Effectiveness of Vaccination
[consolidated information no single source] A simple, inexpensive, oral vaccination developed in 1961, administerable by non-physician volunteers, is the primary method of preventing polio among children. The vaccination produces antibodies in the blood to all three types of polio virus which prevent the virus from spreading to the nervous system. A single dose costs less than a dime. In a community where the polio virus would be spread through feces contact, so can the immunization be passively spread through the same mechanism. A single dose protects most recipients. Three doses protects 95% of recipients, probably for life. 100% immunity, while ideal, is not necessary to eradicate the virus, which will naturally die out if it cannot spread through a population.
Polio was a most feared disease in industrialized countries, paralyzing thousands of children every year, until the development of vaccines in the 1960s and the beginning of routine immunization in countries around the world. From the Global Polio Eradication Initiative website:
In 1988, when the Global Polio Eradication Initiative began, polio paralysed [sic] more than 1000 children worldwide every day. Since then, 2.5 billion children have been immunized against polio thanks to the cooperation of more than 200 countries and 20 million volunteers, backed by an international investment of more than US$ 8 billion. Today, polio has been eliminated from most of the world and only four countries remain endemic. In 2009, fewer than 2000 cases were reported for the entire year.
What bad news does that terse report hide? The four endemic countries are Afghanistan, India, Nigeria, and Pakistan. But four other countries no longer on the endemic list have re-established active and persistent transmissions following an importation: Angola, Chad, Democratic Republic of Congo, and Sudan. Add to that the countries currently experiencing outbreaks due to importation (Congo, Kazakhstan, Liberia, Mali, Mauritania, and 8 others including Russia) and the challenge of containing the virus long enough to eradicate it becomes obvious.
Eradicability of Polio
Polio is a perfect candidate for eradication because the virus infects only humans, is carried in the body for a short period of time, and has an effective intervention. “We have great vaccines against polio,” says Harry Hull, chief of the World Health Organization’s (WHO’s) Polio Eradication Program. The WHO-led campaign uses the oral “Sabin” vaccine because it is cheap–8 cents a dose–can be easily administered by mouth by an untrained volunteer, and produces high levels of intestinal immunity.
IMPEDIMENTS TO ERADICATION
An editorial in the journal Lancet, SEP 2006, indicates that polio vaccination campaigns have met with distrust in communities over the years. Incorrect but understandable fears that mass vaccination is a conspiracy by the developing world against poor countries complicate the efforts of volunteers to conduct one-day mass immunization efforts which have been the most effective part of the WHO plan for years. Just as important as funding, volunteers, and sufficient doses, is building trust among poor and often suspicious people through sustained efforts.
STARTLINGLY EFFECTIVE SINGLE-DAY EFFORTS
FROM THE JOURNAL SCIENCE
One early morning, millions of people across India, from the snow-peaked Himalayas to the deserts of Radjastan, set off by foot, camel, bike, car, or helicopter to run polio vaccination posts in 650,000 Indian villages. By the time this army of volunteers arrived home at the end of the day, 127 million children under the age of 5 had been immunized against this crippling disease. “Everybody said it just couldn’t happen. And, yet it does,” says Harry Hull, chief of the World Health Organization’s (WHO’s) Polio Eradication Program. Initiatives such as the Polio Eradication Program show that WHO’s foot soldiers can make a huge difference to the majority of the world’s population without adequate health care.
The Nagging Autism Case
From JSPN (Journal for Specialists in Pediatric Nursing): A decade ago, a British researcher and 12 coauthors published a paper describing abnormal gastrointestinal features among 12 children who had been referred to their clinic. All children had some type of developmental disorder, and in 9 of the children, a diagnosis of autism had been made. In 6 of the 9 autistic children, either the parent or a physician had linked the onset of developmental regression with the receipt of the MMR vaccine for measles, mumps and rubella (Wakefield et al., 1998). In 2000, a second paper was published, in which measles virus RNA fragments were found in 3 of the 9 children. (Kawashima et al., 2000). This odd, tiny, substantially anecdotal evidential link is the basis for fears persisting until today that somehow measles vaccinations cause autism.
In 2004, 10 of the 11 coauthors of Wakefield original paper asked to “formally retract the interpretation placed upon these findings . . .” However, these initial reports of a possible relationship between the MMR vaccine and the onset of autism received significant attention, and in England, measles vaccinations dropped considerably.
In about 1 case per 3 million, the vaccine virus can itself cause paralysis. (A current theory is that paralysis results in recipients with existing immune deficiencies.) This risk, while devastating, is “accepted” by administering agencies as a necessary cost of saving “hundreds of thousands” of children each year from being crippled.
Counterintuitivity of Vaccination
The CDC reports 152 confirmed cases of paralytic poliomyelitis from 1980 through 1999 in the United States, an average of 8 cases per year. Six cases were acquired outside the United States and imported. The last imported case was reported in 1993. Two cases were classified as indeterminant. The remaining 144 (95%) cases were vaccine-associated paralytic polio (VAPP) caused by live oral polio vaccine.
In order to eliminate VAPP from the United States, ACIP recommended in 2000 that IPV be used exclusively in the United States.
Inactivated poliovirus vaccine (IPV) was licensed in 1955 and was used extensively from that time until the early 1960s.
Trivalent OPV was the vaccine of choice in the United States and most other countries of the world after its introduction in 1963. Use of OPV was discontinued in the United States in 2000.
By the end of 2003, international effort had eliminated polio from all but 6 countries in the world. In the 6 remaining countries, the disease was highly localized. But a series of misunderstandings about the safety and intentions of the vaccinators shut down the campaign, caused a nationwide epidemic, and led to reinfection of many polio-free countries. For the first time in history, more countries suffered importations of polio than were actually endemic for the disease, putting the entire eradication initiative at risk.
In Kano, northern Nigeria, local leaders began theories that the vaccine contained HIV and anti-fertility agents. Very soon, the local media were reporting the popular conspiracy theory that the polio campaign was an effort to depopulate the north of the country. Within months, political leaders in Kano and adjoining states had suspended the polio campaigns; almost immediately, hundreds of children had been paralyzed as epidemic polio returned. The virus rapidly spread from Kano to the megacity of Lagos and beyond, reinfecting polio-free countries, costing over US $100 million in emergency response activities. One of Africa’s most impressive achievements in health and international cooperation was undone by a rumor.
Resurgent Measles Threat
“Twenty-five years ago, the vast majority of measles cases were among elementary schoolchildren who caught it from their classmates, but that group now accounts for less than 10 percent of cases. Schools now require measles vaccine for enrollment.”
“Also, the disease is now attacking population groups that have not been vaccinated, perhaps through parental ignorance or neglect, or been exposed to the disease because of their age. Historically, deaths rates have always been high in such groups. Before the advent of a measles vaccine in 1963, virtually everyone could count on frequent exposure.”
“There were nearly half a million cases of measles nationally each year in the early 1960’s. The number of cases dropped to a low of around 2,000 in 1983, two decades after the development of a vaccine. But the disease began a dramatic comeback in 1989, and 1991 promises to be a bad year, particularly in the Northeast. New York City reported more cases in the first 12 weeks of 1991 than in all of 1990.” NY Times April 24, 1991.
“New York City isn’t an anomaly, though. Diseases that are and have been avoidable in the U.S. thanks to vaccines, are resurfacing all across the country. Measles, for instance, was considered wiped out in 2000, but there have been several outbreaks in the past few years.
“Though measles outbreaks are primarily linked to unvaccinated people, McDonald notes that some vaccines aren’t foolproof. For example, the whooping-cough vaccine may lose its efficacy over time. And, overall, most people do get their vaccinations. A CDC reportlooking at children entering kindergarten for the 2012–13 school year in all U.S. states found that more than 90% of these kids had their vaccines.
“Still, there are people — including public figures and celebrities — who don’t vaccinate their kids and promote their choices. Most infamously, Jenny McCarthy has espoused her anti-vaccination position because she believes vaccines are full of toxins and cause autism. When she recently posed a question on Twitter about finding a mate, the vaccination backlash was loud and clear.
“Just how harmful are these notions, though? Below are some preventable diseases making a vicious return thanks to people not getting their vaccinations.
[Sections on measles, mumps, whooping cough, and chicken pox follow in the Time article.]
Topic for Smaller Paper
Distinguish Smallpox Eradication from Polio Eradication (or make a strong analogy)
If there’s a class difference between polio and smallpox that interferes with this conclusion, I may be able to devote one of my smaller papers to detailing that difference, either to minimize it or to recommend a different approach for eradicating polio than was successful for smallpox.
However, in 1796, there was a remarkable discovery that was to change history. An English country physician, Edward Jenner, discovered a vaccine that protected against acquiring the disease. It was history’s first vaccine. Local lore believed that milkmaids did not develop smallpox because they had acquired from cows an infection on their hands that caused pustules resembling those of smallpox. Jenner took material from such a pustule and scratched it into the skin of a young boy. The boy developed a single pustule but was not ill. Six weeks later, Jenner showed that he was protected from smallpox. The disease of cowpox was caused by a virus similar to smallpox. When it was implanted in the skin, an infection occurred and the vaccine produced antibodies that provided protection against the related smallpox. It offered hope that some day the disease might be conquered. However, 180 years were to elapse before the last case was recorded.
