The Continual Polio Crisis

For centuries, infectious diseases have lead to a great burden, causing disability and mortality for people worldwide.  As countries have developed, technologies advanced, and pharmaceuticals created, infectious diseases have become less of a burden, giving way to chronic disease.  However, in most developing countries, infectious disease remains a major cause of disability and mortality.  The toll of infectious disease is difficult to accept when we speak of diseases that can be easily prevented with a vaccine.  Such is the case with the polio, a virus that invades the central nervous system, which can lead to paralysis or death in severe circumstances.  The vaccine against polio is highly effective, inexpensive, and provides lifelong immunity against the tremendously devastating effects of the virus.

For many years, polio was endemic to over 125 countries, but vaccination efforts proved useful in eliminating the disease in most of these.  The World Health Assembly launched the Global Polio Eradication Initiative in 1988, ensuring that all countries were able to work towards eliminating polio from their population [3].  A country or a nation is certified polio-free after demonstrating several components.  First, there must be three consecutive years of zero new cases of “wild” polio.  Second, they use surveillance methods to account for new disease burden.  Finally, they maintain the capabilities to detect, report, and respond to any new cases caused from travel or importation of the virus [6].  The Americas were the first large global region to effectively eliminate polio from the population.  Consisting of 36 countries, the Americas were declared polio-free in 1994.  The Western Pacific followed suit in 2000, certifying its 37 countries and areas polio-free.  Finally, the 51 countries in the European Region were certified polio-free in 2002 [3].  The remaining illness was found in Northern Africa, the Middle East, and India.  Eradication efforts in these areas, however, have proven a little more difficult.  As of 2008 Afghanistan, Pakistan, India, and Nigeria remain the only four countries worldwide where polio is endemic [4].  

The road to elimination of polio in these areas has been very rocky and massive campaign efforts have met extreme resistance, particularly in India and Nigeria.  Due to the nature of the disease, it is necessary to vaccinate at least 90% of the children in order to prevent further spread of the disease [6].  The course of vaccinations in Nigeria showcases the importance of reaching this number of children.  With simply one infected person, polio was imported to neighboring Chad in 2003 where the disease was no longer endemic.  However, not all children in Chad were vaccinated at the time, and polio once again began to spread quickly.  This began a subsequent rapid spread to people in 25 neighboring countries that were previously considered polio-free until 2005 [3].  Massive efforts were again launched to stop the spread of the disease and regain the prior elimination status.  In Nigeria, however, religious leaders caused panic in the people about the vaccine.  Rumors spread that the vaccines were contaminated and would transmit HIV/AIDS or cause infertility in the recipient [2].  The government stopped all polio vaccination attempts for eleven months.  Meanwhile, polio was rapidly spreading through the Nigerian people and quickly being exported to surrounding countries. 

Once the ban on the polio vaccine was lifted, public health professionals in Nigeria were faced with the daunting task of mass immunizations.  Not only were they faced with the need to immunize the thousands of children, they needed to extensively educate the people on the truths of the disease, the benefits of the vaccine, and dispel any myths they had heard.  Convincing extremely religious people that their religious leaders gave incorrect information did not prove easy.  The mass vaccination campaigns proved helpful to get a large number of children newly vaccinated after the spread to neighboring countries.  Yet, many more children remained unvaccinated, either because of lack of access or because the parents refused the vaccine.

Similar issues have also been faced in India with people being afraid of the vaccine and the possible side effects, either due to rumors, religious beliefs, or simple ignorance on the matter.  Gautam Lewis, a 23-year-old polio survivor was adopted from an orphanage in Kolkata, India as a child and taken to live in the United Kingdom [1].  He decided to return to India as an adult and help with the vaccination campaigns there, similar to those conducted in Nigeria.  His videos (http://www.freedomintheair.org/?p=1545) demonstrate that the efforts of public health workers are often futile.  They met extreme resistance with people of rural India, especially those of the Muslim faith due to similar rumors about the vaccines causing infertility.  Lewis was able to convince some parents that the benefits of the vaccine far outweigh the costs of becoming crippled such as he was.  However, he faced many cultural barriers.  Some women explained that even though they wanted to vaccinate their children against polio, their husbands would beat the women if they found out.  Additionally, some people that answered his knocks at their homes insisted that the children were not theirs, even if the women were nursing one of the infants.  Lewis was only able to coax the parents to a certain extent, but he knew that he could not convince everyone simply because the cultural and religious beliefs were too strong for the parents to waiver on their opinions.  Unfortunately, Lewis’ experiences in India were very similar to the vaccination efforts (and not exceptional outcomes) in Nigeria. 

