~ l ~ ~~~,r,;a· ~ RLD W -~ THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION HEALTH

In this issue Caver. WHO/ EPI

World Health Day 1995 Target 2000- A world without polio 3 Hiroshi Nakajima WHO'S new vaccines programme 4 Jong-Wook Lee Target 2000 6 Nicholas Word & Harry Hull Atemplate for the world 8 Ciro A. de Quadros Tracking the virus 10 Barbara Hull Rotary's Polio Plus 12 Cary Silver The quest for a vaccine 14 Fred Robbins Towards a world without polio 16-17 Supplying the vaccine 18 David Halliday & Julie Milstien Rehabilitating children with polio 20 Ann Goerdt Paying the price for one's beliefs 22 Paul Oostvogel Courage in adversity 24 JuneGoodfiel d No pain, no gain 26 Juan M. Flavier Egypt tackles polio 27 Esmat Mansour The role of women 28 Khadija A. Msambichaka Reaching the hard-to-reach 29 Stanislava Popova Costs and savings 30 David M. Salisbury page 2 1

World Health • 48th Year, No . 1, World Heolth is the officio! illusttoted mogozine of the World Health Articles ond photographs thot ore not copyright moy be reproduced provided January-February 1995 Orgonizonon . It oppeors six nmes oyeor in English, french, Russian ond credit is given to the World Health Organization . Signed articles do not Spanish, ond four times o yeor in Arabic ond fo ~i. The Ara bic edinon is necessar ily reflect WHO 's views. The designonons employedo nd the IX ISSN 0043-8502 ovoiloble fromWHO 's Regional Office fo r the Eastern Mediterranean, P.O. Box presentation of moteriol published in World Health do not im plyth e expression Correspondence should be addressed to the Editor, World Health Mogozine, 1517, Alexondrio 21511 , Egypt. The forsi edinon is obtoinoble from the of ony opinion whatsoever on the port of the Orgonizonon concerning the World Health Orgonizonon, CH· 1211 Geneva 27 , Switzerland, or direcriy to Public Health Cornrninee, Iro n University Press, 85 Pork Avenue, Teheran legol stotus of any country, territory, city or oreo or of its outhorines, or authors, whose addresses ore given ot the end of eoch article . 15875-47 48, Iron. The Russian edi non con be obtained from "Meditsino" concerning the delimitonon of its fronne rs or boundaries. for subscriptions see order form on poge 31 . Publishing Ho use, Petroveri gski per. , 6/ 8, 10 1000 Moscow, Russian federonon. World Health • 48th Year, No . l, Jonuory-february 1995 3

Editorial World Health Day 1995 Target 2000 - A world without polio Hiroshi Nakajima

he world now stands on the Japan and the United States, are brink of global eradication of cooperating to ensure that critical Tpoliomyelitis. needs for advocacy, support and Since Jonas Salk in 1955, vaccine are being met. followed by Albert Sabin in 1961, Before we can sit back and enjoy produced and demonstrated the the benefits of polio eradication, effectiveness of their vaccines however, the job has to be against polio, and especially since completed. There is a need for WHO and UNICEF's Expanded national immunization days to be Programme on Immunization organized, for sustainable supplies brought potent, well-stored, safely of good quality vaccine to be administered polio vaccines to over stocked and delivered, for personnel 80% of the world's children, polio to be trained, and for epidemiological has been in retreat. In 1988, the Dr Hiroshi Nako;;ma, Director-General of the World Health survei llance to be established. World Health Assembly targeted Organization. But the task is not confined global polio eradication for the year exclusively to public health services. 2000, a fitting gift from health Only by joining forces with workers of this century to the governmental and nongovernmental children of the next. The key to success is the organizations, United Nations On 29 September 1994, an application of certain simple and agencies, and the public at large can International Commission headed by highly effective strategies. National the target be met on time. Everyone Dr Frederick Robbins was able to immunization days, during which involved in the polio eradication declare that the disease had been vaccine is given within a day or two initiative should be proud of the eradicated throughout the Region of to all children under five, supplement fact that his or her local efforts are the Americas, just ten years after the routine immunizations. Systems of making possible the realization of Directing Council of the Pan surveillance, which include testing the global goal. TARGET 2000 can American Health Organization faecal samples for the poliovirus, only be achieved by ensuring that committed its Member States to the identify and investigate all cases of village after village, district after eradication target. All regions of the flaccid paralysis in children. As district, country after country is world are now making steady fewer and fewer cases occur, wide­ polio-free. progress towards that goal. spread house to house immunization The eradication of polio is within The whole area of the Western finally reduces transmission to zero, our grasp. We owe it to future Pacific is about to become the second thus leading to eradication. generations not to let it slip away. • polio-free region in the world. On Many partners are working World Health Day- 7 April 1995 - towards this common goal. While it is anticipated that at least 15 almost 80% of resources needed for countries in Europe and the Eastern success will come from the endemic Mediterranean will provide polio countries themselves, many agencies vaccine to their children and institutions besides WHO, simultaneously. notably Rotary International, UNICEF, the US Centers for Disease Control and Prevention, and the Hiroshi Noka;ima, M.D. , Ph.D. International Development Banks, as well as the governments of Canada, 4 World Health • 48th Year, No. 1, Janua ry-February 1995 WHO's new vaccines programme Jong-Wook Lee

Pitfalls ahead

This is a remarkable achievement. What then are the problems that demand a new approach to immunization? Firstly, instead of ris ing to 90% as planned, immuniza­ tion coverage is now falling. In addition, there are at least 18 coun­ tries where immunization coverage remains less than 50%. If we are to protect every child, we must redou­ ble our efforts to increase coverage in countries which have extremely low coverage and stop the trend towards lower coverage in some Centre for total care in Egypt. An integrated approach to immunization offers children a better successful countries. chance to grow up in good health. Secondly, EPI has essentiall y been limited to the six antigens initially recommended by the pro­ have a right to be immunized- to a gramme. With some exceptions, we WHO's new Global broader one: all children must be have fai led to incorporate other, ex­ protected from death and di sability isting vaccines into the programme. Programme on Vaccines and by making the best vaccines Children in the developing world re­ available and using them in the most main at ri sk for hepatitis B, rubell a Immunization intends to use effective manner. To meet these ("German measles") and in some polio eradication as aleading needs, WHO has created a new countries yellow fever and infection Global Programme on Vaccines and with Ha emophilus injluenzae. Now wedge to implement Immunization (GPV). that so many countries are doing so effective, surveillance-based Twenty years ago, when the well , we must accelerate the intro­ Expanded Programme on duction of additional vaccines into approaches to neonatal Immunization (EPI) was founded, EPI programmes around the world. fewer than 5% of children born each Thirdly, poor quality vaccines tetanus elimination and year were immunized. In the last two have been used in some countries. measles control. decades, immunizat:on programmes All the effort involved in immuniz­ have been establi shed in every coun­ ing a child is wasted when there is no try of the world . WHO estimates that immunological response to the vac­ more than 75 % of infants born in cine. If un safe or impotent vaccines HO has embarked on a new 1993 were fu ll y immunized and 45% are used, parents lose faith and will phase in its task of protect­ of pregnant women were immunized no longer bring their children for im­ Wing the health of children to protect their infants again st neo­ munization. We must, therefore, around the world. An improved, natal tetanus. Wi th current levels of work with countries to ensure that integrated approach to immunization immunization, EPI prevents an only safe and effective vaccines are is needed if the world's ch il dren are estimated 2 900 000 deaths from used in EPI programmes. to grow up healthy. In turn, there is measles, neonatal teranus and Fourth ly, EPI's three disease a need to change the philosophy from whooping cough and 560 000 cases control objectives have yet to be a simplistic approach - all children of poliomyelitis each year. reached. WHO estimates that each World Health • 48th Yeor, No. 1, Jonumy-februory 1995 s year 110 000 children are still being crippled by polio, 500 000 babies die from neonatal tetanus, and I 200 000 children die from measles. Controlling these three diseases re­ quires an epidemiological approach to disease, defining high-risk groups and targeting immunization to those most in need. As is clear from this issue of World Health , the global po­ liomyelitis eradication target for the year 2000 is the most advanced of the three objectives. All the evidence indicates that this disease has been eradicated from the Western Hemi­ sphere, and rapid progress is being made towards the goal in the five A young child in Costa Rico receives protection against measles. WHO Regions where polio remains endemic. GPV is fully committed to the polio eradication goal and intends to use polio as a leading wedge to implement effective, surveillance­ based approaches to neonatal tetanus elimination and measles control. Fifthly, global research and devel­ opment of vaccines has primarily been driven by the market forces and scientific interests of the industrial­ ized countries. If we are to achieve our goal of protecting the most vul­ nerable children, special efforts will be required to channel the develop­ ment, testing and licensing process so that appropriate new and/or improved vaccines are available to immunization programmes in devel­ A pregnant woman in Bangladesh is immunized against tetanus. oping nations. WHO's leadership in developing a more thermostable oral polio vaccine, for example, will WHO Regional Offices. VSQ will VSQ and VRD will work synergisti­ result in simplified logistics and work with countries, donors, and cally to link vaccine research, devel­ lower costs for conducting mass vaccine manufacturers to ensure that opment, supply and delivery so as to campaigns. At the same time, the adequate quantities of vaccines are accelerate our efforts to protect chil­ likelihood that a child will receive available to all national EPI dren from illness, disability and an impotent vaccine will be greatly programmes, and that only safe and death. I anticipate that the most im­ reduced. fully potent vaccines are provided to mediate effects wi ll be the eradica­ those programmes. VRD will tion of polio and dramatic improve­ stimulate and support the research ments in the control of measles, Three operational units and development activities, which neonatal tetanus and other EPI will lead both to new vaccines and diseases. In addition, our capacity GPV will implement this new to improved, existing vaccines and will be increased to prevent and con­ approach to immunization through will provide the scientific basis for trol other diseases and bring us closer its three operational units, the their optimum use. to WHO's ultimate goal of Health for Expanded Programme on I believe that the three sections of All. • Immunization (EPI), Vaccine Supply the new Global Programme for and Quality (VSQ), and Vaccine Vaccines and Immunization are in Research and Development (VRD). keeping with the ideal of the EPI will define global immunization Children's Vaccine Initiative- to link Dr jong·Wook Lee is Director of the Global Programme for Vaccines and Immunization , policies and provide technical all stages of the vaccine life-cycle World Health Organization, I 2 I I Geneva support to countries, through the from the bench to the bush. EPI, 27, Switzerland. 6 World Health • 48th Yeor, No. 1, Jonuory-Februory 1995 Target 2000 Nicholas Ward &Harry Hull

