Nigeria: Progress and All that is Wrong with Polio Eradication

During high season for polio this year, Nigeria has seen only one case of paralysis caused by the wild virus – an achievement which, if viewed in isolation, can be hailed as a great global health success.

But the single-minded focus on polio eradication appears to have left routine immunization behind. Measles deaths spiked last year not only in Nigeria but globally.

Now, ironically, Nigeria’s exceptionally poor immunization system is obstructing the goal of polio eradication.

Read the rest on Humanosphere...

Gates Foundation Crushing Polio in Nigeria

It's high season for polio in Nigeria--and there have been no cases for seven weeks. The Gates Foundation arguably runs the polio eradication effort, and apparently to good effect.

The remarkably low numbers seen in Nigeria are probably not due to missed cases. The quality of surveillance can be measured in a number of ways. There usually is at least one case of non-polio paralysis a year for every 100,000 children. Below that ratio, surveillance is considered inadequate. To distinguish polio from non-polio paralysis, stool samples must be analyzed, with a goal of testing 80% of cases. Nigeria's scores on both these measure have been climbing since 2006. The stool sample rate now approaches 100%.

It is difficult to descry changes in these measures easily attributable to new and improved management. Regardless, in a kind of pincer movement, better surveillance and increasing quality of immunization campaigns are slowly crushing polio.

Nigeria might or might not make it to the end of 2014 with no cases. If it does, transmission in the country could be declared as halted, which might be important for meeting the global eradication deadline of 2018. However, Pakistan, which faces an intense although geographically circumscribed polio explosion, unquestionably will not halt transmission this year. If the eradication timeline is taken literally, Pakistan's situation will require adding one year to the schedule, i.e. missing yet another eradication deadline and likely adding roughly $1 billion to the budget. 

The Independent Monitoring Board, de facto interpreter of the eradication plan and arbiter of progress, will have a report out soon.

Polio: What the “other” global health crisis tells us about Ebola

The World Health Organization (WHO), technically responsible for the world’s health and declaring emergencies, is actually in charge of neither. In late July, before declaring Ebola to be a global public health crisis, WHO’s Emergency Committee declared polio a public health emergency of international concern. Ebola only graduated to the same status a week later after American health care workers became infected. The world then ignored WHO’s alarm for weeks as Ebola exploded. The other “emergency”—polio—overshadowed an actual Ebola crisis, and makes visible WHO’s decline to infantilized order taker and the primacy of the Gates Foundation.

Polio "Emergency"

When WHO declared polio to be a public health emergency on May 5th, 2013, the risk of polio spreading sat near its lowest level in human history.

Polio is more than 99% extinguished compared to 1988 when there were 350,000 cases in 125 countries. The polio “emergency” came not from risk to public health but risk of not making the eradication schedule. To make a 2018 deadline, polio transmission must be stopped by the end of this year. Similarly, in 2011, the CDC declared polio to be a maximal, Level 1 crisis to meet a now-passed 2012 deadline. Still today, the CDC Emergency Operations Center recognizes two emergencies: polio and Ebola.

Calls for WHO to make polio a global health emergency originated from the Independent Monitoring Board (IMB) of the polio eradication initiative. Set up in 2010, IMB says it was “convened at the request of the World Health Assembly.”  However, there is no World Health Assembly resolution that mentions or requests an independent monitoring board. “I have just had a good look too,” said IMB spokesperson, Paul Rutter, “and can't find it either.”

Notwithstanding the unclear provenance of IMB’s authority, the WHO Director-General in effect reports to IMB. According to IMB’s charter, the Director-General must “immediately inform the relevant Ministry of Health and donor or partner agency” of IMB recommendations and establish corrective action plans “within 4 weeks of notification.”

In late 2013, the IMB expressed its desire that WHO declare polio to be a public health emergency. However, the International Health Regulations governing emergencies emphasize “public health risk,” not schedule risk. But the campaign for a polio emergency continued. At the end of January, the United States’ representative to the WHO Executive Board, Nils Daulaire, asked WHO to declare polio to be a public health emergency and set a deadline of mid-May, 2014.

Before being named US representative to WHO, Daulaire served for more than a decade as president and CEO of the Global Health Council. Among its function, the council selected the winner of the $1 million Gates Award for Global Health. Under Daulaire, from 2000 forward, the Global Health Council received $36 million from the Gates Foundation. In 2006, Daulaire’s wife went to work at the foundation, continuing there until the end of 2013.

Daulaire has said he "does not see the Gates Foundation or private entities as having a rightful role in establishing WHO’s priorities.” He dismissed suggestions that the foundation has an outsized role although he said: “There are member states who believe the Gates Foundation has more influence than it ought.” Daulaire said it is “entirely wrong” that the United States is increasing the foundation’s role.

Polio eradication has topped the Gates Foundation’s priorities for several years. In 2011, then foundation president, Tadataka Yamada, answered critics of the polio-centric agenda saying: “They are right. We are overemphasizing polio eradication.” Earlier this year, Bill Gates said “polio is the single thing I work on the most.”

The WHO Executive Board did not vote on Daulaire’s proposal for a polio emergency. The board, which rotates, did happen to include a number of countries impacted by polio: Pakistan, Nigeria, India and Syria. None of their representatives supported or mentioned the US call for a public health emergency. The United States itself has been polio-free for more than three decades. The CDC saw no increased threat to Americans. 