Progress in smallpox control was slow. It improved when, during the 19th century, vaccine began to be produced by growing it in large amounts on the skin of calves. In the more developed parts of the world where health services and communication were improving, many could be vaccinated and smallpox epidemics controlled. However, the vaccine was susceptible to heat and was usually ineffective after only 2–3 days. In the developing countries, vaccine production was difficult or impossible as was vaccine distribution to most areas. Meanwhile, smallpox epidemics continued to occur. In fact, during the 20th century alone, an estimated 300 million people died of the disease – more than twice the death toll of all the military wars of that century. Indeed, until the proclamation of eradication, virtually all industrialized countries continued to conduct national smallpox vaccination programs and international travelers carried special certificates indicating that they had been vaccinated within the preceding 3 years.
Not until the 1950s were methods perfected to produce large amounts of a heat-stable vaccine that were so important for its use in tropical areas. With its development the stage was set for a program that might be able to eradicate the disease.
The first proposal that the countries of the World Health Organization (WHO) undertake a global eradication campaign was made by its first Director-General in 1953. The proposal was rejected as being “unrealistic”.
Many countries expressed frustration that more progress was not being made and asked the WHO Director General to develop a plan and budget that could eradicate the disease in 10 years. In 1966, this was considered by the World Health Assembly. It called for a special program to which WHO would contribute $2.4 million per year. Additional amounts would be required and these would have to be met by national budgets and voluntary donations. There were many who opposed the proposal, some on the grounds that eradication was an impossible goal and some who argued that WHO could not afford it.
[SIMILARITY] The scope of the smallpox program was unprecedented. It required the cooperation of all countries throughout the world and the active participation of more than 50. It was a universal effort unlike any that had ever been undertaken. Most countries eventually proved to be readily responsive but strong persuasion was necessary for some. National antipathies were generally set aside. Most remarkable was the cooperation and collaboration between the Soviet Union and the United States even during the darkest days of the Cold War. Effective collaboration and coordination between WHO’s six regional offices and its headquarters was no less a challenge. Special efforts would be needed to sustain the confidence of member countries over the targeted 10 year duration of the program and the subsequent 2 year period of certification.
The challenge was formidable. During 1967, the first year of the program, cases were reported from 43 countries; subsequent surveys showed that there had been at least 10 million cases and more than two million deaths. The endemic countries included Brazil, most African countries south of the Sahara Desert, and, in Asia – India, Pakistan (including what is now Bangladesh), Afghanistan, Nepal, and Indonesia. Their population was more than one billion persons.
Indispensable to the success of the program was an adequate supply of heat-stable, fully potent vaccine. At the time the program was to begin, vaccine was being produced in more than 40 different countries. WHO-designated centers in Canada and the Netherlands volunteered to test and certify all batches of vaccine as they were being produced. Initially, less than 10% of the vaccine batches were fully potent and stable. A standard production manual was developed; WHO consultants worked with laboratories to improve production methods; and UNICEF provided equipment to produce the stable, freeze-dried product. By the sixth year of the program, more than 80% of the vaccine needed was produced in the developing countries. Meanwhile, continuing generous donations of vaccine from the USSR and USA permitted most countries to begin to develop and strengthen their programs.
The vaccine shortage was further abated by the fortuitous discovery of a new tool for vaccination – the bifurcated needle – whose use resulted in a higher rate of successful vaccinations. More important, was the fact that it required only one-fourth as much vaccine as traditional techniques. Wyeth Laboratories, where the needle was developed, waived all fees for use of the needle. It was soon in use throughout the world.
[PURPOSEFUL SUMMARY] The program consisted of three parts
[SIMILARITY] 1. Endemic countries vaccinated 80% of their population 2. Responding to weekly reports of any outbreaks, teams were sent to vaccinate family and close contacts 3. Surveillance reports and new techniques were shared by all participating countries. Beginning in 1967, reports became global in 1968, published very 2-3 weeks until 1977.
[PURPOSEFUL SUMMARY] Just 3 years, 5 months into the program, smallpox was eradicated from 20 West African countries among the world’s most heavily infected.
[PURPOSEFUL SUMMARY] [SIMILARITY] Eradication for the 700 million residents of India and Bangladesh (and to a lesser degree Ethiopia and Somalia) was complicated by constant population movement, natural disasters, maddening bureaucracy, and dislocations caused by civil war. It was suggested that the “Ganges River basin of India [was] the natural home of smallpox from which the virus could not be dislodged.”
[MY NOTE] Throughout the article, doubt and skepticism is a recurring theme. Plans to mount national campaigns are questioned as “unlikely,” or “too ambitious,” or “too expensive.” In every case cited by the author, “unrealistic” goals are met.
Smallpox eradication had called for systematic, monitored vaccination programs extending throughout endemic countries with a goal of reaching 80% of the population. In almost all areas, vaccination was not only accepted – it was welcomed. Resistance was rare. Where local political authorities, teachers, and religious leaders provided support, a health worker could readily vaccinate 500 or more persons per day.
[COMBINATION STRATEGY EPI] The question arose as to why not administer other vaccines at the same time. Earlier studies had demonstrated that several vaccines could be given simultaneously with safety and efficacy . Therefore, in December 1970, the smallpox unit took the initiative to arrange for WHO to convene a group of national health leaders to consider a recommended policy for national vaccination programs . The meeting endorsed the creation of dedicated national vaccination programs in all developing countries that, in addition to smallpox vaccine, would provide DPT, polio and measles vaccines. It was given the name – “Expanded Program on Immunization” (EPI) and so it has remained . It began a marked transformation of interest in vaccine programs. In fact, some refer to the 1970 meeting as the beginning event of a Vaccine Era.
[CATEGORICAL DIFFERENCE] Such problems were also encountered during the smallpox vaccination program, but usually the program could be executed during periods of as little as 3–6 months of comparative tranquility in an area. However, there are 2 major differences in dealing with the control of smallpox and polio in insecure areas that are difficult to access. First, surveillance to determine whether and where the smallpox virus was present was comparatively simpler than polio surveillance and could be accomplished rapidly. The vast majority of patients had a distinctive rash; there were no asymptomatic patients and no long-term carriers. Thus, a team could rapidly search an area and determine whether the virus was present and, if it was, determine its extent and distribution without consulting a laboratory. Contrast this with the surveillance problems presented by poliomyelitis, in which there are ⩾200 asymptomatic infections for every paralyzed patient. The only way one can ascertain whether the virus continues to circulate in an area is by an extended period of surveillance, during which a great number of stool specimens are examined. Time and access to a laboratory are critical requirements.
The second difference has to do with the efficacy of vaccination. One inoculation of smallpox vaccine protects nearly 100% of those vaccinated. However, in areas where polio is endemic, at least 3 doses of OPV, and often 5 or 6 doses, are required to achieve protective levels of 90% against types I and III poliovirus, which are the predominant paralytic strains . Therefore, although vaccination immunity against smallpox could be increased rapidly in areas of conflict where access was possible for only a few weeks or months, this is not possible for polio.
At present, most industrialized countries are using IPV and most developing countries are using OPV. There are cogent reasons for this difference. Soon after licensure of OPV in 1962, it became the vaccine of choice for almost all countries. This was primarily because it was much easier to administer, it provided substantial intestinal immunity against infection with wild poliovirus, and it spread to close contacts, thereby protecting a number of people who were not themselves vaccinated. The only drawback to the use of OPV was the occasional occurrence of a case of paralytic illness among vaccine recipients and, sometimes, their close contacts. This occurred with a frequency of about 1 case per 1 million recipients of first doses of vaccine and, overall, about 1 case per 3 million doses of vaccine distributed .
By Bruce Aylward, Rudolf Tangermann Vaccine, Volume 29, Supplement 4, 30 December 2011, Pages D80-D85
Following the rapid progress towards interrupting indigenous wild poliovirus transmission in the Americas in the early 1980s, the Global Polio Eradication Initiative (GPEI) was launched with a resolution of the World Health Assembly (WHA) in 1988. The GPEI built on many lessons learned from smallpox eradication, including the large-scale deployment of technical assistance, implementing agendas of innovation and research and the use of professionally planned and guided advocacy. By the year 2000, the incidence of polio globally had decreased by 99% compared with the estimated >350,000 cases reported from 125 endemic countries in 1988. By 2002, three WHO Regions (the Americas, Western Pacific and European Regions) had been certified polio-free. By 2005, transmission of indigenous wild poliovirus (WPV) had been interrupted in all but 4 ‘endemic’ countries: India, Nigeria, Pakistan and Afghanistan, where eradication efforts effectively stalled. WPV exported from northern Nigeria and northern India subsequently caused >50 outbreaks and paralysed >1500 children in previously polio-free countries across Asia and Africa. In each of the four remaining polio-endemic countries different challenges, or a combination of factors, prevented to build up sufficient levels of population immunity to stop transmission. Consequently, specific strategies were increasingly tailored to each setting.