nization days. These Rapid decline in cases campaigns ad­ minister two As these strategies have been suc­ doses ofOPV cessfully undertaken by more and to all children more countries, the number of cases under five, in­ is declining rapidly and the wild cluding those poliovirus is being confined to a who have geographically restricted area of the previously world. The number of cases reported received the in 1993 by WHO's Member States basic course of was only 9164. This is a 74% de­ immunization. cline from the 35 225 cases reported The goal: to immunize as many infants as possible. The object is to to WHO in 1988. stop the spread Six "emerging polio-free zones" of wild have been identified where the wild en, in 1988, the World poliovirus by boosting the immunity virus has either disappeared or is at Health Assembly estab­ of children who have already been such a low level that eradication Wlished the year 2000 as the vaccinated and by immunizing chil­ could be rapidly achieved. These target for global poliomyelitis eradi­ dren not reached by routine services. zones are: The Americas, Western cation, a period of 12 years was As the virus cannot live for long peri­ and Central Europe, North Africa, allotted to accomplish that goal. As ods outside the human body, national the Middle East, Southern and East 1995 begins, more than half that time immunization days effectively Africa, and the Western Pacific. has elapsed and it is appropriate to remove the wild poliovirus from West and Central Africa and South examine the progress that has been countries where the disease is Asia are the principle reservoirs of achieved and what remains to be ac­ endemic. wild poliovirus. complished if we are to wipe out the The third strategy is to establish In the American Region, it is naturally occurring or "wild" polio­ extremely sensitive surveillance sys­ more than three years since the last virus within the next five years. tems, capable of detecting every last case occurred in the entire Western The strategies for polio eradica­ case of poliomyelitis in a country. Hemisphere, affecting a two-year-old tion recommended by WHO are Because other paralytic conditions boy from Peru who was paralysed in simple in concept. Firstly, to support can mimic polio, stool specimens are August 1991. The Region has been routine immunization systems and collected from all children with acute certified free of wild virus, but chil­ immunize as many infants as possi­ flaccid paralysis. These stool speci­ dren are still being immunized to ble with 3-4 doses of oral polio mens are then tested in certified prevent any spread if the virus should vaccine (OPV). High routine cover­ laboratories to determine if the paral­ be reintroduced from other conti­ age reduces the incidence of polio to ysis is caused by wild poliovirus. nents. low levels and forms the base for the The final strategy is to use Although much has been accom­ polio eradication initiative. Third­ surveillance data to plan and carry plished and there are many reasons to dose (OPV3) coverage rose rapidly out localized immunization be confident that Target 2000 will be during the 1980s, and WHO esti­ campaigns, targeting high-risk achieved, global polio eradication is mates that 80% of infants born in districts where the last few cases of far from assured. What are the major 1993 have been immunized with polio occur. In these "mopping-up" obstacles to be overcome if we are to three doses of OPV. campaigns, OPV is taken from door reach the goal? First among these is The second polio eradication to door, and two doses are adminis­ insufficient political commitment. strategy is to conduct national immu- tered to all children under five. World Health • 48th Year, No. 1, Jonuary-Februory 1995 7

The World Health Assembly estab­ lished the polio eradication target in 1988 and reaffirmed that commitment in 1993. UNICEF and more than 130 world leaders adopted the same goal at the World Summit for Children in 1990. Yet sufficient support to achieve the goal is only beginning to materialize. Rotary International, in particular, is to be commended for its advocacy efforts on behalf of polio eradication. But if global eradication is to be achieved, all polio-endemic countries will need to make the commitment to eradica­ tion at the highest levels. Since the benefits of polio eradi­ cation will accrue to all countries, On National Immunization Day, every child receives the life-saving "polio drop". additional financing for the initiative should be provided by both industri­ rent production capacity is sufficient war pose constant threats to the alized countries and the international to manufacture all the vaccine Polio Eradication Initiative. donor agencies. Additional political needed, but additional funds for vac­ If the world unites to provide the commitment and expanded external cine purchase are still needed. additional financial resources, per­ funding will be particularly impor­ Global immunization coverage sonnel and vaccine needed, all these tant as each year passes, for as the peaked in 1990 when 85% of infants obstacles can and will be overcome. target approaches, wild poliovirus born that year had received three or We can then look forward to the day will exist only in the least vigilant more doses of OPV; since then there when parents need no longer fear countries and the most difficult has been a gradual decline in immu­ that their child will be crippled by regions within those countries. nization coverage for all vaccines. poliomyelitis. • Financing the initiative remains The combination of falling coverage problematic. The most recent and low disease incidence results in a estimate of the total external cost of rapidly increasing population of chil­ polio eradication is more than $800 dren who have not been vac-cinated Or Nicholas Ward and Dr Harry Hull are with million, nearly two-thirds of which is but are also not immune through nat­ the Expanded Programme on Immunization, Global Programme for Vaccines and for the purchase of oral polio ural infection. Political upheavals, Immun ization, World Health Organization, vaccine. If funds are available, cur- economic change, social unrest and 121 1 Geneva 27, Switzerland

Eradication approaching in China The front lines of the global war again st pol iomyelitis have sh ifted from South America to As ia. Th e battle has been fierce in the world's most populous na ti on, China, but polio is now in full retreat, and there are high hopes th at w ild vi rus transmission w il l be stopped in time to meet China's 1995 eradication goal. Th a nks to the excellent primary health care system, pol io see med to be disappearing from China when the global eradication target was establ ished. Widespread epidemics with some 5000 cases in both 1989 and 1990 dimmed hopes, but Ch ina has fought back. Provincial-level immuniza ti on days in 199 1 and 1992 set the stage for th e worl d's largest publi c health events - national immuni zation days held a year ago and currently being repeated this winter. The resu lt of these campaigns has been a rapi d decline in the pol io cases reported- only 653 in 1993 . More revealing is evidence provided by laboratory-based virological survei llance. Wild pol iovi rus was fou nd in seven ou t of 30 provinces in 1993 and in only one province during the first ha lf of 1994 . The seven provi nces were ta rgeted for final-stage immunizations last autumn. Pl a nning the fin al ass ault on pol io requires accurate, timely knowledge about the last chains of virus transm ission , obtainable only by cul turing stool specimens from every paralysed ch ild in th e country. Virology laboratories in most provinces lack esse ntia l supplies and work with outdated equipment. A coalition of donors, led by Rotary Intern ati onal, japan, the USA, Aus tralia and UNICEF, is plann ing to upgrade Chinese vi rology la boratories to cope with th e expanded workload. As one donor puts it: "If these improvements are not made soon , C hin a could even face the possibility of having eradicated polio and not being able to prove it to a sceptical world." 8 World Health • 48th Yeor, No. l, Jonuory-Februory 1995 A template for the world Ciro A. de Quadros

The disappearance of poliomyelitis from the Americas since 1991 offers a foretaste of the benefits that mankind can expect from new and improved vaccines in the years to come.