On May 5, just ahead of Daulaire’s deadline, WHO declared polio a public health emergency. On the same date, WHO reported a cumulative 239 cases of Ebola and 160 deaths in three countries.

Daulaire, according to Executive Board meeting minutes, also said “His Government attached high priority to strengthening the International Health Regulations and had established global health security as a key issue,” precisely where WHO would soon fail. However, according to a Reuters report, a 2011 proposal for a $100 million epidemics task force was shot down by member states. Also, budget cuts forced WHO’s Africa regional office to cut its epidemic team from 12 to four staff over the past two years. As Peter Piot, discoverer of Ebola noted, WHO budgets cuts were “approved by the USA and other member states.”

The polio emergency, sought and won by Daulaire, had been based on the worry that “Pakistan, Cameroon, and the Syrian Arab Republic pose the greatest risk of further wild poliovirus exportations in 2014,” according to WHO. Subsequently, neither Cameroon nor Syria exported polio and domestically experienced no onset of polio-induced paralysis since before the first declaration. Pakistan, where polio transmission has never been interrupted, continued to export polio—as it always has, although without having prompted a global emergency. Nonetheless, WHO concluded on July 31st that “the international spread of polio in 2014 continues to constitute an extraordinary event and a public health risk to other States.”

At the same time, WHO also reported a total of 1,323 Ebola cases, 729 deaths and even the export of the disease to a fourth country, Nigeria. However, Ebola apparently did not come up at the polio meeting, according to Vice Chair Robert Steffen: “with the targeted agendas I would not imagine that the polio [Emergency Committee] suggested there should be an Ebola [Emergency Committee].”

Unmentioned at the emergency meeting, Ebola had become uncontrolled more than a month earlier. On June 23rd. Médecins Sans Frontières (MSF) issued a press release declaring “We have reached our limits.” An MSF spokesperson said, “we are no longer able to send teams to the new outbreak sites,” which numbered more than 60 across Guinea, Sierra Leone, and Liberia. MSF, which described itself as the sole responder to the epidemic, said: “The epidemic is out of control.” The next day, WHO Ebola expert Pierre Formenty briefed top WHO officials in Geneva. Days later, the WHO Ebola situation report recognized “Currently, the coverage of effective outbreak containment measures is not comprehensive,” as Formenty’s presentation had shown. WHO updates began reporting cases and deaths not in sentences but using a grid. The rout was on.

The science of epidemiology should have been able to predict, albeit tentatively, when the efforts of MSF were doomed to fail. But just as with polio, epidemiology played no role in the timing of emergency declarations and international response. WHO’s emergency announcement came only on August 8th when there were 1,778 cases—including, for the first time, two Americans.

After the Ebola Emergency: No Response 

Declaring polio an emergency did not unleash vast new efforts to stamp out the disease. Most everything had already been done in the $1 billion a year effort —except consecrating eradication as the single most important public health issue in the world. The day after the polio declaration, the Gates Foundation blog explained that “The sounding of an emergency often is seen as a sign of distress, and news of this announcement certainly communicated that.” Indeed, the supposed emergency fueled headlines like “Polio, Spreading Abroad, Threatens US.” Not only was there no increased threat, the risk of spread was near historic lows. Instead “what this alarm really signals,” continued the foundation blog, was doing “what it takes to end this disease as quickly as possible,” that is, meeting the 2018 deadline.

When WHO declared an Ebola emergency, its declaration also did not unleash vast new efforts to stamp out the disease. WHO lacked resources to do anything itself while whatever heft the UN has was not applied. UN Secretary General Ban Ki Moon was not at Margaret Chan’s side as the WHO Director-General announced the Ebola emergency. Moon appears more frequently with Bill Gates. Gates partnered with Moon and the UN, not WHO, for the Gates Foundation vaccine summit that raised more than $4 billion for polio. And, as symbolized by an article co-written by the two on vaccination, Gates and Moon author the global health agenda, not WHO.

The world reacted to WHO’s Ebola emergency as if declared by a clerk. The CDC dispatched a small team to Liberia to areas that had not yet reported any cases. Its purpose was not to assist in containment but to assess preparedness which was found to be woeful. The CDC’s “surge” response dispatched 50 more disease control experts to be deployed within a month. Although issuing a travel warning to US citizens, the CDC was “not screening passengers traveling from the affected countries.” For the ongoing polio emergency, the CDC reported “an average of 60-70 people” working on eradication at its Emergency Operations Center.

Gates Foundation Plays Down Ebola 

For the Ebola crisis, the Gates Foundation pledged $1 (one) million to “help address the immediate need on the ground,” according to foundation CEO, Sue Desmond-Hellmann. But the next day, on its “Impatient Optimists” blog, the foundation optimistically moved on. A piece entitled “How to Prevent the Next Health Crisis,” explained how the next threat, cerebro-spinal meningitis, “could end up being far more destructive than the current Ebola epidemic.”

Three weeks later, on August 25, Desmond-Hellman tweeted about how “Nigeria is using what they’ve learned battling polio to contain the ebola outbreak.” The story was not about Nigeria as harbinger of inexorable spread but how polio eradication investments had saved the day. And indeed, the $1.5 billion being spent in Nigeria for polio might have contributed to extinguishing Ebola there.