[HISTORICAL NOTES ERADICATION OF SMALLPOX]
The global certification of smallpox eradication in 1980 created considerable interest in further infectious disease eradication efforts. Following the rapid progress towards interrupting indigenous wild poliovirus transmission in the Americas in the early 1980s, the Global Polio Eradication Initiative (GPEI) was launched with a resolution of the World Health Assembly (WHA) in 1988 , and has since grown to become one of the largest internationally coordinated health initiatives in history.
[DIFFERENTIATION OF POLIO AND SMALLPOX]
The GPEI was fortunate to learn from the smallpox eradication experience and built on many lessons from that historic programme. However, polio eradication still faced unique challenges, in part due to the nature of virus it was targeting, in part due to the suboptimal efficacy of the oral polio vaccine (OPV) in inducing mucosal immunity in some areas of the world, and in part due to the very different era and geopolitical environment in which this eradication effort was conducted.
This paper summarizes some of the major challenges the GPEI encountered in its 20-year history, approaches that were taken to address those challenges, and the prospects for the successful completion of the polio eradication going forward.
By the year 2000, the incidence of polio globally had decreased by 99% compared with the estimated number of cases in 1988. By 2002, three WHO Regions (the Americas, Western Pacific and European Regions) had been certified polio-free. As importantly, the last case of polio due to wild poliovirus type 2 transmission anywhere in the world was recorded in Uttar Pradesh, India in 1999. By 2005, transmission of indigenous WPV had been interrupted in all but 4 ‘endemic’ countries: India, Nigeria, Pakistan and Afghanistan.
With most of the world polio-free by 2005, eradication efforts in these four remaining endemic countries effectively stalled, and WPVs exported from two of these areas (northern Nigeria and northern India) caused multiple outbreaks in previously polio-free countries across Asia and Africa since then . Although these last four ‘endemic’ countries have been the exceptions rather than the rule in the GPEI, they have provided some of the most important lessons learned.
[PURPOSEFUL SUMMARY: Challenges to Ultimate Eradication—The Last 1%] —Management failures at the provincial level to overcome remoteness and lack of infrastructure compromised the quality of immunization activities in the four remaining endemic countries. —In India, failure of trivalent OPV to overcome widespread childhood diarrhea before it was replaced with monovalent and bivalent types as a remedy. —In Nigeria, rumors that OPV rendered children sterile resulted in a devastating loss of community support for vaccination. —Underserved mobile and migratory populations moving vulnerable children who missed their vaccination rounds continued to transmit the virus. —War and civil strife in Afghanistan and Pakistan deprive health workers access. —Re-spreading of virus to previously polio-free countries (Angola, Chad, and DR Congo imported polio which re-established for 12 months or more). —Insufficient funding for SIAs has resulted in re-emergence outbreaks in African countries near Nigeria.
[QUOTATION MATERIAL: Polio is Crucially Different than Smallpox]
Paralytic poliomyelitis cannot be reliably diagnosed on clinical grounds. Also, for each reported paralysed polio case, there are at least 200 infected, virus-shedding individuals who do not show symptoms, resulting in wide-spread ‘silent’ virus transmission. To allow the detection of all remaining areas with poliovirus transmission, systems of detecting and investigating all cases of acute onset flaccid paralysis (AFP) in persons <15 years, followed by virological examination of stool specimens, were established in most WHO member states. By the mid-2000s it became clear that despite meeting global surveillance performance standards for AFP surveillance, some countries were still missing WPV transmission chains due to persistent subnational gaps in AFP surveillance quality. These surveillance gaps at the sub-national level compromised the speed of outbreak response activities (e.g. in central Africa) as well as programme planning in some endemic areas (e.g. northern Nigeria and Pakistan). To overcome these gaps and ensure more rapid detection and response to circulating viruses, in 2005 the target rate for AFP reporting in each province/state of endemic, re-infected and high risk countries was increased to >2 cases per 100,000 population aged <15 years, double the usual performance standard. In addition, environmental sampling of sewage was established in India, Pakistan, and Nigeria to complement the AFP strategy and to provide a clearer epidemiological picture, particularly in areas with discordance among epidemiological and programmatic data.
[QUOTATION MATERIAL: Polio is Crucially Different than Smallpox]
The Sabin vaccine mutates in the human intestine, causing “vaccine-derived” viral infections.
Another challenge to global eradication emerged in 1999 with the documentation of polio outbreaks due to circulating vaccine-derived polioviruses (cVDPVs). Due to genetic mutations during replication in the human intestine, the Sabin vaccine virus was found to revert to the point of regaining not only neurovirulence but also the ability to circulate and cause polio outbreaks. Although still quite rare, the regular emergence of circulating VDPVs (particularly due to serotype 2) has now been confirmed through new diagnostic tests , requiring the GPEI to enhance surveillance and response activities for such viruses (in addition to WPVs) as well as to incorporate planning for VDPVs into its post-WPV eradication risk management strategies.
[QUOTATION MATERIAL: Why Eradication is still Essential]
After more than 20 years of strategy implementation, the GPEI has been criticized for failing to achieve eradication and some critics have called for returning to a strategy of “effective polio control”. However, experience with the GPEI showed that ‘control’ is not an option as long as the disease remains endemic in any country. Failure to eradicate polio would again lead to tens of thousands of new cases within the next ten years. Between 2003 and 2009, a total of 59 polio outbreaks occurred in 30 countries, resulting in more than 1500 children paralysed for life, with over US $500 million in global outbreak response costs. On the other hand, achieving eradication would result in extraordinary humanitarian benefits by permanently eliminating an infectious disease which would otherwise continue to cripple thousands of children for life. Eradication would also have major economic benefits. An economic analysis of the GPEI  has recently estimated that, if transmission of wild poliovirus is achieved within the next five years, the net benefits of the GPEI could top US $50 billion through 2035.
[ENDGAME QUOTATION MATERIAL: Different than Smallpox?]
‘Endgame’ strategies include the global certification of wild poliovirus eradication soon after wild poliovirus transmission is interrupted globally, and the management of risks associated with the use of oral poliovaccines (vaccine-associated paralytic poliomyelities (VAPP) and vaccine-derived poliovirus (VDPV)) by preparing for the cessation of oral poliovaccine use for both routine and supplementary immunization activities.
Three major developments now appear to allow for a more efficient polio ‘endgame’, by shifting from sequential to parallel management of the highest risks over a potential five-year timeframe. This seems possible based on evidence  showing that more than 80% of the emergences of circulating vaccine-derived poliovirus are due to cVDPV type 2 (while type 2 wild poliovirus was eliminated >10 years ago ), and because of the availability and large-scale use of bOPV.
Also, there is significant progress towards making inactivated polio vaccine post-eradication affordable even for low-income countries, such as through the use of intra-dermal application of IPV which greatly reduces the amount of antigen needed per IPV dose , through alternative seed vaccine strains allowing low-cost IPV production in developing countries, and through the use of IPV schedules with a reduced number of doses.
To this effect, the GPEI is currently assessing the feasibility of the phased removal of Sabin polioviruses from immunization programmes, beginning with type 2 Sabin virus, through a synchronized switch from trivalent OPV to bivalent OPV (i.e. without type 2 component) for routine immunization.
Why did the world succeed in eradicating smallpox? Though eradication is a global public good, theory suggests that it should not have been vulnerable to free riding. Some countries, however, lacked the capacity to eliminate smallpox. Success thus depended on the other countries providing assistance. Theory suggests that this public good also should not have been vulnerable to free riding. However, financing proved challenging, even though the global benefit-cost ratio for eradication exceeded 400:1. Contrary to what theory suggests, what may have been the greatest achievement of international cooperation ever was not inevitable. Indeed, it very nearly failed.
Game Theory applied to the smallpox eradication effort. Awesome set of references. Uncertain ultimate value as a source but worth reading for mindset.
Highly detailed report and plan for hopeful eradication by 2012. Largely a PR publication that emphasizes efforts to eradicate “wild” virus with only the barest acknowledgment that a substantial portion of current outbreaks result from Sabine mutation strains.
By C E Taylor, F Cutts, M E Taylor American Journal of Public Health (AJPH) published online August 30, 2011
Intensification of polio eradication efforts worldwide raises concerns about costs and benefits for poor countries. A major argument for global funding is the high benefit-cost ratio of eradication; however, financial benefits are greatest for rich countries. By contrast, the greatest costs are borne by poor countries; the Pan American Health Organization has estimated that host countries bore 80% of costs for polio eradication in the Americas. The 1988 World Health Assembly resolution setting up the Polio Eradication Initiative carried the proviso that programs should strengthen health infrastructures. Drastic cuts in donor funding for health make this commitment even more important. Two international evaluations have reported both positive and negative effects of polio and Expanded Programme on Immunization programs on the functioning and sustainability of primary health care. Negative effects were greatest in poor countries with many other diseases of public health importance. If poor countries are expected to divert funds from their own urgent priorities, donors should make solid commitments to long-term support for sustainable health development.