The challenge

In May 1985, the Director of the Pan A health centre in Costa Rica provides routine polio vaccination. American Health Organization (PAHO), WHO's Regional Office for sis (AFP) for subsequent investiga­ the Americas, proposed that polio­ tion to determine whether they were The results myelitis be eradicated from the due to wild poliovirus. Western Hemisphere by 1990. At High immunization levels were In 1985, there were nearly 1000 that time the Expanded Programme maintained by holding national cases of poliomyelitis reported in the on Immunization (EPI) in the immunization days, usually twice a Region of the Americas, compared Americas had achieved a certain year one or two months apart, when with over 10 000 cases estimated to level of success, with coverage all children under five years of age be occurring annually in the 1970s. increases to around 60% for some received a dose of OPV, regardless of By the end of 1990, only 18 cases vaccines in the programme, such as their previous immunization status. were reported, and transmission was DPT, BCG and measles, and over This strategy had proved successful on the verge of being interrupted. 75% for poliomyelitis vaccine. in several countries, starting with Interruption was finally achieved in This proposal, which was met by Cuba in 1962. Subsequently, "mop­ 1991, when only nine cases were scepticism by many, was endorsed up" operations or house-to-house identified: eight in Colombia until by the PAHO Directing Council in vaccination campaigns with OPV April, and one in Peru- a two-year­ September of 1985 and was launched were carried out in districts which old boy named Jose Fermin, with with objectives that aimed at the were still at high risk of wild polio­ date of onset 23 August- believed to eradication of polio, as well as virus circulation. be the last polio case in the organizing surveillance systems Over 20 000 health units were Americas. and improving the overall organized in a surveillance network immunization programme. for the weekly reporting of cases of The obstacles AFP, and a cadre of health workers The strategy was trained in the epidemiological Among the major obstacles at the investigation of these cases. Two outset of the programme were the The strategy was based on maintain­ stool samples had to be collected lack of political will and the limited ing high immunization levels with and properly transported to one of resources available. The social norm oral poliomyelitis vaccine (OPV) in a network of laboratories equipped that hitherto had accepted children the target population of children with trained personnel and modern being maimed every year by a virus under five years of age and establish­ technologies for testing those that could be eradicated had to be ing a surveillance system for detec­ samples to determine if they changed. Intensive social mobiliza­ tion of cases of acute flaccid paraly- harboured wild poliovirus. tion that followed the initiative World Health • 48th Year, No. l, Janua ry-February 199 5 9 brought about increased awareness their commitment to the health and among communities and their politi­ well-being of their children. The last case of polio in the cal leaders of the need to reach the Americas goal. Civil wars in some countries The lessons learned Luis Fermi n Tenorio Cortez (see threatened vaccination campaigns, bock cover of this issue ) is now fi ve years old and li ves in a small but days of ceasefire for immuniza­ The effort demonstrated a sound town in Pe ru ca ll ed Pichino ki , tion were observed by the warring strategy to eradicate poliomyelitis a bout 4 00 km east of Lim o. parties every year, demonstrating worldwide. Following the successful When he was two years old, on once again the social will generated results achieved in the Americas, the 23 August 1991 , he woke up World Health Assembly in 1988 set by the goal. For example, in Peru, suffering from a fever and muscle the goal of global poliomyelitis during the control of the last focus pains, followed by wea kness in of infection, around 2 million house­ eradication by the year 2000. The both legs a lth ough his left leg holds were visited and nearly 2 strategies that worked so well in the w as mo re affected. He could million children were vaccinated in Americas are now being applied not w a lk and attempts by local the course of one week without any elsewhere. The success has also hea lth se rvices to treat him ho d disruption. The less than optimal demonstrated that results can be no effect In early Septem ber, he efficacy and heat stability of OPY achieved when there is a specific and was referred to Son Juan de Dios was overcome, both by strict cold measurable objective and sufficient Hospital in Limo , the most sought­ chain control and by the rapid distri­ and well-managed resources. The after hospital in Peru for chi ldren bution and use of the vaccine during participation of communities was an with walking difficulti es and one national immunization days and essential element for the success of of the weekly reportin g si tes for mop-up operations. the initiative. the notional polio eradicatio n The overall immunization programme. programme greatly benefited from Th e attendi ng physician The coalition the effort. By the end of 1993, suspected pol io myelitis and immunization coverage for the other ca ll ed the Ministry of Hea lth , This enormous undertaking would vaccines included in most national where the epidemi o log ist in not have been possible without a immunization programmes - DPT, charge declared it a "probable" coalition to generate the financial BCG, measles - had reached an case of polio. Local health and human resources needed to all-time high in the history of the authori ties in the district of achieve the goal. Most importantly, Americas. The AFP surveillance Pichi noki began on immediate vaccination cam paig n the national governments themselves system is now used for the surveil­ In N ovember, the la boratory and their thousands of health workers lance of other communicable confirm ed that th e paralysis was who worked tirelessly under often diseases, such as measles and neo­ due to wild poliovirus type l . Lui s difficult conditions were the driving natal tetanus. Recent field research Fermin 's case was a rallyi ng cry force that made the effort successful. indicates that the efforts to eradicate To support their work, several for everyone to defeat the w ild poliomyelitis from the Americas poli ovirus in Peru , which then agencies backed PAHO in a coordi­ have had a very important positive la un ched the largest "mop-up" nated effort which became known as impact on the overall strengthening vaccinati o n drive in the the Interagency Coordinating of the health services. Americas. Health workers and Committee, mobilizing resources to Finally, this achievement has volunteers visi ted two millio n complement those provided by the demonstrated the impact that homes and imm un ized over two countries themselves. Between 1987 vaccines can have when properly million chil dren in a single week. and 1991, some US$ II 0 million utilized and the benefits that Th e boy proved to be the lost were contributed by PAHO, the mankind can expect with the advent case of po li o not on ly in Peru but United States Agency for of new and improved vaccines which in the w hole of th e Americas. International Development (USAID), the technological advances of the last A fter reho bi I itali a n, Luis the United Nations Children Fund decades will certainly put at the dis­ Fermin now ploys soccer w ith his (UNICEF), Rotary International, the posal of health policy-makers in the friends despite a noticeable limp Interamerican Development Bank years to come. • in his left leg. While it is (IDB) and the Canadian Public reg retta ble that he con tracted Health Association (CPHA). Other poli o, he w ill grow up knowing nongovernmental organizations both that he helped in the eradication national and international partici­ effort by inc iting all of Pe ru 's Dr Ciro A de Ouadros is Special Advisor to pated on a country-by-country basis. the Director-General of WHO on the Global hea lth workers to conquer thi s Most importantly, the governments Programme for Vaccines and Immunization, damaging disease once and for WHO Reg ional Office for the Americas, 525, al l. themselves contributed over US$440 23rd Street N. W , Washington, DC 20037, million (80%) in a demonstration of USA. 10 World Health • 48th Year, No . 1, Jonuory-Februory 1995 Tracking the virus Barbara Hull

Where is the wild virus? It was clear that clinical criteria alone were not enough to monitor the occurrence and disappearance of this disease. How would we know which child with acute flaccid paralysis (AFP) really had polio? Conversely, how do we know that poliovirus is not circulating silently among susceptible individuals and even among immune children and adults, showing no signs but ready to strike? When high immunization coverage and mass vaccinations reduce virus circulation to a few focal areas, how can these be detected? Where is the Each child is assessed far acute Flaccid paralysis. wild virus? A network of virology laborato­ ries has been established by WHO to The natural history of poliovirus undertake this task of virus surveil­ Anetwork of virology indicates that eradication is possible. lance. Their critical function is the Under normal circumstances, man is accurate and reliable isolation and laboratories has been the only host. There are no animal or identification of poliovirus in clinical insect reservoirs which can harbour specimens using standardized tech­ established by WHO to the virus, and therefore the preven­ niques and reagents. undertake the task of virus tion of human-to-human transmis­ The network is organized on a sion will result in its elimination. three-tiered system, with more than surveillance - isolating and Survival in the environment is possi­ 60 national laboratories working in identifying the poliovirus to ble, but is limited to a few days in the close coordination with epidemiolo­ presence of high temperatures and gists who investigate AFP cases. determine where eradication bacterial contamination. Unlike These are supported by 15 regional activities must be stepped up. many other pathogenic organisms, reference laboratories, which supply infection does not result in a long­ reagents, provide on-the-bench train­ term carrier state but in elimination ing, and perform more sophisticated s the global incidence of of the virus from the body and the techniques. Five specialized labora­ poliomyelitis cases declines development of protective life-long tories provide global support for Aand countries become polio­ immunity. From a detection point of research, production of specific free, increasingly sophisticated viral view, a key problem is the fact that reagents, and development of train­ detective work is being developed to less than one per cent of infected ing materials. Not all countries have pinpoint not only the type of polio­ children develop paralysis- the most the necessary facilities, and arrange­ virus responsible for an outbreak, but obvious symptom of polio. A further ments must be made to transport also its precise geographical origin 10% develop mild, non-specific specimens, under refrigeration, to the and relationship to other strains of symptoms while the vast majority of nearest competent laboratory. The the virus. Eradication of the disease infections are symptom-free. A competence of the WHO network entails eradicating the virus which further complication is the fact that laboratories is assured by constant causes it. Poliovirus types 1, 2 and 3 polio-like paralysis may be caused training, provision of high quality an­ are a closely related group of small by other infectious agents (including tisera and sensitive cell cultures, and ribonucleic acid (RNA) viruses, with other enteroviruses), by neurological annual proficiency testing. the ability to invade and replicate in disorders or even by toxic substances The surveillance system for polio the motor neurones of the central and trauma. relies on prompt reporting by health nervous system. workers in clinics and hospitals of all World Health • 48th Yeor, No. 1, January-February 1995 11

determining the relationship between viruses of the same type. High con­ formity in the sequence of the build­ ing blocks of the genetic material of two wild viruses indicates that very few transmission cycles have occurred from their common ances­ tor. They are therefore considered as members of the same genomic family. Larger differences indicate a more distant diversion in the past, and independent lines of transmission. Testing stool specimens. Differences of greater than 10% are taken to indicate different children with AFP. These are As the number of confirmed cases "genotypes" or families of viruses. examined by paediatricians and declines and several countries Analysis of strains from many epidemiologists, and specimens­ become polio-free, fresh questions countries and regions has revealed stool samples- are collected for arise. Have the indigenous strains of "homelands" of various genotypes­ laboratory investigation. In countries wild polio really disappeared? If a limited geographical areas within with few cases, specimens are also case or an outbreak occurs after a which they circulate for a given time. collected from healthy children who period of months or years, was this Maps have been constructed showing are close contacts. virus silently circulating all this time, the global distribution of the major The isolation and typing of a po­ representing a failure of the virus genotypes. liovirus does not end the laboratory surveillance system, or has it been The programmatic implications of investigation. Oral poliovaccine is a recently reintroduced from another molecular epidemiology are far­ live attenuated mixture of the three country? reaching. Eradication activities can types, which multiply in the gut and Research designed to answer be directed at eliminating genotypes are excreted for several weeks after these questions has been spearheaded from their homelands even when they vaccination. Vaccine virus grows by a team at the Centers for Disease extend across national and regional readily in cell culture, and is initially Control in Atlanta, USA, who are borders. These coordinated surveil­ indistinguishable from its virulent, leaders in the field of "molecular lance and immunization strategies are "wild" relative, so special tests have epidemiology" - viral detective being undertaken in several groups of been developed to differentiate wild work which is based on observed countries. The need for intensified from vaccine-derived strains. small changes in the RNA over time. activities becomes apparent in highly Studies on the endemic countries which are sources genetic material of virus. Developed countries and of a large number donor agencies are being encouraged of strains have to provide technical and financial shown that, as assistance to those countries. the virus is Until the poliovirus is eradicated transmitted from from every part of the world, all person to person, countries are at risk and will have to mutations occur maintain constant epidemiological at a rate of vigilance and viral surveillance. • approximately 2% of a selected portion of the genome each year. These changes do not affect the Dr Barbara Hull is a virologist with the Expanded Programme on Immunization, Global susceptibility of Programme for Vaccines and Immunization , the virus to World Health Organization, 121 1 Geneva antibody derived 27. Switzerland. from vaccination or natural infec­ tion, but provide Examining cell cultures. a useful tool for 12 World Health • 48th Year, No. l, Jonuory-Februory 1995 Rotary's PolioPius Cary Silver

