tag:theconversation.com,2011:/au/topics/polio-4428/articlesPolio – The Conversation2023-04-27T12:31:56Ztag:theconversation.com,2011:article/1905182023-04-27T12:31:56Z2023-04-27T12:31:56Z‘Got polio?’ messaging underscores a vaccine campaign’s success but creates false sense of security as memories of the disease fade in US<figure><img src="https://images.theconversation.com/files/523213/original/file-20230427-22-64ll1p.jpg?ixlib=rb-1.1.0&rect=55%2C130%2C3285%2C2434&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For much of the 20th century, Americans were used to seeing people bearing the signs of past polio infection.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/boy-helps-his-brother-a-polio-victim-confined-to-a-news-photo/526756448">Genevieve Naylor/Corbis via Getty Images</a></span></figcaption></figure><p>“<a href="https://twitter.com/sofia_vignolo/status/1129501200716636160">Got Polio? Me neither. Thanks, Science.</a>”</p>
<p>Messages like this are used in memes, posters, T-shirts and even some billboards to promote routine vaccinations. As this catchy statement reminds people of once-feared diseases of the past, it – perhaps unintentionally – conveys the message that polio has been relegated to the history books.</p>
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<a href="https://images.theconversation.com/files/520043/original/file-20230410-5132-hx8ppo.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Leonardo DiCaprio meme 'Remember that time you got polio? Nope? Me neither? Thanks Science!'" src="https://images.theconversation.com/files/520043/original/file-20230410-5132-hx8ppo.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/520043/original/file-20230410-5132-hx8ppo.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/520043/original/file-20230410-5132-hx8ppo.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/520043/original/file-20230410-5132-hx8ppo.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/520043/original/file-20230410-5132-hx8ppo.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/520043/original/file-20230410-5132-hx8ppo.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/520043/original/file-20230410-5132-hx8ppo.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">This pro-science message uses a popular ‘cheers’ meme format.</span>
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<p>Phrasing that aims to encourage immunizations by highlighting their accomplishments implies that some diseases are no longer a threat.</p>
<p>Few people today know much about polio. In 2022, only one-third of surveyed adults in the U.S. were <a href="https://www.annenbergpublicpolicycenter.org/what-u-s-adults-know-and-believe-about-polio-and-the-bivalent-covid-booster/">aware that polio has no cure</a>. Moreover, a 2020 poll had found that <a href="https://news.gallup.com/poll/276929/fewer-continue-vaccines-important.aspx">84% of adults viewed vaccinating children as important</a>, a 10% decline from 2001. The COVID-19 pandemic amplified anti-vaccination messaging, while also <a href="https://doi.org/10.1002/hsr2.516">delaying routine immunization</a>.</p>
<p>Vaccine-preventable diseases are far from eradicated. Measles outbreaks in unvaccinated or under-vaccinated American communities have begun resurfacing in the past few years, despite a <a href="https://www.cdc.gov/measles/elimination.html">2000 declaration</a> that the virus had been eliminated in the U.S. <a href="https://wonder.cdc.gov/nndss/static/2019/annual/2019-table2l.html">Pertussis cases have been on the rise</a>, with more than 18,000 cases reported in 2019. And in July 2022, polio reappeared in an unvaccinated New York man – the first U.S. diagnosis since 1979. This case helped return attention to polio, causing at least some young adults to <a href="https://www.nytimes.com/2022/08/17/health/polio-vaccine-history-millennials.html">wonder about their own vaccination status</a>.</p>
<p>A shift in focus to <a href="https://polioeradication.org">immunization in developing countries</a> has further lulled Americans into a false sense of security. While global approaches have been effective and are certainly needed, as the author of “<a href="https://www.umasspress.com/9781625345288/constructing-the-outbreak/">Constructing the Outbreak: Epidemics in Media and Collective Memory</a>,” I suggest that the celebratory messaging is no longer as effective as it once was and runs the risk of making it seem as if polio only lives in history books.</p>
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<a href="https://images.theconversation.com/files/523214/original/file-20230427-560-ekoj1v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="semicircle of patients in iron lungs use mirrors to watch a TV" src="https://images.theconversation.com/files/523214/original/file-20230427-560-ekoj1v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523214/original/file-20230427-560-ekoj1v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=463&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523214/original/file-20230427-560-ekoj1v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=463&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523214/original/file-20230427-560-ekoj1v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=463&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523214/original/file-20230427-560-ekoj1v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=582&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523214/original/file-20230427-560-ekoj1v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=582&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523214/original/file-20230427-560-ekoj1v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=582&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Polio patients at Baltimore’s Children’s Hospital watched television from inside the iron lungs that breathed for them.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/iron-lung-victims-get-television-set-baltimore-md-iron-lung-news-photo/515427562">Bettmann via Getty Images</a></span>
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<h2>Campaigning against a devastating disease</h2>
<p>Before vaccines, polio – called infantile paralysis or poliomyelitis – was the most feared childhood disease in the U.S. Frequently affecting elementary school kids, the disease sometimes presented like a cold or flu – fever, sore throat and headache. In other cases, limb or spinal pain and numbness first indicated that something was wrong. Paralysis of legs, arms, neck, diaphragm or a combination could occur and, depending on the area affected, render patients unable to walk, lift their arms, or breathe outside of an iron lung.</p>
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<a href="https://images.theconversation.com/files/520095/original/file-20230410-3779-u51y6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="magazine add with images of kids with polio asks for donations" src="https://images.theconversation.com/files/520095/original/file-20230410-3779-u51y6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/520095/original/file-20230410-3779-u51y6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=780&fit=crop&dpr=1 600w, https://images.theconversation.com/files/520095/original/file-20230410-3779-u51y6h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=780&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/520095/original/file-20230410-3779-u51y6h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=780&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/520095/original/file-20230410-3779-u51y6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=980&fit=crop&dpr=1 754w, https://images.theconversation.com/files/520095/original/file-20230410-3779-u51y6h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=980&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/520095/original/file-20230410-3779-u51y6h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=980&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Full page ads like this one from 1953 solicited funds to help polio patients.</span>
<span class="attribution"><span class="source">March of Dimes</span></span>
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<p>Only time could <a href="https://doi.org/10.1136%2Fbmj.1.4602.465">reveal whether the paralysis was permanent</a> or would recede, sometimes to return decades later as <a href="https://www.ninds.nih.gov/health-information/disorders/post-polio-syndrome">Post-Polio Syndrome</a>. Enough people were infected in outbreaks in the 1930s, 1940s and early 1950s that the effects of paralytic polio were quite visible in everyday life in the form of braces, crutches, slings and other mobility devices.</p>
<p>Thanks to the National Foundation for Infantile Paralysis, beating polio became a national priority. The NFIP grew out of President Franklin Delano Roosevelt’s Warm Springs Foundation. <a href="https://theconversation.com/what-fdrs-polio-crusade-teaches-us-about-presidential-leadership-amid-crisis-137215">Roosevelt himself had been partially paralyzed</a> by polio, and the NFIP provided funds for public education, research and survivors’ rehabilitation.</p>
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<a href="https://images.theconversation.com/files/523215/original/file-20230427-986-uvz7nc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Eleanor Roosevelt smiles with a young boy holding a 'Mothers March on Polio' scroll" src="https://images.theconversation.com/files/523215/original/file-20230427-986-uvz7nc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/523215/original/file-20230427-986-uvz7nc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=760&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523215/original/file-20230427-986-uvz7nc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=760&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523215/original/file-20230427-986-uvz7nc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=760&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523215/original/file-20230427-986-uvz7nc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=955&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523215/original/file-20230427-986-uvz7nc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=955&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523215/original/file-20230427-986-uvz7nc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=955&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Eleanor Roosevelt helped inaugurate the Mothers’ March on Polio to raise money to fight the disease.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/the-mothers-march-on-polio-was-inaugurated-december-10-1953-news-photo/535083978">Bettmann/CORBIS via Getty Images</a></span>
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<p>Its campaigns were prolific and diverse, combining interpersonal and mass communication strategies.</p>
<p>From FDR “Birthday Ball” celebrations to parades and elementary school fundraising competitions, various groups raised money. <a href="https://www.umasspress.com/9781625345288/constructing-the-outbreak/">High schoolers performed polio-themed plays</a>, putting the disease itself on trial in “The People vs. Polio.” People passed around collection boxes at movie theaters and other public gatherings.</p>
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<a href="https://images.theconversation.com/files/520093/original/file-20230410-18-dbduj8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="text of three 'I will not' and 'I will' points" src="https://images.theconversation.com/files/520093/original/file-20230410-18-dbduj8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/520093/original/file-20230410-18-dbduj8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1569&fit=crop&dpr=1 600w, https://images.theconversation.com/files/520093/original/file-20230410-18-dbduj8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1569&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/520093/original/file-20230410-18-dbduj8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1569&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/520093/original/file-20230410-18-dbduj8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1972&fit=crop&dpr=1 754w, https://images.theconversation.com/files/520093/original/file-20230410-18-dbduj8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1972&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/520093/original/file-20230410-18-dbduj8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1972&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">An ad placed in Vogue in 1952 laid out the ‘Polio Pledge.’</span>
<span class="attribution"><span class="source">National Foundation for Infantile Paralysis</span></span>
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<p>Campaigns used every medium. Brochures and short films raised awareness of the threat of polio, emphasizing the need for funding to support patient rehabilitation and scientific research. The National Foundation for Infantile Paralysis generated scores of radio scripts and hired Frank Sinatra, Elvis Presley and other famous voices to read them. <a href="https://youtu.be/fOkJAIPkxRA">Judy Garland, Mickey Rooney</a>, <a href="https://www.youtube.com/watch?v=BOXw-Px-X-8&t=4s">Lucille Ball</a> and other Hollywood stars also joined the fight. Comic strips and cartoons featuring Mickey Mouse and Donald Duck rallied for March of Dimes funds to help polio patients.</p>
<p>Starting in 1946, the NFIP featured children with crutches and braces who had survived polio as “<a href="https://www.marchofdimes.org/about/news/memoriam-donald-anderson-first-poster-child-1940-2014">poster children</a>” asking for funds to help them walk again. News stories covered outbreaks and polio epidemics, detailing the devastation of the disease on individuals, families and communities, while advising families how to reduce risk through the “Polio Pledge for Parents,” which provided a <a href="https://nyshistoricnewspapers.org/lccn/sn83031653/1952-07-17/ed-1/seq-4/">list of do’s and don'ts</a> during summer months.</p>
<h2>From public enemy No. 1 to success story</h2>
<p>The work of the National Foundation for Infantile Paralysis yielded unprecedented and continuous success, providing hospitals with equipment during epidemics and supporting the development of vaccines. Following the largest vaccine trial in history, on April 12, 1955, the Poliomyelitis Vaccine Evaluation Center announced that Jonas Salk’s vaccine was <a href="https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.45.5_Pt_1.575">80%-90% effective</a> against paralytic polio and officially <a href="https://theconversation.com/the-great-polio-vaccine-mess-and-the-lessons-it-holds-about-federal-coordination-for-todays-covid-19-vaccination-effort-152806">ready for general use</a>.</p>
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<a href="https://images.theconversation.com/files/523216/original/file-20230427-27-uurxai.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="families in line outside a school with a sign 'Entrance for polio shots' in 1955" src="https://images.theconversation.com/files/523216/original/file-20230427-27-uurxai.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523216/original/file-20230427-27-uurxai.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=449&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523216/original/file-20230427-27-uurxai.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=449&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523216/original/file-20230427-27-uurxai.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=449&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523216/original/file-20230427-27-uurxai.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=565&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523216/original/file-20230427-27-uurxai.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=565&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523216/original/file-20230427-27-uurxai.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=565&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Once a vaccine was available, people lined up to protect themselves and their families from the virus.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/san-diego-california-first-and-second-graders-at-the-kit-news-photo/514704620">Bettmann via Getty Images</a></span>
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<p>Over the next decade, the NFIP shifted its focus to widespread immunization, again using both mass media and local campaigns. With Salk’s vaccine, and then Albert Sabin’s, polio cases fell quickly, from the peak of 57,879 cases in 1952 to <a href="https://doi.org/10.2307/4593032">only 72 cases in 1965</a>, with the <a href="https://www.cdc.gov/polio/what-is-polio/polio-us.html">last naturally occurring U.S. case in 1979</a>.</p>
<p>The repeated declaration of what polio vaccines could and were accomplishing was <a href="https://www.npr.org/sections/health-shots/2021/05/03/988756973/cant-help-falling-in-love-with-a-vaccine-how-polio-campaign-beat-vaccine-hesitan">strategically effective</a> in persuading more people to get their shots. The American public of the 1960s and 1970s had lived through repeated polio epidemics and knew both the fear of contracting the disease and its visible aftereffects. As of 2021, <a href="https://immunizationdata.who.int/pages/coverage/POL.html?CODE=USA&ANTIGEN=POL3&YEAR=">92.7% of Americans</a> were fully protected by the vaccine, though these rates have been in decline since 2010 and <a href="https://www.cdc.gov/vaccines/imz-managers/coverage/schoolvaxview/data-reports/index.html">fluctuate by region</a>.</p>
<p>Public health rhetoric that <a href="https://doi.org/10.1016/j.vaccine.2011.10.005">focused on this vaccine success story</a> worked around the world in the late 1980s and 1990s. Gradually, though, the perceived threat in the U.S. of polio and other vaccine-preventable diseases dissipated over generations as vaccinations largely eliminated the risk. Most people in developed countries <a href="https://www.fda.gov/consumers/consumer-updates/vaccines-protect-children-harmful-infectious-diseases">lack firsthand experiences</a> of just how terrifying these diseases are, having never experienced polio, diphtheria, measles or pertussis, or lost family members to them.</p>
<p>At the same time that polio has been largely forgotten in the U.S., <a href="https://theconversation.com/covid-19-misinformation-scientists-create-a-psychological-vaccine-to-protect-against-fake-news-153024">anti-vaccination messages have been spreading disinformation</a> that distorts the risk of vaccines, ignoring the realities of the diseases they immunize against.</p>
<p>Rhetoric from polio vaccine campaigns in the 1950s and 1960s emphasized the risks of not getting immunized – acute illness, life-changing pain and paralysis or even death. In the 21st century U.S., immunization campaigns no longer emphasize these risks, and it’s easy to forget the potentially deadly repercussions of skipping vaccines.</p>
<p>I believe pervasive public health messaging can counter anti-vaccination disinformation. A reminder for the American public about this still dangerous disease can help ensure that “Got Polio?” does not become a serious question.</p><img src="https://counter.theconversation.com/content/190518/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katherine A. Foss does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Polio vaccines have been a massive public health victory in the US. But purely celebratory messaging overlooks the ongoing threat if vaccination rates fall.Katherine A. Foss, Professor of Media Studies, Middle Tennessee State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2024472023-03-30T08:32:44Z2023-03-30T08:32:44ZPolio: leading virologist offers a beginner’s guide to the different viruses and vaccines<figure><img src="https://images.theconversation.com/files/517403/original/file-20230324-26-x1sewv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Nicholas Kajoba/Xinhua via Getty Images</span></span></figcaption></figure><p><em>In mid-March 2023, the World Health Organization (WHO) <a href="https://www.afro.who.int/countries/burundi/news/burundi-declares-outbreak-circulating-poliovirus-type-2">announced</a> that health officials in Burundi and Democratic Republic of Congo (DRC) had detected cases of vaccine-derived poliovirus. The WHO said the Burundian government had declared the detection of the virus a national public health emergency after three cases were confirmed. The Conversation Africa’s Wale Fatade spoke to virologist Oyewale Tomori, who maps out the terrain of polio viruses, and their mutations, as well as what’s happening on the vaccine front.</em></p>
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<h2>Can you talk us through the various polioviruses?</h2>
<p>There are two types of polioviruses that can cause paralysis in humans. These are the wild poliovirus and the vaccine-derived poliovirus. Wild poliovirus is the most commonly known form of the poliovirus, with three serotypes 1, 2 and 3. Global efforts since 1988, using oral polio vaccine to immunise children, <a href="https://polioeradication.org/wp-content/uploads/2018/07/GPEI-cVDPV-Fact-Sheet-20191115.pdf">have reduced wild poliovirus cases by 99.9%</a>. Of the three wild poliovirus serotypes, only one – the wild poliovirus type 1 – remains in circulation, and in only two countries (Pakistan and Afghanistan).</p>
<p>However, there is another form of poliovirus that can spread within communities: <a href="https://polioeradication.org/polio-today/polio-prevention/the-virus/vaccine-derived-polio-viruses/">circulating vaccine-derived polioviruses</a>, or cVDPV. While they are rare, they have been increasing in recent years due to low immunisation rates.</p>
<p>In the last 20 years mutated forms of the virus contained in the vaccine have emerged in people who have been vaccinated. This is what has been detected in the most recent cases in Burundi and the DRC. The mutations are different from the wild poliovirus, though they too can cause paralysis. A vaccine has been developed to manage the mutated variety.</p>
<h2>Can you explain the differences? And the link to vaccines?</h2>
<p>There are two types of polio vaccines – the oral polio vaccine and the inactivated polio vaccine. The use of the oral polio vaccine containing attenuated or weakened virus, has brought the wild poliovirus to the brink of eradication. <a href="https://www.who.int/news-room/spotlight/history-of-vaccination/history-of-polio-vaccination">The oral vaccine is safe and provides better immunity</a> in the gut (where polio replicates), than the inactivated vaccine. </p>
<p>However, the weakened or attenuated virus in the oral polio vaccine can be excreted in the stool. This is of advantage in communities with low-quality sanitation, where the vaccine virus can spread from person to person and help protect the community. That’s if it doesn’t have time to mutate first.</p>
<p>But in communities with low immunisation rates the vaccine virus can spread from one unvaccinated or under-vaccinated child to another over a long period of time – often over about 12-18 months. During this period, the virus can mutate and take on a form that can cause paralysis just like the wild poliovirus. This is called vaccine derived poliovirus. When it spreads in communities, we have what is called <a href="https://polioeradication.org/polio-today/polio-prevention/the-virus/vaccine-derived-polio-viruses/">circulating vaccine-derived poliovirus</a>. </p>
<p>More than 10 billion doses of oral polio vaccine have been given to nearly three billion children worldwide since 2000. About 2,500 cases of paralysis from circulating vaccine-derived poliovirus paralysis have been registered. </p>
<p>It’s important to note that vaccine-derived poliovirus and circulating vaccine-derived poliovirus are <a href="https://polioeradication.org/wp-content/uploads/2018/07/GPEI-cVDPV-Fact-Sheet-20191115.pdf">not indicative of a re-emergence of wild poliovirus</a>. </p>
<p>Since vaccine-derived poliovirus was <a href="https://pubmed.ncbi.nlm.nih.gov/15106296/">first reported in Hispaniola in 2000</a>, three types of circulating vaccine-derived poliovirus have been identified in over 50 countries in every region of the world, except Antarctica. They have been named cVDPV type 1, cVDPV type2, and cVDPV type 3. </p>
<p>This is what’s known about the reach of each of them:</p>
<ul>
<li><p><strong>cVDPV type 1:</strong> Between <a href="https://polioeradication.org/wp-content/uploads/2023/03/weekly-polio-analyses-cVDPV-20230314.pdf">2000 and mid-March 2023</a>, 213 (53.4%) of 399 reported isolates were associated with paralysis in humans. The remaining 186 isolates were recovered from healthy contacts and community samples, as well as environmental sewage samples. </p></li>
<li><p><strong>cVDPV type 2:</strong> It is the cause of 2,407 cases of paralysis in humans, representing 53.4% of 4,507 isolates <a href="https://polioeradication.org/wp-content/uploads/2023/03/weekly-polio-analyses-cVDPV-20230314.pdf">during the same period</a>. Contacts of cases, other people in the community, and environmental sewage samples were the sources of the remaining 2,094 isolates of type 2. </p></li>
</ul>
<p><strong>cVDPV type 3:</strong> <a href="https://polioeradication.org/wp-content/uploads/2023/03/weekly-polio-analyses-cVDPV-20230314.pdf">Only 53</a> isolates were reported between 2020 and March 15, 2023. Only one case has been associated with human paralysis. Environmental samples yielded 52 (98.1%) of all cVDPV type 3 isolates. </p>
<h2>What’s being done? And what more needs to be done?</h2>
<p>The Global Polio Eradication Initiative and its partners have introduced a <a href="https://polioeradication.org/nopv2/">novel oral polio vaccine type 2 (nOPV2)</a>, to minimise the risk of the vaccine virus mutating and causing polio in under-immunised children. </p>
<p>It’s a <a href="https://polioeradication.org/wp-content/uploads/2022/06/nOPV2-Clinical-Development-Summary_June-2022-Update_Final-EN.pdf">modified version</a> of the existing monovalent oral polio vaccine type 2 (mOPV2), currently in use to respond to circulating vaccine-derived poliovirus type 2 outbreaks. </p>
<p>The new vaccine has been shown in clinical trials to provide protection comparable to the older oral vaccine against <a href="https://polioeradication.org/nopv2/">poliovirus</a>. In addition, it is more genetically stable and less likely than the earlier vaccine to revert to a form which <a href="https://polioeradication.org/wp-content/uploads/2022/06/nOPV2-Clinical-Development-Summary_June-2022-Update_Final-EN.pdf">can cause paralysis</a>.</p>
<p>The genetic stability will reduce the risk of seeding new mutations into the community. </p>
<p>Field use of oral polio vaccine type 2 started in March 2021. By March 2023 close to 600 million doses of the vaccine had been administered across 28 countries. Its introduction has resulted <a href="https://www.who.int/groups/global-advisory-committee-on-vaccine-safety/topics/poliovirus-vaccines">in the interruption of further transmission</a> of circulating vaccine-derived poliovirus type 2 after two immunisation rounds. In 14 of the 17 countries, where two rounds of nOPV2 vaccine have been used to control circulating vaccine-derived poliovirus outbreaks, there has been no reported breakthrough cases </p>
<p>In Tajikistan, the new vaccine was used at the peak of transmission. And after two big campaigns and a smaller one, the transmission was interrupted. </p>
<p>However, in northern Nigeria local transmission continues despite several campaigns with the new vaccine. And the recent reports of circulating vaccine-derived poliovirus type 2 in Burundi and DRC <a href="https://polioeradication.org/news-post/gpei-statement-on-cvdpv2-detections-in-burundi-and-democratic-republic-of-the-congo/">are the first instances of vaccine-derived poliovirus</a> since roll-out of the new vaccine began in March 2021. </p>
<p>While the affected families and communities will find the outbreak of polio difficult to understand and see the outbreak as a tragedy, especially as <a href="https://www.nature.com/articles/d41586-020-02501-3">Africa has been declared free from wild poliovirus</a>. It is important to make the populations aware that with vaccine-derived poliovirus in circulation, and the widespread use of <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32541-1/fulltext#:%7E:text=Two%20novel%20type%202%20oral%20poliovirus%20vaccine%20(OPV2)%20candidates%2C,vaccine%2Dderived%20type%202%20polioviruses.">OPV2</a> vaccines, such instances of polio cases are expected. </p>
<p>The outbreaks in Burundi and DRC, as well as the situation in Nigeria, suggest that it is not only vaccines that are important to stop local transmission. Reaching vulnerable and under immunised children with the vaccine before it mutates is also key. </p>
<p>The use of the new vaccine is another supplementary activity to enhance immunisation and protection against outbreaks of circulating vaccine-derived poliovirus. </p>
<p>Countries must ensure adequate and full immunisation of every child to prevent the outbreak of vaccine-preventable diseases. There is no shortcut to full and adequate immunisation of every child.</p><img src="https://counter.theconversation.com/content/202447/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Oyewale Tomori does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Countries must ensure adequate and full immunisation of every child to curb polio mutations.Oyewale Tomori, Fellow, Nigerian Academy of ScienceLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1985432023-01-26T13:34:59Z2023-01-26T13:34:59ZEliminating neglected diseases in Africa: there are good reasons for hope<figure><img src="https://images.theconversation.com/files/506411/original/file-20230125-16-drokh2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Head nurse Luke Kanyang'areng' with a visceral leishmaniasis patient at the Kacheliba Sub-County Hospital in Kenya.</span> <span class="attribution"><span class="source">Rowan Pybus-DNDi</span></span></figcaption></figure><p>Togo had reason to celebrate in 2022 when it became the first country in the world <a href="https://www.theguardian.com/global-development/2022/aug/25/togo-achieves-major-feat-of-eradicating-four-neglected-tropical-diseases">to eliminate four neglected tropical diseases</a>. The west African nation stamped out <a href="https://www.cdc.gov/parasites/guineaworm/index.html">Guinea worm disease</a> in 2011, <a href="https://www.cdc.gov/parasites/lymphaticfilariasis/index.html">lymphatic filariasis</a> in 2017, <a href="https://www.cdc.gov/parasites/sleepingsickness/">sleeping sickness</a> in 2020, and <a href="https://www.cdc.gov/hygiene/disease/trachoma.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fhealthywater%2Fhygiene%2Fdisease%2Ftrachoma.html">trachoma</a> last year. </p>
<p>These diseases are transmitted in various ways. Guinea worm disease, for instance, is water-borne while sleeping sickness is transmitted by the tsetse fly. </p>
<p>They are just a few among a host of neglected tropical diseases, which mostly affect impoverished communities and that are exacerbated by instability, climate change, and poor living conditions. Every year, <a href="https://www.who.int/news/item/16-07-2020-neglected-tropical-diseases-treating-more-than-one-billion-people-for-the-fifth-consecutive-year">1.7 billion</a> people are affected by these diseases. They cause immense suffering, stigma, disability – and sometimes death. </p>
<p>Togo achieved its milestone through a combination of measures. These included door-to-door mass drug administration, training of healthcare staff, sustained financing, and strong political support. </p>
<p>Other African countries also made significant progress in tackling neglected tropical diseases in 2022. Benin, Rwanda and Uganda managed to <a href="https://www.who.int/news/item/24-05-2022-benin--uganda-and-rwanda-eliminate-human-african-trypanosomiasis-as-a-public-health-problem">eliminate sleeping sickness</a>. Malawi <a href="https://www.who.int/news/item/21-09-2022-malawi-eliminates-trachoma-as-a-public-health-problem">eliminated trachoma</a> and the Democratic Republic of Congo (DRC) <a href="https://www.who.int/news/item/15-12-2022-the-democratic-republic-of-the-congo-certified-free-of-dracunculiasis-transmission-by-who">eliminated Guinea worm disease</a>. </p>
<p>On another continent, in India, Prime Minister Narendra Modi applauded his country’s success in eliminating smallpox, polio and Guinea worm disease, while expressing confidence it could “<a href="https://www.freepressjournal.in/india/mann-ki-baat-pm-modi-talks-about-eradicating-kala-azar-what-is-it-what-are-its-symptoms">soon</a>” eliminate another neglected tropical disease, visceral leishmaniasis.</p>
<p>All of this means there’s plenty of reason to celebrate. But the global health community cannot rest on its laurels. These diseases are still present in some areas. </p>