Actually, a mixture of ethical and practical reservations about top-down, nationalized, mandated programs with specific immunization percentage goals:
However, a common negative effect in the poorer countries was that targeting of immunization programs caused diversion of resources and effort at “the expense of other health activities.” Negative observations were made when social mobilization produced excessive topdown pressure and “negative feelings about repeated visits for only one purpose.”
A strong conclusion was that the benefits of polio eradication in the Americas can be directly applied to policymaking only in countries with established and sustainable health systems, strong leadership at central and district levels, a well-organized infrastructure, and local ownership and decision making. A 1995 United Nations Children’s Fund study” focused on the sustainability of universal child immunization in achieving 80% coverage with all Expanded Programme on Immunization vaccines by 1990. Case studies in six countries in Africa and Asia, along with a desktop review of global activities, were conducted.
The greatest achievement was reported to be raising the immunization coverage of infants worldwide to 80% in a short time period, although only somewhat more than half of developing countries reached 80%. Universal child immunization helped focus global attention on prevention and demonstrated that services could effectively reach the periphery.
However, the increase in global coverage obscured problems in many poor countries. In the African region, 25% of countries reported 80% or higher coverage for three doses of oral poliovirus vaccine in 1990, but only 17% achieved this rate in 1994/95.24
In the case study countries, health service personnel said that, because universal child immunization goals were set globally and negotiated politically, there was little local involvement in setting targets, which were imposed on national health systems and communities. When health systems were weak, universal child immunization tended to override local delivery strategies and create parallel and unsustainable systems of financing, vaccine supply, transport, and supervision.
Top-down social mobilization increased apparent local participation, but communities were simply told what to do. Conflict resulted between local demand for integrated services, especially essential drugs, and national immunization targets.
When donor support for recurrent costs waned after 1990, little capacity or
commitment to maintain coverage remained in poor countries. In an independent
study in Ghana,25 a district medical officer said, “The approach used was: here is the money, go out! We want 80 percent by December.” A 1992 review reported that a rapid rise in coverage was followed by a fall; the rate leveled off at approximately 32%.
Wild virus 3 has already been eradicated, eliminating the urgency for a trivalent vaccine.
The public health value of this inexpensive and easily administered oral polio vaccine has been extraordinary. However, OPV is not without risk. An estimated 250–500  cases of vaccineassociated paralytic poliomyelitis (VAPP) are anticipated to result each year from sustained OPV use in a world free of wild poliovirus transmission.
Once wild poliovirus transmission is interrupted by OPV, the only poliomyelitis due to poliovirus will be caused by OPV. At the present time, reducing the numbers of VAPP cases through reducing OPV coverage is not an option. In highrisk populations free of wild poliovirus transmission, sub-optimal immunisation rates increase the
risks of poliomyelitis outbreaks caused by both wild polioviruses from the remaining endemic countries and from circulating vaccine-derived polioviruses (cVDPV) with transmission and neurovirulence characteristics of wild polioviruses.
Continued high coverage with OPV is necessary to prevent poliomyelitis caused by viruses derived from OPV. Poliovirus will be eradicated only when OPV use is stopped. In this review we discuss the virologic issues that underlie the OPV paradox and describe the programme options under discussion for cessation of OPV immunisation.
The very high mutation rate and recombination frequency of naturally replicating polioviruses provides a powerful tool for epidemiological tracking of circulating wild polioviruses, but it also provides an appreciation for the dynamic character of the poliovirus genome in nature. This genome instability is the source of greatest risk associated with the continued use of OPV.
The first official report of VAPP was issued by the US Surgeon General in 1962 and was associated with Sabin type 3 . Not every one accepted the association, given the absence of reported VAPP during the initial field trials and the subsequent years of use. With additional years of experience, the risk of VAPP has been reasonably
well defined for many countries. The estimated risk of VAPP was 1 case per 1.4 million OPV doses administered in England and Wales for the period 1985–1991 , 1 case per 2.5 million doses in the US for the period 1980–1989 , and 1 case per 1.5–2.2 million doses in Latin America . In general, the first-dose risk is higher than subsequent-dose risk, with children with B-cell immunodeficiency being at greatest risk. More recent data from India report an estimated overall risk of 1 case per 4.1 million OPV doses administered through mass immunisation.
How frequently cVDPVs may have occurred in more than 40 years of OPV usage is unknown. The powerful molecular epidemiological tools of nucleotide sequencing , referral to the poliovirus molecular clock , and rapid determination of global phylogenetic relationships have been a routine component of poliovirus surveillance for less than a decade. It is likely that revertants with increased potential for neurovirulence and transmissibility were regularly selected in communities where OPV was used, but revertant spread was restricted by high population immunity acquired through continued circulation of wild poliovirus and/or immunisation programmes.
Eradication of smallpox ranks as one of medical science’s greatest contributions to public health, saving millions from disease and eliminating the need for vaccination. The World Health Organization (WHO), in cooperation with the Centers for Disease Control and Prevention (CDC), Rotary International, and governments around the world, is in the process of completing another such accomplishment, but in a considerably different social climate and with a different pathogen. The worldwide effort to eradicate polio is likely to reach its goal by 2003, if current levels of funding and cooperation continue. While we applaud this goal and the progress that has been made, we feel that the crucial final steps in the campaign need to be reconsidered.
The WHO has implemented a plan that takes advantage of the seasonal nature of poliovirus spread. National Immunization Days (NIDs) are held during the winter, or “polio-low season.” They involve massive publicity campaigns, followed by door-to-door visits to unvaccinated households. Additional doses of the vaccine are distributed as needed during the “high season,” when outbreaks occur. This approach maximizes the effect of vaccination and bypasses many of the logistical difficulties of a year-round effort. The eradication campaign uses live Sabin oral polio vaccine (OPV) exclusively, because it is cheaper than inactivated polio vaccine (IPV) and does not require trained personnel and sterile needles (1), resources which many lesser developed countries lack.
The WHO also rigorously tracks cases of infantile paralysis and screens sewage and river water for poliovirus in targeted areas. Whenever an outbreak is detected, a local immunization campaign is carried out to prevent the virus’ spread (2). The results of the eradication effort have been impressive. Poliomyelitis caused by wild-type poliovirus (wild polio) is rapidly vanishing from even the most remote regions worldwide. The CDC projects that the world will be polio-free by 2003 (3), leaving behind a medical infrastructure for vaccination that can then be used in a campaign against measles. Under this plan, polio vaccination will be stopped by 2005, which will save about $200 million a year in vaccine-associated expenses in the U.S. alone (3). After this date, laboratory stocks of poliovirus would either be destroyed or restricted to highlevel containment facilities (3).
While this plan is promising, it is not complete. Because the WHO is relying on OPV, certification of an area as “polio-free” is accurate only by a narrow definition: no wild polio detectable in the population, the sewage, or the drinking water over a period of years. Because Sabin strains mutate readily back to virulent forms (4), potentially pathogenic viruses are still being released into the aquifers. Vaccine-associated poliomyelitis will still occur in these “polio-free” areas, at rates of 1 in 300,000 (5) to 1 in 500,000 (6) recipients of OPV. Because recycling of waste water is necessary in many parts of the world, virus excreted by vaccinees may persist indefinitely (7).
A broader, more intuitive definition of eradication would be elimination of both vaccine and wild strains–a goal that cannot occur if only OPV is used. Difficulties in distribution and lack of medical resources are cited as reasons for using OPV, but terminating the effort without making a transition to IPV contradicts the WHO goal of establishing an infrastructure for future eradication campaigns. One way to accomplish both goals would be to continue polio vaccination until IPV can be distributed worldwide. Then the campaign would not be an isolated effort, but part of a broader public health initiative (8).
Before vaccination can be stopped safely, it will be necessary to destroy most existing viral stocks and restrict access to the remainder to prevent accidental and deliberate release. For smallpox, virus stocks were located in only a few institutions before eradication, which meant that inventory control was relatively straightforward. There is no central record of poliovirus stocks, which are distributed among hundreds, or possibly thousands, of sites. Without an accurate inventory, it is unlikely that all virus stocks can be found and destroyed. For example, during structural studies of coxsackievirus B1, an enterovirus, it was discovered that the virus stock was contaminated with polio (9). This incident emphasizes the difficulty in identifying poliovirus repositories in research laboratories. Experience with influenza virus suggests that accidental release of an infectious agent from laboratory stocks may occur(10). As with smallpox, there is the possibility that some wild virus will survive for long periods in the environment (11, 12). Even if total virus destruction could be accomplished, the small size of the poliovirus genome (7.5 kb), whose sequence is known (13, 14) and whose complementary DNA is infectious (15), would make it possible for a terrorist to synthesize a new stock.
In the post-vaccine world, the susceptible population would increase each year and the large number of potential sources of reintroduction would soon constitute a major threat. Vaccination of laboratory personnel who are studying the virus or maintaining emergency vaccine stocks then creates a dilemma. If workers are vaccinated with OPV, they will shed live poliovirus into the environment. Use of IPV would allow these workers to act as carriers (because infection of the gut is still possible), increasing the probability of an outbreak. For smallpox, the fact that vaccine and virulent strains differ substantially made it possible to avoid this difficulty.