Bill Gates weighed in on Ebola for the first time on September 10, more than two months after MSF said the outbreak had become uncontrolled. Gates tweeted about the foundation’s upcoming chat on Twitter:

The foundation now pledged $50 million; earlier in the year, it committed $1.8 billion to polio. The United States, now finally acting on Ebola, drew applause from Desmond-Hellmann: “The time to act on Ebola is now,” she said with the case count at 4,963. But just days and 2,507 cases later, Desmond-Hellman wrote of Ebola: “If the world doesn't learn from this outbreak, one day we’ll have a real pandemic on our hands.”

It was not the foundation’s job to detect and declare emergency outbreaks. But the foundation and Gates evaluated the Ebola threat and publically projected the conclusion that Ebola was no emergency.

Gates Foundation Running Polio Eradication

Gates is influential. “If … I need to go to the Indian parliament and say, ‘Let’s get serious about vaccines,’ ” said Gates, “then yes – since I’m giving my own money [on a] large scale and spending my life on it and I’m a technocrat – yes, that can be quite valuable.” In 2011, Gates had gone to the World Health Assembly and said it needed to get serious about vaccines. He explained to the assembly “how you can provide the leadership to make this the Decade of Vaccines.” The WHA followed Gates’ leadership advice and approved his initiative. Memorably, Gates also told the WHA:  "Our priorities are your priorities."

Not only did polio come to uniquely occupy the pinnacle position in international public health, the Gates Foundation has come to effectively run the eradication effort. The Director-General began answering to the Independent Monitoring Board in 2010. In 2011, a Polio Partners Group (PPG) replaced a meeting previously convened by WHO. WHO participates in the new group but is barred from serving as its chair by PPG bylaws. The PPG “was not summoned into existence per se” by act of the World Health Assembly, according to its current chair, John Lange. As with the IMB, there is no resolution requesting that the PPG be instantiated. Lange, now at the UN Foundation, previously worked at the Gates Foundation from March 2009 to June 2013. He was a foundation employee when elected PPG chair. Lange said the PPG was conceived at a meeting held not in Geneva at WHO but the CDC in Atlanta in December 2011, at or near the time when the CDC elevated polio to a maximum level threat.

Space for initiative-taking by WHO has been systemically closed off, as if child-proofing a room by blocking electrical power outlets. In 2013, a new entity, the Polio Oversight Board (POB), took over operational decision-making from WHO. According to Lange, the POB "effectively oversees and manages" the polio eradication effort, although “technically” the POB does not have authority over budgets, for example. Nonetheless, said Lange: "Its decisions are implemented." The first POB chairperson was Lange’s former boss, Chris Elias, president of global development at the Gates Foundation.

Gates Foundation, Not WHO, Sets Global Health Agenda

The Gates Foundation’s subjugation of WHO is not new. WHO lost its global leadership and capacity to set the world’s health agenda years before. At the 2007 Malaria Forum, for example, the convening power of the Gates Foundation, not WHO, brought together the world’s leading malaria researchers and policy makers. WHO Director-General Margaret Chan sat in the audience as Melinda Gates shocked her invitees by proposing to eradicate malaria. Malaria eradication had been tried and failed disastrously. However, Chan converted on the spot, jumped up and, taking the microphone, enthusiastically supported eradication. At the time of the Malaria Forum, the foundation had cumulatively invested $1 billion in malaria, starting with an early, $50 million grant in 1999. By contrast, the purchasing power of WHO’s budget in 2007 had fallen by almost 25 percent compared with 2000.

The foundation did not ask WHO, its Director-General or the researchers it invited to the conference for their opinion about malaria eradication. For polio, the World Health Assembly voted on and approved a resolution on eradication. But a Gates Foundation spokesperson, asked whether there would be a vote on malaria eradication, said: “Not as far as I know.” Arata Kochi, then the head of malaria at WHO, fought back against what he described as a foundation “cartel.” He was replaced after his memo leaked to the New York Times. In 2014, the president of the American Society of Tropical Medicine and Hygiene (ASTMH) is Alan Magill, the head of malaria at the Gates Foundation. The keynote speaker for this year's ASTMH conference is Bill Gates.

The Gates Foundation isn’t on the sidelines haphazardly supporting good causes but actively architecting global health policy. The “overemphasis” on polio comes from foundation plans for malaria eradication. As Bill Gates recently explained: “Polio we hope to get done by 2018. Then the credibility, the energy from that we will allow us to take the new tools we’ll have then and go after a malaria plan.” The current malaria plan was paid for by the Gates Foundation. A year after shifting malaria policy to eradication, in 2008, the foundation became and has remained the largest funder of polio eradication.

Absent this link to malaria eradication, the foundation’s overemphasis of polio makes little sense. Even Gates acknowledges that, among eradication efforts, polio is borderline. Smallpox he said, “was a good choice. Polio is a hard but reasonable choice." Much better is malaria, which he characterized as "a very reasonable choice.” At no time in the past or present has polio merited the world’s sole focus—unless for symbolic reasons. Other diseases, like diarrhea, are more prevalent and deadly. Polio, for all its awfulness, rarely causes death. 