<p>The insects that transmit many of these diseases don’t respect borders – so no one is safe until everyone is. The COVID-19 pandemic gravely disrupted control programmes, <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(22)00360-6/fulltext">delaying the achievement of elimination goals by years</a> for some diseases. Some countries are also struggling to tackle neglected tropical diseases because of instability and conflicts that hinder control efforts, or because they have large remote regions that are difficult to reach.</p>
<p>Adequate funding is needed to support drug distribution, training of healthcare staff, and raising awareness. Funding for research and development is crucial, too, so that the promising innovations emerging from African laboratories and clinical trial sites can reach doctors and patients.</p>
<h2>Improved treatments</h2>
<p>One of the challenges in tackling many neglected tropical diseases is the absence of adequate treatments. Existing medicines are often not effective enough or are difficult to administer, such as regular injections that require hospitalisation. Some treatments are very painful. Others are downright toxic. For some diseases, such as a fungal infection called <a href="https://dndi.org/diseases/mycetoma/facts/">mycetoma</a>, which is endemic in Sudan, there are no effective treatments at all – amputation is often the only option.</p>
<p>Because these diseases affect the poorest communities and there is little profit to be made from developing new drugs, they have been historically ignored by traditional pharmaceutical research.</p>
<p>But the abundance of good news last year has given me hope. 2022 was an incredible year for visceral leishmaniasis, which is endemic in eastern Africa and is <a href="https://theconversation.com/innovation-and-research-are-key-to-killing-off-neglected-tropical-diseases-in-africa-153914">my field of expertise</a> as a physician and specialist in infectious diseases and tropical medicine.</p>
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Read more:
<a href="https://theconversation.com/innovation-and-research-are-key-to-killing-off-neglected-tropical-diseases-in-africa-153914">Innovation -- and research -- are key to killing off neglected tropical diseases in Africa</a>
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<p>The disease is fatal if left untreated. It’s the deadliest <a href="https://www.reuters.com/article/global-health-disease-idAFL3N2O9075">parasitic killer</a> after malaria. Those infected with visceral leishmaniasis suffer from fever, weight loss and intense fatigue. Many are unable to work, which means a loss of income for their families.</p>
<p>But in September 2022, a <a href="https://www.nature.com/articles/d44148-022-00138-0">shorter, more effective new treatment</a> was announced. Developed with several partners, including Médecins Sans Frontières, this treatment partially removes the need for daily injections. </p>
<p>In June, the World Health Organization also <a href="https://www.npr.org/sections/goatsandsoda/2022/07/07/1110146123/a-nasty-disease-is-even-nastier-for-patietnts-with-hiv-now-theres-encouraging-ne?ft=nprml&f=">recommended</a> an improved treatment specifically for people who are co-infected with HIV and visceral leishmaniasis. This gives hope for the thousands of patients – often young seasonal migrant workers – who respond poorly to standard treatment.</p>
<p>Promising results for a new, one-dose drug for sleeping sickness were also <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(22)00660-0/fulltext">announced</a> last year following clinical studies conducted in the DRC and Guinea by Congolese and Guinean researchers. This new medicine would be a significant improvement over existing drugs and could open the door to sustainably eliminating the disease. This is a remarkable achievement. I still remember when the only drug available to my fellow doctors in the DRC was an arsenic derivative so toxic it <a href="https://www.doctorswithoutborders.org/latest/fire-veins-still-injecting-arsenic-derivatives-treat-african-sleeping-sickness">killed 5%</a> of their patients.</p>
<h2>Collaboration and partnerships</h2>
<p>However, research and development efforts alone are not enough. Collaboration and partnerships are key. These are not just buzzwords: past successes in tackling neglected tropical diseases have been rooted in close-knit partnerships between national health authorities, international donors, medical research institutes, universities and industry.</p>
<p>The new treatments I mentioned above were all developed thanks to such coalitions. I am the director of the Eastern Africa office of a global non-profit medical research organisation called <a href="https://dndi.org/">Drugs for Neglected Diseases Initiative</a>, which took an active role in all these research and development collaborations.</p>
<p>The good news is that new partnerships keep being formed. In 2022, we established LeishAccess, a regional collaboration in Eastern Africa working to <a href="https://news.scienceafrica.co.ke/new-program-to-scale-up-access-to-leishmaniasis-treatments-launched/">promote access to visceral leishmaniasis treatments</a> and remove the obstacles that still prevent half of patients from accessing the life-saving drugs they need.</p>
<p>All these advances give me hope. These extraordinary efforts will eventually pay off. I am convinced that, in a not-so-distant future, people will stop dying from leishmaniasis, and will be safely cured thanks to simple oral drugs.</p>
<p>Many gaps remain, with millions of people still suffering from diseases that could be cured. And neglected tropical diseases that are slowly disappearing can suddenly come back with a vengeance, fuelled by conflicts, economic crises, increased poverty, or climate change.</p>
<p>But if sustained investment is coupled with African political leadership and scientific excellence, there’s good reason to hope for the elimination of neglected tropical diseases on the continent.</p><img src="https://counter.theconversation.com/content/198543/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Monique Wasunna is the director of the Drugs for Neglected Diseases initiative Africa Regional Office.</span></em></p>Every year, 1.7 billion people, most in the world’s poorest areas, are affected by NTDs. The diseases cause suffering, stigma, disability and sometimes death.Monique Wasunna, Researcher, Kenya Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1905652022-09-21T13:11:00Z2022-09-21T13:11:00ZCOVID pandemic created immunisation gaps in Africa. Over half a million children are at risk<figure><img src="https://images.theconversation.com/files/485537/original/file-20220920-18-c12wfn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Routine immunisation has resulted in diseases like measles being drastically reduced.</span> <span class="attribution"><span class="source">Laszlo Mates/shutterstock</span></span></figcaption></figure><p>The COVID pandemic exposed the fault lines in health systems and national routine immunisation programmes around the world. </p>
<p>A <a href="https://www.who.int/news/item/15-07-2022-covid-19-pandemic-fuels-largest-continued-backslide-in-vaccinations-in-three-decades">recent</a> World Health Organization (WHO) report showed that the pandemic fuelled the largest sustained decline in childhood vaccine coverage rates. </p>
<p>These declines threaten to undo the exceptional efforts made in preventing and controlling the devastating burden of vaccine preventable diseases globally. Routine immunisation has prevented <a href="https://ourworldindata.org/vaccination#global-decline-in-vaccine-preventable-diseases">two to three million deaths</a> yearly. Of the lives saved, <a href="https://www.afro.who.int/health-topics/immunization#:%7E:text=Immunization%20currently%20prevents%20over%204,every%20year%20because%20of%20vaccines.">800,000</a> were in the Africa region. Routine immunisation has led to a drastic reduction in diseases like neonatal tetanus and measles. And bacterial meningitis (type A) and polio have virtually been eliminated across the continent. </p>
<p>The repercussions of the pandemic on routine immunisation programmes in the African region are yet to be fully realised. What we do know so far is that the pandemic has resulted in substantial disruptions to national routine immunisation programmes. As a result, the continent is seeing an increased number of outbreaks of vaccine preventable diseases. </p>
<p>African countries had nearly eliminated the deadly form of meningitis type A. But a four-month-long meningitis outbreak was reported in the <a href="https://www.afro.who.int/news/meningitis-outbreak-democratic-republic-congo-declared-over#:%7E:text=Meningitis%20outbreak%20in%20Democratic%20Republic%20of%20the%20Congo%20declared%20over,-24%20December%202021&text=Brazzaville%2FKinshasa%20%E2%80%93%20The%20Democratic%20Republic,and%20205%20deaths%20were%20recorded.">Democratic Republic of Congo</a> in 2021. It accounted for 2,665 cases, claiming 205 lives. This resurgence has been <a href="https://www.voanews.com/a/covid-threatening-resurgence-of-deadly-meningitis-in-africa/6736714.html?s=09">linked</a> with the suspension of meningitis vaccination campaigns at the height of the COVID pandemic. In February 2022, <a href="https://www.afro.who.int/news/malawi-declares-polio-outbreak">Malawi</a> reported its first wild case of poliovirus type 1 in 30 years. A second case followed in <a href="https://www.afro.who.int/countries/mozambique/news/mozambique-confirms-wild-poliovirus-case">Mozambique</a> three months later. The outbreaks sparked <a href="https://doi.org/10.1016/s1473-3099(22)00269-9">mass polio vaccination campaigns</a> across southern Africa. </p>
<p>UNICEF and the WHO have <a href="https://www.who.int/news/item/27-04-2022-unicef-and-who-warn-of--perfect-storm--of-conditions-for-measles-outbreaks--affecting-children">warned</a> of the heightened risk for measles outbreaks, given widening immunisation gaps. </p>
<p>Currently, Zimbabwe is contending with a devastating measles outbreak. Within five months, there have been <a href="https://twitter.com/MoHCCZim/status/1567416772512415744?s=20&t=JslCu5Tki9SCpNLaJXclwg">6,551 confirmed measles cases</a> and <a href="https://www.reuters.com/business/healthcare-pharmaceuticals/zimbabwe-measles-outbreak-death-toll-rises-685-health-ministry-2022-09-03/">704 related deaths</a>. </p>
<p>These emerging outbreaks are a matter of great concern. They call for urgent and sustained public health interventions. Unless these are put in place, the compounding effects of the pandemic could derail regional progress towards the global <a href="https://www.who.int/teams/immunization-vaccines-and-biologicals/strategies/ia2030">immunisation targets</a> that secure the health and wellbeing of infants and children.</p>
<p>The resurgence of deadly vaccine preventable diseases underscores the importance of maintaining high vaccination coverage rates. Children everywhere must have access to all the recommended lifesaving vaccines they need. The disruptions observed during the COVID pandemic also highlight the importance of establishing resilient health systems. Systems must be able to withstand acute and prolonged shocks while delivering essential health services like immunisation programmes. </p>
<h2>Immunisation before COVID</h2>
<p>It is important to contextualise the performance of routine immunisation programmes within the African region. Even before the pandemic, the African region was already contending with a precarious situation. </p>
<p>For one, an <a href="https://www.afro.who.int/publications/investment-case-vaccine-preventable-diseases-surveillance-african-region-2020-2030">estimated</a> 30.7 million children under five continue to suffer from vaccine preventable diseases. These include rotavirus diarrhoea, pneumonia, pertussis and measles. Of these children, more than 520,000 die each year because of poor access to essential immunisation services. </p>
<p>The continent’s health systems have to manage on average <a href="https://www.afro.who.int/health-topics/disease-outbreaks/outbreaks-and-other-emergencies-updates">150 cases of disease outbreaks and other public health emergencies</a> every year. These range from armed conflicts to climate-related disasters (including flooding, drought, and famine) and disease outbreaks. National routine immunisation programmes have had to function in this context. </p>
<h2>The pandemic widened immunisation gaps</h2>
<p>On the continent the pandemic has substantially disrupted national routine immunisation programmes. In many countries health systems were forced to divert limited resources to combat the pandemic. This often left immunisation services vulnerable. </p>
<p>At the height of the pandemic, <a href="https://doi.org/10.1016/S2214-109X(21)00512-X">several countries reported</a> having to suspend vaccination services. There were disruptions to vaccine supply chains which led to stockouts. The number of people taking up immunisation services declined due to restrictions on public gathering. Many people also feared being exposed to the virus at health facilities. </p>
<p>A good measure of the COVID-related disruptions to immunisation programmes is the coverage of the three doses of the diphtheria-tetanus-pertussis (DTP3) vaccine. The <a href="https://www.who.int/data/gho/data/indicators/indicator-details/GHO/diphtheria-tetanus-toxoid-and-pertussis-(dtp3)-immunization-coverage-among-1-year-olds-(-)">WHO</a> uses the coverage of DTP3 to monitor access to immunisation services and measure the performance of broader health systems. </p>
<p>The <a href="https://www.who.int/news/item/15-07-2022-covid-19-pandemic-fuels-largest-continued-backslide-in-vaccinations-in-three-decades">WHO report</a> shows that the COVID-19 pandemic contributed to a general decline in DTP3 coverage globally – irrespective of economic power or income level. </p>
<p>In Africa, national immunisation programmes in several countries maintained optimal performance, achieving <a href="https://immunizationdata.who.int/index.html">DTP3 coverage rates above 90%</a>. These included Algeria, Botswana, Burkina Faso, Burundi, Ghana, Kenya, Malawi, Mauritius, Namibia, Sierra Leone, Uganda and Zambia. </p>
<p>Of concern, however, are the 29 countries that recorded coverage of less than 90%, creating substantial immunisation gaps.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/485610/original/file-20220920-3689-nsysvx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/485610/original/file-20220920-3689-nsysvx.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=293&fit=crop&dpr=1 600w, https://images.theconversation.com/files/485610/original/file-20220920-3689-nsysvx.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=293&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/485610/original/file-20220920-3689-nsysvx.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=293&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/485610/original/file-20220920-3689-nsysvx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=368&fit=crop&dpr=1 754w, https://images.theconversation.com/files/485610/original/file-20220920-3689-nsysvx.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=368&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/485610/original/file-20220920-3689-nsysvx.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=368&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">DTP vaccine coverage in many African countries was below the WHO’s 90% threshold.</span>
<span class="attribution"><span class="source">Data Source: WHO, https://immunizationdata.who.int/index.html</span></span>
</figcaption>
</figure>
<p>The increased misinformation and disinformation during the pandemic also led to some decline in public trust and confidence in immunisation services. This has significantly affected vaccine demand. </p>
<h2>Charting a way forward</h2>
<p>The pandemic provides useful lessons on the importance of continuously strengthening health systems and “crisis-proofing” national routine immunisation programmes. </p>
<p>COVID-19 has been a catalyst for renewed political interest in immunisation programmes. But this must be followed up with regional solidarity to re-prioritise routine immunisation in the national and regional public health agendas. </p>
<p>National governments will have the responsibility to secure and sustain donor funding while increasing domestic financial commitments that will fill the funding gaps for national immunisation programmes. This is in line with the <a href="https://www.afro.who.int/health-topics/immunization/the-addis-declaration-immunization">declarations they have endorsed</a>. </p>
<p>But most importantly, there’s a need to intensify demand for vaccines and immunisation programmes. This is critical to build back public confidence and trust in vaccines and immunisation services in a post-COVID world.</p><img src="https://counter.theconversation.com/content/190565/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Edina Amponsah-Dacosta does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The pandemic has disrupted national immunisation programmes. As a result, the African continent is seeing more outbreaks of vaccine preventable diseases.Edina Amponsah-Dacosta, Postdoctoral Research Fellow, Vaccines for Africa Initiative, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1899342022-09-21T12:35:27Z2022-09-21T12:35:27ZPolio vaccination rates in some areas of the US hover dangerously close to the threshold required for herd immunity – here’s why that matters<figure><img src="https://images.theconversation.com/files/484423/original/file-20220913-3906-gl2l50.jpg?ixlib=rb-1.1.0&rect=0%2C18%2C4102%2C2990&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In 1956, during the height of the polio epidemic in the U.S., health officials in Chicago offer polio shots at a public school.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/free-chicago-illinois-mrs-rose-stamler-uses-microphone-to-news-photo/514975204?adppopup=true">Bettmann via Getty Images</a></span></figcaption></figure><p>Given recent headlines, you may be wondering why polio is even an issue in 2022. For more than 60 years, vaccines against the poliovirus <a href="https://www.cdc.gov/vaccines/pubs/pinkbook/polio.html#">have protected virtually everyone</a> in the United States from the disease. Due to an enormously successful polio vaccination campaign beginning in the 1950s when the <a href="https://www.who.int/news-room/spotlight/history-of-vaccination/history-of-polio-vaccination">first polio vaccines became available</a>, by 1979 polio was <a href="https://www.cdc.gov/polio/why-are-we-involved/index.htm#">considered eliminated in the U.S.</a> </p>
<p>Unfortunately, even today, there are communities in the U.S. that have lower-than-necessary polio vaccination rates. Because many people have not been vaccinated, there is now a real <a href="https://theconversation.com/fears-of-a-polio-resurgence-in-the-us-have-health-officials-on-high-alert-a-virologist-explains-the-history-of-this-dreaded-disease-189107">possibility of a resurgence of polio in the U.S</a>. </p>
<p>As a <a href="https://scholar.google.com/citations?user=G2EkJJ0AAAAJ&hl=en">clinical professor of pharmacy</a>, I train future pharmacists about how vaccines work, their importance and how they prevent diseases. </p>
<p>Public health experts’ longstanding concerns over falling vaccination rates rose to the surface when, in July 2022, a man from Rockland County, New York, <a href="https://www.cdc.gov/mmwr/volumes/71/wr/mm7133e2.htm">was diagnosed with polio</a>, the first such diagnosis in the U.S. <a href="https://www.nytimes.com/2022/07/21/nyregion/polio-case-new-york.html">in nearly a decade</a>. The patient – who developed the severe, paralytic form of the disease – had been exposed to an <a href="https://theconversation.com/polio-in-new-york-an-infectious-disease-doctor-explains-this-exceedingly-rare-occurrence-187518">altered live vaccine strain from overseas</a>.</p>
<p>Then on Sept. 9, 2022, New York declared a <a href="https://www.governor.ny.gov/executive-order/no-21-declaring-disaster-state-new-york">state of emergency</a> due to ongoing poliovirus transmission. As of that date, using wastewater surveillance, officials had identified <a href="https://health.ny.gov/diseases/communicable/polio/wastewater.htm">57 samples of poliovirus in wastewater</a> from four New York counties. More than half of those were detected in the same county where the adult patient is from, just outside New York City.</p>
<p>As a result of the continued poliovirus detection in wastewater, the Centers for Disease Control and Prevention declared that the U.S. now meets the World Health Organization’s criteria for “a <a href="https://www.cdc.gov/media/releases/2022/s0913-polio.html">country with circulating vaccine-derived poliovirus</a>.”</p>
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<figcaption><span class="caption">The U.S. has recorded its first case of polio in the U.S. in nearly a decade.</span></figcaption>
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<h2>Two main poliovirus vaccine types</h2>
<p>There are two key types of polio vaccine <a href="https://www.cdc.gov/cpr/polioviruscontainment/diseaseandvirus.htm">in use around the world today</a>. The <a href="https://polioeradication.org/polio-today/polio-prevention/the-vaccines/ipv/">inactivated poliovirus vaccine</a> is given as a shot, and the <a href="https://polioeradication.org/polio-today/polio-prevention/the-vaccines/opv/">oral attenuated (or weakened) poliovirus vaccine</a> is administered as oral drops, sometimes on a sugar cube.</p>
<p>Since 2000, the U.S. has exclusively used the inactivated poliovirus vaccine, which cannot cause disease since it does not contain live virus. But in countries where the poliovirus continues to circulate, <a href="https://polioeradication.org/where-we-work/polio-endemic-countries/">such as Pakistan and Afghanistan</a>, the <a href="https://polioeradication.org/polio-today/polio-prevention/the-vaccines/opv/">oral attenuated poliovirus vaccine</a> is still used. </p>
<p>In <a href="https://polioeradication.org/wp-content/uploads/2016/09/Position-statement_OPVsafety.pdf">extremely rare cases</a>, the weakened live vaccine used in other countries can mutate back into its virulent form and lead to paralysis. This is how the adult in New York is believed to have come into contact with the virus.</p>
<h2>How ‘herd immunity’ for polio is determined</h2>
<p>The degree to which a community is protected from a pathogen like poliovirus comes down to <a href="https://doi.org/10.1001/jama.2020.20895">herd immunity</a>. When a community – the so-called herd – reaches a threshold of immunity, it can prevent the transmission of a pathogen from person to person, thereby quelling the pathogen. </p>
<p>The herd immunity threshold for a given disease is calculated based upon the expected number of individuals who an infected person would spread it to if they were susceptible. The higher the number of individuals who would become infected, the higher the percentage of the community or population that <a href="https://doi.org/10.1093/cid/cir007">needs to be vaccinated</a> to avoid continued spread of the disease. </p>
<p>For poliovirus, researchers estimate that between five and seven individuals would be infected for each case <a href="https://doi.org/10.4161/hv.18444">if those people were susceptible</a>. Based upon these calculations, experts determined that at least 80% of a community or population should be vaccinated against poliovirus to prevent its spread. </p>
<h2>Falling vaccination rates</h2>
<p>Throughout the U.S., vaccination rates for polio vary significantly. </p>
<p>The CDC recommends that infants and young children receive a <a href="https://www.cdc.gov/vaccines/vpd/polio/public/index.html#">four-dose schedule of the inactivated poliovirus vaccine</a> at 2 months, 4 months, 6 to 18 months and 4 to 6 years. For those who begin vaccination later – as older children, teens or adults – three doses is considered to be complete vaccination. This is because three doses of inactivated poliovirus vaccination have been shown to provide <a href="https://www.cdc.gov/vaccines/vpd/polio/hcp/effectiveness-duration-protection.html#">between 99% and 100% protection against severe disease</a>. </p>
<p>Although all U.S. states are currently above the 80% herd immunity threshold for poliovirus, there are areas within the country that include many pockets of unvaccinated or undervaccinated individuals – those who have not received a total of three lifetime doses of the inactivated vaccine.</p>
<p>New York state, for example, holds one of the highest kindergarten polio vaccination rates in the country, <a href="https://www.cdc.gov/vaccines/imz-managers/coverage/schoolvaxview/data-reports/index.html">with 97.9%</a> of kindergartners vaccinated in the 2020-2021 school year. But current estimates by the New York State Department of Public Health suggest that only <a href="https://health.ny.gov/diseases/communicable/polio/county_vaccination_rates.htm">79% of 2-year-olds in that state</a> have received three doses of the polio vaccine. </p>
<p>Further, in certain pockets and counties of New York, such as Rockland, Orange and Sullivan, three-dose vaccination rates may be far lower based on the 2-year-old age group, which is the only data that is available by county: Rockland 60%, Orange 59% and Sullivan 62%. In fact, 46% of counties in New York are below the three-dose poliovirus vaccination <a href="https://health.ny.gov/diseases/communicable/polio/county_vaccination_rates.htm">herd immunity threshold for 2-years-olds</a>. </p>
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<figcaption><span class="caption">Most people today don’t remember the polio outbreak that terrorized Americans during the first half of the 20th century.</span></figcaption>
</figure>
<h2>Vaccine recommendations</h2>
<p>When children fall more than one month behind on recommended polio vaccination, doctors recommend routine catch-up throughout adolescence. </p>
<p>Because most adults in the U.S. today were vaccinated as children and the <a href="https://www.cdc.gov/polio/why-are-we-involved/index.htm#">U.S. had eliminated polio as of 1979</a>, there was little reason for health experts to believe an adult would come into contact with poliovirus in the U.S. For that reason, catch-up vaccination for adults has not been included on the routine adult vaccination schedule. </p>
<p>But in August 2022, the CDC updated its guidance. In light of the fact that there are communities where poliovirus vaccination rates have fallen below the 80% threshold needed for herd immunity, coupled with the ongoing circulation of poliovirus in New York, the CDC now recommends that all unvaccinated or undervaccinated adults in these communities <a href="https://www.cdc.gov/vaccines/vpd/polio/public/index.html#">receive a poliovirus vaccination</a>. </p>
<p>Additionally, the CDC suggests that some fully vaccinated adults who are at increased risk of exposure may benefit from a single lifetime poliovirus booster dose. This includes health care providers who care for those with poliovirus, or people traveling to areas where poliovirus has not been eliminated.</p>
<p>If you are unsure if you need vaccination or what steps you should take, talk to your pharmacist or primary care physician.</p><img src="https://counter.theconversation.com/content/189934/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer Girotto consults for Lexi-Comp. She has received grant funds from Pfizer to support independent quality improvement specific to outpatient antimicrobial stewardship. </span></em></p>With poliovirus circulating in New York, health authorities worry that pockets of the county with low polio vaccination rates could give the virus a foothold.Jennifer Girotto, Clinical Professor of Pharmacy Practice, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1891072022-09-07T12:23:49Z2022-09-07T12:23:49ZFears of a polio resurgence in the US have health officials on high alert – a virologist explains the history of this dreaded disease<figure><img src="https://images.theconversation.com/files/482541/original/file-20220902-13382-7ko4kb.jpg?ixlib=rb-1.1.0&rect=0%2C22%2C2995%2C2308&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Critical-care patients in the emergency polio ward at Haynes Memorial Hospital in Boston in August 1955. </span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/POLIOEPIDEMIC/ade0290b02e5da11af9f0014c2589dfb/photo?Query=polio%20iron%20lungs&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=14&currentItemNo=6">Associated Press photo</a></span></figcaption></figure><p>Fears of polio <a href="https://history.nih.gov/display/history/Polio+Timeline">gripped the U.S. in the mid-20th century</a>. Parents were afraid to send their children to birthday parties, public pools or any place where children mingled. Children in wheelchairs served as a stark reminder of the ravages of the disease.</p>
<p>To prevent polio outbreaks, <a href="https://www.pulitzer.org/winners/david-m-oshinsky">government officials used tactics</a> now familiar in the era of COVID-19: They closed public spaces and shut down restaurants, pools and other gathering places. </p>
<p>In 1952, two years prior to the introduction of a trial polio vaccine, there were an estimated <a href="https://ourworldindata.org/polio">58,000 cases of polio and 3,145 deaths due to polio in the U.S.</a>. These cases included children who were paralyzed for life. But those numbers dropped dramatically following a widespread vaccination campaign against polio, beginning in 1955. </p>
<p>By the 1970s, there were fewer than <a href="https://www.cdc.gov/polio/what-is-polio/polio-us.html">10 cases of paralysis due to polio</a> in the U.S., and the polio virus was <a href="https://www.cdc.gov/polio/why-are-we-involved/index.htm#">considered eliminated from the U.S. by 1979</a>. Since then, collective fear of the virus has been mostly lost to history – many people alive today are lucky enough not to know someone who has experienced polio.</p>
<p>So when news broke in July 2022 that an <a href="https://www.nytimes.com/2022/07/21/nyregion/polio-case-new-york.html">unvaccinated adult man in New York had contracted polio</a> – the first case in the U.S. since 2013 – and developed paralysis from the disease, it sent a ripple of fear throughout the public health community and raised the question of whether an old foe was making a comeback. </p>
<p>I am a <a href="https://medschool.cuanschutz.edu/immunology-and-microbiology/faculty/rochford">virologist and a professor of immunology and microbiology</a> and have spent my career both teaching about and doing research on how viruses can cause disease. </p>
<p>There is no cure for polio. The only treatment is prevention. And the tool for prevention is vaccination, the same tool that <a href="https://historyofvaccines.org/history/polio/timeline">eliminated polio in the U.S. in the first place</a>. </p>
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<figcaption><span class="caption">Health experts are urging unvaccinated Americans to get vaccinated against polio.</span></figcaption>
</figure>
<h2>Life cycle of the poliovirus</h2>
<p><a href="https://www.cdc.gov/polio/what-is-polio/index.htm">Polio – or poliomyelitis – the disease</a>, is caused by the poliovirus, which is passed from person to person through the mouth. And while no one would knowingly ingest a virus, touching a contaminated object like a spoon or a glass or accidentally swallowing contaminated water can unknowingly lead to infection. </p>
<p>When someone is infected with the poliovirus, they shed the infectious virus in their feces. This is why recent reports that poliovirus has been <a href="https://www.cnbc.com/2022/08/16/polio-circulating-locally-in-nyc-area-poses-risk-to-unvaccinated-cdc-says.html">circulating in New York City wastewater for months</a> and that the virus now has been <a href="https://health.ny.gov/diseases/communicable/polio/wastewater.htm">detected in three New York counties</a> are particularly concerning. </p>
<p>In August 2022, New York State Health Commissioner Mary Basset said that the state health department is “treating the single case of polio as just the <a href="https://www.health.ny.gov/press/releases/2022/2022-08-04_polio_detected_nys.htm">tip of the iceberg of much greater potential spread</a>.” </p>
<p>“Based on earlier polio outbreaks,” she added, “New Yorkers should know that for every one case of paralytic polio observed, there may be hundreds of other people infected.” </p>
<p>A single case of polio reflects a larger potential spread of the virus because most people infected either don’t show any symptoms or have a very mild illness with <a href="https://www.who.int/news-room/fact-sheets/detail/poliomyelitis">symptoms similar to the flu</a>. But even without symptoms, an infected person is still excreting virus in their feces, which means they can be a source of infection to others. </p>
<p>The virus, which is very stable in the environment, is easily spread through surface contamination. For this reason, hand-washing is a critical prevention tool. Although many disinfecting agents, such as alcohol or diluted Lysol, fail to inactivate the virus, <a href="https://doi.org/10.1016/j.biologicals.2020.07.007">chlorine bleach does destroy it</a>. This is why public health officials started <a href="https://www.utahhumanities.org/stories/items/show/425#">chlorinating swimming pools</a> decades ago <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2038672/">in order to inactivate the polio virus</a>.<br>