To evaluate the potential impact of a single reintroduction of poliovirus into the post-vaccine world, we can use the 1992-93 Dutch epidemic as a model. In this incident, 67 cases of paralytic poliomyelitis were reported, but the virus spread to many more individuals. High levels of vaccination with IPV meant that the paralytic cases were restricted almost entirely to members of a religious group that refused the vaccine (16). Within this subpopulation and its immediate contacts, the virus spread very efficiently; ~7% of the children in this group were actively secreting wild polio in a single sampling taken during the epidemic (17). This epidemic occurred in a nation with high standards of health care, where paralytic cases were reported promptly and additional doses of IPV and OPV were distributed to the affected area immediately. Such high standards of preparedness are unlikely to continue after cessation of vaccination. In a city of 10 million unvaccinated individuals, a rough estimate would be that a single release of virus could result in 7000 paralytic cases. It would take more than 700 years of vaccination to produce that number of cases of vaccine-associated paralysis in the U.S.
The control of poliomyelitis has substantially improved the quality of life worldwide, and the completion of this task will allow lesser developed countries to focus on other public health issues. To succeed, however, the polio eradication effort should take a balanced approach as part of a larger campaign to improve health and sanitation.
By Kent A. Sepkowitz, M.D.,
International Journal of Infectious Diseases,
July–September, 1998, Volume 3, Issue 1, Pages 54–60
A discussion of the particulars leading to the eradication of smallpox is pertinent to both investigators and the public as the clamor for more “breakthroughs” intensifies. The rational allocation of biomedical research funds is increasingly threatened by disease-advocacy groups and congressional earmarking. An overly simplistic view of how advances truly occur promises only to stunt the growth of researchers and research areas not capable of immediate great breakthroughs. The authors review the contributions of Jenner and his countless predecessors to give a more accurate account of how “overnight medical breakthroughs” truly occur—through years of work conducted by many people, often across several continents.
In the public eye, few achievements are regarded with such excitement and awe as the medical breakthrough. Developments such as the discovery of penicillin and the eradication of polio and smallpox have each become a great story built around a singular hero. Edward Jenner, for example, is credited with discovering a means of safely conferring immunity to smallpox. The success of vaccination and subsequent eradication of this disease elevated Jenner to a status in medical history that is rivaled by few.
However, the story of the eradication of smallpox does not start or end with the work of Jenner. Men such as Benjamin Jesty and Reverend Cotton Mather as well as unnamed physicians from tenth century China to eighteenth century Turkey also made critical contributions to the crowning achievement. Inoculation to prevent smallpox was commonplace in Europe for generations prior to Jenner’s work. Jenner himself was inoculated as a child. In fact, vaccination with cowpox matter was documented in England over 20 years prior to Jenner’s work.
The authors’ review of primary and secondary sources indicates that although Jenner’s contribution was significant, it was only one of many. It is extremely rare that a single individual or experiment generates a quantum leap in understanding; this “lone genius” paradigm is potentially injurious to the research process. Wildly unrealistic expectations can only yield unsuccessful scientific investigation, but small steps by investigators supported by an informed public can build toward a giant leap, as the story of smallpox eradication clearly demonstrates.
Additional Sources for Definition Topic
Lessons from the eradication of smallpox:
an interview with D. A. Henderson
Regarding the successful eradication of smallpox from the planet, an article in the May 8, 2010 Lancet offers insight I may need to use.
Force was, of course, sometimes used to achieve immunisation [sic] targets…. Organised [sic] and violent resistance during epidemics could provoke ferocious responses from vaccination teams…. Opposition to vaccination was widely regarded as being dangerous to communities in regions that had been freed from the scourge, and this was seen as sufficient justification for the use of compulsion. Compulsory vaccination schemes were implemented with the assistance of police and paramilitary forces which had considerable societal support.
The possibility of eradicating disease has been discussed for more than 100 years. A significant number of diseases have been targeted for eradication at various points, including hookworm (1907), yellow fever (1915), yaws (1954) and malaria (1955). So far, however, only one human disease, smallpox, has been eradicated,1 with rinderpest, a major disease of cattle, eradicated more recently.2 Both of these were viral infections that could be prevented with a highly effective, long-lasting vaccine. Polio and Guinea worm are now tantalisingly close to eradication, but polio eradication has been close to eradication for a decade and so shows how hard it is to achieve.
Eradication is highly attractive as a concept. The idea that one generation can, for all time, get rid of a disease for all successive generations is very motivating, including to people not usually involved in public health. Under some circumstances, eradication can be highly cost effective, because a time-limited surge in spend can save for all time, and this certainly was the case for smallpox.3 Even doing the preparation for an eradication campaign can stimulate innovation and change mindsets; the fact that malaria eradication is currently being considered has led to a systematic search for new tools and approaches.4
Three factors must be present. Easy diagnosis—so evident with smallpox—is not present with polio. Does this factor alone make eradication impossible?
Three factors have always been considered essential to any eradication effort. The first is effective interventions that alone or in combination can interrupt transmission of infection or at least take it well below R0 = 1 in all epidemiological settings. The second is that the disease has to be easy to diagnose, preferably with minimal complex laboratory facilities, so that the final cases at the end of eradication are identifiable. Smallpox, for example, could be diagnosed just by looking at someone, so finding the last cases was relatively easy and, indeed, schoolchildren were good case finders in the final stages.5 Finally, there must be no significant animal reservoir. A number of important infectious diseases that are now rare in humans, such as plague, will never be eradicated, because there is always a wild animal reservoir for the disease. In addition, for any eradication to be successful, we will need relatively simple-to-use technology, considerable central organisation, and sustained political will and money.
Should we be content with “good control,” or is the huge investment of resources necessary for eradication warranted?
It is possible to be highly ambitious in reducing the impact of a disease globally or eliminating it in a few defined areas without going for the final step of eradication, and this will be the right approach for the great majority of diseases.
Purposeful Summary: While successful eradication is hugely expensive (though not as expensive as the ongoing social cost of doing nothing to control a disease), attempting but failing to eradicate can be both costly and disastrous to the continuance of less ambitious efforts. Malaria was substantially reduced globally and eliminated locally during an effort to eradicate it. But because the stated goal was eradication, the campaign was considered a failure. Morale flagged as a result, funding for research dried up, and the disease rebounded.
Purposeful Summary: The risk of trying but failing to eradicate is greatest when the natural transference rate is high, as it is for polio. A single lingering case can start an epidemic.
Measles example: ” . . . in some high-risk groups, the incidence bounces back as soon as vaccine coverage drops, as has repeatedly been seen with polio. The recent mini-epidemics of measles in several communities in the UK where uptake of the measles, mumps and rubella (MMR) vaccine was low show how easily this can happen.”12
Eradication of polio could fail for several reasons:
Shifts in antigens for vaccine targets
Social and political factors
Small group resistance to final severe controls
Indifference of target groups as eradication nears
(“Polio, which has been very close to eradication for more than a decade, suffered in part from imperfect organisation9 but more from social concerns from social and religious groups in Nigeria and Pakistan, who see no reason to collaborate on a disease they seldom now see.”)10
“When the disease is very uncommon, the political advantage of investing a lot of resource into getting rid of the very final cases is low, as other public health problems become relatively more important to the population.”
To achieve eradication you need good technology, the maths must be right and, above all, the social, economic and political science for the endgame must be there before we start. Calling for eradication is easy, achieving it is not, and it will take a long time – always longer than planned and with most efforts in the ‘final mile’ when political support begins to evaporate. When eradication works, it leads to large investments producing indefinite gains. Trying and failing eradication is costly,17 pulls resources from other priorities, breeds cynicism and may destroy good control programmes. The key, therefore, is not to call for it where we cannot achieve it, and, for most diseases, we cannot. Once committed to a few sensible and achievable targets for eradication, determination, organisation, stoicism, deep pockets for a very long haul, innovation and flexibility are essential.
An editorial from Eastern Mediterranean Health Journal 2016
Closer to a polio-free Eastern Mediterranean Region
Things were looking very good in 2012 before the “final stage” of eradication was interrupted by social factors.
By the end of 2012, when only 95 cases were reported in total from the Region, it seemed that finally stopping the transmission of poliovirus was just around the corner. The number of cases and countries were at the lowest-ever recorded levels
Purposeful Summary: Despite social and political setbacks, in 2012, 2013, and 2014, rapid and effective responses have brought several outbreaks under control in Nigeria, Pakistan, and Afghanistan. Constant conflict in Afghanistan, bans on inoculation in some regions, attacks on inoculators in Pakistan, complicated eradication efforts and reversed successes. A virus imported from Nigeria caused an outbreak in Somalia. Etc.
Coupled with a massive surge in partner agency technical support – WHO alone has more than doubled the size of the teams working on polio in the two countries since the start of 2014, and now has nearly 2500 technical and operational experts in the field – these improvements have had a significant operational impact. At the time of writing, only 30 cases of polio have been recorded by Pakistan (18 cases) and Afghanistan (12 cases) combined so far in 2016 – a far cry from the 334 cases recorded by these countries in 2014 (9). Similarly, in 2016 only about one in 10 environmental samples in Pakistan has been positive for wild poliovirus, compared to one in every two in 2014.