To date, Rotary International otarian Eddie Obianwu has has allocated more than stunned the world by raising more travelled thousands of miles US$ 181 million for Polio Plus than $240 million- one of the largest Rand recruited thousands of vol­ fundraising efforts of its kind in unteers to help deliver poliomyelitis projects in 98 nations to history. To date, the Rotary vaccine to remote villages in Nigeria. Foundation of Rotary International For the last four years, he has de­ protect some 500 million (which administers the fu nds) has voted himself almost night and day children. allocated more than $181 million for to the PolioPlus Programme of PolioPlus projects in 98 nations to Rotary International. He has vowed protect some 500 million children. that no child should ever be crippled motto of "Service Above Self'. Carlos Canseco, who served as by this disease, as long as the tech­ Rotarians believe that concerned and Rotary 's president when the pro­ nology exists to prevent it. involved volunteers can achieve gramme was officiall y launched in Eddie is part of a massive force of seeming miracles where 1984, called PolioPlus "a gift Rotary more than one million Rotarians governments traditionally fail. has given to the world. Not only the worldwide who are pursuing the gift of vaccine, but the gift of our same goal. Their strategies are as di­ vision and energy." Rotarians have verse as their cultures and countries. Acoalition for health donated their time, talents, and But they all have the same dream: to money. But their greatest contribu­ wipe out polio. In India, 36 000 In 1985, Rotary became the first tion may be their ability to recruit Rotarians and their families help to international private organization and motivate volunteers from a wide staff immunization posts and health to make a major commitment to cross-section of the community. centres. In the United States, child immunization in developing Rotary realized that it could pur­ Rotarians fight complacency with the countries. Through a programme sue its goal of polio eradication only public service message, "Be Wise, called PolioPlus, it pledged to pro­ as part of a global coalition, along­ Immunize." In Zambia, they provide vide oral polio vaccine for newborn side WHO, UNICEF, the Pan polio vaccine to refugees from babies for up to five consecutive American Health Organization, the Mozambique. In the Philippines, years to any country that requested US Centers for Disease Control and they conduct house-to-house surveys assistance. The PolioPlus campaign Prevention, the Task Force for Child to determine which children have not had as its first goal to raise US$ 120 Survival and Development, and been immunized. million to fight polio. Rotarians others. These groups have combined Rotary their expertise International is an and resources to organization of attack polio more than 1.2 from all sides. million business and professional men and women in 26 000 clubs worldwide which Polio-free provide humani­ status? tarian service, encourage high Perhaps Rotary's ethical standards, greatest success and help build has been in the goodwill and Americas, which peace in the has not reported world. The orga­ a single case of nization is non­ indigenous polio­ political and non­ The PolioPius Programme of Rotary In ternational is playing a maior role in extending polio myelitis since sectarian, with a vaccination coverage to all children . August 1991. World Health • 48th Year, No. 1, Jonuory-februory 1995 13

In Peru - site of the last reported polio case in the Americas ­ Rotarians have had to cope with guerrilla warfare, economic pro­ blems and a cholera epidemic. In 1992, Peruvian members helped the government to carry out a massive "mop-up" effort to immunize two million children- the largest ever conducted in Latin America. While government vehicles were attacked, the Rotarians were able to enter areas controlled by the Shining Path guer­ rillas to deliver vaccine. In Africa, the campaigners con­ front overwhelming obstacles on a daily basis - civil war, political insta­ bility, declining economies and poor infrastructure. In Liberia, Rotarians such as Gus Simpson have demon­ strated great courage in a country plunged into civil war. Simpson (whose house was burned down by rebels) and fellow Rotarians have continued to deliver vaccine, even in rebel-held areas. When asked why he hasn't given up on PolioPius, he responds: "My attitude is that you shouldn 't complain, but make things better." The campaign is also actively im­ munizing children in the developed

nations. US Rotarians, who once So long as there ore children affected by polio in the world, there can be no room for focused only on fundraising, have complacency. jump-started efforts to boost the low coverage levels in their own country. to achieve that last degree of cover­ be our gift to future generations. "It is crucial that we boost immu­ age. Indeed the greatest threat at this And for me personally, it will be a nization rates in the United States, point may be complacency. "We dream fulfilled." • because polio can still be re­ must stay motivated," says 1994-95 introduced from other countries," Rotary International President Bill warns Charles C. Keller, a former Huntley of England. "We must Rotary president. One of the latest guard against complacency until regions to benefit from PolioPlus is every country is certified as polio­ Eastern Europe, where new Rotary free. I am confident that we will clubs are being founded. In 1991, celebrate that day before Rotary's Romania became the first country in lOOth birthday in 2005." Eastern Europe to receive a In 1992, Rotary provided a grant PolioPlus grant. of $250 000 to WHO to help develop Ms Cary Silver is Assistant Editor of The Rotarian, official magazine of Rotary Despite the significant progress a heat-stable vaccine. In tum, WHO International. She has travelled to Thailand, made, PolioPlus faces new chal­ has recognized Rotary 's historic Indonesia, Nigeria, Mexico and Bolivia as a photo-journalist to cover Rotary's PolioPius lenges in the years ahead. The main achievements by presenting the Programme. Her address is 1560 Sherman focus of Rotarians today is on three organization with its highest honour, Avenue, Evanston, IL 6020 1·3968, USA areas: support to national immuniza­ the "Health for All" gold medal. tion days, particularly through social "It will be a proud day when we mobilization; surveillance; and advo­ can celebrate the end of polio- and cacy. As countries move closer to to know that we played a part," says the day they are certified as "polio Eddie Obianwu of Nigeria. "It will free", it becomes even more difficult 14 World Health • 48th Year, No . 1, January-february 1995 The quest for a vaccine Fred Robbins

Acentury ago, "infantile paralysis".,had alow mortality rate and r6rely caused paralysis. Then the character of poliomyelitis changed. Faced by amuch more crippling disease, medical science urgently needed to The key to polio eradication is ensuring that a safe and effective vaccine reaches every child in the discover safe and effective world. vaccmes. largely limited to very young keys by inoculating directly into the children. The non-paralytic polio brain a suspension of central nervous virus infection resulted in life-long system tissue from a fatal polio­ immunity to the disease so that most myelitis patient. The infectious of the population were immune from agent was later shown to be a small orty years have elapsed since an early age. virus which is one of the entero­ the field trial of the killed The disease began to change its viruses, and the disease proved to be Fpoliomyelitis vaccine (KPV), character in the late 19th century in primarily an infection of the developed by Jonas Salk, resulted in the industrialized countries. It gastrointestinal tract. Virus was the first safe and effective vaccine occurred in epidemics in the summer present for a few days in the patient's becoming available for general use. and early autumn in the northern throat and for as long as several Some years later the live attenuated hemisphere. The first major weeks in the faeces. Two groups of vaccine of Albert Sabin (OPV) epidemic was described by Medin United States investigators in 1936 became available. In the space of 40 in Stockholm in 1887. Epidemics prepared vaccines from the brain and years, poliomyelitis has largely began to occur throughout the indus­ spinal cord of infected monkeys disappeared from the industrialized trialized world and the age incidence which were treated to inactivate the world and, on 29 September1994, of paralytic disease steadily in­ virus. Hundreds of subjects were eradication or "the interruption of creased, resulting in a more severe vacci-nated but some developed transmission" of polio from the disease and more patients with paralysis, presumed to be caused by Americas was certified. involvement of the muscles of respi­ virus that had escaped inactivation. The polio viruses have probably ration. These were the patients who These experiments were promptly been parasites of man for thousands required care in a respirator or "iron terminated and further progress in of years. Until the latter part of the lung" and among whom the mortality polio prophylaxis awaited technical 19th century, polio was endemic rate was highest. Many of the respi­ advances. throughout the world. Most people rator patients who survived were became infected early in life but only severely crippled and some required 1 in 100 or fewer of infected persons respiratory assistance for the remain­ A safe vaccine at last developed paralysis. Thus it was der of their lives. truly "infantile paralysis", with a low In 1909, Landsteiner and Popper With the report in 1949 from Enders' mortality rate and residual paralysis were able to transmit polio to mon- laboratory at the Boston Children's World Health • 48th Yeor, No. 1, Jonuory-Februmy 1995 IS

Hospital that polio virus could be grown in cultures of a variety of non­ nervous tissues, the means were at hand to produce safe and effective vaccines. It was five years later that the Salk killed vaccine, prepared from virus grown in monkey kidney cell cultures and inactivated with for­ malin, became available. The 1954 field trial, which showed it to be safe and effective, involved almost two million children in Canada, Finland and the USA. With the availability of an effec­ tive vaccine, many countries and communities embarked upon vacci­ nation campaigns with encouraging results. Indeed, in Sweden, where a high polio vaccination rate was rapidly achieved, paralytic polio dis­ appeared within a few years and the virus could no longer be detected in jonas Salk , who developed the first safe and Albert Sabin discovered the live attenuated the environment. However, for much effective vaccine to be made available For polio vaccine - OPV- today massively used in of the world the KPV was not the general use. campaigns throughout the world. ideal product since it required needles and syringes and was relatively expensive. In 1985, the Pan American Health rupted in the Americas, which In 1960, the Sabin live attenuated Organization (PAHO) announced the means that eradication has been vaccine (OPV)- delivered orally­ goal of eradicating polio from the achieved. The Americas have became available and was adopted as Americas. The polio eradication pro­ shown what can be done. The rest of the vaccine of choice by the USA gramme was coordinated by PAHO the world must follow suit so that we and many other countries because of but a great deal of effort to organize can achieve the WHO goal of a its ease of administration, low cost, and carry out the programme was re­ polio-free world by the year 2000. the multiplier effect of transmission quired within each country. There from vaccinees to their unvaccinated had to be strong political support • contacts, the greater effect upon the since a significant part of the cost susceptibility to reinfection and the was borne locally in spite of financial lower cost. It did however, have two support from many partners, includ­ disadvantages. The vaccine is ing Rotary International. The Rotary sensitive to inactivation by heat and Clubs provided substantial financial therefore must be refrigerated during assistance, and their members transport and storage, which can be a volunteered their help. serious problem in many tropical and The programme for eradication of less developed countries. Also it was polio from the Americas was extra­ discovered that a rare recipient or ordinarily successful. The last case contact developed paralysis due to of polio due to wild virus in the the vaccine virus. This was a small Americas occurred in Peru in August but definite price to be paid for a 1991. A special commission in each Dr Fred Robbins, Nobel/aureate (with john Enders and Thomas Weller) For medicine and very great benefit to society. Thus, country reviewed their country's data physiology in 1954, is Professor Emeritus in by 1960 two effective and relatively and in August 1994 all reported that the Department of Epidemiology and safe vaccines were available. Within they were satisfied that the virus had Biostatistics, Case Western Reserve University, I 0900 Euclid Avenue, Cleveland, Ohio the next 10 to 20 years, polio was been eradicated from their country. 44 106·4945, USA eliminated from most industrialized On 29 September, at PAHO head­ countries, but persisted as an quarters in Washington DC, the endemic di sease in the less International Commission to Certify developed countries where most of Eradication of Polio from the the world's population live. Americas concluded that wild polio virus transmission had been inter- 16 World Health • 47th Year, No.6, November-December 1994 Towards a worl

n five years, the world has changed colours, as seen in countries of the former Soviet Union are almost all the two maps showing the number of cases of shown in yellow -which means that they reported less I poliomyelitis due to a wild virus reported by than 10 polio cases. The whole of the American countries. The 1988 map is heavily stained in red, as continent and several countries in each of the other many countries reported more than 10 cases, and green continents are now shown in green. The world is areas- 0 polio cases- were still scarce. For 1993, the marching towards polio eradication.