Typically, the human body uses stomach acid to <a href="https://www.elsevier.com/books/mims-pathogenesis-of-infectious-disease/nash/978-0-12-397188-3">protect against ingested viruses</a>. But poliovirus can survive stomach acid to travel to your gastrointestinal tract. There, the virus reproduces itself to establish an infection. </p>
<h2>What is paralytic polio?</h2>
<p>Unfortunately, one person out of about 200 people infected with poliovirus will <a href="https://www.who.int/news-room/fact-sheets/detail/poliomyelitis">develop paralysis</a>. Scientists still don’t know why one person is susceptible to the paralytic disease while most are not. </p>
<p>In the small subset of people that get paralytic polio, <a href="https://doi.org/10.1016/j.virol.2005.09.015">the virus can attack</a> the lower motor neurons found in the brain stem and spinal cord, which are <a href="https://biologydictionary.net/motor-neuron/">important for controlling muscles</a>. Infection of those neurons leads to the muscle paralysis that is characteristic of paralytic polio. The legs are typically affected – often on only one side of the body – and paralysis can range from mild to severe. Other muscle groups can also be affected.</p>
<p>In the worst cases of paralytic polio, the virus can damage the centers of the nervous system that control breathing. <a href="https://www.sciencemuseum.org.uk/objects-and-stories/medicine/iron-lung">Respirators known as “iron lungs”</a> were early medical devices that aided those with damaged respiratory muscles, helping them breathe until their muscles healed enough to work on their own. Patients could die when the paralysis was severe and sustained. </p>
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<figcaption><span class="caption">Anti-vaccination sentiments and an overall drop in routine vaccination rates during the COVID-19 pandemic have likely contributed to the resurfacing of the poliovirus in the U.S.</span></figcaption>
</figure>
<h2>Levels of severity</h2>
<p>Although polio can be devastating for those who contract the severe form of it, most people’s immune systems are well-equipped to combat it. When someone recovers from polio, researchers can detect <a href="https://doi.org/10.1016/j.immuni.2022.04.007">poliovirus-fighting antibodies in the blood</a>.</p>
<p>But even long-term survivors of paralytic polio can develop <a href="https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S0003999311001353">late-onset muscle weakness and fatigue</a>, which is <a href="https://doi.org/10.1002/mus.26168">known as post-polio syndrome</a>. While the <a href="https://doi.org/10.1002/mus.20259">muscular effects of post-polio syndrome are well-recognized</a>, a number of <a href="https://doi.org/10.3389/fneur.2019.00773">other symptoms can be associated with post-polio syndrome</a>, including chronic pain, sleep disturbances, cold intolerance and difficulty swallowing.</p>
<p>Because post-polio syndrome is diagnosed only based on symptoms, there is no consensus on the <a href="https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S0003999311001353">number of polio survivors who develop it</a>, but <a href="https://doi.org/10.1002/mus.26168">estimates range from 15% to upward of 80%</a>. </p>
<h2>Prevention of polio is key</h2>
<p>The decline in polio in the U.S. and globally is a direct result of the introduction of vaccines and the willingness of the public to accept them. In 1988, the World Health Organization, in partnership with Rotary International, the Centers for Disease Control and Prevention and other national governments, launched the Global Polio Eradication Initiative with the goal <a href="https://polioeradication.org/">to wipe out polio worldwide</a>, as is <a href="https://www.cdc.gov/smallpox/index.html#">the case with smallpox</a>. </p>
<p>When this initiative was launched, there were still an <a href="https://www.cdc.gov/mmwr/volumes/70/wr/mm7034a1.htm?s_cid=mm7034a1_w">estimated 350,000 children with polio in 125 countries</a>. In 2021, there were <a href="https://www.who.int/news-room/fact-sheets/detail/poliomyelitis">only six reported cases</a>. </p>
<p>Two types of polio vaccine are in use worldwide. The one used <a href="https://www.cdc.gov/media/pressrel/r990617.htm">in the U.S. since 2000</a> is an injection made from inactivated poliovirus. Inactivation kills the virus and prevents it from spreading. <a href="https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html">Children in the U.S. get this shot</a> at 2 months, 4 months and between 6 to 15 months of age, and it essentially provides lifelong protection from polio. </p>
<p>The second vaccine type, still in use in many parts of the world, is an attenuated – or weakened – form of the virus that is taken orally. In places where community transmission remains significant, <a href="https://www.npr.org/blogs/health/2012/09/21/161549217/on-the-road-to-polio-eradication-in-pakistan">like Pakistan</a>, the oral vaccine is preferred because it prevents people from getting polio and also stops person-to-person transmission. In the U.S., where person-to-person transmission of the poliovirus has been virtually nonexistent for decades, the inactivated vaccine is preferred since the focus is on preventing disease in the vaccinated person and there’s less concern about spreading the virus. </p>
<p>But in extremely rare cases, the vaccine virus mutates after it’s been excreted in feces. And if immunization levels fall below a critical threshold – as is the case in some areas of the world – <a href="https://theconversation.com/polio-in-new-york-an-infectious-disease-doctor-explains-this-exceedingly-rare-occurrence-187518">this poliovirus can cause disease</a>. The recent New York polio case has been traced back to a mutated vaccine-derived poliovirus thought to be acquired overseas.</p>
<p>Most people in the U.S. are vaccinated through routine childhood vaccinations. Because immunity to polio following vaccination is lifelong, the CDC is <a href="https://www.cdc.gov/vaccines/vpd/polio/public/index.html">not recommending booster vaccinations for the general population</a> for people who completed the full series. However, the CDC does recommend that anyone who has not been vaccinated against polio virus get vaccinated, including adults.</p>
<p>In my office, I keep a painting of <a href="https://www.salk.edu/about/history-of-salk/jonas-salk/">Dr. Jonas Salk</a>, the virologist who developed the first polio vaccine. It serves as my reminder of the importance of biomedical research to help eliminate human suffering caused by infectious diseases.</p><img src="https://counter.theconversation.com/content/189107/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rosemary Rochford receives funding from National Institutes of Health.</span></em></p>Health officials say the new case of polio in New York state and the presence of poliovirus in the municipal wastewater suggests that hundreds more could already be infected with the disease.Rosemary Rochford, Professor of Immunology and Microbiology, University of Colorado Anschutz Medical CampusLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1889892022-08-21T20:03:12Z2022-08-21T20:03:12ZThe latest polio cases have put the world on alert. Here’s what this means for Australia and people travelling overseas<figure><img src="https://images.theconversation.com/files/479994/original/file-20220818-459-q63sig.jpg?ixlib=rb-1.1.0&rect=1%2C1%2C997%2C664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/covid-19-measles-ebola-vaccinated-doctor-2120184491">Shutterstock</a></span></figcaption></figure><p>Until recently, polio had only been detected in a handful of countries, thanks to global eradication efforts.</p>
<p>But this year’s polio alerts in the United States, United Kingdom and Israel are a reminder that as long as poliovirus is found anywhere, it is a potential problem everywhere. </p>
<p>That could include Australia.</p>
<p>Here’s what the latest polio cases mean for Australia – including under-vaccinated communities and people travelling internationally.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1559646185324953601"}"></div></p>
<h2>The US case</h2>
<p>In July this year, a young man in Rockland County, New York, developed paralysis and was diagnosed with polio, the <a href="https://www.statnews.com/2022/07/21/n-y-state-detects-polio-case-first-in-the-u-s-since-2013/">first US case since 2013</a>.</p>
<p>He had never been vaccinated against polio, which is not uncommon among <a href="https://forward.com/news/512089/polio-rockland-county-new-york-vaccine-orthodox-jew/">Orthodox Jewish people</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8549591/">in some countries</a>. Rockland County has the highest percentage of Orthodox Jewish people in the US. Currently, only <a href="https://health.ny.gov/diseases/communicable/polio/county_vaccination_rates.htm">about 60%</a> of children in the county are vaccinated against polio, compared with <a href="https://www.cdc.gov/nchs/fastats/immunize.htm">more than 90%</a> nationally.</p>
<p>As of August 12, poliovirus was <a href="https://www1.nyc.gov/site/doh/about/press/pr2022/nysdoh-and-nycdohm-wastewater-monitoring-finds-polio-urge-to-get-vaccinated.page">still being detected</a> in sewage in New York City and other counties in New York State, indicating the virus is still circulating in the community.</p>
<p>The reason there have been no further cases of paralysis reflects the fact that only around <a href="https://www.who.int/news-room/fact-sheets/detail/poliomyelitis">one in 200 people</a> infected by the virus develops paralysis. </p>
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Read more:
<a href="https://theconversation.com/polio-in-new-york-an-infectious-disease-doctor-explains-this-exceedingly-rare-occurrence-187518">Polio in New York – an infectious disease doctor explains this exceedingly rare occurrence</a>
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<h2>A child in Israel</h2>
<p>One <a href="https://twitter.com/propublica/status/1558140096028737539">indirect link</a> to the New York man may be in Jerusalem where, in March 2022, poliovirus <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON366">was found</a> in sewage and <a href="https://www.nature.com/articles/s41564-022-01201-0">one case</a> of paralysis occurred in an unvaccinated child.</p>
<p>Vaccination rates among Ultra-Orthodox Jewish people in Israel have been historically low, including <a href="https://apnews.com/article/coronavirus-pandemic-health-middle-east-religion-israel-557e9d18f3f78f4fc141eeddaaefb8eb">low uptake</a> of COVID vaccines.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1519466024357273600"}"></div></p>
<h2>UK ramps up vaccination</h2>
<p>In June this year, the UK government <a href="https://www.gov.uk/government/news/poliovirus-detected-in-sewage-from-north-and-east-london">reported</a> wastewater surveillance in north and east London between February and May had identified poliovirus on consecutive occasions. </p>
<p>This indicated a provisional “silent” outbreak and prompted health officials to instigate catch-up vaccination campaigns. No cases of paralysis have been reported.</p>
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<p>This is reminiscent of an earlier “silent” outbreak of polio in 2013-2014 when, after decades without a case, Israel <a href="https://www.pnas.org/doi/10.1073/pnas.1808798115">detected</a> poliovirus in wastewater samples in many areas, mainly in southern regions.</p>
<p>Stool surveys indicated the outbreak was restricted mainly to children under the age of ten in the Bedouin population of <a href="https://pubmed.ncbi.nlm.nih.gov/27334457/">southern Israel</a>. The virus originated in Pakistan and arrived in Israel via Cairo and then, probably, through Bedouin communities in Egypt and Israel.</p>
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<strong>
Read more:
<a href="https://theconversation.com/polio-vaccine-boosters-offered-to-london-children-an-expert-explains-whats-going-on-188564">Polio vaccine boosters offered to London children – an expert explains what's going on</a>
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<h2>Hang on, hasn’t polio been eradicated?</h2>
<p>It’s tempting to think polio has been eradicated. </p>
<p>The last case of locally acquired polio in Australia <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/cda-pubs-cdi-2002-cdi2602-cdi2602l.htm">was in 1972</a>. Australia was declared polio-free on October 29, 2000, along with the other 36 countries in the Western Pacific Region of the World Health Organization. The last case reported in Australia <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2660702/">was in 2007</a>, when a student contracted the infection in Pakistan.</p>
<p>The <a href="https://polioeradication.org">Global Polio Eradication Initiative</a>, launched in 1988, successfully eliminated wild poliovirus from all but two countries – Pakistan and Afghanistan – where in recent years there have been very few cases. </p>
<p>In <a href="https://polioeradication.org/where-we-work/afghanistan/">Afghanistan</a>, there were four cases last year and one so far this year. In <a href="https://polioeradication.org/where-we-work/pakistan/">Pakistan</a>, there was one case in 2021 and 14 so far this year.</p>
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Read more:
<a href="https://theconversation.com/polio-were-developing-a-safer-vaccine-that-uses-no-genetic-material-from-the-virus-185721">Polio: we're developing a safer vaccine that uses no genetic material from the virus</a>
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<p>The recent cases and wastewater detected polioviruses in the UK, US and Israel are not the wild variety. Instead, they are derived from the oral polio vaccine.</p>
<p>When a child receives a dose of the oral vaccine, they excrete the virus in the stool for several weeks. In very rare cases, the vaccine-derived virus mutates to a form that causes paralysis. This form is called a circulating vaccine-derived poliovirus (cVDPV). This occurs only in populations where polio vaccine coverage is low.</p>
<p>Just recently, cVDPV was reported in the Democratic Republic of the Congo, Mozambique and Yemen, as well as in wastewater in five other countries.</p>
<p>Australia, like all high-income countries, does not use the oral polio vaccine. Instead, children receive <a href="https://immunisationhandbook.health.gov.au/contents/vaccine-preventable-diseases/poliomyelitis">injectable inactivated polio vaccine</a>, which prevents paralysis but does not prevent transmission of the virus. </p>
<p>This is why so-called silent outbreaks can occur in countries that use the injectable vaccine. This is when the virus spreads from child to child but does not cause paralysis.</p>
<h2>What are the implications for Australia?</h2>
<p>Given Australia’s open international borders, there is no reason why someone who has recently received the oral polio vaccine wouldn’t enter the country and excrete the virus.</p>
<p>In Australia, at the age of five, <a href="https://www.health.gov.au/node/38782/childhood-immunisation-coverage/current-coverage-data-tables-for-all-children#five-year-olds">about 95% of children</a> are fully vaccinated against polio. </p>
<p>However, there are places with lower vaccine coverage, such as <a href="https://www.theguardian.com/australia-news/2021/aug/14/when-covid-came-to-the-anti-vax-capital-of-australia">Byron Shire</a> in northern New South Wales, with lower rates of childhood vaccination, including against polio.</p>
<p>This vaccine-hesitant community is vulnerable to the introduction of polio and has had cases of diphtheria, whooping cough, measles and tetanus in recent years.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1543912515372929025"}"></div></p>
<p>Unlike some other Orthodox Jewish communities overseas, there is no evidence this community in Australia is more vaccine hesitant than other Australians.</p>
<h2>How do we look out for cases?</h2>
<p>For years, wastewater monitoring has been routinely implemented in many countries. This acts as an early warning system to identify and rapidly mitigate the spread of many pathogens, <a href="https://theconversation.com/sewage-surveillance-is-the-next-frontier-in-the-fight-against-polio-105012">including poliovirus</a>, hepatitis viruses and, recently, SARS-CoV-2 (the virus that causes COVID).</p>
<p>At wastewater treatment facilities, sewage from an entire region is combined. This allows scientists to <a href="https://www.nature.com/articles/s41564-022-01201-0">detect pathogens</a> at the population level and before anyone presents with symptoms.</p>
<p>In December 2017, Victoria’s environmental testing program <a href="https://www.health.vic.gov.au/media-releases/health-surveillance-system-detects-poliovirus">detected</a> a rare type of poliovirus in pre-treated sewage from the Western Treatment Plant in Melbourne. </p>
<p>No cases of paralytic polio were detected but all Victorians up to the age of 19 were offered three doses of vaccine, free of charge, as part of catch-up arrangements.</p>
<p>Australia’s poliovirus infection outbreak response plan <a href="https://www.health.gov.au/sites/default/files/documents/2022/05/poliovirus-infection-outbreak-response-plan-for-australia.pdf">focuses on</a> clinical surveillance (where health workers report suspected cases to health authorities) and laboratory investigations of people who present with acute paralysis. </p>
<p>While the plan refers to examples of wastewater surveillance overseas, it does not propose a specific strategy in Australia. </p>
<p>Other than Victoria, it is not clear where wastewater polio surveillance is being conducted in Australia.</p>
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<strong>
Read more:
<a href="https://theconversation.com/sewage-surveillance-is-the-next-frontier-in-the-fight-against-polio-105012">Sewage surveillance is the next frontier in the fight against polio</a>
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<h2>What happens next?</h2>
<p>Australia is just as vulnerable to importations of poliovirus – both wild and vaccine-derived – as any other country.</p>
<p>Australia should ensure routine wastewater surveillance for poliovirus is conducted, at least in metropolitan areas.</p>
<p>Community-based vaccination campaigns should be sensitively conducted in vaccine-hesitant communities, such as in Byron Shire, to achieve high coverage.</p>
<p>Education should also be provided through GPs to parents planning to travel to Jerusalem, New York City and Rockland County. They should ensure all travelling family members are fully vaccinated against polio. Visitors to Israel may be able to access a dose of oral polio vaccine in that country for their children (which will prevent them being infected) but this is not available in the US.</p>
<p>Poliovirus enters the body through the mouth, usually from hands contaminated with the stool of an infected person. So parents should also pay special attention to their children’s hand hygiene, particularly if travelling overseas to any of the locations mentioned.</p><img src="https://counter.theconversation.com/content/188989/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Toole receives funding from the National Health and Medical Research council.</span></em></p>Polio cases in the US, UK and Israel remind us that this could also happen in Australia. Here’s what we should watch out for.Michael Toole, Associate Principal Research Fellow, Burnet InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1885642022-08-15T10:12:44Z2022-08-15T10:12:44ZPolio vaccine boosters offered to London children – an expert explains what’s going on<figure><img src="https://images.theconversation.com/files/478904/original/file-20220812-3904-gx33u5.jpg?ixlib=rb-1.1.0&rect=19%2C0%2C6507%2C4354&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/vaccination-concept-little-kid-medical-face-1914690256">Studio Romantic/Shutterstock</a></span></figcaption></figure><p>In June, the <a href="https://www.gov.uk/government/news/poliovirus-detected-in-sewage-from-north-and-east-london">UK Health Security Agency</a> reported that poliovirus had been detected in sewage in north and east London between February and May 2022.</p>
<p>Following this, people were advised to ensure their children were <a href="https://www.england.nhs.uk/london/2022/07/20/get-your-child-vaccinated-against-poliovirus-urges-londons-nhs/">up to date</a> with their polio vaccinations.</p>
<p>On August 10, the <a href="https://www.gov.uk/government/publications/vaccination-strategy-for-ongoing-polio-incident-jcvi-statement/joint-committee-on-vaccination-and-immunisation-statement-on-vaccination-strategy-for-the-ongoing-polio-incident">UK Joint Committee on Vaccination and Immunisation</a> (JCVI) recommended that a further booster dose of polio vaccine be offered to all children in London aged between one and nine.</p>
<p>So what’s happened between June and now, and why this change in vaccination policy?</p>
<p>First, a bit of background. Poliomyelitis, or <a href="https://www.nhs.uk/conditions/polio/">polio</a>, is a devastating disease that has historically seen paralysis and death around the world, mainly in children. It’s caused by an RNA virus (poliovirus) that spreads easily from person to person, usually through virus shed in faeces. </p>
<p>The vast majority of infections with poliovirus actually go unnoticed, but a small proportion of those infected will develop paralysis (or paralytic poliomyelitis), which can lead to respiratory failure or long-term deformities.</p>
<p>In the 1950s, <a href="https://www.sciencemuseum.org.uk/objects-and-stories/medicine/polio-20th-century-epidemic">two polio vaccines</a> were developed: a live attenuated vaccine administered orally (the Sabin vaccine), and an inactivated vaccine given by injection (the Salk vaccine). A live attenuated vaccine is based on a virus that’s still able to reproduce, but is weakened so it doesn’t cause disease. An inactivated vaccine, on the other hand, cannot reproduce.</p>
<p>Both vaccines are highly effective at preventing paralytic poliomyelitis. The oral vaccine in particular can induce strong immunity <a href="https://www.nature.com/articles/d42859-020-00015-6">in the gut</a> and so is better at reducing faecal shedding of the virus, and therefore <a href="https://www.futuremedicine.com/doi/10.2217/fmb.15.19">reducing transmission</a>. </p>
<p>However, the oral vaccine can very occasionally <a href="https://www.ncbi.nlm.nih.gov/books/NBK236293/">cause paralysis</a> (about two to three cases per million doses). For this reason, most countries, including the UK, now prefer to use the inactivated vaccine. The oral vaccine is still used in a small number of countries though.</p>
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Read more:
<a href="https://theconversation.com/poliovirus-in-london-sewage-what-you-need-to-know-185744">Poliovirus in London sewage – what you need to know</a>
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<h2>Wastewater monitoring</h2>
<p>Children who receive the live vaccine will shed it for a short time in their faeces, which is why we might detect “<a href="https://www.gov.uk/government/publications/polio-detection-of-vdpv2-in-london-sewage-samples/immediate-actions-in-response-to-detection-of-vaccine-derived-polio-virus-type-2-vdpv2-in-london-sewage-samples">vaccine-like</a>” polioviruses in wastewater. This normally happens two or three times a year in the UK, where this weakened version of the virus is introduced to the sewage by a child who received the oral vaccine overseas.</p>
<p>This isn’t dangerous in itself, but it’s possible that if these viruses continue to circulate in a population, over time they can mutate, and possibly revert to a version that causes paralysis. These then become classified as <a href="https://polioeradication.org/polio-today/polio-prevention/the-virus/vaccine-derived-polio-viruses/">vaccine-derived polioviruses</a>. Circulation of vaccine-like and vaccine-derived polioviruses is more likely when fewer children are up to date with their vaccinations.</p>
<figure class="align-center ">
<img alt="A mother holds her son on her lap while they are seen by a doctor." src="https://images.theconversation.com/files/478924/original/file-20220812-15-w384kk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/478924/original/file-20220812-15-w384kk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478924/original/file-20220812-15-w384kk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478924/original/file-20220812-15-w384kk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478924/original/file-20220812-15-w384kk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478924/original/file-20220812-15-w384kk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478924/original/file-20220812-15-w384kk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Polio is included in routine childhood vaccinations.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/family-getting-covid-vaccine-home-doctor-1994923175">Jacob Lund/Shutterstock</a></span>
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<p>This is the process which appears to be playing out in London now. From the JCVI’s statement, it’s clear that since the virus was first detected in February, it has evolved and acquired mutations that <a href="https://www.gov.uk/government/publications/vaccination-strategy-for-ongoing-polio-incident-jcvi-statement/joint-committee-on-vaccination-and-immunisation-statement-on-vaccination-strategy-for-the-ongoing-polio-incident">increase the risk</a> of paralytic disease. </p>
<p>These same genetic analyses show a high diversity of viruses being detected, which suggests the virus is circulating in separate networks of people across affected areas of north London.</p>
<p>The JCVI also stated that occasional positive results are being recorded in areas beyond where the virus was originally detected, including Enfield, Barnet and some areas south of the Thames. So it does appear that the virus is continuing to circulate, and may be circulating more widely than before. If this continues, it would only be a matter of time before we’d start to see cases of paralysis among children who are not vaccinated.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/polio-was-recently-detected-in-sewage-in-the-uk-heres-what-else-scientists-look-for-in-our-wastewater-185799">Polio was recently detected in sewage in the UK – here's what else scientists look for in our wastewater</a>
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<h2>Vaccination is key</h2>
<p>Monitoring of wastewater for polioviruses is carried out by many countries primarily to identify when such viruses are <a href="https://www.cambridge.org/core/journals/epidemiology-and-infection/article/role-of-environmental-poliovirus-surveillance-in-global-polio-eradication-and-beyond/DBB1EC7A25FBB252D7EDF9F2F7939FE3#">circulating in the community</a>, before these viruses start to cause paralysis. The fact the issue was detected in London earlier this year and we are yet to see any cases of paralysis shows that such monitoring is achieving its objectives.</p>
<p>The only effective way to control spread of the virus, and importantly, to prevent the emergence of paralytic disease, is to ensure vaccine coverage is as high as possible. Fortunately we have an ample supply of effective and safe vaccines.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1557363689367502850"}"></div></p>
<p>In England the policy has been to give three doses of polio vaccine within a baby’s first 16 weeks, a further booster shortly after three years, and <a href="https://www.nhs.uk/conditions/polio/">again at age 14</a>. The polio vaccinations are usually given in combination with vaccinations against other conditions.</p>
<p>Part of the logic behind the advice for <a href="https://www.gov.uk/government/publications/vaccination-strategy-for-ongoing-polio-incident-jcvi-statement/joint-committee-on-vaccination-and-immunisation-statement-on-vaccination-strategy-for-the-ongoing-polio-incident">an additional booster dose</a> is that <a href="https://academic.oup.com/cid/article/71/8/1984/5754490?login=false">since 2012</a> the UK has been offering a whooping cough vaccine to pregnant women to protect their babies in the early weeks after birth. This is the same vaccine used in children at age three which also contains a dose of the inactivated polio vaccine. </p>
<p>There is some evidence that high levels of maternal antibodies to polio may <a href="https://www.gov.uk/government/publications/vaccination-strategy-for-ongoing-polio-incident-jcvi-statement/joint-committee-on-vaccination-and-immunisation-statement-on-vaccination-strategy-for-the-ongoing-polio-incident">reduce the effectiveness</a> of the first three vaccine doses, meaning children who miss their booster at age three could still be susceptible.</p>
<p>In the affected areas of London, uptake of the polio booster at age three is <a href="https://www.gov.uk/government/publications/vaccination-strategy-for-ongoing-polio-incident-jcvi-statement/joint-committee-on-vaccination-and-immunisation-statement-on-vaccination-strategy-for-the-ongoing-polio-incident">particularly low</a>, so there is concern that many children in these areas may have inadequate protection. The <a href="https://www.gov.uk/government/news/all-children-aged-1-to-9-in-london-to-be-offered-a-dose-of-polio-vaccine">programme</a> will begin in these areas.</p>
<p>While children who have missed their booster will be most vulnerable, according to the JCVI, offering an additional dose to those who are vaccinated will boost antibody levels and may help to reduce asymptomatic shedding of the virus.</p><img src="https://counter.theconversation.com/content/188564/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Hunter consults for the World Health Organization. He receives funding from National Institute for Health Research, the World Health Organization and the European Regional Development Fund.</span></em></p>The move follows recent detections of poliovirus in London’s wastewater.Paul Hunter, Professor of Medicine, University of East AngliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1875182022-07-22T21:53:50Z2022-07-22T21:53:50ZPolio in New York – an infectious disease doctor explains this exceedingly rare occurrence<figure><img src="https://images.theconversation.com/files/475697/original/file-20220722-18-x3p6wo.jpg?ixlib=rb-1.1.0&rect=2%2C0%2C1794%2C1196&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Polio is endemic only in Afghanistan and Pakistan in 2022.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/Polio/221757d74c22419095b557a6d3e4ab75/photo?Query=polio&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=1705&currentItemNo=2">Sarah Poser, Meredith Boyter Newlove/CDC via AP</a></span></figcaption></figure><p><em>The first case of polio in the U.S. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5779436/">since 2013</a> was announced by New York state <a href="https://health.ny.gov/press/releases/2022/2022-07-21_polio_rockland_county.htm">health officials on July 21, 2022</a>. The U.S. resident had not been vaccinated.</em></p>
<p><em>Polio was a common cause of paralysis in children before <a href="https://theconversation.com/lessons-from-how-the-polio-vaccine-went-from-the-lab-to-the-public-that-americans-can-learn-from-today-145604">safe and effective vaccines were invented</a> in the mid-20th century. Thanks to global vaccination campaigns, polio is now almost eradicated, with <a href="https://polioeradication.org/polio-today/polio-now/this-week/">only 13 cases of endemic wild poliovirus reported</a> in 2022 to date worldwide.</em></p>
<p><em>The New York patient reportedly contracted a form of polio that can be traced back to the live, but weakened, poliovirus used in the <a href="https://www.cdc.gov/vaccines/vpd/polio/public/index.html">oral polio vaccine</a>. This version of the vaccine has <a href="https://www.cdc.gov/media/pressrel/r990617.htm">not been used in the U.S. since 2000</a>. Health officials said the virus affecting the male patient, who has muscle weakness and paralysis, <a href="https://health.ny.gov/press/releases/2022/2022-07-21_polio_rockland_county.htm">likely originated somewhere overseas</a>, where oral vaccines are still administered.</em></p>
<p><em><a href="https://scholar.google.com/citations?user=6yMIM1MAAAAJ&hl=en&oi=ao">William Petri</a> is an infectious disease specialist and chair of the World Health Organization’s <a href="https://polioeradication.org/tools-and-library/current-research-areas/polio-research-committee/">Polio Research Committee</a>. Here he explains what <a href="https://www.cdc.gov/vaccines/vpd/polio/hcp/vaccine-derived-poliovirus-faq.html">vaccine-derived poliovirus</a> is and why the inactivated polio vaccine administered in the U.S. today can’t cause it.</em></p>
<h2>What are the two kinds of polio vaccine?</h2>
<p>Vaccines introduce a harmless version of a pathogen to your body. The idea is that <a href="https://www.cdc.gov/vaccines/hcp/conversations/understanding-vacc-work.html">they train your immune system</a> to fight off the real germ if you ever encounter it.</p>
