There's a polio problem in Nigeria. You may have heard that. Unfortunately what you haven't heard -- and what one could even characterize as a cover-up -- is that among the many cases of polio in northern Nigeria and surrounds, there are also 69 cases of paralytic polio in children from the type 2 vaccine strain:
Nigeria has found 69 cases of children paralyzed by polio not caused by wild polio viruses, but rather weakened viruses from polio vaccine that have circulated and regained their power to cause disease, a team of international scientists reported Thursday.The ongoing outbreak in northern Nigeria, which started in 2005, is also responsible for two cases of polio in neighbouring Niger, the scientists reported in Morbidity and Mortality Weekly Review, a journal published by the U.S. Centers for Disease Control.
The article details polio cases that trace back to circulating vaccine viruses, one of the major wild-cards in the labouring international effort to eradicate polio. (Helen Branswell, cnews)
The live vaccine is given in a sugar drop orally, is cheap and is the method of choice in the developing world. The vaccine virus can also infect care givers and those not vaccinated, usually a good thing as it involves increased vaccine coverage, albeit involuntary. The live virus used in vaccines is a weakened form of the wild type, but on rare occasions the virus changes in ways that aren't clear and causes paralytic disease. Paralytic polio from live virus vaccine (the Sabin vaccine) is very uncommon but when millions of people get a vaccine, even uncommon things happen. Because about half the very small number of paralytic polio cases in the US were vaccine associated, some years ago the decision was made to return to the killed virus (Salk) preparation. That is an intramuscular injection and takes much more in the way of resources. It also involves needles and their disposal. So the live virus vaccine remains the WHO polio eradication program's weapon of choice. They rationalize this by their view that when a rogue vaccine virus appears, its chain of transmission is relatively short and easy to halt. They further explain the Nigerian outbreak as a result of the low vaccination rates there, where rumors that the campaign was related to population control sent vaccination compliance plummeting. But a main reason for targeting a population surely must be it has a low vaccination rate.
Obviously this outbreak is a sensitive topic because of the fear it will further impede compliance with polio eradication efforts and set the whole program back, perhaps irreparably. The fears may be understandable, but not revealing the existence of a problem of this size seems a sure way to lose credibility, without which no program can hope to succeed.
While they acknowledge the sensitivity of the topic, a number of polio experts are dismayed the outbreak has taken so long to come to light. They've been hearing about the cases for months, through contacts and back channels.
"This has been going on for more than a year and a half and we have nothing at all about it until now? If we're this concerned about the [vaccine-derived polio viruses] let the information become public," Dr. D.A. Henderson, the infectious diseases expert who led the successful smallpox eradication program, said from Baltimore, Md.
The size of this vaccine-derived outbreak is worrisome. It would seem that either a particular batch reverted to virulence or all the cases are spread from one original case or cases. We need to know what is going on here. Not reporting it for fear of alarming the public hampers systematic investigation and is destructive of public trust.
Not well handled.
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How can these pharma companies continue to get away with these crimes against humanity? Capitalism in the USA has become a distorted, evil-doing shell of what it once was.
Michael: This isn't a pharma issue. It is a public health policy issue about how you communicate with the public and how you retain credibility. I don't know how old you are, but in my youth polio epidemics happened every year and they were frightening and they took a terrible toll. Vaccination against polio is very important and the Sabin live virus vaccine is still much better than nothing. Much, much better. We are talking about how it is administered. In the age of the internet health authorities cannot afford to withhold information, even information they fear will make people think twice about vaccination, because the alternative, loss of trust, will affect not only that program but many other programs. Like everything, it is a balancing act. The proper balance wasn't achieved here, IMO.
They further explain the Nigerian outbreak as a result of the low vaccination rates there, where rumors that the campaign was related to population control sent vaccination compliance plummeting.
People who eschew vaccination will, in the long term, find out that Nature has its own methods of population control. Ones which are far more unpleasant.
--
Especially in the larger context of trust/lack thereof in public health efforts in Africa. I was just ranting the other day about that African Archbishop who says European countries are deliberately infecting condoms with HIV to wipe out Africans. Is that credible? No. Does he have an anti-safe sex axe to grind? Yes.
But coverups like this one do nothing to make either of those facts clearer.
And it's not like Europeans and world authorities had a surfeit of African trust to squander, for sound historical reasons.
More directly on-topic....Even assuming they're unwilling or unable to switch to a Salk vaccine, wouldn't they want to consider recalling that batch? I mean, aside from tracking what has happened, wouldn't you want to put a lid on it continuing to happen?
Preventing new cases would seem to me to be pretty important if your goal was to keep people getting the vaccine. Because it's not like these kids are getting paralytic polio and no one's noticing. Even if the public health authorities never cop to it, it's kinda hard to miss.
I contracted polio in 1954 at a family reunion when I was 13 months old. At that time the vaccine had been given to school aged children but not to the infants and toddlers in Indiana. There has not been a day, a breath, a step in my life unaffected by polio.
69 cases of children paralyzed by polio may not seem like a huge number, but for those Americans who have forgotten, polio is not like catching a cold. These children will never completely recover from this virus. A report released last year showed that in developing nations many children having the deformities of polio are ostracized from their communities, denied any opportunity for education and are usually considered unacceptable as potential spouses.