Reported cases due to wild virus 1988 Data available as of August 1994

.·

No report - More than 10 cases c::J 1 - I 0 cases - Ocases

Reported cases due to wild virus 1993 Data available as of August 1994

•

• • • • • • • I • • ~- = No report - More than I0 cases = 1-IOcases - Ocases • /; World Health • 48 th Year, No. l, Jan uary- February 1995 17 d without polio

The two other maps show what countries are doing. from a polio infection. Stools of children under 15 with All of them are carrying out routine immuni zation, and flaccid paralysis are examined in search of the wild polio many intensify their efforts by organizing National virus. If no virus is found, eradication can be confi rmed. Immunization Days (NIDs). Furthermore, almost half The article "Target 2000" on pages 6-7 gives a fuller of the world's population is covered by surveillance of account of these activities and of the progress of polio acute flaccid paralys is, which may- or may not - result eradication worldwide. •

Immunization and National Immunization Days (NIDs) Status as of September 1994

0 0 0

- NIDs (Onduded - NIDs planned for 1994/1995 c::::J Proposed NIDs c::::J Routine immunization

Acute Flaccid Paralysis (AFP) surveillance Status as of September 1994

- AFP surveillan(e c::::J No AFP surveillan(e 18 World Health • 48th Yeor, No. 1, Jonuary-Februory 1995 Supplying the vaccine David Halliday & Julie Milstien

for huge amounts of OPV to be delivered through routine and To ensure that vaccines ore supplemental strategies. Routine available for both routine and strategies use OPV in a predictable fashion throughout the year. supplemental needs, WHO National immunization days are re­ and UNICEF ore exploring new garded as a supplemental strategy and are intended to deliver OPV procurement strategies, new simultaneously over a wide epi­ demiological area, so it is critical to suppliers, better forecasting have large quantities of vaccine and planning, and available at a particular moment. Since national immunization days improvements to the vaccine. might require tens of millions of doses of OPV at a time- China recently delivered 83 million doses of OPV in one day- the need for advance planning is clear. To ensure that vaccines are available for both routine and supplemental needs, WHO and UNICEF are exploring new procurement strategies, new suppliers, better forecasting and planning, and improvements to the vaccine.

Procurement strategies To ensure a steady vaccine supply, UNICEF periodically evaluates and modifies its procurement strategies. For example, to meet a large increase Large shipments of vaccine arriving at a distribution centre in A frica . in demand for vaccines after 1985, UNICEF lengthened to two years its period for receiving price tenders so ince the Expanded Programme the vaccine cold from the moment it as to enable manufacturers to plan on Immunization began in 1974, is bottled until it is finally given to a better for these volumes. The two­ oral poliomyelitis vaccine child. 5 year tendering process provided (OPV) has been given to millions of The UNICEF Supply Division producers with a reasonable children around the world. and WHO have standardized both assurance of demand during the UNICEF's vast supply system has the vaccine and the cold chain equip­ next two to four years. procured and delivered over 2500 ment specifications. Because of this UNICEF is currently discussing million doses of OPV to more than coordination, all OPV purchased new procurement strategies with its 100 developing countries in the through UNICEF is of guaranteed suppliers. For example, a five-year Americas, Africa, Asia, and the quality and can be maintained in tender period may encourage manu­ Middle East, helping to immunize tested, approved equipment. The facturers to invest in additional over 100 million children each year. standardized dosage and model capacity or to lower their prices. Besides supplying the vaccine, wording for leaflets and labels have UNICEF has worked with WHO to also made possible the interchange­ ensure that vaccine arrives safely at able use of vaccine from different New suppliers the health centre. The vaccine "cold manufacturers. chain" is a logistics system to keep The polio eradication goal calls Although much of the world's supply World Health • 48th Year, No. l, Jonuory-Februory 1995 19

years of age adds considerably to the immunization budget available to a country. Many countries have found it too expensive to launch polio eradication activities. Rotary International has been a major donor, with UNICEF, of polio vaccine for the eradication initiative, and many bilateral donors have also been involved in vaccine purchase. But donations alone are not the answer. An important change in the polio eradication effort has been that From the producer's premises to the vaccination posts, polio vaccine has to be transported under governments are beginning to plan refr1gerated cond1t1ons. more carefully and take more responsibility for funding their own of OPV is purchased from five major future, countries will be rewarded for vaccine needs, rather than relying on suppliers located in the industrialized better planning. donors. Governments are developing world, local production of vaccines stronger, more sustainable systems meets the need in several large devel­ for vaccine supply, procurement and oping countries. For OPV, about half Vaccine vial indicators production which will assure the of the vaccine used is manufactured availability of high quality vaccine. within the country of use. But many Vaccine wastage- the amount of These efforts will increase the countries are not making enough vaccine which is delivered to the im­ governments' ability to obtain not vaccine locally to meet their needs, munization centre but is unused and only OPV but all vaccines, even long and the supply must be supplemented thrown away at the end of the day­ after polio has disappeared as a in some other way. One method of has become a serious concern as global threat. • doing this is called production shar­ greater attention is focused on vac­ ing: the importation of bulk vaccine cine supply. Traditionally, discard­ which is mixed and filled into vials ing unused vaccine at the end of the Mr David Halliday is Director, Supply Division, session was recommended to ensure UNICEF, Unicef Plods , Freeport, 2 l 00 in the country. Countries such as Copenhagen, Denmark, and Or julie Milstien is India, Egypt, Pakistan and Brazil that the fragile vaccine was not com­ Scientist, Global Programme for Vaccines, thus use their local resources and in­ promised by exposure to too much World Health Organization, I 21 I Geneva heat. Vaccine wastage can be as high 27, Switzerland. Other members of the dustry while still optimizing capacity WHO/UNICEF Vaccine Supply Team who and quality. Working with UNICEF as 50% of the supply in some contributed to the article are Mr Peter Evans circumstances. The search is continu­ and Ms Amie Batson, of the same WHO pro­ and WHO, countries and the indus­ gramme, and Or Terrel Hill, Principal Advisor, trial producers of bulk OPV have ing for vaccine which will retain its CSU Program Division, UNICEF, 3 United entered into contracts which faci li­ potency at high temperature for a Nations Plaza, New York, NY I 00 17, USA. tate this process. longer period of time. This increased stability, combined with the use of new time-temperature indicators, Forecasting and planning will let the health worker know whether vaccine still left in the vac­ When the EPI began, the emphasis cine vial has received an excessive was on getting as much vaccine as exposure to heat. possible to the children who needed it. Strategies for ordering and deliv­ ering vaccines were not focused on Paying for the vaccine economy. However, as the demand increased, it became clear that better While OPV is not very expensive­ planning was needed. Not only must about US$ 0.08 a dose at current UNICEF pay more for vaccines prices - other factors have an impact bought at the last minute, but inaccu­ on the price. More than 20% of the rate forecasts tend to damage the cost of the delivered vaccine is the relationship and confidence existing cost of air freight to get the vaccine between UNICEF and the manufac­ from the manufacturer to the turers. WHO and UNICEF are starting-point of the country's cold developing new tools to assist coun­ chain. Providing two extra doses Supplying every individual child with the tries to make accurate forecasts. In every year for each child under five vaccine is the key to polio eradication. 20 World Health • 48th Year, No . l, January-february 1995 Rehabilitating children with polio Ann Goerdt

Health workers should actively encourage all families with a child who has polio to ensure that the child has the same experiences as other children in family life, play and school.

Without proper braces and skilled rehabilitation, many victims of polio would not be able to walk.

hen the poliomyelitis children in the activities of the fami ly promote the development of the eradication programme and community. When these child­ child's movement to the extent possi­ Wwas initiated in 1988, an ren become adults, they should have ble, and to ensure that the child has estimated 10 million people had the same opportunities as others to the same experiences as other some degree of disability caused by marry, to contribute to the support of children in fam il y life, play and the disease. It was anticipated that their families, and to take part in all school. between the years 1988 and 2000 the activities of their communities. The greatest obstacle to the re ha­ another two million children would bilitation process in many countries be affected by polio. So countries were encouraged to strengthen their The role of health services rehabilitation services at the same time as they increased their efforts to The health services are usually eradicate polio. responsible for the rehabilitation We are now at the half-way point process, which consists of prevention in the eradication programme. All of deformities, promotion of normal countries have established proce­ growth and development in the dures for the early and thorough young child, and provision of the detection of polio. Yet most coun­ necessary equipment for mobility. tries where polio is still present have Families must learn the methods for not expanded their rehabilitation ser­ preventing deformities, which can be vices for recently detected children taught by health care workers who or those who had polio some time have the appropriate training, or by ago. rehabilitation workers if they are To ensure the normal develop­ available. Many families automati­ ment and social integration of cally promote the normal develop­ children who have had polio, it is ment of a child with paralysis, partic­ necessary to prevent deformities, ularly if the paralysis affects only one provide means for mobility, include limb. However, health workers should actively encourage all fami­ the children in local schools, and Learning how to walk after a severe attock of integrate them along with all other lies with a child who has polio to polio World Health • 48th Yeor, No. 1, Jonuary-F ebrumy 1995 21 has been providing leg braces to chil­ polio is identified, these services polio, but also on the physical, men­ dren who need them for walking, should go into action. But the com­ tal and social well-being of children since trained personnel must be prehensive rehabilitation of people with polio. The goal of "no more available to make the appliances. with polio requires the collaboration polio" should be interpreted as Orthopaedic workshops with appro­ of health, education and social ser­ insisting that there should be no new priate equipment need to be estab­ vices. The health sector can take the cases of polio and no more deformi­ lished in different parts of the coun­ lead in stimulating other sectors to ti es or severe limitations for those try so that the services are accessible, increase their efforts so as to ensure who got polio before its eradication. and the materials for the appliances the full participation of people with must be provided to the workshops polio in all aspects of family and • on a regular basis. Many developing community life, but other govern­ countries have not had the necessary ment sectors and NGOs must also resources. become more acti ve. Many older children and adults An agreement signed recently with polio could also walk if they between the International Olympic Or Ann Goerdt is o Scientis t with the were provided with braces, although Rehabilitation Unit, World Health Committee and the United Nations Organization, 12 1 1 Geneva 27. they may require surgical procedures Children Fund (UNICEF) includes Switzerland. to correct deformities in the legs so the goal of "No that they can be fitted correctly. This More Polio" as a service is also unavailable to a priority. This majority of people with deformities agreement be­ due to polio. tween a commit­ When government resources are tee which empha­ too limited to provide appliances for sizes excellence mobility or surgical corrections for in sports and an deformities, nongovernmental orga­ organization nizations (NGOs) are encouraged to concerned with promote and support the provision of children's health these services. This is already being focuses attention done in some countries where NGOs not only on the have been active in the polio eradica­ eradication of tion programme, and their role in promoting rehabilitation could also be strengthened. Soon no further cases of polio will occur; but the victims of past outbreaks will still need to be cared for over many years. Long-term rehabilitation By the year 2000, children will no WHO's Guidelines for the prevention of deformities in longer become paralysed by the polio provides information on preventing deformities in young chi ldren poliovirus. However, the need for recently affected by polio . It shows how health workers con teach appliances for those who were fami lies to move o child 's limbs, to position the chi ld during th e day and affected by polio prior to its eradica­ at night, and to make temporary splints to maintain appropriate positions tion will continue for several more for limbs w ith paralysed muscles. decades. Between 1994 and 2000, Guidelines for training personnel in developing countries for prosthetic countries should increase their efforts and orthotic services indicates how personnel con be ·trained to to provide rehabilitation services for international standards for making lower limb bra ces. Personnel trained those children who get polio, as well in this manner could contribute greatly to the supply of braces in countries as for those who are already paral­ with th e highest rates of polio. These two documents ore available free ysed. Planning of services should of charge fro m the Rehabilitation Unit, World Health O rganization, also ensure that the repair and 1211 Geneva 27, Switzerland. replacement of appliances will be Basi c surgical procedures which con be performed by non-speci alist available throughout the lifetime of medical officers ore described in Rehabilitation surgery for deformities people affected by polio. due to poliomyelitis.· techniques for the district hospital. District hospitals The health sector is the one ore likely to provide more accessible services for those who requ ire responsible for identifying new cases surgery prior to being fitted with braces . This publication is available for of polio, and it is the health sector Sw.fr. 25.00, or Sw.fr. 17.50 in developing countries, from Distribution that provides the initial rehabilitation and Soles , World Health Organization , 12 1 1 Geneva 27, Switzerland services. As soon as a child with 22 World Health • 48th Yeor, No . 1, January-february 1995 Paying the price for one's beliefs Paul Oostvogel