<p>The oral polio vaccine, <a href="https://doi.org/10.1126/science.288.5471.1593">originally developed by Albert Sabin</a>, uses a live but weakened poliovirus that one swallows in a sugar cube or droplet. Scientists weaken – or attenuate – the virus so it can no longer cause disease. </p>
<p>The other kind of polio vaccine was <a href="https://doi.org/10.1126/science.288.5471.1593">originally developed by Jonas Salk</a>. It contains inactivated, dead virus. It is administered by an injection.</p>
<p>In the U.S., children receive the inactivated polio vaccine <a href="https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html">at 2, 4 and 6 months of age</a>. It provides nearly complete protection from paralytic polio.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/475699/original/file-20220722-12-3gho47.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="adult hands administer a drop of medicine to a boy with open mouth" src="https://images.theconversation.com/files/475699/original/file-20220722-12-3gho47.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/475699/original/file-20220722-12-3gho47.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/475699/original/file-20220722-12-3gho47.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/475699/original/file-20220722-12-3gho47.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/475699/original/file-20220722-12-3gho47.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/475699/original/file-20220722-12-3gho47.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/475699/original/file-20220722-12-3gho47.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A boy in Pakistan receives a dose of the oral polio vaccine.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/PakistanPolio/23a6599533e34577b64f4932393fa80a/photo?Query=polio&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=1705&currentItemNo=17">AP Photo/Muhammad Sajjad</a></span>
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<h2>How can the live vaccine lead to a case of polio?</h2>
<p>The weakened form of the live virus in the oral vaccine cannot cause disease. However, because the vaccine is given orally, the weakened virus is excreted in the feces and can <a href="https://www.who.int/news-room/questions-and-answers/item/poliomyelitis-vaccine-derived-polio">spread from someone who is vaccinated to their close contacts</a>. If the weakened virus circulates person to person for long enough, it can mutate and regain its ability to cause paralysis.</p>
<p>The <a href="https://www.who.int/news-room/questions-and-answers/item/poliomyelitis-vaccine-derived-polio">mutated virus can then infect people</a> in communities with poor sanitation and low vaccination rates, causing disease and even paralysis. </p>
<p>This is an exceedingly rare occurrence. With more than 10 billion doses of the oral polio vaccine administered since 2000, there have been <a href="https://polioeradication.org/polio-today/polio-now/this-week/circulating-vaccine-derived-poliovirus/">fewer than 800 cases of vaccine-derived polio</a> reported.</p>
<p>Apparently, the current patient in New York was somehow exposed to a mutated poliovirus that had been transmitted after vaccination overseas. Earlier this summer, routine surveillance spotted <a href="https://www.who.int/news/item/22-06-2022-vaccine-derived-poliovirus-type-2-(vdpv2)-detected-in-environmental-samples-in-london--uk">vaccine-derived poliovirus in London’s sewage system</a>, but no cases have been reported there. </p>
<h2>Why use the oral vaccine anywhere if it comes with this risk?</h2>
<p>There’s a positive aspect to the fact that the weakened live virus can circulate in the community once oral vaccine recipients shed it in their feces. Traveling a feces-to-oral route, it can <a href="https://polioeradication.org/polio-today/polio-prevention/the-vaccines/opv/">help induce immunity</a> even in people who weren’t directly vaccinated. The oral polio vaccine is also <a href="https://doi.org/10.1093/infdis/jiu128">cheaper and easier to administer</a> than inactivated polio vaccines.</p>
<p>Most importantly, the live-virus vaccine stops transmission of wild poliovirus in a way that the inactivated-virus vaccine does not. The <a href="https://doi.org/10.1126/science.abb8588">eradication of polio</a> in the Americas, Europe and Africa has been accomplished solely through the use of the live oral vaccine. Once polio has been wiped from a continent, then it is safe to stop using the oral live vaccine and use only the inactivated vaccine, <a href="https://www.cdc.gov/cpr/polioviruscontainment/diseaseandvirus.htm">which does prevent disease in recipients</a> and does not pose the rare risk of vaccine-derived paralytic polio.</p>
<p><a href="https://polioeradication.org/nopv2/">A new and safer oral polio vaccine</a> that has been engineered not to mutate is now <a href="https://doi.org/10.1126/science.abb8588">replacing the earlier live-virus vaccine</a>. Thus, even this extremely rare complication of polio vaccination should soon become a thing of the past.</p>
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<figcaption><span class="caption">WHO: Polio Eradication – Reaching Every Last Child.</span></figcaption>
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<h2>How close is the world to eradicating polio?</h2>
<p>Thanks to <a href="https://polioeradication.org">tremendous global effort</a>, two of the three viruses that cause polio have been eradicated. The world is now on the verge of eradicating the final one, wild poliovirus 1 (WPV1).</p>
<p><a href="https://polioeradication.org/polio-today/polio-now/this-week/">Today endemic polio is found</a> only in Pakistan, with 12 cases of paralytic polio so far in 2022, and Afghanistan, with just one case this year. Africa has two cases, imported from overseas, which are being contained by additional vaccination campaigns.</p>
<p>Once wild poliovirus has been eradicated from the planet, vaccination efforts may be able to switch to the inactivated polio vaccine, eliminating the risk of any future vaccine-derived cases.</p><img src="https://counter.theconversation.com/content/187518/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>William Petri receives research funding from the NIH and the Gates Foundation.</span></em></p>The oral polio vaccine – which is no longer given in the US – relies on a live but weakened virus that can actually be passed from person to person.William Petri, Professor of Medicine, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1857992022-06-30T13:48:03Z2022-06-30T13:48:03ZPolio was recently detected in sewage in the UK – here’s what else scientists look for in our wastewater<figure><img src="https://images.theconversation.com/files/471892/original/file-20220630-16-ni9tsp.jpg?ixlib=rb-1.1.0&rect=13%2C13%2C2980%2C1973&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/aerial-top-view-round-polls-wastewater-1752757745">DedMityay/Shutterstock</a></span></figcaption></figure><p>We recently learned that <a href="https://www.gov.uk/government/news/poliovirus-detected-in-sewage-from-north-and-east-london">poliovirus</a> had been detected in sewage in north and east London between February and May 2022. Poliomyelitis (polio) is an infectious disease that can cause paralysis and death, mainly in children.</p>
<p>But polio is also a triumph of vaccination. The last known case of polio in the UK <a href="https://www.gov.uk/government/news/poliovirus-detected-in-sewage-from-north-and-east-london">was in 1984</a>, and the country was declared polio free in 2003.</p>
<p>While the <a href="https://www.gov.uk/government/news/poliovirus-detected-in-sewage-from-north-and-east-london">UK Health Security Agency</a> has said that the risk to the public is very low, the detection of the virus in London’s wastewater has naturally led to a strong public health response. Experts are investigating the possibility of community transmission, and have urged the public to ensure their vaccinations are up to date.</p>
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<a href="https://theconversation.com/poliovirus-in-london-sewage-what-you-need-to-know-185744">Poliovirus in London sewage – what you need to know</a>
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<p>Polio was detected in sewage as early as <a href="https://doi.org/10.1084/jem.75.1.1">1939 in the US</a>, and today, wastewater is regularly tested for the virus in many parts of the world. Wastewater surveillance for polio was <a href="https://doi.org/10.1007/BF01249932">trialled in Scandinavia</a> starting in the late <a href="https://doi.org/10.3109/00365549209052605">1960s</a>, paving the way for the World Health Organization to recommend it as part of routine polio surveillance <a href="https://apps.who.int/iris/handle/10665/67854">in 2003</a>.</p>
<p>In 2013, a silent outbreak was <a href="https://www.eurosurveillance.org/content/10.2807/1560-7917.ES2013.18.38.20586">identified in Israel</a> in this way. Early detection meant that supplementary vaccination campaigns ended the outbreak swiftly in 2014 with no cases of paralysis.</p>
<p>Without wastewater monitoring, the first indication that polio is circulating in a population could be the paralysis or death of a child.</p>
<figure class="align-center ">
<img alt="An aerial view of the Beckton Sewage Treatment Works." src="https://images.theconversation.com/files/471258/original/file-20220627-18-rujbd6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/471258/original/file-20220627-18-rujbd6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=261&fit=crop&dpr=1 600w, https://images.theconversation.com/files/471258/original/file-20220627-18-rujbd6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=261&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/471258/original/file-20220627-18-rujbd6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=261&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/471258/original/file-20220627-18-rujbd6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=328&fit=crop&dpr=1 754w, https://images.theconversation.com/files/471258/original/file-20220627-18-rujbd6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=328&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/471258/original/file-20220627-18-rujbd6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=328&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Poliovirus was recently detected at the Beckton Sewage Treatment Works in London.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/mwmbwls/50191787136">mwmbwls/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>But polio isn’t the only disease we can look for in our wastewater. Wastewater epidemiology involves testing sewage for biological markers of disease that people shed during normal daily activities, such as going to the toilet. These markers could be fragments of genetic materials of a virus or bacteria, for example.</p>
<p>Other pathogens that can be detected in sewage include <a href="https://doi.org/10.1017/S0022172400028230">typhoid</a> and respiratory syncytial virus (<a href="https://doi.org/10.1021/acs.estlett.1c00963">RSV</a>), though monitoring for signs of these infections doesn’t happen routinely. </p>
<p>During the pandemic, many countries have employed <a href="https://www.covid19wbec.org">wastewater epidemiology</a> to <a href="https://www.medrxiv.org/content/10.1101/2021.03.14.21253564v2">track SARS-CoV-2</a>, the virus that causes COVID-19, and to locate emerging variants. </p>
<p>Wastewater surveillance is particularly useful for pathogens where the proportion of asymptomatic infections is high and in countries where clinical surveillance such as testing may be poor. It has been effectively used in <a href="https://doi.org/10.4269/ajtmh.18-0428">low- and middle-income countries</a> to detect diseases like typhoid.</p>
<p>It’s also possible to test sewage for the broken down products of drugs. In this way, wastewater surveillance has been used to track <a href="https://www.emcdda.europa.eu/publications/topic-overviews/content/wastewater-faq_en">illicit drug use</a>, prescription medication like <a href="https://doi.org/10.1002/etc.27">antidepressants</a>, and even <a href="https://doi.org/10.1038/s41467-019-08853-3">antimicrobial resistance</a>.</p>
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<img alt="A close up view of the poliovirus." src="https://images.theconversation.com/files/471816/original/file-20220630-12-873n5n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/471816/original/file-20220630-12-873n5n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=828&fit=crop&dpr=1 600w, https://images.theconversation.com/files/471816/original/file-20220630-12-873n5n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=828&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/471816/original/file-20220630-12-873n5n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=828&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/471816/original/file-20220630-12-873n5n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1040&fit=crop&dpr=1 754w, https://images.theconversation.com/files/471816/original/file-20220630-12-873n5n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1040&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/471816/original/file-20220630-12-873n5n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1040&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Scientists can detect a range of pathogens, such as poliovirus, in wastewater.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/electron-micrograph-poliovirus-1975-242816125">Everett Collection/Shutterstock</a></span>
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<p>The uses for wastewater-based epidemiology can be grouped into two categories. The first is where just the presence of a pathogen requires a response. This is the case for pathogens that have low rates, like emerging variants of SARS-CoV-2 or diseases nearing elimination like polio or measles.</p>
<p>The second is to quantify the burden of a specific disease. In England, 45 sites were sampled frequently for SARS-CoV-2. Our <a href="https://www.nature.com/articles/s41467-022-31753-y">own work</a> on wastewater surveillance for COVID showed it can be used to estimate how common the disease is – that is, the concentration of viral fragments in the sewage reflected the number of cases in the community.</p>
<p>There are some challenges in interpreting concentrations because they can be affected by <a href="https://doi.org/10.1016%2Fj.watres.2020.116404">environmental factors</a> such as the volume of rainfall diluting the samples. But when we know about these effects, we can account for them.</p>
<p>Wastewater epidemiology captures the contributions of almost all the people within a sewage catchment, which can be a double-edged sword. On the one hand, biases that often affect traditional surveillance, such as localised testing shortages or variability in access to healthcare, are reduced. On the other hand, samples collected from large sewage works serve such a large population (over 4 million people in the case of <a href="https://www.tideway.london/locations/beckton-sewage-treatment-works/">Beckton</a> where the poliovirus was detected) that pinpointing the origins of infection is difficult. Collection of sewage samples closer to the source can help, but is more difficult, harder to analyse and more expensive.</p>
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<strong>
Read more:
<a href="https://theconversation.com/testing-sewage-has-helped-track-covid-soon-it-could-reveal-much-more-about-the-uks-health-178141">Testing sewage has helped track COVID – soon it could reveal much more about the UK's health</a>
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<h2>Budgetary pressure</h2>
<p>Overall, wastewater epidemiology can provide unobtrusive, ongoing surveillance for diseases that is relatively cheap and convenient. Sewage testing complements clinical surveillance, especially when infections spread silently or when early detection gives public health officials a useful early warning. It’s a good thing that poliovirus has been identified in sewage before any children showed serious disease, as there is an opportunity to intervene.</p>
<p>But this type of surveillance is at risk without support and investment. The UK COVID-19 wastewater monitoring programme was wound down earlier this year bowing to budgetary pressures, rather than continuing and pivoting to improve our understanding of other diseases. </p>
<p>The potential of wastewater surveillance has been shown time and again. To realise that potential fully, closer collaboration between researchers, the water industry and policy should be fostered and supported by appropriate funding.</p><img src="https://counter.theconversation.com/content/185799/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Leon Danon receives funding from UKHSA and UKRI. </span></em></p><p class="fine-print"><em><span>Kathleen M O'Reilly receives funding from UKHSA and BMGF.</span></em></p>The clue is in your poo. Two experts explain the history and science behind wastewater surveillance.Leon Danon, Associate Professor in Infectious Disease Modelling and Data Analytics, University of BristolKathleen M O'Reilly, Associate Professor, London School of Hygiene & Tropical MedicineLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1857212022-06-24T10:53:34Z2022-06-24T10:53:34ZPolio: we’re developing a safer vaccine that uses no genetic material from the virus<p><a href="https://www.gov.uk/government/news/poliovirus-detected-in-sewage-from-north-and-east-london">Recent reports</a> of poliovirus detected in samples from a sewage treatment works in London have rightly generated significant concern among public health agencies and medical staff. The poliovirus detected is what is called vaccine-derived poliovirus – this is not “wild poliovirus”. </p>
<p>There are currently two poliovirus vaccines: the oral poliovirus vaccine (OPV) and the inactivated poliovirus vaccine (IPV). Vaccine-derived poliovirus is linked to the use of the OPV as this vaccine uses weakened poliovirus to produce an immune response. </p>
<p>The weakened poliovirus can still infect people and be shed by the vaccinated person. This can result in the weakened virus spreading from person to person. And in rare cases, this weakened poliovirus can change to a more dangerous strain of the virus that can cause disease. </p>
<p>In areas with high levels of vaccination, the community is protected and the spread of the more dangerous virus is stopped. But in areas with lower vaccination rates, unvaccinated people may be exposed to poliovirus that has originated as a weakened vaccine strain but is now a more dangerous version. This virus is referred to as a vaccine-derived poliovirus. </p>
<p>As the global vaccine initiatives have resulted in the <a href="https://www.cdc.gov/polio/progress/index.htm">near eradication</a> of poliovirus, the number of cases of vaccine-derived poliovirus has <a href="https://polioeradication.org/polio-today/polio-now/this-week/circulating-vaccine-derived-poliovirus/">overtaken the number of infections with wildtype poliovirus</a>. In 2021, there were 697 new cases of vaccine derive poliovirus compared with just six cases of wildtype poliovirus, globally. </p>
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<img alt="A person with polio." src="https://images.theconversation.com/files/470752/original/file-20220624-22-2h6o0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/470752/original/file-20220624-22-2h6o0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/470752/original/file-20220624-22-2h6o0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/470752/original/file-20220624-22-2h6o0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/470752/original/file-20220624-22-2h6o0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/470752/original/file-20220624-22-2h6o0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/470752/original/file-20220624-22-2h6o0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Polio causes paralysis or weakness in the limbs in about one out of 200 people.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/patients-polio-will-have-small-legs-1416176807">podsy/Shutterstock</a></span>
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<p>Vaccination with IPV does not immunise people with an infectious virus. Instead, it uses poliovirus that has been chemically inactivated. This means the virus is unable to infect people, removing the risk of vaccine-derived poliovirus. This vaccine is considered very safe. For this reason, many countries have moved away from using OPV and adopted IPV.</p>
<p>The UK switched from using <a href="https://vk.ovg.ox.ac.uk/vk/polio">OPV to IPV in 2004</a>. However, OPV remains an incredibly effective vaccine that has been instrumental in bringing about the near eradication of poliovirus and remains widely used throughout the world. </p>
<p>While there is no risk of vaccine-derived poliovirus infection when using the IPV, the making of IPV does lead to a potential biohazard risk. To make IPV, large volumes of infectious poliovirus must be produced and then inactivated. This large-scale production of poliovirus has inherent risks and any breach of biocontainment in a population with low vaccine coverage can have serious consequences as <a href="https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2017.22.21.30542">poliovirus could be reintroduced</a>. </p>
<h2>Safer vaccine made from yeast</h2>
<p>Vaccination strategies with either OPV or IPV, therefore, involve a certain level of risk. In either case, the risk is astonishingly low. However, for some time scientists have been seeking to develop new and safer methods for poliovirus vaccination. One potential candidate for a new poliovirus vaccine is the use of virus-like particles (VLPs). </p>
<p>VLPs are <a href="https://link.springer.com/chapter/10.1007/978-1-4419-1132-2_11">assembled from the proteins</a> that make up the outer shell of the virus, called a capsid. This allows the immune system to react to this empty shell and triggers a protective immune memory response, so the next time the immune system is exposed to a viral capsid (such as in the case of a viral infection), it can generate an effective response that rapidly controls and eliminates the virus. </p>
<p>Because VLPs contain no genetic material from the virus, they are safe to manufacture and use without the risk of spreading the actual disease. This method has already been used very effectively to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1451224/">produce the human papillomavirus vaccine</a>.</p>
<p>A further advantage of using VLP vaccines for a disease such as poliovirus is the potential to produce VLPs in production systems <a href="https://journals.asm.org/doi/10.1128/mSphere.00838-19">such as yeast</a>. At the University of Leeds, we have <a href="https://pubmed.ncbi.nlm.nih.gov/32161150/">shown</a> that yeast can be made to produce poliovirus VLPs and then grown in large quantities. </p>
<p>The production system for these VLPs uses a similar infrastructure to other yeast-based manufacturing, such as the brewing of beer. This means that large quantities of VLPs can be produced quickly and safely in a very cost-effective way.</p><img src="https://counter.theconversation.com/content/185721/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Keith Grehan has previously received funding from the Bill and Melinda Gates Foundation and the WHO, he is currently funded by a Wellcome Trust grant administered by the University of Leeds. He is affiliated with the University of Leeds.</span></em></p><p class="fine-print"><em><span>Jessica Swanson works for the University of Leeds and receives funding from the WHO. </span></em></p>The oral polio vaccine is cheap and effective, but it comes with some risks.Keith Grehan, Postdoctoral Researcher, Molecular Biology, University of LeedsJessica Swanson, Postdoctoral Research Fellow, Molecular and Cellular Biology, University of LeedsLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1857442022-06-23T16:33:48Z2022-06-23T16:33:48ZPoliovirus in London sewage – what you need to know<figure><img src="https://images.theconversation.com/files/470600/original/file-20220623-51670-tl5zzw.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C2986%2C2043&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Child receiving the polio vaccine.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/chaman-pakistan-apr-08-health-worker-267671438">Asianet-Pakistan/Shutterstock</a></span></figcaption></figure><p>Just as we thought that monkeypox would be the new virus scare for 2022, the UK Health Security Agency (UKHSA) declared a national incident of <a href="https://www.gov.uk/government/news/poliovirus-detected-in-sewage-from-north-and-east-london">repeated poliovirus detection in sewage</a> in north and east London. Repeated positive readings for polio suggest that there is an ongoing infection and likely transmission in the area. This is unexpected since the UK had been declared polio-free since 2003. Here’s what you need to know.</p>
<p><a href="https://www.nhs.uk/conditions/polio/">Poliomyelitis</a> (polio) is a devastating disease that historically has caused paralysis and death around the world. It is caused by polioviruses, small RNA viruses that can damage cells in the nervous system. </p>
<p>It is not found in animals, so, like smallpox, it can be eradicated. And thanks to <a href="https://www.unicef.org/immunization/polio">effective vaccination campaigns</a>, we have been getting closer to this goal every year.</p>
<p>There are <a href="https://www.ecdc.europa.eu/en/poliomyelitis/facts">three types</a> of poliovirus, and infection or immunisation by one type does not protect against another. Type 1 poliovirus has continued to cause outbreaks, but transmission by types 2 and 3 have been successfully interrupted by vaccination. </p>
<p>Poliovirus is transmitted by respiratory droplets, but it can also be caught from food or water that’s been in contact with the faeces of someone who has the virus.</p>
<p>It can survive at normal temperatures for many days. The last remaining outbreaks have been associated with areas with poor sanitation that are hard to reach with vaccines. Afghanistan and Pakistan are the only two countries where wild polio is still endemic, and are targeted by <a href="https://polioeradication.org/">eradication programmes</a> to stop the virus spreading to other countries.</p>
<h2>Crucial role of vaccines</h2>
<p>Vaccines have been crucial in eliminating polio. In 2021, there were <a href="https://www.cdc.gov/mmwr/volumes/71/wr/mm7119a2.htm">fewer than 700 reported cases</a> around the world. </p>
<p>In the UK, the injected polio vaccine is used. It contains inactivated virus (IPV) and is safe and effective in protecting the immunised person from paralysis, but it is less effective at inducing local immunity in the gut, so vaccinated people can still become infected and shed infectious virus, even though they may not show symptoms themselves.</p>
<p>IPV offers excellent protection for the individual, but is not enough to control an epidemic in poor sanitation conditions. The oral polio vaccine (OPV), which contains live but weakened virus, is ideal for this purpose. OPV is administered by drops and doesn’t need trained staff or sterile equipment to administer, so it can reach more communities. </p>
<p>This vaccine can induce potent gut immunity and it can prevent the shedding of wild polioviruses. Because it contains live virus, it can spread to close contacts of the immunised person and protect them too. It is also cheaper than IPV.</p>
<p>The downside of using OPV is that the weakened virus can mutate, and in rare cases, it can revert to paralysis-causing variants. </p>
<p>OPV is cleared by our immune system within days, but this may not be the case in people with weakened immune systems that may carry the virus longer, increasing the chance of mutations. In under-immunised countries, this can lead to circulating vaccine-derived poliovirus (VDPV). Indeed, the virus detected in London sewage was of the vaccine-derived variety, VDPV type 2. There is still no wild poliovirus in the UK.</p>
<p>Vaccine-derived polio can cause asymptomatic infection in IPV-vaccinated people, and it is shed in faeces because there is no local gut protection with IPV. It can therefore be detected in sewage water. </p>
<p>Detection methods are sensitive, but a single positive reading wouldn’t raise the alarm. Type 1 VDPV was <a href="https://www.who.int/india/news/detail/17-06-2022-investigation-of-the-vaccine-derived-polio-virus--found-in-sewage-sample-in-kolkata#:%7E:text=sample%20in%20Kolkata-,Investigation%20of%20the%20vaccine%2Dderived%20polio%20virus,in%20sewage%20sample%20in%20Kolkata&text=India%2C%20along%20with%2010%20other,in%20India%20since%20January%202011.">recently detected</a> in sewage in Kolkata. It is thought to be from an imported case from a vaccinated person with a weakened immune system who was unable to eliminate the vaccine strain from their body. </p>
<p>There are <a href="https://www.gov.uk/government/news/poliovirus-detected-in-sewage-from-north-and-east-london">no reports</a> of polio-related paralysis in the UK.</p>
<p>To prevent disease, we must ensure that family members are up to date with their vaccinations, especially children who may have skipped a course of vaccination due to the COVID pandemic. IPV is safe, free and effective to prevent polio disease. Unlike vaccines for monkeypox that are in short supply and available to high-risk groups, IPV is readily available for everyone in the UK through their GP.</p><img src="https://counter.theconversation.com/content/185744/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Zania Stamataki receives funding from the Medical Research Foundation, Innovate UK and BCHRF and she shares a PhD student with AstraZeneca on an iCASE MRC UKRI studentship. </span></em></p>Poliovirus traces in London sewage from February to May suggest ongoing infectionZania Stamataki, Senior Lecturer in Viral Immunology, University of BirminghamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1705202021-11-03T12:28:31Z2021-11-03T12:28:31ZWhat is herd immunity? A public health expert and a medical laboratory scientist explain<figure><img src="https://images.theconversation.com/files/429598/original/file-20211101-25-544rr1.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C7717%2C5140&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Experts estimate that close to 90% of the U.S. population must be vaccinated to reach herd immunity for COVID-19.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/people-fill-the-santa-monica-pier-as-crowds-gather-on-news-photo/1233207409?adppopup=true">David McNew/AFP via Getty Images</a></span></figcaption></figure><p>The term <a href="https://theconversation.com/why-herd-immunity-may-be-impossible-without-vaccinating-children-against-covid-19-154790">herd immunity</a> means that enough of a population has gained immunity to stifle a pathogen’s spread. You can think of herd immunity as being similar to fire starting in a field: If the field is dry and filled with weeds, the fire will catch and spread quickly. However, if the field is well-maintained with watering and trimming, the fire will fizzle out. Future embers that might land there will be far less likely to ignite.</p>
<p>The embers are much like SARS-CoV-2, the coronavirus that causes COVID-19. </p>
<p>Herd immunity can theoretically be achieved <a href="https://doi.org/10.1001/jama.2020.20895">either through infection and recovery or by vaccination</a>. The danger of trying to achieve herd immunity through infection is that many people will die or be forced to live with post-recovery disabilities. Moreover, research has shown that the immune response resulting from infection does not always provide <a href="https://www.cdc.gov/mmwr/volumes/70/wr/mm7044e1.htm">strong enough long-term protection against COVID-19</a> and <a href="https://www.cdc.gov/coronavirus/2019-ncov/variants/variant-info.html">its evolving strains</a>. Thus, public health experts still recommend vaccination against the coronavirus to achieve the strongest and most reliable protection. </p>
<p>When the COVID-19 pandemic erupted, scientists quickly began to develop vaccines so that populations could develop immunity to <a href="https://doi.org/10.1016/j.immuni.2020.04.012">slow the firelike spread of the coronavirus</a>. In the meantime, nearly all countries mandated or encouraged social distancing, masking and other public health measures.</p>
<p>Unfortunately, the disjointed implementation of these efforts, coupled with large-scale surges and the <a href="https://theconversation.com/delta-variant-makes-it-even-more-important-to-get-a-covid-19-vaccine-even-if-youve-already-had-the-coronavirus-164203">emergence of the highly transmissible delta variant</a>, has forced public health experts to recalculate what it would take to reach “herd immunity” for COVID-19.</p>
<h2>Why herd immunity matters</h2>
<p>Prior experience with respiratory pathogens that were comparable to the new coronavirus allowed public health experts to make educated estimates of what would be needed to reach the lower threshold of herd immunity for COVID-19. Initially they believed that around 70% of the population would need to be vaccinated to <a href="https://www.ama-assn.org/delivering-care/public-health/what-doctors-wish-patients-knew-about-covid-19-herd-immunity">effectively slow or stop the spread of SARS-CoV-2</a>. </p>