The experiences in Nigeria have proven two things: the need for surveillance of disease worldwide to help prevent the further spread of illness in non-endemic areas, and that people who opt out of vaccines are putting not only their own children at risk, but also the lives of all those they come into contact with.  The rapid spread of polio in Northern Africa in the countries surrounding Nigeria was halted relatively quickly due to use of their surveillance and reporting systems.  Health professionals were able to track exact cases, treat them immediately, and report to the World Health Organization, requesting immediate assistance.  Without these methods, the imported virus could have taken a much larger toll and lasted for a longer period of time before being eliminated from those countries again.  The concept of not vaccinating due to beliefs is a much trickier situation to approach.

Learning from the Nigerians, we know that the spread of disease can be rapid and that the effects are magnified in populations where not all children are vaccinated.  Currently in the United States, there is a new trend developing to not vaccinate children.  Reasons are varied, from the belief that vaccines contain thimerosal, to religious beliefs that God will protect all people from illness and thus vaccines are unnecessary.  We will examine the former issue.  Thimerosal, an organomercury compound that is a known human toxin, was used in trace amounts in some multi-dose vaccines as a preservative to prevent the growth of bacteria and fungi in the vaccine [4].  This preservative has sparked huge concern in autism awareness communities, where many parents attribute their child’s autism to the thimerosal in vaccines.  Thus, parents that have one child with autism are generally avoiding vaccinations of subsequent children to attempt to prevent autism a second time.  Additionally, many people that work around this population have become hypersensitive to these claims and are also avoiding vaccinations.  However, since 1999, the vaccines routinely given to children that contained thimerosal have been reformulated to use other preservatives that do not contain mercury [4].  The facts and causes of autism may not be discovered in our lifetime, but the effects of large masses of people not being vaccinated may quickly catch up with us.  These pockets of society that are choosing to not be protected against a myriad of infectious diseases could soon fall victim to severe illness, as well as spreading the disease quickly. 

So, what role should the government, or regulatory agencies, play in enforcing immunization requirements?  Currently in the United States, ensuring vaccination compliance is left to each individual state as requirements for entering the school system.  In California, for example, children are required to show proof of at least beginning vaccination series before entering kindergarten.  However, as stated previously, any parent is allowed waive their child’s vaccination requirement for personal or religious reasons.  Therefore, at any given school we could find a large variance of immunization compliance, making some children very susceptible to contracting an infectious disease.

In future vaccination campaigns, the public health workers should design their campaigns to completely address cultural and educational issues.  A partnership should be formed between the prominent leaders in the country, both religious and political, and public health workers to ensure that both parties are being sensitive to the needs of the other.  With this as a foundation, it might be easier to reach more people in the rural communities of developing countries in vaccination efforts.  Of the countries that once were endemic to polio, over 96% of them have now eliminated the disease and the world is very close to eradicating the disease.  By increasing efforts that are more culturally, spiritually and politically sensitive in combination with similar mass vaccination campaigns, eradication of polio could occur within the next few years.

References

1. Passport from Polio (2008) In Freedom in the Air online.  Retrieved February 8, 2009 from http://www.freedomintheair.org/?p=1545.

2. Pinock, S. Poliovirus spreads beyond Nigeria after vaccine uptake drops.  British Medical

Journal 2004.

3. Poliomyelitis (January 2008) In World Health Organization online.  Retrieved February 7, 2009, from http://www.who.int/mediacentre/factsheets/fs114/en/index.html.

4. Thimerosal in Vaccines (January 14, 2009) In U.S. Food and Drug Administration online.  Retrieved February 7, 2009, from http://www.fda.gov/Cber/vaccine/thimerosal.htm#t1.

5. Wild Polio Virus 2000-2009 Data (February 3, 2009) In World Health Organization online.  Retrieved February 7, 2009, from http://www.polioeradication.org/content/publications/AbujaCommitments_04Feb2009.pdf.

6. Wipfli, H. Global Efforts to Eradicate Polio.  Presentation observed at the University of Southern California, February 9, 2009.