The author is optimistic in 2016. Let’s see whether his optimism was warranted.
Letter to the Editor of Indian Journal of Pediatrics 2004
Of questionable value, but the article does provide the useful term “donor fatigue” to explain the drying up of resources that may be accompanying the final stage of eradication. Also of interest, the worry that the IPV vaccine will drive OPV from the market, leading to scarcity of a commodity needed to inoculate millions who could in no way afford the more expensive alternative.
The USA schedule including inactivated polio vaccine (IPV) costs a prohibitive $11 million per case of vaccine associated paralytic polio prevented (VAPP). 2 It was
hoped that after global eradication this may be discontinued. Post 9/11, with the threat of bio-terrorism, vaccine discontinuation is not priority. Perhaps by coincidence, ‘donor fatigue’ began to set into the global polio eradication programme. The government of India is now left picking up the tab of Rs 400 crores per year. Then suddenly Gresham’s Law manifests itself. Gresham’s law states that the bad drives out the good, and that bad money drives good money out of circulation. In the context of vaccines, the equivalent law will state that if there is a more expensive vaccine along side a cheaper vaccine (good coin of Gresham) the cheaper version will disappear from the market. (Like how the Typhoid A & B and Cholera vaccine [TABC vaccine] inexplicably disappeared, once a more expensive typhoid vaccine arrived on the scene). The government of India is in a quandary. It had given up its capacity to manufacture oral polio vaccine indigenously, on advise from overseas. 4 User-fee will have to be introduced for IPV. The indigent will remain unvaccinated. It is then, that the big surge of polio will sweep across the country, among the unvaccinated.
Endgame for polioeradication? Overcoming social and politicalfactors
This will likely be the primary focus of my argument: the intransigence of “local actors” whose resistance to force, suspicion of foreign agents, and vulnerability to indoctrination make universal cooperation impossible.
Abstract: We examine the social and political factors that are barriers to polio eradication. Options are discussed for solving the current impasse of polio eradication: using force, respecting individual freedoms and gaining support from those vulnerable to fundamentalist ‘propaganda’. The travails of the GPEI indicate the need for expanding the Convention on the Rights of the Child to address situations of war and civic strife. Such a cultural and structural reference will provide the basis for global stakeholders to engage belligerent local actors whose local political conflicts are barriers to the eradication of polio. Disregard for these actors will result in stagnation of polio eradication policy, delaying eradication beyond 2018.
Contains a very nice summary of historical polio policies and successes:
Polio has no known cure but can be prevented by vaccination. Before Jonas Salk invented the polio vaccine in 1955, polio paralysed and killed up to 500,000 people annually worldwide (CCP, 2013). Salk’s inactivated polio vaccine (IPV) reduced polio transmission in the USA from 20,000 cases per year in the 1950s to around 1000 cases by the 1960s (CCP, 2013). In 1961, oral polio vaccine (OPV) was invented by Albert Sabin, and from 1963, the USA replaced IPV with OPV in mass polio vaccination campaigns (CCP, 2013; Gautam, 2005). After the Centers for Disease Control and Prevention (CDC) concluded that the transmission of polio had ended in the USA in 1979, Rotary International committed to provide vaccines to six million children in the Philippines (GPEI, 2014). Due to this successful campaign and followed by campaigns in other countries, Rotary collaborated with Albert Sabin on a plan to vaccinate all children against polio worldwide utilising Sabin’s OPV. The Rotary PolioPlus programme was launched in 1985. In 1988, the Global Polio Eradication Initiative (GPEI) was launched with the goal of eradicating polio by the year 2000. When this goal was not achieved, a five-year extension was enacted. Polio worldwide has decreased from an estimated 350,000 cases in 1988 to just 416 cases in 2013 (CDC, 2014b; GPEI, 2014). However, without complete eradication, polio continues to plague populations and to burden the public health system of all infected countries.
We Can’t Give Up Now: Global Health Optimism and Polio Eradication in Pakistan
The Polio Eradication Initiative, the largest coordinated public health project in history, is currently facing serious difficulties. For years, it has tried and failed to eliminate polio from its last strongholds in Afghanistan, Pakistan, and Nigeria. Drawing on document analysis as well as participant observation and interviews in Pakistan, Atlanta, Geneva, and Montreal, I explore how officials in the Polio Eradication Initiative systematically devalued or quieted evidence that eradication was not achievable and emphasized evidence that it was achievable, thus creating a string of optimistic projections. Polio eradication’s culture of optimism ensures the continuation of the project by convincing donors and officials alike that eradication is immanent. At the same time, it prevents open, objective analysis of the problems the project faces.
Eradication, the permanent obliteration of a disease, is a powerful ideal. World Health Organization (WHO) Director-General Margaret Chan has called it “the ultimate contribution for sustainable health development” and it attracts high-profile supporters such as Bill and Melinda Gates (Gates and Gates 2007). Yet eradication programs have a high risk of failure and a high degree of difficulty. In the twentieth century, seven major eradication programs were attempted—against hookworm, yellow fever, yaws, malaria, smallpox, polio, and guinea worm—but only the Smallpox Eradication Program succeeded.
While the program has made enormous progress, bringing the worldwide polio case count down from hundreds of thousands of cases a year to around a thousand, completing the task in difficult and intractable areas has proved elusive, despite funding of nearly US $1 billion per year (WHO 2010b).
Here, I explore the ways in which officials in the Polio Eradication Initiative systematically devalued or quieted evidence that eradication was not achievable, while they emphasized evidence that it was achievable, so creating a string of optimistic projections.
Part of the reason for optimism in polio eradication, I will argue, is strategic. Because eradication is so high-risk, its proponents must defend their project against those who argue that limited funding would be better spent elsewhere.
The culture of optimism makes polio eradication more difficult by preventing open, objective analysis of the problems the project faces.
The article focuses on the difficulties of achieving end-stage eradication efforts in Pakistan:
Eradicating polio from Pakistan is extraordinarily difficult for several reasons. Fecal-oral transmission of poliovirus is very efficient in Pakistan’s hot climate, high population density, and poor water and sanitation infrastructure. In addition, the per-dose efficacy of oral polio vaccine (OPV) in South Asia is low—children may need to be vaccinated 10 or more times to ensure immunity, with at least a month between each dose (Grassly et al. ). Political and organizational issues also present major challenges (Closser 2010). Pakistan is being pulled apart by power struggles between the army, political parties, lawyers’ associations, the United States, and the Taliban, and polio eradication is not a political priority. Natural disasters—a major earthquake in 2005, flooding in 2010—further diverted political attention from polio. Eradication is not a priority for the Pakistani populace, either: polio is ranked thirty-fourth in one analysis of causes of healthy years lost in the country (Hyder and Morrow 2000), and it is not a disease that concerns mothers greatly.3
But throughout the Polio Eradication Initiative’s 20-year lifespan, these issues have been minimized or disregarded entirely by international officials. Instead, a consistently optimistic stream of rhetoric and planning has proceeded as if these difficulties did not exist. . . . For the past 10 years, Pakistan has done door-to-door campaigns multiple times a year (an endeavor well beyond what was outlined in 1993), yet polio transmission continues.
The Border Crossing Problem
But in 2006, there were still pockets of ongoing virus circulation along the border of Pakistan and Afghanistan, and surveillance data showed that viruses on both sides of the border were genetically closely related (WHO 2007b). The border is a particularly difficult area because infrastructure is nearly nonexistent in many places, nomads and refugees move freely across the international boundary, and United Nations security regulations mean that oversight by WHO or UNICEF employees is all but impossible.
The Problem of Switching from Trivalent Vaccine to Monovalent Type 1 Vaccine:
However, the introduction of mOPV1 in Pakistan did not have quite the effect that was hoped. By the end of 2006, 40 cases of paralytic polio (Type 1 and Type 3) were found in Pakistan, up from 28 in 2005 (see Figure 3). The use of mOPV1 was associated with a reduction in the number of Type 1 cases, to 20 in 2006 compared to 27 in 2005. The unintended side effect of the use of mOPV1 in Pakistan, however, was a resurgence of Type 3 poliovirus: 20 cases of paralytic Type 3 polio in 2006, up from only 1 in 2005.
Growing Donor Skepticism
A few remain staunchly committed to the project: Bill Gates, in a recent video (2011), called polio eradication his “top priority,” despite reports that he harbors some concerns (Guth 2010). But some have quietly begun shifting funds to other projects. Others say that they “have not lost faith yet” but view the Polio Eradication Initiative’s projections with an increasingly skeptical eye.
A representative of another bilateral donor agency told me that they were concerned about very low routine immunization coverage in Pakistan. “One reason may be—polio,” he said, noting that time spent organizing and carrying out polio vaccination campaigns was time not spent on other health issues.