<p>But with <a href="https://theconversation.com/delta-variant-makes-it-even-more-important-to-get-a-covid-19-vaccine-even-if-youve-already-had-the-coronavirus-164203">the delta variant</a> continuing to spread rapidly around the world, experts revised that estimate. Now, epidemiologists and other public health officials estimate that closer to 90% of the U.S. population would need to be vaccinated to <a href="https://www.healthline.com/health-news/how-delta-variant-has-affected-our-ability-to-reach-herd-immunity#When-might-the-U.S.-reach-herd-immunity-through-vaccinations?">reach herd immunity</a> for COVID-19. </p>
<p>Viruses like <a href="https://www.cdc.gov/polio/what-is-polio/polio-us.html">those that cause polio</a> and <a href="https://doi.org/10.1177/0033354919826558">measles required decades of education</a> and vaccination programs to achieve herd immunity and to ultimately eliminate them in the U.S. But given that new U.S. cases of COVID-19 <a href="https://covid.cdc.gov/covid-data-tracker/#trends_dailycases">continue to number in the tens of thousands</a> daily, it’s become clear that <a href="https://www.nature.com/articles/d41586-021-00396-2">COVID-19 is going to stick around</a>.</p>
<p>[<em>Research into coronavirus and other news from science</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-corona-research">Subscribe to The Conversation’s new science newsletter</a>.]</p>
<p>There are several reasons it will take some time to achieve COVID-19 herd immunity. The COVID-19 vaccines are <a href="https://theconversation.com/the-fda-authorizes-pfizers-covid-19-vaccine-for-children-ages-5-to-11-a-pediatrician-explains-how-the-drug-was-tested-for-safety-and-efficacy-169907">currently authorized for some age groups</a> but not others. For perspective, roughly 90% of the U.S. population <a href="https://www.cdc.gov/nchs/fastats/immunize.htm">receives the measles, mumps and rubella vaccine – or MMR</a> – as children, and 93% of the population is vaccinated against polio; both of these have been routine childhood immunizations for decades. Since children make up more than <a href="https://www.census.gov/newsroom/press-kits/2020/population-estimates-detailed.html">20% of U.S. residents</a>, the country likely cannot reach COVID-19 herd immunity without widespread childhood vaccination, even if all eligible adults were vaccinated. </p>
<p>As of Nov. 1, 2021, only 67.8% of the total U.S. population ages 12 and up that are <a href="https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-total-admin-rate-total">vaccine-eligible had been fully vaccinated</a>. Experts have attributed this to multiple factors including <a href="https://www.texasmonthly.com/promotion/right-place-right-time-txst/">vaccine hesitancy</a> and the <a href="https://theconversation.com/us-is-split-between-the-vaccinated-and-unvaccinated-and-deaths-and-hospitalizations-reflect-this-divide-164460">politicization of the pandemic</a>. </p>
<p>Of course, no vaccine is perfect. Vaccinated people can have <a href="https://www.cdc.gov/vaccines/covid-19/health-departments/breakthrough-cases.html">breakthrough infections</a>, although the COVID-19 vaccines continue to effectively <a href="https://www.washingtonpost.com/health/2021/09/10/moderna-most-effective-covid-vaccine-studies/">reduce the most severe cases of COVID-19</a>. In addition, research suggests that those who experience COVID-19 after vaccination <a href="https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/fully-vaccinated-people.html#:%7E:text=Vaccinated%20people%20can%20still%20become,the%20virus%20is%20widespread">may transmit the virus at lower transmission rates</a> than those who are unvaccinated. </p>
<p><em>Read other short accessible explanations of newsworthy subjects written by academics in their areas of expertise for The Conversation U.S.<a href="https://theconversation.com/us/topics/significant-terms-105996">here</a>.</em></p><img src="https://counter.theconversation.com/content/170520/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rodney E. Rohde has received funding from the American Society of Clinical Pathologists (ASCP), American Society for Clinical Laboratory Science (ASCLS), U.S. Department of Labor (OSHA), and other public and private entities/foundations. Dr. Rohde is affiliated with ASCP, ASCLS, ASM, and serves on several scientific advisory boards. See <a href="https://rodneyerohde.wp.txstate.edu/service/">https://rodneyerohde.wp.txstate.edu/service/</a>. </span></em></p><p class="fine-print"><em><span>Ryan McNamara has received/receives funding from the National Cancer Institutes (NCI) and the National Institutes of Allergens and Infectious Diseases (NIAID). Dr. McNamara has served as a contributor for the National Technology Roadmap for Pandemic Responses and Recovery by the Advanced Regenerative Manufacturing Institute. </span></em></p>Vaccination campaigns like the ones that eventually eliminated polio and measles in the United States required decades of education and awareness in order to achieve herd immunity in the U.S. population.Rodney E. Rohde, Professor of Clinical Laboratory Science, Texas State UniversityRyan McNamara, Research Associate of Microbiology and Immunology, University of North Carolina at Chapel HillLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1673962021-09-08T07:07:36Z2021-09-08T07:07:36ZCompulsory COVID-19 vaccination in Nigeria? Why it’s illegal, and a bad idea<figure><img src="https://images.theconversation.com/files/419742/original/file-20210907-29-1eywx9u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Emmanuel Osodi/Majority World/Universal Images Group via Getty Images</span> </figcaption></figure><p><em>Two states in Nigeria – <a href="https://thenationonlineng.net/certificates-of-vaccination-compulsory-in-edo/">Edo</a> and <a href="https://thenationonlineng.net/ondo-makes-covid-19-vaccination-compulsory/">Ondo</a> – recently announced compulsory COVID-19 vaccinations for adults. Even after a court <a href="https://punchng.com/court-restrains-obaseki-from-enforcing-covid-19-vaccination/">restrained</a> the Edo State government from going ahead, it <a href="https://guardian.ng/news/our-directive-on-compulsory-covid-19-vaccination-in-edo-stands-obaseki/">insists</a> the order stands. The Federal Government is also <a href="https://punchng.com/fg-plans-compulsory-covid-19-vaccination-for-civil-servants/">considering</a> making COVID-19 vaccination compulsory for civil servants. Abiodun Odusote weighs in on the legality of these orders.</em> </p>
<hr>
<h2>Do state governments have the legal authority to compel vaccination of adults?</h2>
<p>At the moment, mandatory COVID-19 vaccination in Nigeria is illegal. I am not aware of any legislation or regulation that mandates Nigerians to take vaccines. Mandatory COVID-19 vaccination cannot be made by oral proclamation like what happened in these two states. It must be based on legislation or regulation based on public health and safety otherwise the actions of the state functionaries will amount to violations of citizens’ right to privacy, right to movement and right to religious life. </p>
<p>I agree that making COVID-19 vaccination mandatory could be reasonably justified for contagious and serious diseases like COVID-19 because there is a real and grave threat to public health and safety. This reasoning would make such an order compliant with Section 45 of the <a href="http://www.nigeria-law.org/ConstitutionOfTheFederalRepublicOfNigeria.htm">Constitution</a>. However, there must be a law or regulation to that effect. I am not aware of any at the moment. </p>
<p>There are other issues to consider too. How many people have been vaccinated in Nigeria at the moment? Just over <a href="https://graphics.reuters.com/world-coronavirus-tracker-and-maps/countries-and-territories/nigeria/">four million</a> out of a population of <a href="https://www.worldometers.info/world-population/nigeria-population/#:%7E:text=The%20current%20population%20of%20Nigeria,the%20latest%20United%20Nations%20data.">over 200 million</a>. That’s not up to 2% of our population. Have we interrogated the reasons behind this abysmally low level of vaccination? Are we sure we have enough vaccines to go round? Are we sure the majority of the people are aware of the need and importance of being vaccinated? Have we tried to educate the majority of the people? Are we dealing with deliberate refusal to get vaccinated or are we dealing with vaccine hesitancy? Or are people refusing vaccines for religious reasons? </p>
<p>The government at all levels must provide scientific explanations to these posers before the announcement of a policy of compulsory vaccination. Answers to these questions should inform its response. I am aware that there are more than a few people that would like to be vaccinated but have not been privileged to have a jab. I know of some others that for religious reasons, they prefer not to be vaccinated. Concerns over vaccine safety still remain. Obviously, encouraging these groups to get vaccinated will require different approaches. Making vaccination compulsory is not the only way to obtain high vaccination rates. Research into how to further improve uptake rates among vaccine-hesitant citizens is more important than mandatory vaccination. </p>
<p>It should be noted however that mandatory vaccination has been used to achieve great results in some other countries in respect of child immunisation. <a href="https://ourworldindata.org/childhood-vaccination-policies">Singapore</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3216445/">Belgium, Slovenia</a> and <a href="https://ourworldindata.org/childhood-vaccination-policies">some countries in the Americas</a> – 29 – have mandatory vaccinations. </p>
<p>But coercion through compulsion might not be effective in Nigeria. It may be counterproductive as it has the potential to lend credence to conspiracy theories. Why not be bothered about many dying because of cholera and insecurity? Why the overdrive in respect of COVID-19 vaccination when many more are dying as a result of malaria and insecurity of lives and properties. Government should educate and provide incentives for vaccination rather than threatening and coercing citizens. </p>
<h2>What legal options are available for citizens to fight this?</h2>
<p>Mandating vaccinations for COVID-19 raises many complex and difficult legal questions concerning the interplay of competing human rights. On the one hand there is the issue of health and safety. On the other personal human rights. </p>
<p>There cannot be interference with the human rights of citizens unless:</p>
<ul>
<li><p>it is in accordance with law, and </p></li>
<li><p>is necessary for the protection of health and safety or rights and freedoms of others. </p></li>
</ul>
<p>In the context where mandatory vaccination is being proposed without extant regulations or laws, aggrieved citizens can bring an application to enforce their fundamental rights to privacy, movement, religious beliefs and threatened violation of the right to bodily integrity. </p>
<p>They can also seek to have the order set aside by asking for an order for declaratory relief declaring the mandatory vaccination policy illegal and therefore null and void for failure to follow due process of law. Such an injunctive order would restrain the government from implementing the compulsory vaccination policy. </p>
<h2>Are there any historical precedents?</h2>
<p>During the colonial period in northern Nigeria, there was vaccine hesitancy which resulted in considerably fewer smallpox vaccinations being carried out in the area. The colonial administration introduced a Vaccination Ordinance, originally <a href="https://books.google.com.ng/books?id=qzzAWxv8ObsC&pg=PA21&lpg=PA21&dq=vaccination+ordinance+northern+nigeria&source=bl&ots=pQJrGT2SN_&sig=ACfU3U1xM62EstEUQN7ya444mbhT5NRQ_A&hl=en&sa=X&ved=2ahUKEwiK1K_ur-ryAhUNvRQKHTzdBLkQ6AF6BAgjEAM#v=onepage&q=vaccination%20ordinance%20northern%20nigeria&f=false">enacted</a> in 1917. In 1945, the Ordinance was <a href="https://books.google.com.ng/books?id=qzzAWxv8ObsC&pg=PA21&lpg=PA21&dq=vaccination+ordinance+northern+nigeria&source=bl&ots=pQJrGT2SN_&sig=ACfU3U1xM62EstEUQN7ya444mbhT5NRQ_A&hl=en&sa=X&ved=2ahUKEwiK1K_ur-ryAhUNvRQKHTzdBLkQ6AF6BAgjEAM#v=onepage&q=vaccination%20ordinance%20northern%20nigeria&f=false">amended</a> to include a schedule for compulsory vaccination of adults and their children to be organised by local political authorities. </p>
<p>The Native Authority officials were emirs and traditional chiefs and were responsible for determining penalties for non-cooperation. They had little means of enforcing the penalties. Not much success was recorded. </p>
<p>After independence Nigerian governments took a different approach to national vaccination. Primary health centres were established across the country and citizens were educated and implored to vaccinate their children. Many international NGOs were involved including the Bill & Melinda Gates Foundation as well as state governors and politicians. </p>
<p>With these, tremendous success was recorded especially poliomyelitis. Consequently Nigeria was <a href="https://www.jica.go.jp/english/news/field/2020/20200826_02.html#:%7E:text=On%20Aug.,wild%20polio%20had%20been%20identified.">declared polio free</a> on 25 August, 2020. </p>
<p>I recommend a similar approach for the COVID-19 vaccination and not mandatory vaccination.</p><img src="https://counter.theconversation.com/content/167396/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Abiodun Odusote does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Mandatory COVID-19 vaccination in Nigeria cannot be by oral proclamation, but must be based on legislation or regulation on public health and safety.Abiodun Odusote, Senior Lecturer, University of LagosLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1668112021-09-07T12:52:18Z2021-09-07T12:52:18ZMedicine is an imperfect science – but you can still trust its process<figure><img src="https://images.theconversation.com/files/418963/original/file-20210901-25-big4r.jpg?ixlib=rb-1.1.0&rect=0%2C72%2C2039%2C1085&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Intensive care physicians are yet again facing ICU bed and staff shortages as severe COVID-19 cases rise.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/hospital-coronavirus-emergency-department-ward-royalty-free-image/1321692378?adppopup=true">gorodenkoff/iStock via Getty Images Plus</a></span></figcaption></figure><p><em>The Conversation is running a series of dispatches from clinicians and researchers operating on the front lines of the coronavirus pandemic. You can <a href="https://theconversation.com/us/topics/covid-19-front-lines-84846">find all of the stories here</a>.</em> </p>
<p>As an intensive care physician in Southern California who endured the onslaught of COVID-19 in 2020, it has been deeply disheartening to experience chillingly familiar scenes all over again. The ICUs in the University of California San Diego Health hospital network where <a href="https://profiles.ucsd.edu/venktesh.ramnath">I work</a> are again overflowing – especially with patients who need ventilators. Families peer through tinted hospital windows for glimpses of loved ones. And <a href="https://www.washingtonpost.com/health/staff-shortages-hospitals-covid/2021/08/12/85f636b4-fa97-11eb-8a67-f14cd1d28e47_story.html">hospital administrators scramble</a> to keep up with necessary staffing and beds to accommodate the influx of patients.</p>
<p>What is so vexing is that COVID-19 is still the culprit, despite the availability of <a href="https://www.cdc.gov/mmwr/volumes/70/wr/mm7034e2.htm">highly effective vaccines</a> that <a href="https://doi.org/10.1038/d41586-021-02054-z">slashed U.S. COVID-19 daily case numbers and hospitalizations</a> within months. The vaccines also allowed economies to <a href="https://budgetmodel.wharton.upenn.edu/issues/2021/3/1/epidemiological-and-economic-effects-of-covid-19-vaccine">begin to recover</a> and provided a way for people to experience some sense of normalcy again. </p>
<p>In early spring, the efficacy of the vaccine engendered hope that herd immunity – in which infectious viral spread is prevented through a high proportion of the population’s being immune to the disease – <a href="https://www.wsj.com/articles/well-have-herd-immunity-by-april-11613669731">could be within reach</a> in months. Instead, pandemic panic is again suffocating us, largely because a large part of the public <a href="https://www.nytimes.com/2021/07/31/us/virus-unvaccinated-americans.html">still shuns vaccination</a> – with only 62% of the eligible U.S. population <a href="https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-total-admin-rate-total">fully vaccinated</a> as of early September 2021.</p>
<p>I wanted an answer to the obvious question: Why?</p>
<h2>Straight from the source</h2>
<p>So I turned to my patients for answers. At the bedside in their hospital rooms, I first asked about how they were feeling and performed detailed exams before addressing the elephant in the room. “Did you receive the COVID-19 vaccine?” And if not, I gently asked, “Did you have a specific reason you could share with me, so I can understand better?”</p>
<p>Somewhat surprisingly, patients candidly told me their reasons for avoiding the vaccine.</p>
<p>A common response I heard was that it was simply inconvenient. “I was too lazy and I didn’t get around to it,” some admitted, looking away sheepishly as they did so. Curiously, they did not consider the myriad “inconveniences” of becoming infected, such as medical complications – including death – and associated costs for treatment, lost work, dependence on others for basic necessities such as child care, the risk of infecting family members, the potential for developing <a href="https://theconversation.com/deciphering-the-symptoms-of-long-covid-19-is-slow-and-painstaking-for-both-sufferers-and-their-physicians-164754">long-haul COVID-19</a> and more.</p>
<p>Others expressed a fervid distrust of vaccine-testing methods, stating that people had been “guinea pigs in past vaccine experiments that later caused autism.” Yet more than 25 studies in the past 20-odd years have disproved any <a href="https://www.healthychildren.org/English/safety-prevention/immunizations/Pages/Vaccine-Studies-Examine-the-Evidence.aspx">causal link between vaccines and autism</a>. </p>
<p>Some felt that the forceful public messaging to get vaccinated belied true motivations of the authorities, adding: “I mean, why are they pushing this so hard? Something must be wrong with it.” Yet few question the strong public health stance on healthy eating practices and exercise, or wearing seat belts while driving. </p>
<p>Still others feared the possibility of life-threatening side effects: “Thousands had heart attacks from the vaccine – it’s all on the CDC website,” they told me. So I took <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/myocarditis.html?s_cid=11374:covid%20vaccine%20heart%20problems:sem.ga:p:RG:GM:gen:PTN:FY21">a close look</a> at the CDC website to understand their claims better. </p>
<p>Reports of heart inflammation occurred in 699 cases out of 177 million vaccinated people, or 0.0004%, with causal links to the vaccines still being investigated. Development of blood clots causally associated with the Johnson & Johnson vaccine are <a href="https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-05-12/07-COVID-Shimabukuro-508.pdf">also extremely rare</a>, occurring in 28 cases out of 8.73 million doses given as of May 7, 2021 – a rate of 0.0003%. This extremely low risk of blood clots is still significantly lower than the <a href="https://doi.org/10.1136/bmj.n1931">risk of blood clots</a> from an <a href="https://www.nytimes.com/2021/08/27/health/blood-clots-coronavirus.html">actual COVID-19</a> infection.</p>
<h2>Medicine as art and imperfect science</h2>
<p>In some cases, political affiliation can <a href="https://www.economist.com/united-states/2021/07/27/americas-vaccination-woes-cannot-be-blamed-only-on-politics">partially explain</a> vaccine antipathy. But my patients’ responses highlighted two other themes to me.</p>
<p>First, people often forget that medicine is an art <a href="http://dx.doi.org/10.1136/mh.26.1.18">based on applied science</a>, not a deductive science based on irrefutable forces in nature like gravity. Patients and families often ask me in the ICU to predict what will happen to loved ones unequivocally, only to be disappointed when I avoid speaking in certainties.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An ICU doctor hugs and comforts a patient in a COVID-19 ICU" src="https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/418964/original/file-20210901-15-19x8jad.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Having to deliver devastating news and uncertainties about patient outcomes has taken a heavy toll on ICU physicians during the COVID-19 pandemic.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/dr-joseph-varon-hugs-and-comforts-a-patient-in-the-covid-19-news-photo/1229807339?adppopup=true">Go Nakamura/Getty Images News</a></span>
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</figure>
<p>Once viewed as <a href="https://doi.org/10.1136/bmj.317.7174.1729">omniscient authorities</a>, doctors now openly acknowledge that limitations of medical data require scrutiny and careful application to particular circumstances. COVID-19 has reinforced our appreciation that there are no perfect cures or 100% guarantees of success. Rather, medicine is governed by what is probable. What are the chances I still may have cancer if the test result returns negative? Am I more or less likely to survive pneumonia by taking this specific antibiotic?</p>
<p>Doctors must then engage in <a href="https://doi.org/10.1016/j.chest.2020.05.548">thoughtful analysis</a> of the strengths and weaknesses of scientific methods and data to optimize and tailor our recommendations for individual patients – without the luxury of perfect or even complete datasets to rely on. The vaccine has clearly been shown – its rare side effects notwithstanding – to provide an overwhelmingly high likelihood of benefit over potential risks to almost all individuals. This <a href="https://doi.org/10.1001/jama.2021.11717">includes people</a> who have been <a href="https://apnews.com/article/science-health-coronavirus-pandemic-ad52011f4ca1853fad6eee41a7310c2e">previously infected with COVID-19</a>. Yet the unvaccinated continue to fixate on rare side effects to justify skipping the shot.</p>
<h2>Vaccines are medicines too</h2>
<p>Many of my patients also seem to view vaccines and other public health-based recommendations like offers to buy a used car – with skepticism and independence, threatening to walk away at any moment. Doing one’s part to stop the spread of disease is a culturally nuanced civic virtue, like <a href="https://doi.org/10.1016/j.trf.2014.01.004">safe driving</a>, which transcends absolute autonomy. In the U.S., most drivers willingly do not drive while intoxicated, cross lanes without warning or block other cars that are trying to merge. These are norms that make driving in the U.S. relatively efficient, safe and even pleasant compared with some other countries. </p>
<p>The path to herd immunity, like highway safety, requires majority participation without immediate guarantees of complete personal freedom. Vaccines succeed not because they are 100% risk-free to the individual but because collective efforts focus on achieving the common good.</p>
<p>Oddly, at the same time that my patients rejected the vaccine, they showed strong interest in receiving other types of medicine “shots” like monoclonal antibodies – which mimic natural antibodies – or anti-inflammatory medications. While <a href="https://www.covid19treatmentguidelines.nih.gov/management/clinical-management/">some of these treatments</a> have demonstrated benefits in certain situations – <a href="https://doi.org/10.1001/jama.2021.2747">others</a> <a href="https://doi.org/10.1056/NEJMoa2028700">have not</a>. And some present the risk of <a href="https://www.fox19.com/2021/08/21/seriously-yall-stop-it-fda-dispels-myth-about-ivermectin-covid-cure/">very serious harm</a>. </p>
<p>I reminded my patients that the COVID-19 vaccine stimulates a person’s own immune system to make <a href="https://theconversation.com/what-happens-when-the-covid-19-vaccines-enter-the-body-a-road-map-for-kids-and-grown-ups-164624">antibodies that can neutralize the virus</a> and that surpass the capabilities of <a href="https://www.webmd.com/vaccines/covid-19-vaccine/news/20210826/monoclonal-antibodies-vs-vaccines-vs-covid-19">commercially created antibody formulations</a>. So the vaccines help prevent infection and development of serious illness from COVID-19 in the first place. People who experience the <a href="https://theconversation.com/what-is-a-breakthrough-infection-6-questions-answered-about-catching-covid-19-after-vaccination-164909">rare breakthrough infections</a> following vaccination generally have a <a href="https://www.wsj.com/articles/breakthrough-cases-covid-19-delta-variant-11627596643">shorter and milder course of COVID-19 infection</a> and are far less likely to <a href="https://doi.org/10.1093/cid/ciab543">end up hospitalized</a> than those who are unvaccinated. Vaccines <a href="https://doi.org/10.1038/s41586-021-03738-2">also confer</a> <a href="https://www.npr.org/sections/goatsandsoda/2021/08/30/1032520934/immunity-to-covid-19-could-last-longer-than-youd-think?ft=nprml&f=1032520934">longer-term protection</a>, whereas the other medications are used reactively – when a serious infection has already begun – and those medications have <a href="https://www.coronaviruspreventionnetwork.org/coronavirus-vaccine-and-antibody-science">shorter-term results</a>.</p>
<h2>How past vaccination efforts succeeded</h2>
<p>In the past, many vaccines that successfully vanquished societal outbreaks of <a href="https://www.cdc.gov/polio/what-is-polio/polio-us.html">polio</a>, <a href="https://www.historyofvaccines.org/timeline/measles">measles</a> and <a href="https://www.historyofvaccines.org/content/articles/mumps">mumps</a> are now routinely administered in childhood with minimal objection, despite the fact that there is no such thing as <a href="https://www.cdc.gov/vaccines/vac-gen/side-effects.htm">zero risk</a>.</p>
<p>As I continue to have conversations with patients who suffer greatly from COVID-19 illness as a direct consequence of having avoided the vaccine, my own pain – for being an ineffective healer and witness to such loss – is inexorable. Overcoming this fourth wave of COVID-19 still feels out of reach until our vaccination efforts can somehow better emphasize the effectiveness of vaccines, even when scientifically imperfect, and prioritize civic health care responsibilities over pure autonomy. If not, I fear that our battle against COVID-19 will rage on.</p>
<p>[<em>Get the best of The Conversation, every weekend.</em> <a href="https://theconversation.com/us/newsletters/weekly-highlights-61?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=weeklybest">Sign up for our weekly newsletter</a>.]</p><img src="https://counter.theconversation.com/content/166811/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Venktesh Ramnath does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A critical care doctor brings a frontlines perspective to the frustration of dealing firsthand with vaccine hesitancy and discusses the limitations of science and medicine.Venktesh Ramnath, Associate Clinical Professor of Medicine, University of California, San DiegoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1666252021-08-25T15:11:11Z2021-08-25T15:11:11ZIt’s been a year since Africa was declared polio free. But a threat remains<figure><img src="https://images.theconversation.com/files/417566/original/file-20210824-13-18fxv99.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A child gets a dose of the oral polio vaccine.</span> <span class="attribution"><span class="source">Simon Maina/AFP via Getty Images</span></span></figcaption></figure><p>The <a href="https://www.who.int/news/item/25-08-2020-global-polio-eradication-initiative-applauds-who-african-region-for-wild-polio-free-certification">25th of August marks</a> the first anniversary of a milestone that took over 30 years to achieve. Africa being free from polio – a disease that has caused death and paralysis throughout recorded history.</p>
<p>Polio is a viral illness that can cause sudden weakness, permanent paralysis, or death in people who were previously healthy and had no risk factors or comorbidities. It usually affects children. The virus is spread by faecally contaminated food and water or close contact.</p>
<p>But the outbreaks of this fearful disease have become a thing of the past, told to us by our grandparents. The reason for the disappearance? Vaccination.</p>
<p>The <a href="https://polioeradication.org/">Global Polio Eradication Initiative</a> was launched in 1988. In that year, more than 350,000 people were paralysed. Polio cases were reported from at least 125 countries.</p>
<p>The initiative set an original target of the year 2000 for polio eradication. It introduced polio vaccines into health programmes around the globe and ensured birth cohorts of children were routinely vaccinated. This drive reduced the number of polio cases to only 22 in 2017. </p>
<p>Only <a href="https://polioeradication.org/polio-today/polio-now/wild-poliovirus-list/">two cases</a> of polio from paralysed individuals have been recorded so far in 2021. This is the lowest number ever. But an additional 62 detections of polio have been identified in wastewater treatment plants or surface water downstream of large populations in Pakistan and Afghanistan. So the case number may be artificially low due to poor surveillance or weak health systems.</p>
<p>Despite the efforts of health programmes around the world, there is still a threat that polio could spread again. Even one case would constitute an international event.</p>
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Read more:
<a href="https://theconversation.com/why-eradicating-polio-everywhere-has-been-so-hard-to-crack-105405">Why eradicating polio everywhere has been so hard to crack</a>
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<p>Africa has had a long history with polio. <a href="https://www.news24.com/news24/analysis/barry-d-schoub-africa-is-now-polio-free-with-south-africa-playing-a-pivotal-role-20200831">South Africa</a> used crowd-funding in the <a href="https://www.africakicksoutwildpolio.com/timeline/">1960s</a> to raise funds for a research facility to develop a polio vaccine, <a href="https://www.news24.com/news24/analysis/barry-d-schoub-africa-is-now-polio-free-with-south-africa-playing-a-pivotal-role-20200831">in collaboration with international researchers</a>. The facility originated as the Poliomyelitis Research Foundation and developed into the <a href="https://www.nicd.ac.za/">National Institute for Communicable Diseases</a>, which has more recently played a leading role in the fight against COVID-19, listeria, and other pathogens. </p>
<p>Polio is still a large part of <a href="https://www.gov.za/faq/health/why-should-i-have-my-child-vaccinated">routine childhood vaccinations</a> in South Africa. </p>
<p>No wild polio, that is polio cases caused by the natural ‘wild type’ form of the virus, has been detected in Africa since 2016. On 25 August 2020, the continent was declared free of wild poliovirus. This leaves only two countries on the globe – Pakistan and Afghanistan – where wild polio is found. A weak healthcare system and vaccine hesitancy have allowed the sustained transmission of polioviruses, and the unfortunate consequence: paralysis or death. </p>
<h2>Poliovirus biology and vaccines</h2>
<p>Polioviruses occur in three serotypes (types 1, 2 and 3). It is <a href="https://www.who.int/news-room/fact-sheets/detail/poliomyelitis">estimated</a> that less than one in 100 infected individuals become paralysed. Others may be asymptomatic or have varying degrees of flu-like illness. Thus, when one paralysed case has been detected, there are likely 99 other asymptomatically infected individuals, making it challenging to control the spread. </p>
<p>There have been two vaccines used since the 1960s to prevent polio: the Salk vaccine, which is an inactivated vaccine, and the Sabin vaccine, which is a live attenuated vaccine. A live vaccine contains a weakened version of the natural ‘wild type’ virus. </p>
<p>Both vaccines are excellent at preventing paralysis. The two vaccines differ, however, in their ability to control asymptomatic poliovirus transmission. </p>
<p>The inactivated polio vaccine is an injectable vaccine that induces antibodies in the blood that prevent paralysis should the person later come into contact with wild polio. If a person later encounters wild poliovirus, the wild virus may still replicate in the person’s gastrointestinal tract and shed in their stool, potentially transmitting asymptomatically to others in the community. The inactivated polio vaccine is excellent for personal protection against paralysis. But it’s not effective at controlling outbreaks, as it does not effectively prevent asymptomatic polio transmission. </p>