The Gates Foundation has also hived off childhood immunization from WHO. The cleaving began in in 1998 with the introduction of the Bill & Melinda Gates Children’s Vaccine Initiative. The creators of this early initiative worried that WHO “might consider that we are trying to pre-empt their responsibility,” and worked to “find a way to present ourselves that avoids all presumption of a challenge to WHO." (Quoted in Muraskin, Crusade to Immunize the World's Children.)  The program eventually became what is known today as GAVI. The money for immunization goes to GAVI and no longer directly to WHO and UNICEF.  By 2008, any challenge to WHO was over. A GAVI governance change submerged WHO on a board with 28 other members, its vote counting as much as a representative from the vaccine industry.

WHO is no longer even in charge of global health statistics. The 2013 Global Burden of Disease was assembled and published by the Institute for Health Metrics and Evaluation (IHME). IHME was created by a $105 million grant from the Gates Foundation. Located at the University of Washington, IHME threw down the gauntlet years before, publishing papers on maternal and child mortality that publically contradicted figures from WHO on the front page of the New York Times. At a related 2010 conference, IHME chief Chris Murray said bodies like WHO were “not the definitive producers” of global health metrics. He proposed that WHO become a “disengaged guide,” like Consumer Reports or that WHO present comprehensive results without judging them, a model which Murray likened to Kayak.com. A third, unmentioned alternative is for IHME to simply replace WHO as definitive producer of the world’s global health statistics.

Bill Gates as Global Health Visionary

Seizing control from WHO could be explained, perhaps applauded, given serious questions about its competence and serial, unsuccessful reform efforts. Gates, who made his career trouncing another anachronistic three-letter acronym, IBM, seems not to have considered trying to shore up international global health governance. Not global health but population control had been Gates’ initial focus in the 1990s. As he explained earlier this year "It was only when we found out about this phenomenal connection between improved health and reduced population growth that we felt: Great, let’s just make the foundation as big as possible to go after these health problems.” He courted and, in 2006, won the fortune of Warren Buffett for his foundation’s endowment, explaining at the time: "If you want to deal with billions of people, you need scale."

Institutions of civil society were inadequate. “We must be willing to look at the failure of collective action and see how we can change it,” Bill and Melinda Gates wrote in 2007. More recently, regarding democratic processes, Gates said: “The closer you get to it and see how the sausage is made, the more you go, oh my God!” He questioned whether in the United States, “can complex, technocratically deep things…can that get done?” It was unclear that democracy was equal to complicated modern problems. According to Gates: “The idea that all these people are going to vote and have an opinion about subjects that are increasingly complex – where what seems, you might think … the easy answer [is] not the real answer. It’s a very interesting problem. Do democracies faced with these current problems do these things well?”

How well has Gates done in the face of important global health problems? Prior to Ebola, AIDS represented the greatest global health crisis of the present era. Although AIDS is far from solved, the epidemic has been controlled by the free provision of anti-retroviral therapy (ART). Free ARTs saved lives and reduced transmission of the disease. The PEPFAR program, unexpectedly initiated and signed into law by George W. Bush, made ARTs free in the world’s hardest hit regions. Even Bono credited Bush and American taxpayers: “…10 million people owe their lives to the U.S…George Bush started it,” the U2 frontman said last year.

Bill Gates opposed free AIDS drugs, because of the “harsh mathematics of the epidemic,” as he wrote in The Independent. “[F]or each person who starts getting treatment today, 10 more people will need treatment tomorrow.” Gates cited cost estimates as high as $40 billion a year by 2020. Instead, prices were forced down, anti-retrovirals saved lives and turned the tide of the epidemic.

Aversion to Short-term Crises and Outbreaks

“The battleground is disease prevention, not treatment,” according to an early advisor to the foundation, Bill Foege. His philosophy might have informed Gates’ opposition to free AIDS treatment. Gates named a $60 million building on the University of Washington campus after Foege, saying: “On so many issues, from the importance of disease prevention to the details of how to get partnerships right… Bill [Foege] has pointed the way,” Foege replied:  “I’m grateful for the vision that not only worries about how to get vaccine into a child but is not diverted by the tyranny of the acute from changing the future.”

The Gates Foundation, shaped by Foege, is constitutionally averse to short term crises. When the foundation at last pledged a modest $50 million for Ebola, it made much of how it was its largest ever grant for a humanitarian emergency. The foundation might have viewed Ebola as an acute need potentially competing for resources needed for vaccination efforts or perhaps to rid the world of polio and malaria forever. 

The foundation presumably made assessments of the Ebola threat, but it is not clear how and by whom. The foundation does not appear to have a section or person dedicated to outbreaks. The portfolio of the foundation's Lance Gordon, neglected tropical diseases, perhaps comes closest to Ebola. Gordon did not reply to an email asking how the foundation assessed the Ebola outbreak.

The foundation prioritized meningitis vaccination above Ebola. Gates, perhaps uniquely, audaciously defended the slow response to Ebola, saying “I think it is amazing how the United States has responded to this.” He warned “it’s easy to forget just how much has been done” in response to what he called a “short-term crisis,” although he would not forecast when it would end. The unprecedented deployment of the military he attributed not to the exponentially expanding scale of the disaster but “the president who said let’s get the Department of Defense involved because they’re the ones who can do logistics and get people in and out and get things built.” In contrast to Gates, President Obama has emphasized that "the world is not doing enough" to fight Ebola.