Polio Eradication: Strengthening The Weakest Links
Polio eradication, like all eradication efforts, is a gamble. If it fails, much of the money spent will have been wasted. If it succeeds, the world will reap a dividend. Success or failure and the magnitude of the dividend depend on a long chain of “weakest links.” In this paper I identify these links and explain how the chain can be strengthened. A crucial vulnerability is the current plan to halt vaccination using the live-attenuated oral polio vaccine in the post-eradication era. This weakest link can be strengthened by efforts that lower the cost to poor countries of vaccinating with the inactivated poliovirus vaccine.
The point of this article is not to identify a range of difficulties in eradicating polio but instead to recommend one solution that may overbalance lingering difficulties. However, in its background section, it does in fact summarize the weak links.
Since the global polio eradication initiative was launched in 1988, the number of polio cases worldwide has declined more than 99 percent. This is a remarkable achievement in terms of control, but it falls one percentage point short of eradication. Eradication requires, as a first step, that incidence equal zero—exactly.
Why eradicate? The reason is not only to prevent illness. It is also to avoid the need to vaccinate in the future—the savings from which is sometimes called the “eradication dividend.” The dividend from smallpox eradication was huge. For polio the dividend is likely to be smaller, but it will be positive provided the chances of success are large enough and the risks of stopping vaccination post-eradication are low enough. 2
Eradication is a high-stakes gamble. Indeed, it is important not to be misled by the success of the smallpox eradication campaign, for that effort barely succeeded; also, the ongoing effort to eradicate Guinea worm has stumbled for even longer than that for polio, despite being a much easier target. 3
Eradication succeeds or fails depending on the “weakest links” within each specific component of the eradication effort. For polio, success depends on eliminating the wild viruses from the remaining four endemic countries, while ensuring that transmission continues to be interrupted everywhere else. Every endemic country and every other country that fails to sustain a critical level of population immunity is a weakest link in this section of the chain. Should we succeed in this phase, however, we will then need to confront a new set of challenges and many additional weakest links. These post-eradication challenges must be considered today, because if countries expect that any of these weakest links will fail, support for the current phase will fall away. Plans for the future must be integrated with current planning.
Weak Link: Afghanistan/Pakistan
People move back and forth across the porous border separating Afghanistan and Pakistan, both sides of which are variously ungoverned or under the control of antigovernment, Taliban, Al Qaeda, or tribal groups. To initiate a vaccination campaign in this conflict zone requires a cease-fire, but getting one hinges on the consent of every warring party. Making matters worse, polio can persist in, and spread from, even small populations, and not all groups are friendly to the polio eradication effort. After being warned by religious leaders that polio vaccination “was an American plot to sterilize innocent Muslim children,” many parents refused to vaccinate their children.4 Doctors associated with the polio eradication effort have been killed—targets of roadside bombs and suicide attacks. 5
Weak Link: Kano, Nigeria
The most important single event in the history of the global polio eradication effort was the suspension of vaccination in northern Nigeria, especially Kano State, in late 2003. The suspension was urged by political and religious leaders claiming that “the vaccine could be contaminated with anti-fertility agents…, HIV, and cancerous agents.” 6
To some people living in northern Nigeria, polio eradication seems a misdirected priority. Why should they be urged to vaccinate their children for polio, and be given the vaccine for free, when their children are dying of other diseases, for which no help is being offered? 7 To address this concern, Nigerian health authorities adopted new tools and tactics in early 2006, replacing national immunization days with “immunization-plus days,” during which “a range of childhood vaccinations and other health interventions are offered along with the oral poliovirus vaccine.” 8Immunization improved in some places, but not everywhere. Population immunity remains dangerously low in Kano.
Weak Link: Uttar Pradesh and Bihar, India
The GPEI has also tried to improve the efficacy of the vaccines it is able to administer, by replacing the normal, trivalent oral poliovirus vaccine, which protects against all three types of polio, with monovalent versions, which are more effective at immunizing for individual types. 9
The monovalent vaccines are crucial to the eradication effort in Uttar Pradesh and Bihar, two northern states of India characterized by rapid population growth, high population density, and poor sanitation—ideal conditions for spread. Here, coverage with multiple doses of trivalent vaccine has been high, but the vaccine often fails to stimulate immunity, probably because of the high prevalence of other enteroviruses and diarrhea. According to one study, the efficacy of trivalent oral vaccine in stimulating immunity to types 1 and 3 polio is just 9 percent in Uttar Pradesh. 10 Ordinarily, four or five doses of live oral vaccine should be sufficient to guarantee immunity, but in northern India some children have been paralyzed by polio after receiving ten or more doses. The use of monovalent oral vaccine will help, but the protective efficacy of the type 1 vaccine in Uttar Pradesh is just 30 percent. 11 To boost immunity even more, the GPEI is now considering additional options, including the introduction of bivalent vaccines (to offer protection in areas with both types 1 and 3 polio) and the inactivated (or killed) polio vaccine.
Weak Link: War Zones
Polio has circulated uninterrupted for more than a year in several formerly polio-free countries, including Sudan, Chad, the Democratic Republic of Congo, Angola, and Niger.
Weak Link: Obtaining the Financing
So far, the GPEI has raised more than $6 billion from international sources. This is much greater than the amount raised to eradicate smallpox, but it is not enough. More than $2 billion of additional money will be needed through 2013 (of this total, some money has already been pledged; a gap of about $870 million remains). 12
The willingness to pay for eradication depends on donors’ believing that the effort will succeed. After the Nigerian boycott, donations by the European Union stopped. 13 It was only after vaccination resumed in Nigeria that the money flowed once again. If donors believe that eradication will fail, funding will dry up; then the donors’ expectations will be self-fulfilling.
Weak Link: Weakened live viruses are used in the vast majority of inoculations because they are vastly cheaper and because they can be administered without needles by volunteers who are not doctors. Those live viruses mutate as they spread, and they could in themselves become increasingly dangerous, so even after the eradication of wild virus, the most vulnerable nations will still need to continue to inoculate.
When smallpox was declared eradicated, countries could decide independently whether or not to stop vaccinating. For polio, this approach could prove disastrous. This is because the weakened live virus strains in oral vaccine can evolve to reacquire the ability to cause paralytic disease and to spread. Outbreaks of circulating vaccine-derived polioviruses have occurred before (since 2000 in the Dominican Republic/Haiti, the Philippines, China, Madagascar, Indonesia, Cambodia, Niger, Burma/Myanmar, Nigeria, Ethiopia, and the Democratic Republic of Congo); more are virtually inevitable. Unless steps are taken to limit such outbreaks, and to extinguish those that cannot be prevented, the gains to eradicating wild polio will shrink. Indeed, if the vaccine-derived viruses evolve to resemble the wild viruses, as many virologists believe is likely, and if these strains cannot be eradicated, then the gains from interrupting wild polio transmission will be lost; the entire effort will only have succeeded in replacing one set of viruses with another. 15 The risk is real. Although wild type 2 polio was eradicated long ago, type 2 vaccine–derived polioviruses have circulated in Nigeria for years.
Weak Link: Odds of an outbreak of “vaccine-derived” polio following the eradication of wild poliovirus?
How likely is it that new vaccine-derived virus outbreaks will occur after the wild polioviruses have been eradicated? According to one modeling study, there is a 65–90 percent chance that at least one outbreak will occur within a year of coordinated cessation of vaccination. After that, the annual probability is expected to decline. By the third year the probability may be only 1–5 percent. 16 Note, however, that the impact of such an outbreak will increase over time. The longer the live oral vaccine continues not to be used (and inactivated polio vaccine not used in its place), the greater will be the pool of susceptible people in the population. The risk of a vaccine-derived virus outbreak could rise even as the probability of an outbreak declines.
16. Follow link provided above to its source:
16 See R.B. Aylward , R.W. Sutter, and D.L. Heymann, “OPV Cessation—The Final Step to a ‘Polio-Free’ World,” Science310 , no. 5748 ( 2006 ): 625 –626 Crossref, Medline ; and R.J. Tebbens et al., “Risks of Paralytic Disease Due to Wild or Vaccine-Derived Poliovirus after Eradication,“ Risk Analysis26 , no. 6 ( 2006 ): 1471 –1505. Crossref, Medline
Other Weak Links:
The need to synchronize OPV cessation worldwide
Vulnerability of Immuno-suppressed recipients
Proliferation of IPV production facilities worldwide
Escaped Lab Samples
For polio, surveillance is particularly difficult. Symptoms only show in about one in 200 infected people. Moreover, “acute flaccid paralysis” has other causes than polio. Evidence of polio circulation cannot be proved in the field; it must be confirmed by clinical diagnosis.
The Shame Factor
Surveillance is of value only if the information obtained is reported to the world. National pride can be a barrier to rapid reporting. Officials in Somalia suppressed information about smallpox cases in the final months of that eradication campaign, not wanting their country to bear the stigma of being the last to harbor the virus.
Outbreak Preparedness and Response
Delicate Post-Eradication Strategy
Substituting Live Vaccine
If poor countries could acquire inactivated vaccine more cheaply, this and other post-eradication weakest links would fall away.
The likelihood of a post-eradication outbreak of vaccine-derived viruses would be unchanged, but the consequences of such an outbreak would be less dire. Post-eradication outbreak preparedness and response would also improve.