<p>The Sabin vaccine is a live, orally-administered, weakened vaccine strain given as drops. It produces good intestinal immunity. This means that, should the vaccinated individual come into contact years later with wild poliovirus, the wild poliovirus won’t be shed in the person’s faeces. Thus, in addition to preventing paralysis, the oral polio vaccine can prevent shedding of wild poliovirus in stool. It is therefore very effective at controlling polio outbreaks. This benefit has been instrumental in decreasing polio transmission and bringing polio to the brink of eradication.</p>
<p>The oral polio vaccine is very effective. But if the population vaccination coverage is low, then people who get the live vaccine can transmit this virus to those who are not immunised. Over weeks to months, this transmission among the community has the benefit of immunising susceptible people. Yet, over a long period of more than six months to years, mutations can arise in the virus genome that can turn it back into a disease-causing virus. This is called a vaccine-derived poliovirus. </p>
<p>Vaccine-derived polio is extremely rare. But it has arisen in multiple <a href="https://www.africanews.com/2021/08/17/uganda-confirms-polio-outbreak//">countries</a> over the past decades. </p>
<p>To combat this phenomenon, a new live vaccine has just been developed. This vaccine is called the novel oral polio vaccine, serotype 2 (nOPV2). This vaccine received <a href="https://www.who.int/news/item/13-11-2020-first-ever-vaccine-listed-under-who-emergency-use">emergency use listing</a> in November 2020, just before the SARS-CoV-2 vaccines, and has already been used in seven African countries. Novel oral polio vaccines against serotypes 1 and 3 are currently in development.</p>
<h2>Maintaining efforts</h2>
<p>The development of nOPV2 is a game-changer in the war against polio. The current target for polio eradication has been <a href="https://polioeradication.org/wp-content/uploads/2021/06/polio-eradication-new-Strategy-2022-26-Executive-Summary.pdf">extended to 2026</a>. </p>
<p>To meet this deadline, three things must happen. </p>
<ul>
<li><p>Health systems around the world need to keep vigilant; </p></li>
<li><p>vaccination coverage need to be kept high; and </p></li>
<li><p>we need to keep developing new vaccines to counteract evolving viruses.</p></li>
</ul><img src="https://counter.theconversation.com/content/166625/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melinda Suchard has received speaker honoraria from Sanofi Pasteur. She manages grants from the World Health Organisation for polio surveillance.</span></em></p><p class="fine-print"><em><span>Wayne Howard does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Outbreaks of polio have become a thing of the past, told to us by our grandparents, only because of vaccination.Wayne Howard, Medical Scientist, National Institute for Communicable DiseasesMelinda Suchard, Head, Centre for Vaccines and Immunology, National Institute for Communicable DiseasesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1648272021-08-09T12:26:52Z2021-08-09T12:26:52ZShutting down school vaccine clinics doesn’t protect minors – it hurts people who are already disadvantaged<figure><img src="https://images.theconversation.com/files/414824/original/file-20210805-13-9sbvnr.jpg?ixlib=rb-1.1.0&rect=11%2C0%2C3982%2C2556&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A high school student gets his COVID-19 shot at a pop-up vaccine clinic at a public charter school in Los Angeles.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/year-old-aaron-delgado-receives-his-pfizer-covid-vaccine-news-photo/1234436892">Al Seib / Los Angeles Times via Getty Images</a></span></figcaption></figure><p><a href="https://www.newspapers.com/image/119585257/">A 1918 newspaper article</a> captures public attitudes toward a typhoid vaccine clinic at the Oakdale schoolhouse in Louisville, Kentucky. “Everybody comes – railroad men, children, young girls, old people, housewives,” it reads, “all with sleeves that roll up and arms ready for the brief stick with the fine needle.” </p>
<p>Until recently, school-located vaccination clinics, or SLVs, have been applauded, or <a href="https://doi.org/10.1177/1059840510369231">simply taken for granted</a>. That changed in mid-July of 2021, when Tennessee <a href="https://www.tennessean.com/story/news/health/2021/07/13/tennessee-halts-all-vaccine-outreach-minors-not-just-covid-19/7928701002/">halted COVID-19 vaccination clinics on school property</a>. The decision was part of a broader effort to cease vaccine messages geared toward children and adolescents. The pause lasted only 10 days and has since been <a href="https://www.tennessean.com/story/news/health/2021/07/23/tennessee-restart-vaccine-outreach-paused-amid-gop-pressure/8043482002/">somewhat reversed</a>, limiting vaccine promotion to messages geared at parents and holding some vaccine events on school property.</p>
<p>Those who want to eliminate school-located COVID-19 vaccination clinics say the sites exist to immunize children without parental consent. However, even before the Food and Drug Administration expanded eligibility to include 12-to-15-year-olds, school-located sites offered COVID-19 vaccines to school staff and other eligible adults.</p>
<p>I am an <a href="https://scholar.google.com/citations?user=KeAdSmgAAAAJ&hl=en">expert on the history of epidemics</a>, and my research shows that this current move is an unprecedented detour from schools’ historical promotion of routine vaccines. Preventing school vaccination clinics does not keep waves of teenagers from getting immunized without consent. Rather, it penalizes those who want to get vaccinated but struggle with access. </p>
<h2>Partisan divide</h2>
<p>Tennessee’s “pause” stemmed from the <a href="https://www.kff.org/policy-watch/the-red-blue-divide-in-covid-19-vaccination-rates-is-growing/">Republican Party’s resistance</a> to publicly embracing COVID-19 vaccination, paired with overhyped attention to the <a href="https://www.tn.gov/content/dam/tn/health/documents/Mature_Minor_Doctrine.pdf">Mature Minor Doctrine</a>. </p>
<p>The Mature Minor Doctrine is a Tennessee law allowing “medical treatment and vaccinations to patients as young as 14,” enabling adolescents to make <a href="https://mckinneylaw.iu.edu/ihlr/pdf/vol13p1.pdf">decisions</a> about their own health. It is especially useful for those who don’t live with their parents, are in situations of neglect or abuse or face emergency circumstances. However, it also covers preventive health care and treatment including vaccinations. Many states hold similar consent exceptions.</p>
<p>Whether minors can get the COVID-19 vaccination without parental approval has <a href="https://www.kff.org/policy-watch/covid-19-vaccination-and-parental-consent/">varied by city and state</a>. After the Pfizer vaccine’s emergency authorization expanded to include ages 12 to 15, <a href="https://www.nytimes.com/2021/06/26/health/covid-vaccine-teens-consent.html">news coverage</a> called attention to teenagers receiving COVID-19 vaccines without consent, in some cases questioning the practice without addressing its prevalence or the <a href="https://www.tennessean.com/story/news/american-south/2021/08/04/teen-covid-19-vaccinations-fight-continues-increase-rate-schools-reopen/5430513001/">risk of not immunizing this age group</a>. In Tennessee, the public health department has stated that only <a href="https://www.tennessean.com/story/news/health/2021/07/23/tennessee-restart-vaccine-outreach-paused-amid-gop-pressure/8043482002/">eight adolescents</a> had received a COVID-19 vaccine without parental consent. Furthermore, no evidence has suggested that SLVs have contributed to these cases. </p>
<p>In other words, misplaced ideology, not data on teenagers getting vaccinated without consent, has been the driving force against SLVs, including COVID-19 vaccine clinics at schools. </p>
<h2>From smallpox to HPV</h2>
<p>Since the mid-19th century, schools have been common sites for vaccine clinics to respond to outbreaks and also provide catch-up immunizations. </p>
<p>In 1875, <a href="https://doi.org/10.1177/1059840510369231">17,505 children</a> were immunized against smallpox in New York City school clinics. Temporary <a href="https://www.newspapers.com/image/66584082/">typhoid vaccine clinics</a> emerged in the 1910s and 1920s across the U.S. And the 1954 polio vaccine field trials took place at <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1804435/">15,000 public schools</a> across 44 states. </p>
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<img alt="Nurse puts arm around boy as another nurse administers a polio vaccine shot" src="https://images.theconversation.com/files/414832/original/file-20210805-27-9nnji6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/414832/original/file-20210805-27-9nnji6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=460&fit=crop&dpr=1 600w, https://images.theconversation.com/files/414832/original/file-20210805-27-9nnji6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=460&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/414832/original/file-20210805-27-9nnji6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=460&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/414832/original/file-20210805-27-9nnji6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=578&fit=crop&dpr=1 754w, https://images.theconversation.com/files/414832/original/file-20210805-27-9nnji6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=578&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/414832/original/file-20210805-27-9nnji6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=578&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A boy is injected with polio vaccine at a school, circa 1955.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/boy-grimaces-while-being-injected-with-polio-vaccine-news-photo/587497982">USC Libraries/Corbis Historical Collection via Getty Images</a></span>
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<p>Even before Jonas Salk’s polio vaccine received approval in April 1955, <a href="https://www.newspapers.com/image/359079723/">SLVs were scheduled in anticipation</a>. They became the main locations for children to receive their vaccines. In the 1960s, SLVs across the country hosted “Sabin Sundays,” providing the oral polio vaccine developed by Albert Sabin to any unvaccinated <a href="https://ohiomemory.org/digital/collection/p267401coll36/id/19113">adult or child</a>. During this time, school campaigns also expanded to offer immunizations against <a href="https://www.newspapers.com/clip/82726551/schools-to-provide-free-vaccine-1971/">rubella and measles</a>. </p>
<p>Since then, SLVs have continued to be used for public health outreach, protecting children against hepatitis B, seasonal influenza and HPV. Many sites emerge for a short window each year, <a href="https://www.newspapers.com/image/523426147/">providing catch-up immunizations</a> for kids who are behind on other vaccines as well as shots against seasonal flu. Others spring up as needed, as demonstrated with H1N1 immunizations in 2009. Even the pop-up clinics at schools typically require parental consent for participation. </p>
<p>Moreover, SLVs are often available to whole communities – not just school attendees. They are widely effective in addressing <a href="https://www.doi.org/10.2105/AJPH.2009.176628">disparities in immunization</a> linked to income and insurance status. Like other mass vaccination sites, SLVs can immunize large numbers of people in a short period of time and <a href="https://doi.org/10.1371/journal.pmed.1003238">reduce disease in a community</a>. </p>
<p>They have <a href="https://www.cdc.gov/vaccines/covid-19/planning/school-located-clinics.html">additional benefits</a>, too. SLVs are convenient for families and school staff, provide a large, temperature-controlled space, create awareness of the importance of vaccines and <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/00032366.htm#00000621.htm">boost rates of completion</a> for vaccines given in a series.</p>
<h2>Pandemic disruptions</h2>
<p>The COVID-19 pandemic caused global disruptions in children’s vaccinations. In 2020, <a href="https://www.who.int/news/item/15-07-2020-who-and-unicef-warn-of-a-decline-in-vaccinations-during-covid-19">routine vaccinations decreased</a> because of stay-at-home orders, <a href="https://www.who.int/news/item/15-07-2020-who-and-unicef-warn-of-a-decline-in-vaccinations-during-covid-19">delay or cancellation of immunization programs</a> and other reasons connected to the global health crisis. </p>
<p>For the diphtheria, tetanus and pertussis vaccines, known as DTaP, New York City experienced a decrease of <a href="https://www.nytimes.com/live/2021/06/10/world/covid-vaccine-coronavirus-mask">16% for children under 2 and 60% for ages 2 to 6</a>. Researchers estimate that routine vaccinations need to increase <a href="https://doi.org/10.1016/j.vaccine.2020.11.074">as much as 15%</a> for vaccine rates to return to pre-pandemic levels. </p>
<figure class="align-center ">
<img alt="A toddler sits in chair with sleeve pulled down to receive flu shot" src="https://images.theconversation.com/files/414835/original/file-20210805-19-1vmi0re.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/414835/original/file-20210805-19-1vmi0re.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/414835/original/file-20210805-19-1vmi0re.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/414835/original/file-20210805-19-1vmi0re.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/414835/original/file-20210805-19-1vmi0re.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/414835/original/file-20210805-19-1vmi0re.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/414835/original/file-20210805-19-1vmi0re.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A nurse gives a 3-year-old a flu shot at a mobile immunization clinic set up behind John Ruhrah Elementary/Middle School in Baltimore in October 2020.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/nurse-hellen-lougon-gives-a-flu-shot-to-3-year-old-sofia-news-photo/1229662559">Katherine Frey/The Washington Post via Getty Images</a></span>
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<p>It’s important to remember that vaccine-preventable diseases are not distant memories. Only smallpox has been globally eradicated – polio, diphtheria, rubella and other dangerous viruses still exist.</p>
<p>Vaccination reductions can produce costly community outbreaks. A single measles case in 2018 erupted into <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1912514">over 600 cases</a> in an undervaccinated community in New York, costing US$8.4 million in public health response efforts, medical expenses and productivity loss. Similarly, Washington state’s <a href="https://doi.org/10.1542/peds.2020-027037">2019 Clark County measles outbreak</a> cost an estimated $3.4 million. </p>
<p>[<em>Understand new developments in science, health and technology, each week.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-understand">Subscribe to The Conversation’s science newsletter</a>.]</p>
<h2>SLVs for COVID-19</h2>
<p>Starting in March 2020, schools across the country began offering COVID-19 vaccines – first for staff and community members, and in May for those ages 12 and up. Such sites have been <a href="https://doi.org/10.1177/1942602X21991643">especially important</a> for <a href="https://edsource.org/2021/new-l-a-school-vaccination-sites-to-open-for-families-of-students-in-hard-hit-communities/652263">low-income and other underserved communities</a> significantly affected by the pandemic. </p>
<p>Once the eligible age expands to include children ages 11 and younger, school vaccine clinics can serve entire families. The <a href="https://www.nytimes.com/2021/08/05/us/politics/school-vaccinations-biden.html?smid=tw-nytimes&smtyp=cur">White House has encouraged</a> every school district to host at least one pop-up vaccination clinic. As with the typhoid and polio clinics before them, the intention is to curb the spread of disease and improve overall public health – the message that should underscore all vaccination decisions for this pandemic.</p><img src="https://counter.theconversation.com/content/164827/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katherine A. Foss does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>For decades, US schools have been common sites for vaccine clinics to respond to outbreaks and provide catch-up immunizations. So why are they suddenly controversial?Katherine A. Foss, Professor of Media Studies, Middle Tennessee State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1632212021-06-30T15:52:07Z2021-06-30T15:52:07ZWill COVID-19 vaccination enthusiasm last? Lessons from polio and H1N1<figure><img src="https://images.theconversation.com/files/408260/original/file-20210624-13-vxe6fk.jpg?ixlib=rb-1.1.0&rect=1%2C0%2C909%2C618&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Two public health nurses vaccinate adults at a polio clinic in Southey, Sask. in 1960.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/lac-bac/49587866686/in/photolist-2m3Vqeq-T7XMum-ovDmHk-oerCAi-odc6cv-tkGxDo-owgyyA-2ixUM9J-xrxZmo-xHttWf-xFN125-xnv3jo-od9pYA-x8jPuc-sG6bND-tAzahh-xb5kzq-xsFWuV-odcPp7">(Canadian Nurses Association fonds. Library and Archives Canada)</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><iframe style="width: 100%; height: 175px; border: none; position: relative; z-index: 1;" allowtransparency="" src="https://narrations.ad-auris.com/widget/the-conversation-canada/will-covid-19-vaccination-enthusiasm-last--lessons-from-polio-and-h1n1" width="100%" height="400"></iframe>
<p>Canadian enthusiasm for COVID-19 vaccination is impressive. After repeated lockdowns, long separations from friends and family and economic losses, Canadians are lining up overnight at <a href="https://toronto.ctvnews.ca/hundreds-line-up-as-pop-up-clinics-offer-covid-19-vaccines-to-children-aged-12-and-over-1.5433466">pop-up clinics</a> and <a href="https://www.thestar.com/news/gta/2021/05/03/miss-out-amid-this-mornings-scramble-to-get-a-vaccine-appointment-for-people-18-in-covid-19-hot-spots-you-werent-alone.html">crashing websites</a> with their eagerness to book appointments.</p>
<p><a href="https://ourworldindata.org/covid-vaccinations">Canada is currently a global leader</a> with over <a href="https://health-infobase.canada.ca/covid-19/vaccination-coverage/">75 per cent of the eligible population</a>, as of June 25, having received their first dose.</p>
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<img alt="" src="https://images.theconversation.com/files/410911/original/file-20210712-19-geybnm.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/410911/original/file-20210712-19-geybnm.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/410911/original/file-20210712-19-geybnm.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/410911/original/file-20210712-19-geybnm.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/410911/original/file-20210712-19-geybnm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/410911/original/file-20210712-19-geybnm.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/410911/original/file-20210712-19-geybnm.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><a class="source" href="https://theconversation.com/ca/topics/vaccine-confidence-in-canada-107061">Click here for more articles in our series about vaccine confidence.</a></span>
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<p>Does this mean we can stop worrying about vaccine uptake? Experience from history suggests not. As historians <a href="https://doi.org/10.1503/cmaj.171238">Heather MacDougall and Laurence Monnais</a> have argued, people do not get the recommended vaccines for a variety of reasons, including apathy. Another reason is misinformation, like the <a href="https://www.historyofvaccines.org/content/articles/do-vaccines-cause-autism">unfounded and discredited claim that the measles, mumps and rubella vaccine can cause autism</a>. </p>
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Read more:
<a href="https://theconversation.com/private-messages-contribute-to-the-spread-of-covid-19-conspiracies-162725">Private messages contribute to the spread of COVID-19 conspiracies</a>
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<p>Some <a href="https://doi.org/10.1080/10810730.2017.1312720">are not convinced</a> that the disease in question will impact them or their families. Others are deterred by the difficulty of accessing the vaccine. More than a few are scared of <a href="https://doi.org/10.1016/j.vaccine.2012.05.011">needles</a>. We have seen all of these factors play out in past epidemics.</p>
<p>We examined the response to polio and the H1N1 vaccines in Canada. At the height of the epidemics, Canadians were keen to get vaccinated, but vaccine enthusiasm waned once the crisis had passed.</p>
<h2>The case of polio</h2>
<p>Parents were terrified by polio in the early decades of the 20th century. Usually striking in the otherwise carefree summer months, <a href="https://www.who.int/news-room/fact-sheets/detail/poliomyelitis">polio could leave children paralyzed</a>. In some cases children were confined in <a href="https://longreads.com/2020/05/26/among-the-last-in-an-iron-lung/">iron lungs</a> and in the very worst cases, death. </p>
<p>The first trial of the Salk polio vaccine took place in the United States in 1954, <a href="https://www.thecanadianencyclopedia.ca/en/article/canada-and-the-development-of-the-polio-vaccine">using a vaccine produced in Toronto’s Connaught Laboratories</a>. </p>
<p>The vaccine proved highly effective. Other laboratories were licensed to product the vaccine, but one of them, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1383764/">the Cutter Laboratories, failed to properly de-activate the polio virus</a> and 10 children died from polio. The U.S. <a href="https://www.nytimes.com/1955/05/07/archives/u-s-halts-flow-of-polio-vaccine-pending-a-study-u-s-halts-flow-of.html">halted the vaccination program</a> on May 7, 1955.</p>
<p>In Canada, a trial using the vaccine produced at the Connaught Laboratories continued. Health officials assured Canadians that the Connaught Laboratories product <a href="https://news.google.com/newspapers?nid=QBJtjoHflPwC&dat=19550509&printsec=frontpage&hl=en">was safe and effective</a>. By June 1956, <a href="https://www.jstor.org/stable/41981152">1.8 million Canadian children had been vaccinated</a>. But this did not eradicate polio — there were significant epidemics in the late 1950s and early 1960s. </p>
<figure class="align-center ">
<img alt="A nurse stands next to man in an iron lung" src="https://images.theconversation.com/files/408414/original/file-20210625-28-jwj8ja.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/408414/original/file-20210625-28-jwj8ja.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/408414/original/file-20210625-28-jwj8ja.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/408414/original/file-20210625-28-jwj8ja.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/408414/original/file-20210625-28-jwj8ja.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/408414/original/file-20210625-28-jwj8ja.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/408414/original/file-20210625-28-jwj8ja.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A photo of a man in an iron lung from July 1957.</span>
<span class="attribution"><span class="source">(Library and Archives Canada)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>The Salk vaccine schedule required three separate doses, making it a challenge to complete the full course of vaccination. </p>
<p>Many adults believed that polio only impacted children and were reluctant to take the vaccine. <a href="https://www.jstor.org/stable/41981576">Only 10 per cent of Canadian adults</a> had received the required three doses of the Salk vaccine by June of 1959, compared to a rate of 90 per cent among school-aged children. </p>
<p>The year 1959 was one of the worst years for polio in Canada, with nearly <a href="https://www.cpha.ca/story-polio">2,000 paralytic cases</a>. In Montréal <a href="https://news.google.com/newspapers?nid=Fr8DH2VBP9sC&dat=19591015&printsec=frontpage&hl=en">there were over 950 cases and 51 fatalities</a>. Across Canada, more young adults died than children between the ages of five and 19, most of the cases occurring among those who had not been vaccinated. </p>
<p>During the 1959 epidemic people swamped the vaccination clinics in Montréal. And three years later, following <a href="https://news.google.com/newspapers?nid=Fr8DH2VBP9sC&dat=19620829&printsec=frontpage&hl=en">an outbreak in Hull, Que.</a>, residents came to the vaccination clinics in droves. </p>
<h2>Introduction of oral vaccine</h2>
<p>The introduction of the oral polio vaccine (Sabin vaccine) in 1961 led to an uptick in polio vaccinations. </p>
<p>In just three months in 1962, over <a href="https://www.jstor.org/stable/pdf/41983496.pdf">four million Canadians</a> received the oral polio vaccine. Many adults who had resisted earlier appeals to get the Salk vaccine <a href="https://news.google.com/newspapers?nid=Fr8DH2VBP9sC&dat=19620521&printsec=frontpage&hl=en">showed up to sip</a> the tasteless Sabin vaccine, often served on a sugar cube. <a href="https://news.ourontario.ca/88728/page/278074?q=polio+OR+vaccine">Newspapers raved</a> that no needles were necessary. And by the 1970s, polio had all but disappeared in Canada. </p>
<p>When the Salk vaccine came out, parents were very keen to have their children vaccinated, but young adults were not convinced that they were at risk and did not get vaccinated. Only after additional epidemics showed that that they too could die or be paralyzed by polio did adults turn up to get vaccinated. The vaccination effort was further aided by tasty Sabin vaccine.</p>
<figure class="align-center ">
<img alt="Group of people waiting for vaccines" src="https://images.theconversation.com/files/408264/original/file-20210624-23-19pt0mr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/408264/original/file-20210624-23-19pt0mr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=471&fit=crop&dpr=1 600w, https://images.theconversation.com/files/408264/original/file-20210624-23-19pt0mr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=471&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/408264/original/file-20210624-23-19pt0mr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=471&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/408264/original/file-20210624-23-19pt0mr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=591&fit=crop&dpr=1 754w, https://images.theconversation.com/files/408264/original/file-20210624-23-19pt0mr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=591&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/408264/original/file-20210624-23-19pt0mr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=591&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People lined up to get their H1N1 vaccination in Oct. 2009 in St. Eustache Que. Waiting times of seven hours were common as vaccination centres were overwhelmed by the demand.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Ryan Remiorz</span></span>
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<h2>H1N1 vaccination campaign</h2>
<p>In spring of 2009, a novel H1N1 influenza virus began spreading in <a href="https://doi.org/10.1016/S0140-6736(09)61638-X">Mexico</a>. The first cases were reported in <a href="https://www.thecanadianencyclopedia.ca/en/article/h1n1-flu-of-2009-in-canada">Canada</a> that April.</p>
<p>In June, the <a href="https://www.cdc.gov/h1n1flu/who/">World Health Organization</a> declared H1N1 to be a global pandemic. Like the flu of 1918-19, which killed as many as <a href="https://www.cdc.gov/flu/pandemic-resources/1918-pandemic-h1n1.html">50 million people</a> around the world, the 2009 flu had a disproportionate impact on <a href="https://www.thestar.com/life/health_wellness/news_research/2009/10/28/h1n1_is_serious_but_no_need_to_panic.html">younger people</a>. </p>
<p>That fall, vaccination clinics opened across Canada for priority groups. Early polls showed that only <a href="https://www.thestar.com/life/health_wellness/news_research/2009/10/22/h1n1_vaccine_headed_to_a_clinic_near_you.html">one-third of Canadians</a> planned to get the H1N1 vaccine, which was <a href="https://www150.statcan.gc.ca/n1/pub/82-624-x/2015001/article/14218-eng.htm">on par with seasonal flu shot vaccination rates</a>. Less than <a href="https://doi.org/10.1093/infdis/jis283">perfect efficacy rates</a> of the seasonal flu shot did little to inspire the Canadian public to seek out the H1N1 vaccine. </p>
<p>But four days after vaccination clinics opened in Ontario, a previously healthy <a href="https://toronto.ctvnews.ca/boy-killed-by-h1n1-was-my-best-friend-says-dad-1.447725">boy in Toronto died</a>. The tragic news stirred fear among Ontarians, prompting thousands to <a href="https://www.macleans.ca/news/canada/swine-flu-screw-up/">rush to clinics</a>. Many waited in line for hours, while others were turned away.</p>
<p>Vaccines became available to all Ontarians in November 2009, but by then, people’s fears had eased — it seemed that H1N1 <a href="https://doi.org/10.1503/cmaj.100900">was not as lethal as had originally been feared</a>. </p>
<p>Ultimately, <a href="https://www.thecanadianencyclopedia.ca/en/article/h1n1-flu-of-2009-in-canada">between 40 and 45 per cent</a> of the Canadian population was vaccinated against H1N1. </p>
<p>Once again, vaccine enthusiasm was high in the middle of the crisis, but it diminished after the flu appeared to be less dangerous.</p>
<h2>Lessons for COVID-19</h2>
<p>Polio and H1N1 reveal the complexities of vaccine enthusiasm. People rush to get vaccines when they perceive an immediate health risk to themselves or their family members. But without that fear, it is easier to delay or avoid getting vaccinated.</p>
<p>Many Canadians know someone who has gotten sick from COVID-19 and many have lost friends and family members to the disease. It’s no wonder we are eager to get vaccinated. But enthusiasm may wane as case counts fall. </p>
<p>If it proves that we need boosters, but case counts are low, will people make the same effort to get out to the vaccine clinics?</p>
<p>The biggest challenge may be ensuring the continuing uptake of vaccines once the initial crisis has passed. In addition to measures to <a href="https://theconversation.com/how-canadians-can-use-social-media-to-help-debunk-covid-19-misinformation-155653">combat vaccine misinformation</a>, public health authorities need to ensure that vaccines are readily available and convenient to access. </p>
<p><em>Do you have a question about COVID-19 vaccines? Email us at <a href="mailto:ca-vaccination@theconversation.com">ca‑vaccination@theconversation.com</a> and vaccine experts will answer questions in upcoming articles.</em></p><img src="https://counter.theconversation.com/content/163221/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine Carstairs has received funding from SSHRC, AMS Healthcare and the University of Guelph. This research was funded by a grant from the University of Guelph, SSHRC Institutional Explore Grant.</span></em></p><p class="fine-print"><em><span>Curtis Fraser does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>At the height of polio and H1N1, Canadians were keen to get vaccinated, but vaccine enthusiasm waned once the crisis had passed — what does that mean for COVID-19?Catherine Carstairs, Professor, Department of History, University of GuelphCurtis Fraser, Graduate Student, History, University of GuelphLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1593212021-05-10T20:00:34Z2021-05-10T20:00:34ZHow better conversations can help reduce vaccine hesitancy for COVID-19 and other shots<figure><img src="https://images.theconversation.com/files/399076/original/file-20210505-17-jjtl9o.jpg?ixlib=rb-1.1.0&rect=452%2C331%2C5854%2C4134&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Empathetically exploring the positive motivations of people who are vaccine hesitant may help improve acceptance for COVID-19 vaccines and others.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 250px; border: none; position: relative; z-index: 1;" src="https://narrations.ad-auris.com/widget/the-conversation-canada/final-how-better-conversations-can-help-reduce-vaccine-hesitancy-for-covid-19-and-other-shots" width="100%" height="400"></iframe>
<p>New parents have many decisions to make soon after their baby is born. One of them is about vaccination.</p>
<p>Between the cooing and crying, cards and bouquets, and yet another change of clothes, parents will be asked about inoculating their infant against childhood illnesses. Where once the answer would have been “yes” by default, the past few decades <a href="https://www.canada.ca/en/public-health/services/publications/healthy-living/2017-vaccine-uptake-canadian-children-survey.html">have seen more Canadian parents hesitate</a>. </p>
<h2>Vaccine hesitancy</h2>
<p>While vaccination remains the norm, for a range of reasons exhausted mothers and nervous fathers are saying “We’ll wait” or even “No” to vaccinations in maternity wards across the country. </p>