The US response, according to Gates wasn’t late. "Was there some other government who took decisive action before we did?” he asked. “Was there a CDC equivalent who flew in and personally toured [the affected countries]?” WHO did not figure in his world. However, looking to the CDC as global sentinel—waiting for Tom Frieden’s trip report—further  delayed the international response several weeks. Frieden recently said "Speed is the most important variable here.” But for Gates, only Frieden’s trip revealed that: “even though the US and we had given money,” a reference to the foundation’s $1 million pledge, “that seeing the urban impact, that we really all needed to step up.” Frieden, unlike Gates, has said of the outbreak “this was preventable." But the trigger for Gates was anecdote from a top official, not epidemiology, reports from those on the ground, nor a WHO emergency.

It is not the CDC’s job to be the first-line monitor of international disease outbreaks, being neither not suited nor designed for it. Pointing out the obvious, a Lancet editorial noted “the US Government is not a multilateral health agency.” WHO, not the CDC, has an international surveillance network tied into national ministries of health in nearly every country. “The final responsibility to prevent the international spread of disease rests with WHO and IHR [the International Health Regulations],” the editorial concluded.

But whether one looks to the CDC or WHO, as the polio emergency demonstrates, both agencies toe the line set by the Gates Foundation. The foundation has downplayed Ebola, with Gates defending the timing and strength of the international response.

Gates’ “Big idea” on Ebola is to circumvent WHO to speed approval of experimental drugs: He asked: “Who decides that if there’s some slight increased risk of a side effect the benefits here outweigh that?” Legal authority and responsibility lie with WHO. A WHO panel of ethicists has already approved untested treatments.  But according to Gates, “It’s very tricky because really the world is not very practiced at what resources should come in and how these decisions should be made.”

Gates’ consistent answer to the world’s health problem remains: take away the functions served by the World Health Organization. He has been successful. Today WHO is timorous, enfeebled, and incapacitated, playing a mostly ceremonial, subservient role. Gates is protagonist. Ebola is out of control.

WHO Attacks Credibility of Suspected Drug-Resistant Malaria Case from Angola

[Note: See the latest developments here.]

The World Health Organization (WHO) rejects the findings of a paper describing suspected drug-resistant malaria in a Vietnamese migrant worker returning from Angola. (See previous post.) According to WHO's Pascal Ringwald, "It took 4 months for WHO to discover the truth and we will make sure that there will be retraction from the authors." But Patrick Kachur, chief of the Malaria Branch at the Centers for Disease Control (CDC), said "I doubt there will be a retraction," and that the CDC is going ahead with plans in Angola to search for similar cases and conduct tests on parasite clearance times.

Nearly all aspects of the case have been questioned. WHO has contended that the first line of treatment, artesunate, came from a batch recalled because of quality issues. The second line drugs, dihydroartemisinin and piperaquine, were delivered by nasogastric tube, a departure from preferred practice.  Also, the dose given, 1 mg/ kg given twice a day, achieves lower blood concentrations, according to mathematical models, than the recommended single dose of 2.4 mg/ kg once a day. The third line of treatment, quinine and doxycycline, were also delivered by nasogastric tube instead of intravenously as recommended. (Intravenous quinine was not available.) Still, nasogastric quinine worked, saving the patient's life. 

The apparent failure of the artemesinin-based drugs to clear the patient's malaria parasites has been attributed to hyperparasitemia which can impair clearance of parasites from the blood after they have been killed by the drug. Finally, genetic sequencing of the malaria parasites found them negative for K13, the biomarker associated with drug resistant malaria in Southeast Asia. 

The paper's authors have stood behind their research, refuting, for example, the claim that the artesunate used was of poor quality. But the battle continues. "Maybe," said WHO's Ringwald concerning the refutation. "But," when it comes to retraction, "CDC will," he continued.

All current containment efforts focus on Southeast Asia. The possible case from Angola threatens to expand an already fast-growing front, perhaps accounting for the heated debate.

Bin Laden Vaccine Ruse not Behind Spike of Polio in Pakistan

The fake vaccination campaign to ensnare Osama Bin Laden unquestionably harmed polio vaccination efforts in Pakistan. But cases began rising beforehand, in 2008, and actually declined in 2012—after Bin Laden's assassination and the swift disclosure of the fake vaccination plot in mid-2011. 

The Taliban's announcement opposing polio immunization came a year after the vaccine imbroglio and fingered drone attacks. A month after the anouncement, vaccinator shootings began. Nonetheless, the polio situation in 2013 was better than in 2008.

Polio is a political game piece. Religio-political beliefs once halted polio vaccination in Nigeria. The Bin Laden ruse harmed Pakistan's polio effort but by focusing already existing anti-Western, anti-polio sentiments. Kristofer Harrison's article in Foreign Policy, which blames Pakistan's polio regress on the leaking of the vaccine ruse, oversimplifies too dramatically the chain of causality.

Timeline

May 2011 Bin Laden killed

July 2011 Vaccination ruse revealed

June 2012 Taliban announces anti-polio stance because of drones

July 2012 First vaccinators shot

Caseless Polio Outbreak in Israel Extinguished; what about Brazil?

Wild poliovirus began circulating in Israel in early 2013 but, more than a year later, appears to have been halted with no cases of polio reported. Cotemporaneously, however, a sewage sample in Brazil from March tested positive for polio, a strain related to an outbreak in Equatorial Guinea. No further samples in Brazil have tested positive nor have any cases been reported. Risks are likely lower at the World Cup than the annual pilgrimage to Mecca where stringent vaccination requirements have squelched transmission since a large outbreak in 2005.