ne day in September Vaccine-refusing groups 1992, a 14-year-old 0 boy cycles to his Since the introduction of in ­ secondary school in activated polio vaccine (Salk) Rotterdam, some 25 km from in the National Programme in his home village of 1957, the first seven localized Streefkerk. The next day, and the last two nationwide whi le cycling, his back starts outbreaks occurred within aching and a throbbing vaccine-refusing communities. headache begins. Despite They have their own churches increasing pain he cycles back and schools and li ve in clusters to Streefkerk. On the third day, from the northeast to the his legs and back hurt so badly southwest of the Netherlands. The that he cannot attend school. After number of susceptible people at risk the pains have disappeared he tries to of infection with poliovirus is contin­ get out of bed at the request of the The polio virus is still o reality in some countries. uously increasing. Because of the family doctor, but he cannot stand : Nobody con afford to relax their vigilance. long periods between epidemics, the his legs are too weak. classical pattern of infantile paralysis The boy is immediately referred no longer applies, and the mean age to the neurology department of the of victims shows a striking increase, nearest regional hospital. As he changing from 1-4 years in 1961 to belongs to a community which Several communities in the 15-19 years in 1992. This fact refuses vaccination on religious Netherlands have long refused reflects the virtual absence of virus grounds, the suspected diagnosis is circulating in the Netherlands. This clear: poliomyelitis. The neurologist vaccinations of all kinds on the change in average age is not contra­ notifies his clinical diagnosis imme­ dicted by the fact that the youngest diately to the regional and national grounds that they are "against victim of the 1992 outbreak was only health authorities. The media hear of the will of God". As this I 0 days old and four cases were aged it and present it on radio and televi­ under one month. In earlier days sion as a major item. Headlines article and the following one these infants would have been appear in the national press even be­ show, young people paid protected by antibodies from the fore the laboratory has confirmed the mother. suspected case, but specimens from heavily for not receiving their The outbreak caused confusion both the patient and his 12 fami ly for several weeks throughout the members show the presence of wild full protection against population. Fear of infection and poliovirus type 3. The single dose of poliomyelitis. paralysis, even among the older vaccine virus type! which the boy people who had been immunized, had at the age of two months, during was widespread. People stopped a previous outbreak in 1978, only sharing public transport, and soccer protected him against type1 and not matches and other social events against type 3. man from the same region, confirms scheduled to take place near places Municipal public health services that the outbreak is a serious threat to like Streefkerk were cancelled. offered mass vaccination to try to this community, after 14 years with­ Once it was seen that cases only stop the outbreak, and the enormous out any case. At its peak in the occurred among similar unvacci­ demand for vaccines from the middle of November, clinicians nated communities, confidence in the general public caused chaotic situa­ reported ten cases in one week. The vaccine was reassured. Discussions tions in Rotterdam. Within two final count was 71 victims within then focused on ethical aspects. Why weeks a second case, in a 23-year-old five months, two of whom died. were the excellent vaccines available World Health • 48th Year, No . l, Jonumy-Februo ry 1995 23

More widespread travel throughout the world makes importation of wild virus to the Netherlands increasingly probable, with an ever greater danger of triggering a new outbreak. The wild poliovirus which circulated within the risk community during the last outbreak will protect less than one generation and then only against one type. Only the eradication of all polioviruses will finally protect all non-immunized people in the world from this fearsome paralytic disease. The Netherlands has faithfully supported the Expanded Programme on Immunization, and fully shares A complete course of vaccinations con protect against all types of the virus. WHO's confidence in attaining the final goal: eradication of all polio­ being withheld from young children? extent restricted to the risk group. virus. Meanwhile the daily Why does the government allow One remarkable finding emerged wheelchair taxi from Streefkerk to parents to do this? How can future from a virological analysis of river­ Rotterdam, which is provided for the outbreaks be prevented? Members water from near Streefkerk, taken boy who was the first victim of the of parliament raised these and other some three weeks before notification 1992 outbreak, is a good example of questions. Nevertheless, the option of the first case. A poliovirus was help for the disabled in an industrial­ of making immunization obi igatory isolated which appeared to be molec­ ized, welfare society. At the same was again rejected. Some of the ularly identical with the causative time it shows what simple immuniza­ Dutch reformed churches consider virus for the 1992 outbreak. This tion could have prevented. • immunization as an act against the finding prompted virologists of the will of God. To counter this view, the RIVM to propose an environmental strategy of the government and the surveillance plan which would serve medical council was based on educa­ as an early warning system for any tion and information. But even further circulation of the virus. today, immunization coverage in In the end, all these investigations Dr Paul Oostvagel is a medical microbiologist at the Virology Laboratory (WHO municipalities such as Streefkerk is probably did not result in the final Collaborating Centre for Reference and still as low as 60%, compared with destruction of poliovirus type 3 in Research on Poliomyelitis}, National Institute for over 97% for the country. 1992-93. The simple lesson once Environmental Protection and Public Health (RIVM), P 0. Box 1, 3720BA Bilthoven, more is that, in high coverage areas Netherlands. with excellent hygienic conditions, Atraditional pattern local circumstances Soon after the outbreak began, the may cause National Institute of Public Health pockets of low and Environmental Protection immunization (RIVM) started trying to trace the coverage where virus that was causing the trouble polio may strike throughout the country. Techniques over and over were developed and tested which again. Accept­ may eventually be useful for the ance of polio global eradication initiative. Proving vaccine within the presence of the virus and the high-risk predicting the final course of an community dur­ outbreak could contribute to greater ing the last out­ immunization acceptance. A large break was scat­ population survey finally confirmed tered, therefore that this had been an almost the immunity traditional outbreak pattern in the prevailing after Netherlands. Not only cases but also the outbreak re­ Protected by vaccine, this youngster can en;oy a healthy life without risk the spread of the virus was to a large mains uncertain. of contracting polio. 24 World Health • 48th Year, No. 1, Jonuory-Februory 1995 Courage in adversity June Goodfield

Polio victims - famous or unknown - have set signal examples of the capacity of the human spirit to triumph over severe physical and psychological disabilities.

he end-game in our battle with poliomyelitis approaches. Yet Tas we contemplate the future with optimism we should glance back down the corridors of the past and recall the millions of people Roelofie Mussche, who controcted polio when she was 1 1, is now a skilled actress with on from all over the world who caught important message to convey. the virus. So many of them suffered paralysis, and either died or lived to Fundy. Early that evening he felt battle constantly with twin disabili­ chilled and went to bed. The next Fundraising ties: their own physical limitations day he had a high fever, and pain in and the psychological isolation im­ his back and legs. By Friday he Twelve years later, in March 1933, posed by other people's fear. While couldn't move hi s legs at all. A F. D. Roosevelt, by then severely anticipating the triumph to come, we famous diagnostician decided that paralysed, became President of the should remember them with compas­ FDR had suffered a blood clot. His United States. The fo llowing sion and salute them for what they prescription - frequent massages; his January his first President's Birthday have taught us about the enduring bill- US$ 600, in those days an Ball took place, during which impas­ strength of the human spirit. enormous amount of money. sioned appeals were made for funds Their roll-call includes the Over the next three weeks, FDR's to sponsor polio research. famous (US President Franklyn condition became worse. Eventually Roosevelt's former law partner, Basil Delano Roosevelt) and the unknown his devoted wife Eleanor and his O 'Connor, founded the National (22 small boys playing football in friend Louis Howe had to do every­ Foundation for Infantile Paralysis Nigeria, all of whom had polio). The thing for him: shave him, brush his and became its first Director. He Roosevelt family took their summer teeth, administer catheters, massage started the famous "March of Dimes" vacation at Campobello on Canada's his legs. Only on 25 August did a fundraising campaign, which was eastern rocky shore. FDR, aged 39, Boston specialist correctly diagnose committed to finding effective vac­ arrived at Campobello in 1921 infantile paralysis- polio. For 15 cines. So successful was this exhausted, but on I 0 August, after an days FDR had been having campaign that, ten years later, when active day, he decided he wanted to absolutely the worst treatment. But polio had been controlled in the swim. So he jogged two miles to in reality there was nothing at all United States, there were still swim in the icy waters of the Bay of anyone could do. millions of dollars left in the bank. World Health • 48th Year, No. 1, January-February 1995 25