<p>In an era of patient-centrism and individual autonomy, the parents’ right to hesitate is accepted. But health-care professionals are often worried by both the individual risks and societal consequences of the choices that are being made. Life threatening and altering diseases <a href="https://doi.org/10.1503/cmaj.109-4812">like polio</a> <a href="https://www.canada.ca/en/public-health/services/diseases/measles/measles-in-canada.html">or measles</a> — once eradicated or marginalized by vaccines — are creeping back.</p>
<figure class="align-center ">
<img alt="An infant being vaccinated" src="https://images.theconversation.com/files/399837/original/file-20210510-13-w2fw32.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/399837/original/file-20210510-13-w2fw32.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/399837/original/file-20210510-13-w2fw32.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/399837/original/file-20210510-13-w2fw32.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/399837/original/file-20210510-13-w2fw32.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/399837/original/file-20210510-13-w2fw32.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/399837/original/file-20210510-13-w2fw32.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">While vaccination remains the norm for babies and children, some parents have become more hesitant about vaccines.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Canadians’ attitudes towards COVID-19 vaccines suggest hesitancy and its societal consequences are not limited to the choices of newly minted parents. Recent surveys <a href="https://angusreid.org/canada-covid-vaccine-january/">in Canada</a>, <a href="https://doi.org/10.1038/s41591-020-1124-9">and globally</a>, show many of us are hesitant about vaccines that have been produced with such herculean effort and enormous cost. So many, in fact, that the immunization thresholds required to tame COVID-19 are under threat. </p>
<p>This hesitancy has been described <a href="https://doi.org/10.1016/j.vaccine.2015.04.036">in detail</a>, and linked to <a href="https://www.cnn.com/2021/02/15/politics/covid-vaccine-hesitant-partisan-split/index.html">people’s politics</a>, past <a href="https://www.thestar.com/opinion/contributors/2021/02/06/vaccine-hesitancy-in-the-black-community-is-deeply-rooted-in-a-history-of-racism-overcoming-that-lack-of-trust-will-be-a-tough-task.html">community traumas</a> and attitudes towards <a href="https://doi.apa.org/doiLanding?doi=10.1037%2Fhea0000586">science and industry</a>.</p>
<p>However, just what to do about it has been less clear. While most Canadians will say yes to COVID-19 vaccines, many of us also know a friend or a family member who is, at least for the moment, saying no. </p>
<p>Most of us know someone who mistrusts some element of the vaccine — from the speed of its production, to the intentions of its manufacturers or deliverers. Indeed, COVID-19 vaccine hesitancy is said to be on the rise, nudged upwards by the various <a href="https://doi.org/10.1136/bmj.n883">pauses, or stops, introduced by governments</a>. How, under these conditions, might we turn a “no” into a “maybe,” or even a “yes?” </p>
<h2>Motivational interviewing</h2>
<p>My research team at the University of Calgary’s School of Public Policy started our most recent work with just this question in mind. It turns out the answer was just a few provinces away in Québec, and took us back to newborns and their parents. </p>
<p>We have been working with Canadian federal and World Health Organization funding to support family doctors as they respond to the pandemic. To support better conversations about vaccine hesitancy, we met with Dr. Arnaud Gagneur, a hospital-based neo-natalogist in Sherbrooke. He and his colleagues are world leaders in improving dialogue around vaccination with new parents. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/399839/original/file-20210510-5687-1naadl8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A family doctor in a face mask talking to a patient" src="https://images.theconversation.com/files/399839/original/file-20210510-5687-1naadl8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/399839/original/file-20210510-5687-1naadl8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/399839/original/file-20210510-5687-1naadl8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/399839/original/file-20210510-5687-1naadl8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/399839/original/file-20210510-5687-1naadl8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/399839/original/file-20210510-5687-1naadl8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/399839/original/file-20210510-5687-1naadl8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Family doctors are well positioned to have productive conversations with patients about vaccination, including COVID-19 vaccination.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The technique they’ve been working with for more than a decade is called motivational interviewing and it has shown great success.</p>
<p>Described in <a href="https://doi.org/10.1016/j.vaccine.2019.03.076">academic journals</a> and <a href="https://www.nytimes.com/2021/01/31/opinion/change-someones-mind.html">media coverage</a>, a motivational interview is based on a seemingly simple idea: find a vaccine-hesitant person’s positive motivation. The art of accomplishing this lies in long and empathetic engagement with the person to get to the roots of their hesitancy. </p>
<p>Those roots will often be negatively expressed: “I don’t like the way it was made,” or “It’s a conspiracy, you know.” Under the principles of motivational interviewing, these roots are to be respected and acknowledged, regardless of how gnarled they might appear. Attempting to chop them off with arguments and facts will only encourage the person to <a href="http://doi.org/10.1001/jamapediatrics.2017.2219">sink deeper into their hesitancy</a>. Unless the person’s concerns are acknowledged as valid, facts are more likely to hinder than help. </p>
<p>The aim isn’t to chop off the negative, but rather to have the positive reveal itself. This takes conversation, close listening, empathy and above all, trust. Shifting out of the negative reason and into an expression of a positive aspiration is something that takes time, not argument. This, in motivational interviewing, is the key to moving from “I’m religiously opposed to the vaccine,” to helping someone understand that vaccination may allow them to attend worship again soon.</p>
<h2>Progress in primary care</h2>
<p>Our team was originally dismayed by this. Of course it worked for Dr. Gagneur and his team, but they have huge blocks of time to talk to new parents about their hesitancy. Neither all that time, nor the intensity of a recent birth, are common features of family medicine as practised in Canada. Could the principles of motivational interviewing be distilled into the short encounters of most primary care visits? </p>
<p>We were encouraged to seek an answer because family doctors have <a href="https://www.annfammed.org/content/18/4/349">the expertise</a> and <a href="https://doi.org/10.1136/bmj.m3898">the relationships</a> to deal with COVID-19 and its <a href="https://doi.org/10.1136/bmj.m3026">long-tailed consequences</a>. They have also been identified as <a href="https://www.milbank.org/2021/03/leveraging-trust-in-primary-care-to-promote-behavior-change-during-covid-19/">key players</a> in countering vaccine hesitancy. This is because they have the long-term relationships with patients who trust them, and the space to understand and validate the concerns those patients raise. </p>
<p>Where many people might struggle to find the positive motivation in a friend or family member’s hesitancy, a family doctor is better positioned to do so. With this in mind, our team has been working with doctors from across Canada to develop a pragmatic tool to help them navigate tricky conversations with people considering COVID-19 vaccines, or with parents making decisions about their children. </p>
<p>The tool will be web-based and stocked with helpful examples. Along with the family doctors who have been so generous with their time in developing the tool, we are hoping it will contribute to better conversations about vaccine hesitancy.</p><img src="https://counter.theconversation.com/content/159321/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Myles Leslie receives funding from SSHRC, and the WHO. </span></em></p>From maternity wards to primary care, Canadian researchers are looking to find the positive motivations of vaccine hesitant people, whether they are new parents or other adults.Myles Leslie, Associate Professor, School of Public Policy, University of CalgaryLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1538402021-02-21T12:05:55Z2021-02-21T12:05:55ZCOVID-19 vaccination: What we can learn from the great polio vaccine heist of 1959<figure><img src="https://images.theconversation.com/files/385353/original/file-20210219-21764-r1fsgf.jpg?ixlib=rb-1.1.0&rect=40%2C5%2C3794%2C2149&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In a pandemic, vaccines are in very high demand, and this threatens their supply.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>We find ourselves at a precarious time in global health. Many people are anxiously awaiting their turn to receive a vaccine for COVID-19, yet roll-out is slow and disorganized, with many countries <a href="https://www.bbc.com/news/explainers-52380823">facing supply shortages</a>. </p>
<p>The conditions are ripe <a href="https://www.washingtonpost.com/outlook/coronavirus-vaccine-rich-people/2020/12/18/3a2f188e-40ae-11eb-8bc0-ae155bee4aff_story.html">for opportunists</a> to exploit the situation. Reports of unethical line-jumping by wealthy elites have <a href="https://www.bbc.com/news/world-us-canada-55805907">started to surface</a>, while others warn of the <a href="https://www.statnews.com/2020/12/03/how-rich-and-privileged-can-skip-the-line-for-covid19-vaccines/">potential for a black-market trade in vaccines</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1362718577468432386"}"></div></p>
<p>This isn’t the first time people have waited anxiously for a vaccine. The looking-glass of history reveals the uneasiness of emotion that accompanies moments like these, as well as the dark consequences that can arise when evil-doers take advantage of them.</p>
<p>One case in particular stands out as an important lesson for today: <a href="https://www.thestar.com/news/canada/2020/12/06/covid-19-vaccines-are-about-to-be-the-hottest-commodity-on-earth-how-do-we-keep-them-safe.html">when thousands of vaccine doses were stolen by armed men during a supply shortage in 1959</a>.</p>
<h2>The polio epidemic</h2>
<p>It was the summer of 1959, when <a href="https://www.cpha.ca/story-polio">the last great epidemic of poliomyelitis swept across Canada</a>. Québec saw the most cases that year, with the <a href="https://www.newspapers.com/clip/68318101/polio-statistics-for-1959/">newspapers reporting</a> over a thousand cases and 88 deaths.</p>
<p>Although the health authorities in Montréal warned the public about the seriousness of the summer epidemic, they also begged the populace to remain calm. This was far from comforting for parents who feared for their children. </p>
<p>Polio infection could cause permanent paralysis and was deadly in five per cent of cases. Montréalers rushed to the vaccine clinics, sometimes waiting for hours in the rain. </p>
<p>Vaccine production in Canada was limited to only two laboratories, with the majority being provided by Connaught Labs at the University of Toronto. This put intense pressure on vaccine supplies and Québec, like the rest of North America, <a href="https://www.newspapers.com/image/500224904/?terms=polio&match=1">soon faced a vaccine shortage</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/380370/original/file-20210125-13-1jhc9r1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Three newspaper photos showing people lining up" src="https://images.theconversation.com/files/380370/original/file-20210125-13-1jhc9r1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/380370/original/file-20210125-13-1jhc9r1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=238&fit=crop&dpr=1 600w, https://images.theconversation.com/files/380370/original/file-20210125-13-1jhc9r1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=238&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/380370/original/file-20210125-13-1jhc9r1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=238&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/380370/original/file-20210125-13-1jhc9r1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=299&fit=crop&dpr=1 754w, https://images.theconversation.com/files/380370/original/file-20210125-13-1jhc9r1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=299&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/380370/original/file-20210125-13-1jhc9r1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=299&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Headline images showing the lone lines of people waiting to get a Salk vaccine. ‘The Montreal Gazette,’ Aug. 11, 1959.</span>
<span class="attribution"><a class="source" href="http://newspapers.com/">The Montreal Gazette</a></span>
</figcaption>
</figure>
<h2>A planned robbery</h2>
<p>By August, Montréal was waiting desperately for more vaccines. It was a great relief when a huge shipment of the cherry-red vials arrived from Connaught Labs at the end of the month. The supply was enough to cover the city, and the surplus was planned for redistribution across the province.</p>
<p>Yet the redistribution never came to pass. One man by the name of Jean Paul Robinson, a temporary vaccine worker, had found the circumstances too enticing. Robinson had been tasked with running vials between the various clinics. He knew there was a shortage and that people were desperate. He also knew where the main supply of vaccine was stored: at the Microbiology Institute in the University of Montréal. </p>
<p>At 3 a.m. on Aug. 31, 1959, Robinson and two accomplices broke into the university armed with revolvers. They first locked the night guard <a href="https://www.newspapers.com/clip/68326610/detailed-article-about-the-vaccine/">in a cage with 500 lab monkeys</a>. The thieves then broke the lock on the massive refrigerator, looted all the cases of the vaccine and stole the guard’s car as the getaway vehicle. In the end, they made away with 75,000 vials, <a href="https://www.newspapers.com/clip/68463642/the-robbery-made-front-page-news-all/">valued at $50,000</a> (equivalent to almost $500,000 today). Robinson rented an empty apartment building and stashed his prize.</p>
<p>The crime shocked the country. The next day, <a href="https://www.newspapers.com/clip/68327257/no-vaccine-left-in-the-city-of-montreal/">the city announced it had completely run out of its vaccine supplies</a>. Reporters seized on the situation, publishing reports of desperate mothers turned away from vaccine clinics in vain. </p>
<p>The provincial police were called in, and a special four-man team of investigators was assembled. They began by interviewing the hapless night guard. He couldn’t identify the culprits — who had been wearing nylon leggings over their faces — but he did overhear them speak about transporting the vaccines. The conversation provided the only lead: it seemed that at least one of the men had been “familiar with medical terms.”</p>
<p>The police soon brought in a medical student for questioning. By the next day, they had <a href="https://www.newspapers.com/clip/68273272/">seized a supply of fresh vaccine</a> from the shelves of a Pont-Viau drug store. The confiscated vials displayed the same serial number as the missing supply. Yet questioning both the medical student and the druggist led the police nowhere, and over the next few days, all leads ran dry. Worse yet, it seemed that the city was facing an upswing in infections, <a href="https://www.newspapers.com/clip/68333733/the-week-after-the-vaccine-was-stolen/">with another 36 patients admitted to hospital</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/385350/original/file-20210219-17-1j0hc14.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Black and white photograph of children in a row of hospital beds with an attending nurse." src="https://images.theconversation.com/files/385350/original/file-20210219-17-1j0hc14.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/385350/original/file-20210219-17-1j0hc14.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=463&fit=crop&dpr=1 600w, https://images.theconversation.com/files/385350/original/file-20210219-17-1j0hc14.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=463&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/385350/original/file-20210219-17-1j0hc14.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=463&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/385350/original/file-20210219-17-1j0hc14.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=581&fit=crop&dpr=1 754w, https://images.theconversation.com/files/385350/original/file-20210219-17-1j0hc14.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=581&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/385350/original/file-20210219-17-1j0hc14.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=581&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The widespread application of the polio vaccine in the 1950s and ‘60s helped bring polio under control in the early 1970s. Canada was certified 'polio free’ in 1994. This image of polio patients was taken in September 1947 in Edmonton, Alta.</span>
<span class="attribution"><a class="source" href="https://www.cpha.ca/story-polio">(Canadian Public Health Association)</a></span>
</figcaption>
</figure>
<h2>Risk and capture</h2>
<p>Meanwhile, Robinson was trying to figure out what to do with his ill-gotten supply of vaccine. Keeping the product cold was a difficult task — if left unrefrigerated for too long, the vaccine would be useless. He filled the refrigerator (saving one shelf for beer), while the rest of the cases were simply left on the floor at room temperature. Although he had been lucky to sell 299 vials for a tidy sum of $500 to the druggist at Pont-Viau, dispensing with the rest of the vaccine was too risky.</p>
<p>Taking a chance that the police were more interested in recovering the vials than catching the culprit, Robinson placed a call to the public police line. <a href="https://www.newspapers.com/clip/68332052/tip-from-citizen-leads-sleuth-to/">Posing as a concerned citizen</a>, he declared that he had seen a large amount of suspicious cases labelled “Connaught Laboratories” being loaded out of a car on St. Hubert Street in the East End.</p>
<p>The police quickly discovered the missing cases of vaccine, but before they could be used, the vaccines would need to be tested thoroughly. This process <a href="https://www.newspapers.com/clip/68334882/full-story-of-the-recovery-of-the/">could take up to two months</a>, meaning the vials could not be used despite the epidemic. Fresh shipments of the vaccine were not planned to arrive for a few more weeks.</p>
<p>The public met the outcome of the investigation with outrage, with the <em>Montréal Star</em> going so far as to speculate that the police had made a deal with the guilty parties in order to recover the vaccine. Truly, it declared, “in the history of justice in Canada, this case must be unprecedented.” The stolen vaccines were eventually cleared for general use in October.</p>
<p>For their part, the police were far from done investigating. They soon turned their attention to identifying the culprit. They discovered that the man who had provided the police tip was also <a href="https://www.newspapers.com/clip/68335832/article-covering-the-hearing-of/">the man who had sold the Pont-Viau druggist his 299 vials</a>. Evidence continued to mount against Robinson when the janitor of the apartment building identified him. After denying all charges, Robinson fled. He was discovered three weeks later hiding out in a small shed on an “isolated backroad farm.”</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/380387/original/file-20210125-13-327pxz.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4333%2C1216&q=45&auto=format&w=1000&fit=clip"><img alt="Newspaper front page BANDITS TAKE POLIO VACCINE IN BIZARRE LABORATORY RAID" src="https://images.theconversation.com/files/380387/original/file-20210125-13-327pxz.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4333%2C1216&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/380387/original/file-20210125-13-327pxz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=172&fit=crop&dpr=1 600w, https://images.theconversation.com/files/380387/original/file-20210125-13-327pxz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=172&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/380387/original/file-20210125-13-327pxz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=172&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/380387/original/file-20210125-13-327pxz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=216&fit=crop&dpr=1 754w, https://images.theconversation.com/files/380387/original/file-20210125-13-327pxz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=216&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/380387/original/file-20210125-13-327pxz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=216&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The vaccine heist of 1959 shocked the Canadian public and made headlines across the country. ‘Victoria Daily Times,’ Aug. 31, 1959.</span>
<span class="attribution"><span class="source">(Victoria Daily Times)</span></span>
</figcaption>
</figure>
<h2>‘Beyond reasonable doubt’</h2>
<p>Prosecuting Robinson turned out to be a much harder task, and <a href="https://www.newspapers.com/clip/68457605/results-of-the-prolonged-trial-of-jean/">the case eventually fell apart</a>. Although one of his accomplices had originally identified Jean Paul Robinson as the mastermind of the heist, when the trial came around two years later, the witness recanted his original statement (he would later be <a href="https://www.newspapers.com/clip/68458189/the-gazette/">charged with perjury</a>). </p>
<p>Robinson himself proved imperturbable during courtroom interrogations. He painted himself a public-spirited citizen who had simply tried to <a href="https://www.newspapers.com/clip/68460048/robinson-proved-to-be-unshakable-in-the/">“retrieve” the stolen vaccines from the true criminal mastermind</a>: a mysterious man by the name of Bob. Robinson claimed that Bob had set the whole thing up before he had disappeared and escaped justice. The judge eventually ruled that although Robinson’s story was “strange and a little far-fetched,” in the end, “the Crown had not proven a case beyond a reasonable doubt” and he was acquitted.</p>
<p>As millions of people worldwide anxiously await the distribution of the COVID-19 vaccines, this case warns of the possible consequences of disorganized and poorly planned vaccine programs. <a href="https://www.interpol.int/en/News-and-Events/News/2020/INTERPOL-warns-of-organized-crime-threat-to-COVID-19-vaccines">Those looking to profit from mistakes, shortages and desperation are out there</a>, and it is important that policy makers keep this in mind as vaccination programs are rolled out.</p><img src="https://counter.theconversation.com/content/153840/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paula Larsson receives funding from the Social Sciences and Humanities Research Council of Canada (SSHRC). </span></em></p>In 1959, three armed men broke into the University of Montréal and stole the whole supply of polio vaccine — 75,000 vials valued at $50,000. What have we learned from this event?Paula Larsson, Doctoral Student, Centre for the History of Science, Medicine, and Technology, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1531202021-01-20T12:06:25Z2021-01-20T12:06:25ZVaccine rollout: history shows us that it’s always a bit shambolic<p>“The scientists have done it,” <a href="https://www.theguardian.com/politics/2020/dec/02/the-scientists-have-done-it-boris-johnson-hails-covid-vaccine">said the UK prime minister, Boris Johnson</a> in December 2020, hailing the development of the new COVID-19 vaccine. Johnson insisted that this success brought “sure and certain knowledge” that people would soon be able to reclaim their lives. But since this optimistic declaration, the COVID vaccine rollout has been beset by challenges. </p>
<p>British GPs were quick to call the process a <a href="https://www.bmj.com/content/371/bmj.m4849">“shambles”</a>, as delivery delays forced them to cancel appointments and poor communication left them waiting for stock that didn’t arrive on time. In the US, the rollout has been hindered by public confusion, supply shortages, and yet more delays. The federal government failed to achieve its goal of giving <a href="https://edition.cnn.com/2020/12/23/health/vaccine-rollout-slow-data-lags/index.html">20 million people</a> an initial dose of the vaccine by the end of 2020. By <a href="https://www.bostonglobe.com/2021/01/10/nation/throughout-history-mass-vaccine-rollouts-have-been-beset-by-problems/">December 31</a>, the number of vaccinated Americans stood at just 2.8 million. By <a href="https://covid.cdc.gov/covid-data-tracker/#vaccinations">January 8, only 6.68 million</a> had received their first dose. </p>
<p>In several countries where the vaccines have been authorised, criticism is mounting over proposed strategies to stretch supplies. <a href="https://www.nationalgeographic.com/science/2021/01/experts-debate-half-doses-and-delayed-boosters-for-covid-vaccines/">Experts and healthcare professionals</a> have raised concerns about proposals that include administering half doses and <a href="https://www.reuters.com/article/us-health-coronavirus-vaccines-germany/germany-mulls-delaying-second-covid-19-vaccine-shot-denmark-approves-delay-idUSKBN2991M4">extending the time between</a> the two doses. </p>
<p>Some governments have pointed the finger at <a href="https://www.reuters.com/article/us-health-coronavirus-vaccine-breakingvi/breakingviews-vaccine-bottlenecks-are-main-obstacle-to-recovery-idUKKBN28D1JA?edition-redirect=uk">manufacturers for bottlenecks</a>, while vaccine developers insist it’s an issue of supply. Others cite complications with distribution plans and a shortage of trained staff to administer the shots. </p>
<p>Only 516 people were vaccinated in the first week of <a href="https://www.telegraph.co.uk/news/2021/01/04/snail-paced-french-vaccination-campaign-state-scandal-emmanuel/">France’s campaign</a> and, while Germany has administered over a million doses, its government is still facing <a href="https://www.ctvnews.ca/health/coronavirus/as-world-begins-vaccination-push-delayed-rollouts-draw-criticism-1.5261477">criticisms</a>. The <a href="https://www.politico.eu/article/netherlands-coronavirus-vaccination-slow-start-mark-rutte-hugo-de-jonge/">Netherlands</a> only started its rollout last week, making it one of the last EU countries to do so.</p>
<h2>Misplaced optimism</h2>
<p>But these issues have always affected large-scale vaccination rollouts, and we only have ourselves to blame for misplaced optimism. The polio vaccine campaign in 1950s America has assumed a kind of mythological status as a straightforward success – but as a <a href="https://www.bostonglobe.com/2021/01/10/nation/throughout-history-mass-vaccine-rollouts-have-been-beset-by-problems/">public health professor from Columbia University</a> said, “there was a lot of confusion, there was a lot of chaos, and the federal government was actually widely criticised for its failure to anticipate the public demand for the vaccine”. </p>
<figure class="align-center ">
<img alt="Mass polio vaccination in Columbus, US, circa 1961." src="https://images.theconversation.com/files/379589/original/file-20210119-13-h7wtz4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/379589/original/file-20210119-13-h7wtz4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=390&fit=crop&dpr=1 600w, https://images.theconversation.com/files/379589/original/file-20210119-13-h7wtz4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=390&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/379589/original/file-20210119-13-h7wtz4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=390&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/379589/original/file-20210119-13-h7wtz4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=490&fit=crop&dpr=1 754w, https://images.theconversation.com/files/379589/original/file-20210119-13-h7wtz4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=490&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/379589/original/file-20210119-13-h7wtz4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=490&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Mass polio immunisation in the US.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=1650082">CDC/Charles N Farmer</a></span>
</figcaption>
</figure>
<p>The federal government failed to plan or coordinate an effective distribution and relied on an ad hoc selection of pharmaceutical companies for support. They offered little oversight and it was, somewhat unsurprisingly, a disaster. No one knew where to get the vaccine or when they would receive doses – and even doctors had only a limited understanding of the processes involved. And there was the infamous tragedy associated with the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1383764/">Cutter Laboratories</a>, where some batches of the vaccine given to the public contained live poliovirus.</p>
<p>On the other side of the Atlantic, the British Ministry of Health instituted a <a href="https://doi.org/10.1080/13619462.2016.1247701">vaccination programme against polio in 1956</a>, but it too ran into a range of supply and administrative issues. When, just a year later, Coventry experienced an outbreak, it came to symbolise this tragic public health failure. </p>
<p>Both countries saw their vaccine distribution systems repeatedly tested over the second half of the 20th century. In 1976, a strain of <a href="https://www.smithsonianmag.com/smart-news/long-shadow-1976-swine-flu-vaccine-fiasco-180961994/">influenza emerged</a> in America. Similar problems soon emerged, and the government accelerated a new vaccination programme and more than 400 people who received the jab developed Guillain-Barré syndrome, a <a href="https://www.nhs.uk/conditions/guillain-barre-syndrome/">rare neurological disorder</a> that can result in paralysis. </p>
<h2>The norm</h2>
<p>Delays, administrative hurdles, messiness and complexity seem, therefore, to be the norm rather than the exception when it comes to the rollout of vaccines. Why then do politicians still insist on framing the development of new medical technologies as the ultimate quick fix to complex healthcare challenges such as pandemics? </p>
<p>Part of the problem is that the notion that science is an easy cure-all is very appealing. It promotes the work of science and scientists, ties in with attractive and self-satisfying narratives of national progress, and offers the promise of relief in a time of intense global suffering. Politicians, as well as some scientists, have all played their part in promoting this notion. </p>
<p>Histories of science can also perpetuate these narratives. They can gloss over messiness and complexity and paint straightforward stories of “magic bullets” and technological fixes. These stories sell. They provide readers with a comforting sense that science is reliable, morally neutral, and always in aid of the social good. </p>
<p>The real stories are, on the face of it at least, far less comforting. Scientific knowledge is made by people and is subject to their whims and biases. The application of scientific discoveries to challenging healthcare problems is even more complex and even more likely to be waylaid by political needs, special interests and incompetence. But the messiness of medical history can also provide crucial lessons about managing expectations and the value of adaptability. </p>
<p>The history of vaccination programmes makes clear the importance of navigating the many varieties of the human condition and tells us that science cannot be understood separately from society. But just because these programmes have almost always been a shambles does not mean that populations should not hold their governments to account. It just means that we should be extra sceptical of excessive optimism and cautious about rhetoric that frames science as the one and only solution to our collective ills.</p><img src="https://counter.theconversation.com/content/153120/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Agnes Arnold-Forster does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>History tells us that delays, administrative hurdles, messiness and complexity are the norm.Agnes Arnold-Forster, Research Fellow, History of Medicine and Healthcare, University of BristolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1534432021-01-20T02:51:40Z2021-01-20T02:51:40ZThe big barriers to global vaccination: patent rights, national self-interest and the wealth gap<figure><img src="https://images.theconversation.com/files/379635/original/file-20210119-24-isdzkh.jpg?ixlib=rb-1.1.0&rect=22%2C0%2C4942%2C3438&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">www.shutterstock.com</span></span></figcaption></figure><p>We will not be able to put the COVID-19 pandemic behind us until the world’s population is mostly immune through vaccination or previous exposure to the disease. </p>