The caseless transmission seen in Israel is possible in any population immunized only with inactivated polio vaccine (IPV). IPV protects against the potentially debilitating effects of poliovirus but does not prevent infection. Infected vaccinees can remain healthy but still transmit the virus.

The virus in Israel is related to strains originating in Pakistan. Perhaps coming by way of Egypt, the virus found its way into southern Israel, in Be'er Sheva, and spread northward. Those affected were "[m]ainly Arab Israelis but we believe there was some circulation among Jewish populations," according to Itamar Grotto, Director, Public Health Services at the Israeli Ministry of Health. 

In the developing world, polio mostly circulates where a lack of sanitation systems and clean water lead to ingestion of feces-contaminated water harboring the virus. The virus can survive four to six weeks in sewage. However, in Israel, instead of unclean water, "person-to-person transmission [was] through 'dirty' hands," according to Apoorva Mollya, program manager at the Bill & Melinda Gates Foundation. 

Bruce Aylward, assistant director general at the World Health Organization (WHO), explained: "Polio is one of those viruses where you only need an incredibly small infectious dose to get infected. If the virus is circulating in an area, there’s a high probability that you could get exposed."

Research on an outbreak in 1992-93 in a partially-immunized primary school in the Netherlands found evidence of infection in one third of the students. In New York City in the 1950s, a school outbreak quickly spread to an apartment building then to two more schools. 

According to Donda Hansen at the Centers for Disease Control (CDC), person-to-person spread of poliovirus within households can be as rapid and efficient as the adenoviruses that cause colds.

Israel experienced no cases of polio because of very high population coverage with IPV, roughly 95%, and perhaps a bit of luck that the virus either did not reach or didn't cause disease among those without polio antibodies. To stamp out circulation, Israel employed oral polio vaccine (OPV). OPV not only protects against disease but produces a local, mucosal immune response that limits replication of the poliovirus in the intestine, breaking the oral-fecal chain of transmission. After two waves of vaccination aimed at children under ten, first in Israel and then the West Bank and Gaza Strip, sewage samples positive for polio stopped.

WHO waits half a year before judging a type-1 outbreak like Israel's to be extinguished. "[F]ingers crossed that they make it over the 6-month mark," said WHO spokesperson Sona Bari. But in the eyes of Itamar Grotto, "It really seems that the 'event' is over." 

Israel has added the oral vaccine back to its routine immunization schedule, although it is not without risks. OPV uses a live version of the virus which very rarely mutates and causes polio. There were no vaccine-derived cases in Israel even though millions of children were immunized, perhaps because they were already protected by IPV. The science is not conclusive, but according to the Gates Foundation's Mallya, "Generally, it is thought that IPV would protect/prevent against cVDPV (vaccine-derived poliorvirus)."

Brazil uses both. And with over 90% population coverage and polio-specific immunization campaigns every year, the population of Brazil is thought to be well-protected. Owing to the health emergency recently declared by WHO, travelers from polio-infected nations should be vaccinated at least four weeks before traveling. The annual pilgrimage to Mecca has similar requirements although no chances are being taken: "Irrespective of previous immunization history, all visitors under 15 years arriving in Saudi Arabia will also receive 1 dose of OPV at border points," according to Saudi health regulations. In 2005, Nigerian polio strains were suspected of leading to an outbreak of over 300 cases in Indonesia with pilgrims transporting the virus far across the globe, resulting in heightened vaccination requirements in 2006. 

World Cup polio risks in 2010 were far worse than in 2014, based on number of cases and countries. In 2010, 20 countries combined for over one thousand cases versus (so far) 2014's slightly more than one hundred cases in nine countries. Accordingly, the CDC emphasized flu risks more than polio for the World Cup. Hand washing, however, is also mentioned.

Drug Resistant Malaria in Africa: A Suspected Case from Angola

[Note: See the latest developments here.]

A new paper suggests drug-resistant malaria might be present in Angola, perhaps brought there by an annual flow of some 40,000 Vietnamese migrant workers. Pockets of drug-resistant malaria, first found in Cambodia, now spot much of Southeast Asia, including Thailand, Vietnam, Myanmar and Laos. The expanding front comes despite containment efforts, begun in late 2008, aimed at preventing spread to Africa which already has the world’s highest malaria mortality.

A 58-year old Vietnamese construction worker returned from Angola after three years to his malaria-free village in Nam Dinh Province. Four days later, malaria symptoms appeared which went undiagnosed and eventually resulted in hospitalization. But artesunate, the frontline, fast-acting anti-malarial given to the patient, scarcely dented the number of teeming parasites. Even in severe malaria cases like this, patients usually begin to get better in just one day because artemisinin-based drugs act so quickly. (The patient also received the slower acting clindamycin to eliminate any parasites surviving the artemisinin onslaught, a combination approach meant to prevent drug resistance.)

Switching to a different combination of dihydroartemisinin and piperaquine also failed to knock down parasite levels. Only when subjected to quinine and doxycycline did malaria subside, allowing the once-endangered patient to return home about one month after admission.