This particular set of circum­ years in hospital on artificial respira­ stance changed the history of our tion, and intensive physiotherapy struggle with polio. But it changed was completely neglected. Had she something else too. Eleanor received exercise she could have Roosevelt called her husband's walked; now she is confined to a triumph over his disability "a bless­ wheelchair. ing in disguise". Certainly he must have possessed both strength and courage to overcome severe physical Theatre offered an escape and psychological disabilities and route give just one more example of theca­ pacity of the human spirit to triumph. For the first six years after the Certainly the unflagging devotion of paralysis Roelofje could not talk at his wife played a crucially important all. She breathes only through a slit role. But, as she wrote: "He had to in her windpipe and now, when she think out the fundamentals of living wants to speak, she plugs it with an and learn the greatest of all lessons - ebony stick to allow the air to pass Being a victim of polio did not prevent Franklin D. Roosevelt from being President of the United infinite patience and never-ending over her vocal chords. Asked what States of America from 19 3 3 to 1945. persistence." During painful years of kept her going all those years, she trial, the handsome, debonair, some­ replies it was the theatre. In her what frivolous and spoilt young man wheelchair she was able to watch developed "a new seriousness about plays every week, drama releasing himself, and a deeper empathy for her from the prison of her existence. situation at all. There is also a other people." One day she asked herself: sequence of her dancing, supported Similar examples continue to the "What am I doing on this side of the by a Dutch dancer, in an extra­ present day. Outbreaks of polio in footlights? I should be on the other ordinarily moving and beautiful the Netherlands, for instance, areal­ side, participating on the stage". She choreographed routine. Short most totally confined to people from saw an advertisement seeking a extracts from this play are regularly the various Reformed (Protestant) disabled youngster to take part in a repeated on request- at special churches who refuse vaccination on documentary film. She replied, events ranging from drama groups to religious grounds. One such out­ auditioned and got the job. Then the congresses on health and polio. She break occurred in 1971 , during which documentary was transferred to the is also working on a drama on a child from one of these communi­ stage - as a play specially written for euthanasia. ties, 11-year-old Roelofje Mussche, her role. Produced in 1992, About Roelofje 's story is something developed flu-like symptoms. No Living tells the story of the outbreak quite unusual in the spectrum of paralysis followed and even today in Staphorst. In one scene an aca­ polio victims. Many of them excel in she can move her arms and legs. But demic anthropologist describes what sport or in music, but few have had the nerves and the muscles of her res­ he thinks happened in the village, but the courage to take their disability piratory system were severely Roelofje comes on and shows how quite literally on the stage, to full affected. The girl spent the next six outsiders don't really understand the public exposure. •

Dr june Goodfield is President of International Health and Biomedicine, The Manor House, Alfriston, East Sussex BN26 5SY, England

Many young handicapped people excel in sports. 26 World Heolth • 48th Year, No. 1, January-February 1995 No pain, no gain Juan M. Flavier

aria, a chubby nation, or in the form of and carefree streamers and snacks for Mtwo-year-old, volunteers, and funds for was eagerly awaiting her syringes and vaccines. turn for her patak, her The most important two drops of oral polio support came from the vaccine. She could still frontline health workers. remember how peculiar The vaccinations took the taste was. This is place where people going to be her fourth would usually congre­ patak. Her Aunt Loleng gate- in schools, was affected by this dis­ churches, train and bus ease and she goes around stations, airports, piers, with a heavy limp. The waiting-rooms, day-care Or Juan Flavier (second from the left) plays his part in the polio vaccination thought of last month's campaign. centres, shopping malls, scene when some popular restaurants, mu­ children cried after getting their but today she was trying to be an nicipal and city halls and the houses measles injections made Maria example. "Come on, mother. of vi ll age captains or councillors. somewhat apprehensive. She could Remember, it's just like an ant's bite. One local city mayor even waylaid remember her mother's encourage­ Remember, no pain, no gain," Maria all incoming provincial buses in ment: "Come on, children. It's all and Clara both said with a laugh. order to persuade the travellers to be right. It 's just like an ant's bite. It's immunized. nothing really. Remember, no pain, The response was overwhelming. no gain." Everyone was involved More than nine mi lli on children But today her mother assured her received OPV; six million received and her seven-year-old sister Clara It was 16 March 1994, and all over measles vaccines; and nine million that there would be no pain. Only the the Philippines in more than 60 000 women received tetanus toxoid. women would be given anti-tetanus vaccination centres there were simi­ Armed political dissidents responded injections to protect their future new­ lar lines and activities such as these by declaring a unilateral ceasefire to born babies against neonatal tetanus. in the Lanuza Health Centre. Every­ enable health workers to reach chil­ Clara was enjoying the fiesta-like at­ one was involved- not only the local dren in far-flung areas; some rebel mosphere in the vaccination centre. health workers and local volunteers, groups came down from their moun­ She explained. "Today is National but students, boy scouts and girl tain hideouts to bring their children Immunization Day, like earlier this scouts, civic organizations like the for vaccination. year and twice last year. It's an event Rotary and Lions, professional and Indeed, everyone was involved. for bringing children to the health medical societies, the business sec­ It was one activity that made the centres for vaccinations so they don't tor, nongovernmental organizations, Filipinos feel proud, and united. For get sick. It's our government's effort the drug companies, and even movie some, it was the first time they felt to rid the country of this disease stars, singers and sports stars, and they had a government that cared. which causes the limp and other di s­ politicians - from governors to The long queues were there. The abilities." mayors and vi ll age councillors. chaos, the sweat, the children's wail­ Now Maria eagerly opened her The message was carried by tele­ ing and tears. But everyone was mouth to get her OPV and Vitamin A vision and radio stations, in news­ happy and fulfi lled. Everyone was drops. She heard the midwife tell her papers and magazines, and even in unmindful of the pain. Everyone re­ mother to bring her back next year on advertisements for foodstuffs and alized the gain. • 15 February and 15 March for her soaps. The major streets and high­ next doses. That will be easy to re­ ways all carried streamers announc­ member because 15 February is her ing the National Immunization Day. birthday. Then it was her mother's Support from international and local Or juan Flavier is Secretary of Health, tum to get her anti-tetanus injections. agencies came in various forms­ Department of Health, San Lazaro Compound, She was actually afraid of injections manpower and information dissemi- Santa Cruz, Manila, Philippines. World Health • 48th Year, No. l, January-February 1995 27 Egypt tackles polio Esmat Mansour

The role of women in Egypt's ollowing WHO's resolution to successful fight against eradicate poliomyelitis Fworldwide by the year 2000, poliomyelitis stems from their Egypt's President Hosni Mubarak full integration within all included in his 1989 declaration of "The Decade for the Protection and levels of the health care Development of the Child" the goal of eradicating polio from the country. system. Besides the women Through routine immunization, doctors and nurses, mothers national campaigns and mopping-up operations, immunization coverage too deserve agreat deal of with the oral poliomyelitis vaccine credit. (OPV) reached 93% in 1993. As many as 97% of all infants and chil­ dren under five years of age have been receiving the first dose of this vaccine. Drop-out rates have been cut down by using birth register data to search for unvaccinated children In the front line and extend coverage to them. Nurses can convince mothers of the value of Thanks to the efficient cold chain In fact, women in Egypt represent a vaccinating their children against polio. system and improved surveillance, considerable proportion of all private reporting and follow-up, we had only and public physicians and health 196 acute flaccid paralysis cases in service administrators. As in many 1993, a reduction of 71 % from the other countries, the nursing staff are 671 cases reported in 1992. Nine out predominantly women and are there­ mately the success of our programme of Egypt's 27 governorates and 118 fore engaged in the front-line battle to eradicate polio must also credit the of the 206 health districts have been to eradicate polio. The nurse's role mothers who have listened to the entirely free of new cases of polio for here is much broader than the one information provided at the official at least one year. she plays during clinic hours, and her level of health care and who have The role of Egyptian women in value to her community and its wel­ been convinced that the health of this success stems from their full fare should not be underestimated. their children is worth all the expense integration within all levels of the Not only does she routinely give and effort they make. health care system, with many of the polio vaccine, but she is the Egypt's Expanded Programme on them holding top posts in the primary mechanism for di spensing Immunization is one of the most Ministry of Health, formulating health care information to each effective in the world. Reaching our national policies, working with inter­ child's carers, thus increasing their goal of eradicating polio will be a national organizations, and establish­ awareness about the dangers of dis­ worthy tribute to the hard work ing and guiding the development of ease, the importance of vaccination, contributed by all of us - women programmes and strategies. Women and any possible side-effects of the and men together- to protect our are also engaged in immunization vaccine. Therefore she acts as the children. • research projects and field work, first defence line against the disease, helping to achieve and develop the and her understanding of the early health targets. effects of polio and her ability to recognize the disease is essential. Egyptian society is particularly Dr Esmat Mansour is Executive Director of Eg ypt's Expanded Programme on Immunization blessed by a culture and history that and Child Survival Proiect, I Abd el Megeed produces strong family ties. So ulti- Elremaly Street, Bob El, Louk, Cairo, Egypt. 28 World Health • 48th Year, No. l, Jonuory-Februory 1995 The role of women Khadija A. Msambichaka

oliomyelitis is a crippling dis­ ease. For every person showing Psymptoms of polio, there are 99 others walking around looking healthy but carrying and spreading the virus. Poor sanitation and hygiene have been contributing to the perpetual circulation of the polio virus in the community. Fortunately, the disease is pre­ ventable through improved sanitation and hygiene and through vaccination with polio vaccine. Since man is the only reservoir of the virus causing the disease, we know that it is possi- Almost invariably it is the mothers who take the children to be vaccinated. ble to eradicate polio, and thus to reduce the burden of communities having to care for the sick and disabled. In most developing coun­ community. They often remind each Women should be encouraged to tries, it is the women who care for the other to complete their children's work together with community sick as well as for the disabled in the immunization. Mothers frequently workers or with organizations family. As is the case with other in­ organize themselves into parents ' supporting community-based terventions within the family, it is the groups, discussing among other rehabilitation units in an effort to women who are required to take the things the prevalence of immuniz­ rehabilitate the disabled and to initiative in preventing this disease. able diseases in their district. prevent further disability. Again, In order to eradicate polio by the Most of the health workers rehabilitation will enable mothers to year 2000, all infants need to be vac­ providing immunization services and devote more time to other activities cinated routinely and victims of polio health education are women, and this aimed at self-development and must be detected very early so as to encourages mothers to monitor the improvement of the community. • prevent further spread of the virus as occurrence of any case of sudden well as to reduce or prevent future lameness in their neighbourhood and disability. Good sanitation and strict to report it immediately to the exist­ hygiene within the family are clearly ing village monitoring system or essential. health post. At home, mothers Because of their family caring should encourage and support good responsibility in society, women do hygiene practices in the family by play an important role in tackling training the children and other mem­ Or Khadiia A Msambichaka is Programme Manager of Tanzania 's Expanded Programme polio, and its eradication will reduce bers of the household and setting on Immunization (EPI) , P.O Box 9083, Oar es women's potential burden of caring good examples themselves. Salaam, United Republic of Tanzania. for the sick and disabled. It is nearly always the mothers who take their children for vaccination, and who monitor vaccinations of children below five years of age within their World Health • 48th Year, No. l, Jonuory-Februory 1995 29 Reaching the hard·to·reach Stanislava Popova