The incremental cost to all poor countries of switching from live oral to inactivated vaccine is about $317 million per year.27 This is less than the amount spent each year on polio eradication since 2000; it is less than half as much as has been spent in recent years. 28
Rich countries might be willing to pay for this cost, at least for a period of time (say, five years). Recall that the probability of a post-eradication outbreak of vaccine-derived virus will decline over time. If the risks of such outbreaks can be greatly reduced, then the risk-reward balance will tilt in favor of vaccine cessation, for both poor and rich countries. This would yield the world a return on its eradication investment.
Reducing the Cost of Inactivated Vaccine (IPV)
Reductions in the cost of stimulating population immunity using inactivated polio vaccine would help even more. Shifting production to developing countries could lower production costs,
Another idea is to spread the fixed costs of needle injection by combining inactivated poliovirus with other antigens.
Alternatively, use of intradermal injection would allow inactivated vaccine to be administered with almost as much ease as oral vaccine.
The GPEI is exploring all of these possibilities. Although the world’s attention today is understandably focused on eradicating the wild viruses, the ultimate success of the initiative will depend as much on the steps being taken now to improve the economics of inactivated polio vaccination. These steps will strengthen what is perhaps the most critical weakest link in the post-eradication chain.
National choices related to inactivated poliovirus vaccine, innovation and the endgame of global polio eradication
From the Abstract, a plan to replace Oral Vaccination with IPV (Inactivated Polio Virus) inoculation, which requires needles.
Based on insights from modeling, we offer some perspective on the current status of plans and opportunities to achieve and maintain a world free of wild polioviruses and to successfully implement oral poliovirus vaccine cessation. IPV costs and potential wastage will represent an important consideration for national policy makers. Innovations may reduce future IPV costs, but the world urgently needs lower-cost IPV options.
The continuing problem of persistent endemic pockets that can trigger outbreaks in places that do not maintain high immunization percentages:
However, the last reservoirs of WPV1 in the remaining endemic areas of a few countries continue to experience cases and to export viruses that cause outbreaks (defined as one or more linked paralytic cases) in previously-polio free areas that achieved, but failed to maintain, high population immunity.
Thus, after reaching its lowest ever annual global number of countries reporting WPV cases and total reported WPV cases to date in 2012 , importations of WPV1 into countries with insufficient population immunity to prevent transmission (e.g., Somalia, Kenya and Syria) led to outbreaks in 2013 .
The article made this claim in 2013, in a bold headline:
The world is close to wiping out the poliovirus, but Nigeria threatens to undo it all. Muhammad Ali Pate is on a mission to change that.
Anecdote of Muhammad Ali Pate, Nigeria’s Minister of State for Health, convincing one reluctant boy to permit his family to be vaccinated.
It’s a small victory, he confides later in the back seat of the Land Cruiser. But that’s what it takes to eradicate polio in Nigeria. “There is science to polio eradication,” he says. “But making it happen is art.”
Muhammad Ali Pate has been trying to do what no one has been able to accomplish before him—finally drive the poliovirus from Nigeria, one of the last and most stubborn reservoirs in the world. The stakes are high: The outcome of the 25-year-and-counting effort to wipe the virus off the face of the earth rests in large part on the effort that Pate and his handpicked team have put together here in northern Nigeria.
You can’t do it by fiat, Pate explains to me later during a 3-day car trip in mid-April through the north, where the virus is entrenched. Top down doesn’t work in a country as complicated as Nigeria, an amalgam of colliding cultures and ethnic groups, with a discredited and powerless federal government and relentless insurgency and violence.
Pate is convinced that the virus can be dispatched from the country by the end of 2014, the new deadline set by the leaders of the Global Polio Eradication Initiative (GPEI), which has so far spent more than $10 billion trying to eliminate the scourge of polio worldwide. More data, more money, and more troops are being poured into the effort than ever before, thanks to the Bill & Melinda Gates Foundation and other international partners and donors, who desperately want Nigeria to finish the job so the rest of the world can, too. And they have been betting big bucks that Pate, if anyone, can pull it off. He has come close before, getting cases down to a record low of 21 in 2010.
The Human Development Index ranks Nigeria 153rd out of 187 countries; Transparency International places it among the more corrupt countries in the world. Understandably, there is no love lost between the poor of the North and the government they feel has abandoned them.
So when vaccination teams come around with nothing to offer but drops of oral polio vaccine (OPV), many people are suspicious and fall prey to rumors that the vaccine is contaminated with the AIDS virus or infertility drugs, part of a Western plot to decimate the Muslim population. Rumors and misinformation reached such a frenzy in 2003 and 2004 that four northern states banned all polio vaccination outright, sending cases soaring to 1122 by 2006.
We are going to Kaduna and Katsina states, which last year had about 40% of the polio cases in the country and where, despite the country’s stepped-up effort, vaccinators are still missing too many kids. As we set out, Pate talks about the murders in Kano, another of the high-risk states. At about 9 a.m. on 8 February, gunmen on motorcycles stormed two clinics in rapid succession, killing 10 health workers and one client, all women. The vaccinators had just assembled before heading out for their “mop-up” day, when they try to find and vaccinate kids missed during the previous 3-day door-to-door campaign.
Violence and terrorism in Nigeria are nothing new. The Islamist insurgency is so intense that the president in May declared a state of emergency in three northern states and sent in troops. Schools have been burned, students murdered, villagers massacred. Aid workers have not been immune. In August 2011, 23 were killed and scores injured when the Islamist insurgent group Boko Haram bombed U.N. headquarters in Abuja. But polio workers had never before been directly targeted. No one has claimed responsibility.
Haruna Kaita, a professor of pharmacy at Ahmadu Bello University in Zaria spread rumors about the polio vaccine.[He] analyzed samples of OPV and found traces of estradiol and other contaminants, feeding into the furor that led to the vaccination ban of 2003 and 2004.
The ban was lifted only after intense national and international lobbying, with then-President Olusegun Obasanjo assembling several delegations to test the vaccine, and GPEI providing assurances that only vaccine made in Indonesia, a Muslim country, would be used in Nigeria.
Kaita made a CD repeating earlier assertions that the polio vaccine “contain[s] birth control and birth defect-causing substances … [and] that children could contract other diseases through the [vaccine], it could be cancer, HIV, or mad cow disease …” The cleric, Ibrahim Ahmad Aliyu, said, according to a translation: “Forceful oral polio vaccinations are an American-planned genocide against the Muslim populations in Nigeria.”
Anecdote of an outbreak that spreads from Nigeria throughout the Horn of Africa among the unvaccinated hordes displaced by the ongoing refugee crisis from Somalia.
Always in the News
As I write this, NPR is broadcasting a story of vaccination workers being killed by “militants” in Pakistan. They link the episode to “the CIA used vaccinators to spy on Pakistanis in an effort to find Osama bin Laden.”
[END OF REFUTATION SECTION]
Current State of the Research Paper
The thrust of my research continues to convince me that the effort to once and for all eradicate polio from the planet is a worthwhile and achievable global good. I will propose continued and even stepped-up efforts to eliminate this virus from the planet once and for all, despite excellent arguments to the contrary.
the money could be used to alleviate more suffering more immediately by attacking less recalcitrant diseases;
that human beings will never universally accept the necessity and efficacy of the effort and will therefore sabotage the effort;
that eradication is a myth since new strains will always replace the old before the old dies out.
that resistance will build based upon the awareness that many children will be infected, some paralyzed, some even killed by the eradication effort.
I feel strongly that the tiny risk of transmitted paralysis to one child in 3 million is “acceptable,” God forgive me for saying so.
I also insist that it might be necessary to compel the reluctant last however-many-thousands to submit to vaccination against their wishes.
I recognize the moral dilemma, but think it might be forgivable to lie about that tiny risk if to do so put a rumor to rest that threatened the entire program.
The success rates of various vaccines (there are four);
more opinions on the origins of the Nigerian rumor (there are many);
details of the life-cycle of the poliomyelitis virus (when will we know it’s really, really gone for good?);
ancillary techniques for immunization (can we use bad sanitation to our advantage?).
I love the counterintuitive result that immunization can be spread accidentally the same way the virus is spread!
Suggestion for an Exercise
Exercise E00: A Practice Opening
Let’s produce our own opening together using the preceding story of the counterintuitive setback as our prompt. By the end of class, produce a Practice Opening like those you’ve seen elsewhere in this White Paper. Add it to your post, “Polio Notes—Username.”
On January 15, 2004, the leaders of the World Health Organization and UNICEF met with the health ministers of the 6 remaining polio-infected countries and 3 of the recently reinfected countries to issue the “Geneva Declaration on the Eradication of Poliomyelitis,” stating that 2004 presented the best, and possibly last, chance to achieve this global public good. The declaration introduced an aggressive plan to immunize a total of 250 million children during door-to-door polio immunization campaigns in each country within the next 12 months. The Nigerian minister outlined an extensive program of joint work with Kano state authorities to resolve the remaining doubts about the safety of the polio vaccine and then allow the resumption of the polio immunization campaigns. In 2016, polio still exists in the world. Is the present moment, once again, our “best, perhaps last, chance” to eradicate the disease?