The strength of resistance to the frontline artemisinin-based drugs seems considerably greater than that seen in Southeast Asia. As a rule of thumb, researchers suspect resistance if artemisinin doesn’t fully eliminate parasites after three days in cases of “uncomplicated” malaria. The Vietnamese patient’s severe malaria makes comparisons problematic. Still, Nick White, of Mahidol Oxford Tropical Medicine Research Unit, has "never seen such resistance, even in Cambodia." White, other researchers and the World Health Organization (WHO) are withholding final judgment as to whether this single case means artemisinin-resistant Plasmodium falciparum malaria is now present in Angola. According to White, “No, this doesn’t mean there is resistance in Africa—there may be but you need more than this.”

White raises the possibility that parasites actually killed by artemisinin might have remained in the patient’s blood, giving an appearance of resistance. Pascal Ringwald, WHO lead for the drug-resistant malaria containment effort, further explained: “the hyperparasitemia (10%) associated with insufficient drug blood levels could explain the extremely slow clearance after artesunate treatment...” Christopher Plowe, Howard Hughes Medical Institute investigator and professor at the University of Maryland, notes that “many factors other than intrinsic parasite resistance affect the treatment outcome, including immunity, fluid dynamics, pharmacokinetics and so forth.” But Plowe concludes: “This did look more like bona fide high-level resistance.” Continued Plowe:

“This is deeply worrying. It is just one case but the evidence of resistance is pretty good. It seems plausible that artemisinin-resistant parasites were carried to Angola from Vietnam and then locally transmitted among these migrant workers.”

How has it been missed, particularly if resistance is so strong? “Bit odd no one has noticed this before if this is a focus of the most artemisinin resistant parasites in the world,” observed White. Reports from Angola to WHO in 2013 found no evidence of resistance. There was “No sign of delayed clearance and 100% dihydroartemsinin-piperaquine efficacy,” according to Ringwald, who added that “Data were validated by CDC Atlanta.” However, Ringwald acknowledged that “the studies were not performed in the same province,” Luanda Sul, suspected as the origin of the drug-resistant malaria. The WorldWide Antimalarial Resistance Network (WWARN) has no data on Angola. WWARN is working on a study of three-day parasite clearance rates in Africa based on data from 15,000 patients, but fewer than one hundred are from Angola and come from a 2003 study in Kuito, well outside Luanda Sul province.*

A missing piece of the puzzle is whether malaria parasites in this case exhibit mutations in the K13 gene, a biomarker associated with artemisinin resistance in Southeast Asia. The status of such a test is far from clear. According to Ringwald, “It is not a WHO study and it not under our control,” who notes that the case occurred over a year ago. Conceivably, there are no samples to test. The corresponding author of the study did not reply to an email inquiry.

Ringwald downplays the importance of the case and asserts that “Artemisinin resistance is already reported in Africa.” But while mutations in K13 have been reported, clinical resistance in Africa has not. Also, the mutations reported there so far might merely be polymorphisms that are not part of a genetic network that confers resistance to artemisinin.

While Ringwald expressed skepticism about the Vietnamese case, “Nevertheless, we are investigating with CDC Atlanta in Angola if K13+ is also present like many other countries.” Further, in order “to reassure everybody we will specifically conduct [a study of parasite clearance rates] with dihydroartemisinin-piperaquine in the same province,” Luanda Sul .

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Related: Drug resistant malaria takes new ground, raising fears of global spread

*This post has been updated. WWARN's study of three-day clearance in 15,000 people previously was said to have no data from Angola. The study includes 93 patients from Kuito, Angola in 2003.


Why is WHO crying wolf on polio?

The World Health Organization (WHO) recently declared polio to be a public health emergency, prompting fears and headlines about possible spread even to the United States. But the eradication goal actually sits closer than ever. The “emergency” comes not from health risk but schedule risk to the 2018 eradication deadline. Because polio is the number one priority of Bill Gates, WHO now invokes the specter of polio outbreaks, a ploy to galvanize the public reminiscent of weapons of mass destruction.

Polio is 99% wiped out, crushed over decades from hundreds of thousands of cases to fewer than 2,000 a year so far in the 21st century. Risk of spread has only gone down together with the fall in cases and countries with transmission. Today, in two of the three remaining polio endemic countries, Nigeria and Afghanistan, cases hover tantalizingly close to zero, unprecedented historic lows. Pakistan, the third endemic country, has wrecked eradication progress for years. But the ongoing shooting of vaccinators by extremists in Pakistan, for example, did not prompt the polio “emergency.” Instead, WHO cited an outbreak of 36 cases in Syria and the subsequent export of a single case to Iraq. But the Syrian outbreak has been snuffed and amounts to nearly a non-event in the annals of polio conflagrations. The year before, Somalia saw a much larger, 194-case detonation, large enough to reach Kenya and Ethiopia and paralyze two dozen more. Today, WHO reports the other cause for alarm is cross border polio transmission from Cameroon to Equatorial Guinea. However, the six cases so far, while tragic, are inconsequential compared to Africa as recently as 2011 when four countries leapt from zero cases to 41. The same year, China saw an unprecedented 21 cases. No emergency.

Polio does not even merit consideration for emergency status. Swine flu occasioned WHO’s last emergency declaration in 2009, prompted by a rapid accumulation of 1,003 cases in 20 countries on four continents. Flu can spread swiftly, directly from human to human, unlike polio which usually comes from contact with feces-contaminated water. Wealthy nations are already highly vaccinated against polio whereas swine flu vaccination necessarily followed the discovery of the new virus, H1N1. In the United States, the Centers for Disease Control (CDC) estimated there were 57 million H1N1 infections resulting in 11,000 deaths. Polio rarely kills.