Every year children and teens contract polio through problems in the distribution of the live vaccine given on sugar cubes. To withhold information and to fail to report these problems in a timely manner allows the disease to spread to more children, minimizes the suffering of the children and parents who must now live with this disease, and diminishes the hard work so many groups and individuals have done over the years in an attempt to bring an end to polio. The irresponsibility of WHO has fed, once again, right into the mindset of fear that has prevented the eradication of this disease.
Lea
As an aside, three of my cousins also contracted polio and died because there were insufficient iron lungs available to handle the number of people who needed them. This would appear to be similar to the ventilator situation we may face with H5N1 or its ilk. Has anyone examined the criteria used by hospitals during the polio epidemics to see whether any valuable lessons learned from those difficult decisions may be of help to us?
"Those who cannot learn from history are doomed to repeat it."
When the US switched from live to killed polio vaccine a few years ago, I was initially alarmed. My reading revealed that, at the time, several years had gone by without a single case of wild virus infection and the only cases of polio were from the attenuated kind.
It presents a difficult problem when the most effective method of preventing a disease has a small but measurable rate of a catastrophic adverse event.
OTOH reporting in the West leaves much to be desired. The risks of widespread public dissemination. In a country with one of the worst health system rankings, it is clearly a "rock-and-a-hard-place" challenge.
Lea,
Unfortunately, we humans fail to learn our lessons well. No doubt, after the pandemic has swept its way through, our politicians will blame everything on the pandemic, forgetting of course that hospitals were understaffed, the police were understaffed, the population was under prepared, and the infrastructure was under prepared for what eventuated.
Lesley Robert's article in Science (only the abstract is available without a subscription) states that Nigeria's VDPV outbreak was discovered and reported to CDC and WHO in September 2006.
Among many other issues yet to be communicated, I hope officials will explain to us:
1. What kinds of informed consent efforts are made during mass immunization campaigns in developing countries such as Nigeria.
2. Were there any formal agency analyses that suggested that more children would be paralyzed or killed if the outbreak were announced sooner rather than later? If so, will the agencies share these analyses with the public?
3. Were there any formal surveys and analyses that suggested that more parents would refuse vaccination for their children if they knew about the current VPDV outbreak than if they did not know about it?
4. Officials from Nigeria's MOH, the U.S. CDC, and WHO also owe donors and the rest of us a candid and transparent summary of all internal and inter-agency discussions and dilemma-sharing which led all three agencies to decide to withhold information about this outbreak for at least a year.
When such decisions violate an agency's own "Announcing early" and "Transparency" guidelines, such as The WHO Outbreak Communication Guidelines, it is necessary to fully explain the reasoning.
See the "Announcing Early" and "Transparency" sections of those Guidelines. The "Transparency" section includes this important caveat:
"Announcing the limits of transparency publicly, and explaining why those
limits are being set, is usually well tolerated provided the limits are
justified. But if limits to transparency become excuses for unnecessary
secretiveness, the likely result will be a loss of public trust."
Live virus in with a place that has one hell of a lot of AIDS/HIV.
Anyone want to speculate what the original polio research by the Belgians might have to do with this.
Lots of information suggests, I say again suggests that AIDS/HIV might have had its origins in polio research and the primates they used for the tests.
M. Kruger - stop spreading debunked theories. Here's a great Nature article from 2004 refuting the HIV/polio vaccine link.
Jody,
Polio vaccination isn't mandatory, families can refuse and in fact many do - which is a problematic for the program in areas like Western Uttar Pradesh in India. Of course, there is no informed consent, but the idea is their government considers the campaign to be a public health priority in which there are severe externalities to individual decisions. Many countries however did make smallpox vaccination mandatory with legal consequences but to my knowledge this has not been the case for polio in any country (nor would it be effective given the very different biological and epidemiological characteristics of the pathogens).
The outbreak is unlikely a batch problem - on rare occasions batches have previously been contaminated with virulent poliovirus before additional safeguards were implemented, but these are vaccine derived strains which usually arise after passage through hosts and are then transmitted environmentally in a community with low immunity.
It's important to remember that the polio campaigns aren't control programs, we've committed to eradication which means 0 cases or bust. There won't be a second chance, and worldwide gains over the last 2 decades(which are extraordinary to say the least) will likely revert should we fail. This isn't a justification for withholding information, but there is a balance between that and taking the necessary time to fully explore and understand the situation.
Finally, it's important to understand the context of D.A. Henderson's remarks. In 2002 at the IDSA meeting he created much controversy by urging the polio program to abandon its eradication goal. This isn't meant to bring into question his comments but it helps to know some background.
Naman-that theory hasnt been debunked at all. The study admittedly only found that a NEW SIV virus had been found. Not that the original had not gone transgenic from simian to human. I doubt that it will ever be proven either way. The Belgians did use humans and monkeys in their tests, both without their knowledge in the Congo. Many still bear the results of that.
Good news: WHO explained to Associated Press medical reporter Maria Cheng (former WHO spokesperson) that it wasn't really necessary to inform the world sooner about the world's largest-known VDPV polio outbreak in Nigeria:
PF: I just looked at the new IHR and noticed that polio may be notifiable but only the wild type. I wondered about that qualitification. Now I see it in practical operation. Sigh.
Is it really impossible for WHO to find the resources to give people in Africa the same standard of polio vaccine that people receive in the US, when the killed vaccine is demonstrably safer?