Hit by unemployment and other problems, the gypsy minority of Bulgaria resented mandatory polio immuniza­ tions and neglected them. Asudden outbreak of the disease in 1991 was only stifled by "aggressive outbreak control" with special attention to gypsy children. Most children con easily be reached through campaigns in the schools. However, some minority groups con still slip through the net. small country with 8.5 million people, Bulgaria straddles one Aof the main roads from Europe cally the whole population. Now it affected but the high-risk areas as to Asia, so the presence of highly was not an easy decision but the well. The outbreak ended in six mobile ethnic minorities has always epidemiologist from the "gypsy months. Experts from WHO head­ created problems with the importation capital" was waiting for my answer quarters in Geneva and the European and spread of communicable diseases. and I gave it. "We shall not wait for Regional Office in Copenhagen vis­ The political changes at the end of the laboratory confirmation. Act as if ited the country several times and 1980s were followed by a substantial these are confirmed polio cases. were taken to the affected regions. decrease in the living standards of the Begin tomorrow. Mobilize paediatri­ Over three years have now elapsed population as a whole, and the gypsy cians and immunize all gypsy children and there has not been a single con­ minority in particular. As the first to up to 7 years of age." firmed case of polio in Bulgaria. be severely struck by the wave of During the next few days single One of the most important lessons we unemployment, the gypsies became paralytic cases were reported from learnt was that a country with such a hostile to any governmental activities, other neighbouring regions and all big proportion (over 15 %) of hard-to­ including the mandatory immuniza­ were in gypsy children, not fully or reach inhabitants should not rely on tions. not at all immunized against polio. only the traditional immunization ser­ The most dramatic year after the We decided to ask WHO to find a vices. A national immunization political changes was 1991, when sponsor and supply oral polio vaccine campaign will be launched very there was a shortage of everything­ (OPV) for a national immunization or shortly which will put special empha­ food, medicines and even soap. In reimmunization campaign aimed at all sis on hard-to-reach ethnic and social this grave situation and after years of children up to 15 months and gypsy groups. A National Committee has seeing no poliomyelitis cases, there children up to 7 years of age. been formed under the patronage of came a sudden outbreak of the the country's President and we hope disease. Four paralytic cases were re­ thi s initiative will mark another great ported in gypsy babies. Was it polio? Over in six months step towards polio eradication. • I remembered 1976 when we had an epidemic resembling poliomyelitis We introduced all the activities but caused by another enterovirus. At recommended by WHO for aggres­ that time we could afford large quanti­ sive outbreak control. There was Dr Stanis/ava Popovo is Head of the Communicable Diseases Deportment, Ministry ties of the cheap Russian polio door-to-door immunization; I person­ of Health , 5 Sveto Nedeljo Square, Sofia vaccine and we reimmunized practi- ally visited not only the places 1000, Bulgaria. 30 World Health • 48th Year, No. 1, January-February 1995 Costs and savings David M. Salisbury

n 1971, the Chief Medical Officer, importation down to very low levels, Sir George Godber, wrote to all a critical appraisal of the complica­ I doctors saying that in recognition tions from routine vaccination of the remarkable progress of the showed that the risks had become WHO smallpox eradication pro­ hard to justify. gramme, the risks of introducing In the 20-year period between smallpox into the United Kingdom 1951 and 1970, over fifteen and a were so low that routine vaccination half million vaccinations and revac­ of young children was no longer cinations were carried out. Over the recommended. This decision was same period, there were 759 cases of described at the time as an outstand­ generalized vaccinia and encephalo­ There can be no progressive ing event in the history of public myelitis following immunization and health. After 130 years of routine 85 deaths. A further 16 individuals, winding down of poliomyelitis vaccination, the first vaccine to be people not vaccinated themselves but introduced became the first to be in contact with vaccinated people, immunization or surveillance stopped. What lessons from the died from eczema vaccinatum. Over services until global eradication of smallpox could we the same period, there were 131 apply to our expectations for the indigenous cases of variola major eradication is reached. When eradication of polio? with 4 7 deaths. In 1962, when there that happens, every country Smallpox immunization was were several importations of small­ stopped in the UK when the balance pox resulting in 62 indigenous cases will immediately benefit. between two forces shifted. No with 24 deaths, 19 people died from longer was the overall benefit to the complications of vaccination or after community from protection against contracting the disease through smallpox sufficient when compared contact with vaccinated people. with the risk to the individual from Once it became clear that WHO was vaccination. While there was a winning the worldwide battle against likelihood that smallpox could be smallpox, the vaccine risks imported into the UK, routine vac­ outweighed those of the disease and cination was appropriate. Once the the stopping of routine vaccination WHO smallpox eradication cam­ was announced. paign brought those risks of Enormous savings

What have we saved since 1971? At the time of stopping routine vaccina­ tion, around two million doses of smallpox vaccine were being pur­ chased each year. Assuming that the same levels of vaccination had con­ tinued, the cost until now would have been close to US$ 50 million at 1970's prices! This does not include doctors' fees and other costs incurred. As a result of stopping smallpox vaccination, the savings in health service resources and vaccine-associated morbidity and mortality over the last 23 years have been enormous, in just one country Every child must still be vaccinated against polio until the disease is totally eradicated. alone. World Health • 48th Year, No. l , Jonuory-February 1995 31

The present cost to the Depart­ savings in direct costs- vaccine ment of Health for polio vaccine for purchase and payments for vaccine England is over $5 million, money administration. Even the figures that that would be immediately available have been quoted are underestimates, for other purposes as soon as global since they ignore costs such as the eradication of polio is achieved. The work time of nurses, expenditure on costs of providing polio immuniza­ vaccine storage and distribution, and tion are harder to calculate because the surveillance in place for polio. doctors are paid for routine child­ Humanity will benefit from the erad­ hood immunization, not for each ication of a disease that causes avoid­ immunization given, but only when able paralysis and death. Health ser­ they reach certain targets. Thus, if vices in every country will benefit, 90% coverage is reached each either by releasing human resources quarter, the payment is an additional for other activities or by making $2700 per annum. To reach these finances available to support other targets, doctors have to show services or to introduce new complete immunization of all target vaccmes. • A young victim of smallpox. Routine vaccination against smallpox could be stopped once world children against the main killer Or David M. Salisbury is in the Department of eradication was certified in 1979. diseases of children. Health, Wellington House, 135-155 Waterloo As with smallpox immunization, Road, London, England. What will the eradication of polio there are some adverse events associ­ mean? There are some similarities ated with polio immunization. There with smallpox eradication, but also are on average two cases of vaccine­ Photo Credits some clear differences. Many associated poliomyelitis each year, Front cover: WHO/ EPI Page 3: WHO/ H. Anenden countries had abandoned smallpox one in a vaccine recipient and one in Page 4: Still Pictures/ J. Schytte © vaccination nearly a decade before a contact of a recent vaccine recipi­ Page 5: WHO/PAHO/ G. Cordoba; Shll Pictures/ P. Harrison © global eradication was announced. ent. The former are usually young Page 6: WHO / H. Anenden This is clearly unthinkable for polio children, sometimes with immuno­ Page 7: WHOjV. Abromov immunization. Every country must deficiency diseases, the latter usually Page 8: WHO/ PAHO/ G. Cordoba Page 10: WHO/ PAHO/ C. Goggero maintain the highest possible levels adults who had escaped previous im­ Page 11 : WHO / B Hull of immunization coverage until the munization. Some of the vaccine­ Pages 12 &13: WHO/ Rotary lnternohonoljC. Silver Page 14: WHO/ PAHO/ H. C. Smith last country in the world can prove recipient cases have died and some Poge 15: WHO/ EPI ; Courtesy of Mrs Heloiso Sobin © that it has eradicated polio. Other­ of the vaccine-associated cases have Pages 16 &11: Mops by the WHO/ EPIInformotion wise, the risks of importing wild suffered sufficient paralysis to be eli­ system Poge 18: WHO/ EPI polio virus into an unimmunized gible for payment under the present Page 19: WHO/ UNICEF; WHO/ EPI country are simply too high. The UK vaccine damage payment Page 20: WHO/ EPI; WHO/ PAHO/ C. Goggero Page 21 : WHO/ HAnenden consequences would be epidemic po­ scheme (a single payment of Page 22: WHO liomyelitis in a susceptible commu­ $30 000). When polio immunization Page 23: WHO/ H. Anenden; WHO/ Zafor nity among the children born since stops, there will be no more vaccine­ Page 24: WHO/S. Veeneman Page 25: Notional Geographical Society/ abandonment of routine immuniza­ associated cases with their burden of White House Historical Association ©; tion. There can be no progressive morbidity and mortality. WHO/ Zofor winding down of immunization or It is clear that the eradication of Page 26: WHOjV. Abromov Page 27: WHO/ M. Jacot surveillance services until global smallpox led to very large savings in Page 28: WHO/ EPI eradication is reached. When that direct and indirect health service Page 29: WHO/ D. Henrioud Page 30: WHO/H. Anenden happens, every country will immedi­ costs. The eradication of polio will Page 31: WHO ately benefit. be associated with even greater Bock cover: WHO/ PAHO/ A. Wook

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