However, eradication efforts cost $1 billion a year, a sizeable piece of the $30 billion spent on global health annually. Eradication dollars could be spent on increasing coverage of routine vaccinations, building hospitals and health systems, or providing clean water. But Bill Gates champions polio eradication. It is “the single thing I work on the most,” according to Gates. And it’s his show: Gates, not WHO, orchestrated funding of the $5.5 billion effort to eradicate polio by 2018. “We’ve raised three-quarters of that money,” Gates reported in 2013. But the Gates-approved plan calls for ending transmission by 2014, already impossible. Eradication has never been closer, but the schedule is at risk. Thus the theater of polio public health emergency.

As the Gates Foundation blog notes, “The sounding of an emergency often is seen as a sign of distress, and news of this announcement certainly communicated that.” Indeed, the announcement fueled headlines like “Polio, Spreading Abroad, Threatens US.” However, “what this alarm really signals,” continued the foundation’s blog, is doing “what it takes to end this disease as quickly as possible,” which includes stoking false fear. The CDC isn’t stockpiling oral polio vaccine to extinguish outbreaks. Instead, the CDC said of the polio declaration: “we do not believe this reflects an increased risk to the US.” But with deadlines looming, a WHO spokesperson stated: “we need to pull out all the stops, which is what the emergency should help us to do.”

The International Health Regulations on emergencies emphasize “public health risk,” not schedule risk. Whether technically legitimate or not, the polio “emergency” hides its real motivation and makes people afraid when actual polio risks are close to the lowest level in all of human history.

Eradicating polio, while a noble intention, distorts rational global health priority-setting. Eradication gives the wealthy world a trophy to brandish before its own citizens and taxpayers while ignoring and overriding the priorities of the developing world. The polio emergency wraps this distortion in deception. Bill Gates believes eradication will serves as a symbol and portent of further triumphs. But he has substituted symbol manipulation for the pursuit of optimal global health policy in open society. 

Polio in Nigeria: at the cusp of the cusp

Immunization coverage for polio continues to climb in Nigeria. The most recent campaigns in April reached more children than ever and continue a solid upward trend over the last two years. The key threshold of 80% coverage has been reached. That level, sustained over time, usually crushes polio inexorably.

India, in 2011, stood in similar circumstances just prior to the high season--and knocked polio out, enduringly. Nigeria has a chance as the high season approaches, beginning around July. However, elimination poses different challenges in every country. In Nigeria, not only widely-publicized security issues obstruct. But upcoming elections might also impinge on sustaining coverage gains. With luck, Nigeria might stop polio transmission this year. But the World Health Organization's Sona Bari cautions that India at this point, "was in a far stronger position in terms of surveillance quality, immunity levels and political commitment." Most likely, Nigeria is at the cusp of the cusp

Outbreak Emphasis (Again) Obscures Polio Progress

Polio in Syria and the spread of a single case to Iraq "signal an absolute failure of the global eradication effort," according to an expert quoted by the New York Times. A Guardian headline described the new obstacles as the "most challenging in history." Even global health bloggers concluded eradication is "further off than it had been just a year ago." Actually, eradication is closer than ever. 

Outbreaks, while tragic and not to be taken lightly, are a spectacular side show. There are already five in 2014, equaling the total for all of 2013. But 19 outbreaks hammered the eradication project in 2009, clearly short of any breaking point. Polio coverage emphasizing outbreaks has completely missed that two of the three remaining endemic countries, Nigeria and Afghanistan, have seen only a single indigenous case of the disease this year. 

Nigeria has been steadily raising vaccination coverage in key high risk areas, accounting for the drop in cases. If coverage continues to climb, transmission might be interrupted and polio eliminated from the country. High season, which generally begins in July and extends through September, will be a major test. Any number of factors might derail progress. Still, today polio teeters closer than ever to extinction in Nigeria. 

In Afghanistan, all polio cases this year have been in eastern in provinces near Pakistan, and sequencing shows similarity to strains from from across the border. 

Pakistan performs much worse than the other two endemic nations, but despite even the targeting and killing of polio vaccinators, Pakistan's case level is not extraordinarily high by historical standards.

Choking off endemic sources stops outbreaks from occurring to begin with. Outbreaks plummeted after India knocked out polio at the end of 2010. The Global Polio Eradication Initiative has stamped out every single polio outbreak there has ever been; today there are five more that must also be dispatched. In Syria, the 41 cases so far and emergence of a single related case in Iraq is concerning. But a 2013 outbreak hit Somalia with 194 cases and spread a further two dozen cases to Kenya and Ethiopia. Nonetheless, that fire is now out and probably will remain far larger and thus more difficult than reckoning with the smaller (to this point) recrudescence in Syria. 

War in Syria undoubtedly complicates vaccination efforts there. But in Somalia, kidnappings and killings forced Médecins Sans Frontières to leave the country in the middle of the polio outbreak after more than two decades in the country.

Polio eradication, in retrospect, is not a good idea. "Vertical," single-disease campaigns are inferior to building health systems, and polio has never been as deadly as say, diarrhea. Eradication is extremely costly.

Regardless, however, polio eradication is succeeding. Local news reporting on fires and gunshots distorts the reality of less crime and fewer fires. Similarly, despite media coverage, eradication of polio has never been so near.