<p>A truly global vaccination campaign, however, would look very different from what we are seeing now. For example, as of January 20, <a href="https://ourworldindata.org/covid-vaccinations">many more people have been immunised in Israel</a> (with a population less than 10 million) than in Africa and Latin America combined.</p>
<p>Notwithstanding recent <a href="https://www.theguardian.com/world/2021/jan/19/single-covid-vaccine-dose-in-israel-less-effective-than-we-hoped">questions</a> about the effectiveness of the initial single dose of the vaccine, there is a clear disparity in vaccine rollouts internationally.</p>
<p>That is a problem. As long as there are still existing reservoirs of a propagating virus it will be able to spread again to populations that either cannot or would not vaccinate. It will also be able to mutate to variants that are either more transmissible or more deadly. </p>
<p>Counterintuitively, an increase in transmissibility, such as has been found with <a href="https://www.bbc.com/news/health-55388846">the new UK variant</a>, is worse than the same percentage increase in mortality rate. This is because increased transmissibility increases the number of cases (and hence the number of deaths) exponentially, while an increase in mortality rates increases only deaths, and only linearly.</p>
<p>Evolutionary pressure on the virus will inevitably favour mutations that make the disease more transmissible, or the virus itself more vaccine-resistant. It is clear, therefore, that every nation’s interest is in universal vaccination. But this is not the trajectory we are on. </p>
<h2>Politics and profits</h2>
<p>Fortunately, in the countries already vaccinating, the vaccine is (mostly) not allocated by wealth or power, but by prioritising those facing the highest risk. At a country level, however, national wealth is <a href="https://www.bloomberg.com/news/articles/2021-01-18/vaccine-disparities-raise-alarm-as-covid-variants-multiply">determining vaccine roll out</a>. </p>
<p>Yet in the past we have managed to eradicate diseases worldwide, including small pox, a viral infection with much higher death rates than COVID-19.</p>
<p>There are two barriers that prevent us from rapidly pursuing a similar goal for the current pandemic:</p>
<ul>
<li><p>big pharma is profit-driven and therefore keeps a tight lid on the intellectual property it is developing in the new vaccines</p></li>
<li><p>countries find it difficult to see beyond their national interest; not surprisingly, politicians are committed only to their own voters.</p></li>
</ul>
<p>At this point, we don’t have a global system to confront either of these problems. Each vaccine’s patent is owned by its developer, and the World Health Organisation (WHO) is too weak to be the world’s Ministry of Health.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/should-children-get-the-covid-19-vaccine-153431">Should children get the COVID-19 vaccine?</a>
</strong>
</em>
</p>
<hr>
<h2>The polio vaccine model</h2>
<p>Overcoming big pharma’s profit motive has been achieved before, however.</p>
<p>In 1955, Jonas Salk announced the development of a <a href="https://pubmed.ncbi.nlm.nih.gov/24175215/">polio vaccine</a> in the midst of a huge epidemic. The news initially met with scepticism. Even employees of his own laboratory resigned, protesting that he was moving too fast with clinical experimentation. </p>
<p>When a huge placebo–controlled clinical trial involving 1.6 million children proved him right, however, he declared that in order to maximise the global distribution of this lifesaving vaccine his lab would not patent it. Asked who owned the patent, he famously replied:</p>
<blockquote>
<p>Well, the people I would say. There is no patent. Could you patent the sun?</p>
</blockquote>
<p>In an echo of the current moment, Israel (then a new state) was also experiencing a rapidly spreading polio epidemic. Efforts to purchase vaccines from the US were unsuccessful, as not all American children were yet vaccinated. So a scientist named Natan Goldblum was <a href="https://pubmed.ncbi.nlm.nih.gov/20864699/">sent to Salk’s laboratory</a> to learn how to make the new vaccine. </p>
<p>No lawyers were involved and no contracts signed. The young Dr Goldblum spent 1956 setting up manufacturing facilities for Salk’s vaccine in Israel and by early 1957 mass vaccination was underway. </p>
<h2>Suspend patent rights</h2>
<p>Israel, a small and relatively poor country in the 1950s, became the third country in the world (after the US and Denmark) to produce the vaccine locally and eventually eradicate polio. It took a handful of scientists, a modest budget and, most importantly, no patenting.</p>
<p>Like Salk, Goldblum was aware viruses have complete disregard for political borders. He was also involved in a very successful <a href="https://pubmed.ncbi.nlm.nih.gov/21490330/">Palestinian polio vaccination campaign</a> in Gaza.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-great-polio-vaccine-mess-and-the-lessons-it-holds-about-federal-coordination-for-todays-covid-19-vaccination-effort-152806">The great polio vaccine mess and the lessons it holds about federal coordination for today's COVID-19 vaccination effort</a>
</strong>
</em>
</p>
<hr>
<p>More recently, a highly successful international campaign in the early 2000s saw AIDS treatments <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0020227">distributed in poorer countries</a>. Pharmaceutical companies that owned the patented drugs were forced to supply them at cost or for free, not at market prices set in the rich countries. This was achieved through public pressure and the willingness of governments to support the required policies. </p>
<p>A temporary withdrawal of the patenting rights to the successful COVID-19 vaccines, with or without compensation for the developers, seems a small price to pay for an exit strategy from this global and incredibly costly crisis.</p>
<h2>Act local, think global</h2>
<p>Overcoming national interest is perhaps more complicated. Clearly, countries have an interest in vaccinating their most vulnerable populations first. But at some point, well before everyone is vaccinated, it becomes more efficient for countries to start vaccinating their neighbours (the countries they are most exposed to through movements of people and trade). </p>
<p>Disappointingly, rich countries today behave as though they will reach 100% vaccination rates before they give away a single dose, with many having bought well in excess of what is needed for 100% coverage. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/covid-vaccine-some-waste-is-normal-but-heres-how-it-is-being-kept-to-a-minimum-152772">COVID vaccine: some waste is normal – but here's how it is being kept to a minimum</a>
</strong>
</em>
</p>
<hr>
<p>The <a href="https://www.gavi.org/vaccineswork/covax-explained">COVAX plan</a> to distribute vaccines in poorer countries has so far been an <a href="https://www.reuters.com/article/health-coronavirus-who/new-kinds-of-loans-and-bonds-could-fill-28-billion-covid-funding-gap-who-idUSKBN28P1CG">under-funded effort</a> that has not yet delivered a single dose of vaccine. Even if COVAX were to be fully funded, it mostly aims to donate an insufficient number of vaccine doses to the poorest countries, rather than really bring about a universal vaccination programme.</p>
<p>Nevertheless, overcoming the profit-maximising interest of big pharma and the national focus of governments is not a pipe dream. The world has done it before.</p><img src="https://counter.theconversation.com/content/153443/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As the eradication of polio and the successful rollout of AIDS treatments have shown in the past, global cooperation in the face of COVID-19 is possible.Ilan Noy, Professor and Chair in the Economics of Disasters and Climate Change, Te Herenga Waka — Victoria University of WellingtonAmi Neuberger, Clinical Assistant Professor, Technion - Israel Institute of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1528062021-01-14T13:21:16Z2021-01-14T13:21:16ZThe great polio vaccine mess and the lessons it holds about federal coordination for today’s COVID-19 vaccination effort<figure><img src="https://images.theconversation.com/files/378566/original/file-20210113-23-12pkx5x.jpg?ixlib=rb-1.1.0&rect=0%2C299%2C4991%2C3539&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Elementary students initially received polio vaccines at school.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/view-of-a-classroom-as-children-receive-polio-vaccinations-news-photo/618896932">PhotoQuest/Archive Photos via Getty Images</a></span></figcaption></figure><p>I nervously fell into a long line of fellow first graders in the gymnasium of St. Louis’ Hamilton Elementary School in the spring of 1955. We were waiting for our first injection of the new polio vaccine.</p>
<p>The National Foundation for Infantile Paralysis – with money raised through its annual March of Dimes campaign – had sponsored field tests for a vaccine developed by Jonas Salk. The nonprofit had acquired sufficient doses to inoculate all the nation’s first and second graders through simultaneous rollouts administered at their elementary schools. The goal was to give 30 million shots <a href="https://www.marchofdimes.org/mission/a-history-of-the-march-of-dimes.aspx">over three months</a>.</p>
<p>Now, more than six decades later, attention focuses on the rollout of two COVID-19 vaccines, following their <a href="https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/pfizer-biontech-covid-19-vaccine">emergency use authorization</a> by the U.S. Food and Drug Administration. States have begun to administer them in a <a href="https://www.npr.org/2021/01/03/952969795/what-the-u-s-can-do-about-vaccine-rollout-issues">rocky and frustratingly slow delivery process</a> – while <a href="https://www.statista.com/statistics/1102816/coronavirus-covid19-cases-number-us-americans-by-day/">hundreds of thousands of new cases</a> continue to be diagnosed daily in the U.S.</p>
<p>While not necessarily comforting, it is useful to recognize that the early days and weeks of mass distribution of a new medication, particularly one that is intended to address a fearful epidemic, are bound to be frustrating. Only after examining the complex polio vaccine distribution process as documented in papers collected in the <a href="https://www.eisenhowerlibrary.gov/">Dwight D. Eisenhower Presidential Library</a> did I come to understand how partial my childhood memories actually were.</p>
<h2>Vaccine distribution, 65 years ago</h2>
<p>After I received my polio shot, I remember my parents’ relief.</p>
<p>The polio virus causes flu-like symptoms in most people who catch it. But in a minority of those infected, the brain and spinal cord are affected; polio can cause paralysis and even death. With the distribution of Salk’s vaccine, the <a href="https://global.oup.com/academic/product/polio-9780195152944">much-feared stalker of children and young adults</a> had seemingly been tamed. Within days, however, the initial mass inoculation program <a href="https://www.jstor.org/stable/4638326">went off the rails</a>.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/378571/original/file-20210113-23-6mt7t0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Jonas Salk poses with a flask in lab" src="https://images.theconversation.com/files/378571/original/file-20210113-23-6mt7t0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/378571/original/file-20210113-23-6mt7t0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=789&fit=crop&dpr=1 600w, https://images.theconversation.com/files/378571/original/file-20210113-23-6mt7t0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=789&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/378571/original/file-20210113-23-6mt7t0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=789&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/378571/original/file-20210113-23-6mt7t0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=992&fit=crop&dpr=1 754w, https://images.theconversation.com/files/378571/original/file-20210113-23-6mt7t0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=992&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/378571/original/file-20210113-23-6mt7t0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=992&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The world initially rejoiced as Salk’s vaccine came online. He declined to patent it, to make it available to all.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/view-of-american-scientist-and-physician-jonas-salk-news-photo/109274461">PhotoQues/Archive Photos via Getty Images</a></span>
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<p>Immediately following the government’s licensing of the Salk vaccine, the National Foundation for Infantile Paralysis contracted with private drug companies for US$9 million worth of vaccine (around $87 million today) – about 90% of the stock. They planned to provide it free to the <a href="https://www.google.com/books/edition/Patenting_the_Sun/qIHhAAAAMAAJ?hl=en">country’s first and second graders</a>. But just two weeks after the first doses were administered, the Public Health Service reported that six inoculated children had come down with polio.</p>
<p>As the number of such incidents grew, it became clear that some of the shots were causing the disease they were meant to prevent. A <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1383764/">single lab</a> had inadvertently released adulterated doses.</p>
<p>After considerable fumbling and outright denial, Surgeon General Leonard Steele first pulled all tainted vaccine off the market. Then, less than a month after the initial inoculations, the U.S. <a href="https://oac.cdlib.org/findaid/ark:/13030/kt3c6031cw/entire_text/">shut down distribution entirely</a>. It wasn’t until the introduction of a <a href="https://www.statnews.com/2018/03/01/albert-sabin-polio-vaccine/">new polio vaccine</a> in 1960, created by Albert Sabin, that public trust returned.</p>
<h2>History’s lessons for 2021</h2>
<p>This story offers several lessons relevant to the COVID-19 vaccine distribution just now getting rolling.</p>
<p>First, federal coordination of an emergent lifesaving medical product is critical.</p>
<p>The federal government had declined to play an active oversight and coordination role for the polio vaccine, but still wanted the credit. The federal Department of Health, Education and Welfare (now Health and Human Services) offered no plan for distribution beyond the privately funded school-based program.</p>
<p>The department waited a full month after the vaccine was first administered before bringing together a permanent scientific clearance panel. That delay had less to do with formal procedures than with the ideological opposition of Health, Education and Welfare Secretary <a href="https://www.womenshistory.org/education-resources/biographies/oveta-hobby">Oveta Culp Hobby</a>.</p>
<p>Hobby was a political appointee who had taken office <a href="https://www.tshaonline.org/handbook/entries/hobby-oveta-culp">just months before the vaccine was approved</a>. Her reluctance to involve the federal government in matters that she believed were best left in private hands – and her oft-stated fear of “<a href="https://www.nytimes.com/1955/06/15/archives/mrs-hobby-terms-free-vaccine-idea-a-socialistic-step-charges.html">socialized medicine</a>” – meant that safety checks would be left to the private labs producing the vaccine. The results immediately caused dire problems and even avoidable deaths.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/378573/original/file-20210113-23-steevs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="People protesting pandemic restrictions and rules, one holds a 'No vaccines' sign" src="https://images.theconversation.com/files/378573/original/file-20210113-23-steevs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/378573/original/file-20210113-23-steevs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/378573/original/file-20210113-23-steevs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/378573/original/file-20210113-23-steevs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/378573/original/file-20210113-23-steevs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/378573/original/file-20210113-23-steevs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/378573/original/file-20210113-23-steevs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">In May 2020, Trump supporters in California protested against a COVID-19 vaccine months before one was even available.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/protester-holds-an-anti-vaccination-sign-as-supporters-of-news-photo/1213388386">David McNew/Getty Images News via Getty Images</a></span>
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<p>Second, the polio vaccine distribution process demonstrated how vital it is for the federal government to act in ways deserving of public trust.</p>
<p>In those hopeful first few weeks of the polio vaccine distribution, those of us lining up for shots had little to fear beyond the sting of an injection. That changed quickly.</p>
<p>Once some children had in fact been harmed by the shot, obfuscation by government officials, clumsy explanations and delayed responses engulfed the entire production and distribution process in confusion and suspicion. Trust in the government and the vaccine eroded accordingly. Gallup polls found that by June 1955, almost half of the parents who responded said they <a href="http://www.ibiblio.org/pha/Gallup/Gallup.pdf">would not take any further vaccine shots</a> – and the full regimen of polio inoculation required three doses. In 1958, some drug companies halted production, citing “<a href="https://www.jstor.org/stable/4638326">public apathy</a>.” It wasn’t surprising to see a startling <a href="http://www.ibiblio.org/pha/Gallup/Gallup.pdf">upsurge in polio in 1959</a>, doubling cases from the previous year. </p>
<p>Today, with COVID-19 already highly politicized – polls suggest that a <a href="https://www.kff.org/coronavirus-covid-19/report/kff-covid-19-vaccine-monitor-december-2020/">minority of Americans will decline to take any vaccine</a> – it is critical to administer an effective vaccine delivery program in a manner that builds trust rather than undermines it.</p>
<p>Scattered reports of allergic reactions to the COVID-19 vaccine have generated not the denials of the Eisenhower administration but rather honest and realistic responses from the <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/allergic-reaction.html">Centers for Disease Control and Prevention</a>. Particularly for vaccines that require multiple inoculations – both Pfizer and Moderna vaccines require <a href="https://www.statnews.com/2020/12/19/a-side-by-side-comparison-of-the-pfizer-biontech-and-moderna-vaccines/">two shots administered with a 21- or 28-day gap</a> – mass inoculations will require not just an initial willingness to get the first dose but the maintenance of trust sufficient to get people back for the followup. </p>
<p>There are significant differences in the social-political contexts of the era in which the polio vaccine was distributed and today, including the nature and threat of the two diseases and the technologies of the vaccines. But time and again, the COVID-19 pandemic has revealed disconcerting parallels with mistakes made in the past. The good news is vaccination works – no case of polio has originated <a href="https://www.cdc.gov/polio/what-is-polio/polio-us.html">in the U.S. since 1979</a>. </p>
<p>[<em>Research into coronavirus and other news from science</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-corona-research">Subscribe to The Conversation’s new science newsletter</a>.]</p><img src="https://counter.theconversation.com/content/152806/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bert Spector does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Massive vaccine distribution efforts take a lot of coordination. The rollout of the Salk polio vaccine in the US in 1955 holds lessons for those delivering COVID-19 shots today.Bert Spector, Associate Professor of International Business and Strategy at the D'Amore-McKim School of Business, Northeastern UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1511272020-12-03T12:28:39Z2020-12-03T12:28:39ZWhat Elvis Presley’s televised polio vaccination can tell us about the shortfalls of celebrity-endorsed health campaigns<figure><img src="https://images.theconversation.com/files/372794/original/file-20201203-13-1l8hrn2.jpg?ixlib=rb-1.1.0&rect=4%2C0%2C2903%2C2881&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Elvis Presley received a polio vaccination on the Ed Sullivan Show in 1956</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/united-states-america-circa-2015-stamp-332169260">neftali/Shutterstock.com</a></span></figcaption></figure><p>If you had tuned into the Ed Sullivan Show on October 28 1956, you would have witnessed an unexpected promoter of public health. Just before he took the stage to gyrate his way through his hit version of “Hound Dog”, the teenage heartthrob, Elvis Presley, received a polio vaccination <a href="https://www.theguardian.com/society/2016/apr/24/elvis-presley-polio-vaccine-world-immunisation-week">live on television</a>. The city’s health commissioner, there for the photo op, raved about Presley: “He is setting a fine example for the youth of the country.” </p>
<p>Indeed, young people were the problem. Polio was perceived as a disease of the child, not of the teenager. So when it was announced a year before Presley’s famous injection that the American virologist and medical researcher, Jonas Salk, had produced a vaccine that would stop the ravages of polio, initial distribution efforts were focused on infants and young children. Teenagers, however, were more difficult to convince. </p>
<p>Presley’s on-air vaccination was meant to change all of this. If the king of rock and roll does it, they hoped a generation of teens would say, I will too!</p>
<p>As it turned out, there were many reasons teenagers – and others – came up with to defy their king and refuse vaccination. One of these was almost certainly the 1955 “Cutter incident”, in which improperly prepared doses of the vaccine produced at the Cutter Laboratories in Berkeley, California, reached the market containing live poliovirus. </p>
<p>The ensuing outbreak did not improve public confidence. Another was the logistics of receiving the vaccine: three injections, each $3-5 (around $30-50 per jab in <a href="https://www.in2013dollars.com/us/inflation/1950?amount=5">today’s money</a>), was quite a commitment, especially for a population many did not consider to be urgently in need of immunisation. Indeed, the real game-changer came from the teenagers themselves, who, particularly in an association called <a href="https://doi.org/10.1080/14780038.2016.1145393">Teens Against Polio</a>, organised campaigns and sponsored the very popular (footwear optional) dances known as “sock-hops” for which immunisation was the price of admission.</p>
<h2>Minimal celebrity influence</h2>
<p>Perhaps more important than any of these for us now, however, is that the relationship presumed between public personalities and their fans is not nearly as straightforward as it has sometimes seemed. Individuals, then and now, are capable of being told by a celebrity to do something and, for all sorts of reasons, declining to do it. </p>
<p>This was a fact not lost on those putting forward public health messages in the latter decades of the 20th century. Over time, celebrity endorsements of public health projects fell away in favour of subtler alternatives. One of these was the rise of medical educational entertainment, or “medutainment”. This involved the integration of public health messaging into narrative developments on popular <a href="https://doi.org/10.1093/her/cyx034">medical television programmes</a>. </p>
<p>Since then, the more personal first-hand accounts of celebrities such as <a href="https://www.vogue.com/article/lena-dunham-hysterectomy-vogue-march-2018-issue">Lena Dunham</a>, who has publicly documented her persistent endometriosis, and <a href="https://www.nytimes.com/2020/11/25/opinion/meghan-markle-miscarriage.html">Meghan Markle</a> and <a href="https://www.bbc.com/news/entertainment-arts-54367998">Chrissy Teigen</a>, who have helped to destigmatise miscarriage, have shifted the relationship between celebrities and their fans when it comes to health and disease. </p>
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<p>All of this means we should view with some scepticism the recent proposition that <a href="https://www.theguardian.com/society/2020/nov/29/nhs-enlist-sensible-celebrities-coronavirus-vaccine-take-up">“sensible celebrities”</a> - who have done “sensible things” over the course of the pandemic - ought to be our public health point people in the quest to popularise the COVID-19 vaccine. </p>
<h2>Anti-vax movements</h2>
<p>Rather ironically, on the question of vaccination, celebrities have recently been far more visible in <a href="https://www.nytimes.com/2019/08/23/opinion/anti-vaccine.html">anti-vax movements</a>. We should be thankful, then, that their capacity to influence vaccination uptake either way is as minimal as it probably always has been. </p>
<p>In 2011, <a href="https://amednews.com/article/20110418/health/304189943/6/">researchers in the US</a> found that while only 24% of those surveyed had faith in what celebrities said about immunisation safety, over 70% had “a lot of trust” in their child’s doctor. </p>
<p>We know that vaccine hesitancy has often been about <a href="https://theconversation.com/vaccine-hesitancy-is-not-new-history-tells-us-we-should-listen-not-condemn-150884">valid mistrust</a>. That seems like a very good starting place to think about how to approach the COVID-19 vaccine. </p>
<p>This is not about how likeable or “sensible” the celebrity who urges us to do it is. It is about how much we can trust the various infrastructures and apparatuses that made that vaccine a reality in the first place: the public health experts who tell us to get vaccinated, the pharmaceutical companies who made and tested these vaccines, the medical practitioners who recommend it to us personally, the people who ultimately do the jabbing. </p>
<p>Do we have faith in this system? The goal here should not be about outsourcing likeability or faith to celebrities, but about focusing on repairing and maintaining goodwill between citizens and the state.</p><img src="https://counter.theconversation.com/content/151127/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Caitjan Gainty is the recipient of funding from the Wellcome Trust for her 'Healthy Scepticism' project.</span></em></p><p class="fine-print"><em><span>Agnes Arnold-Forster does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>‘Sensible’ public figures have far less influence on our behaviour than it seemsAgnes Arnold-Forster, Research Fellow, History of Medicine and Healthcare, University of BristolCaitjan Gainty, Lecturer in the History of Science, Technology and Medicine, King's College LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1488572020-11-03T14:11:31Z2020-11-03T14:11:31ZHow ending polio in Africa has had positive spinoffs for public health<figure><img src="https://images.theconversation.com/files/366076/original/file-20201028-21-9w8mqn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The polio eradication programme in Africa directly combated a severe debilitating disease. </span> <span class="attribution"><span class="source">Yasuyoshi Chiba / AFP via Getty Images</span></span></figcaption></figure><p><a href="https://theconversation.com/africa-is-within-reach-of-being-declared-a-polio-free-region-44786">Polio</a> is a highly infectious disease. It’s caused by a virus that enters the body through the mouth. The virus then multiplies in the intestine and attacks the central nervous system – causing paralysis. </p>
<p>Polio was one of the most dreaded diseases in the world in the 20th century. Four decades ago, an estimated 350,000 people were paralysed each year by the poliovirus in <a href="https://www.who.int/news-room/fact-sheets/detail/poliomyelitis">more than 125 countries</a>. This led the World Health Assembly in 1988 to adopt a resolution for the worldwide eradication of polio, drawing inspiration from the eradication of <a href="https://www.who.int/health-topics/smallpox#tab=tab_1">smallpox</a>. </p>
<p>The global programme to <a href="http://polioeradication.org/">eradicate polio</a> is spearheaded by a number of actors. These include national governments, the World Health Organisation (WHO), multiple development agencies, and healthcare workers. </p>
<p>The <a href="https://theconversation.com/africa-is-within-reach-of-being-declared-a-polio-free-region-44786">strategy</a> involves widespread vaccination as part of routine healthcare services as well as mass vaccination campaigns. Sensitive surveillance to detect and rapidly respond to polio cases is also key.</p>
<p>This initiative has been extremely successful. The number of people paralysed by polio decreased by 99.9% – from 350,000 in 1988 to 175 in 2019. During the same period, the number of polio endemic countries fell from more than 125 to only two: Afghanistan and Pakistan. A country is endemic when there’s widespread circulation of polio. </p>
<p>The latest WHO region to be certified polio free is Africa. The region was certified on <a href="https://www.afro.who.int/news/africa-eradicates-wild-poliovirus">25 August 2020</a>. The certification came four years after the last case of poliovirus on the continent. </p>
<p>The polio eradication programme in Africa directly combated a severe debilitating disease. But it also provided a platform for <a href="https://theconversation.com/the-legacy-benefits-from-africas-fight-against-polio-45688">broader healthcare services on the continent</a>. Polio eradication created renewed demand for vaccination services and innovative ways to deliver healthcare services. </p>
<h2>What does it take to eradicate a disease?</h2>
<p>It takes a combination of multiple biological and non-biological factors to eradicate a disease. Only one disease, smallpox, has so far been eradicated. </p>
<p>Polio viruses only survive for a very short time in the environment and there are no animal or insect reservoirs that carry polio viruses. More importantly, effective vaccines exist against polio. Beyond these biological features of polio, the eradication of polio from Africa required sound leadership. </p>
<p>In 1996 African heads of state resolved to stamp polio out of Africa. Then South African President Nelson Mandela launched the “Kick Polio out of Africa” campaign. Thereafter, <a href="https://theconversation.com/the-legacy-benefits-from-africas-fight-against-polio-45688">all-of-society collaborations</a> supporting widespread polio vaccination sprang up across African countries. These involved government departments, the private sector, the civil society, and the community at large to ensure eradication of <a href="https://www.afro.who.int/health-topics/polio">polio from the continent</a>. </p>
<p>Within national governments in Africa, public service departments worked across portfolio boundaries, formally and informally, to achieve the shared goal of polio eradication. All these efforts culminated, 14 years later, in the certification of the eradication of polio from Africa. </p>
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<a href="https://theconversation.com/africa-is-within-reach-of-being-declared-a-polio-free-region-44786">Africa is within reach of being declared a polio free region</a>
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<p>Certification is based on evidence that <a href="https://dictionary.cambridge.org/dictionary/english/certification">something has been achieved</a>. In the case of polio eradication, a region only gets certified when all the countries in the area demonstrate the absence of poliovirus transmission for at least three consecutive years in the presence of extremely sensitive surveillance. </p>
<p>Polio surveillance refers to a disease detection system that involves both community and laboratory components. </p>
<p>Surveillance in the community is done by the general public and healthcare workers. Healthcare workers need to report all cases of children who experience abrupt weakness of the limbs. Community members need to report any newly paralysed children in their communities to healthcare services. In the laboratory, the polio virus responsible for any case of polio paralysis is identified and its source determined. Without such high-quality surveillance it would be difficult to locate where and exactly how the polio virus is circulating or to confirm when its transmission has <a href="https://theconversation.com/africa-is-within-reach-of-being-declared-a-polio-free-region-44786">been eradicated</a>.</p>
<p>Twenty years ago, Africa was close to polio eradication; then <a href="https://theconversation.com/africa-is-within-reach-of-being-declared-a-polio-free-region-44786">misinformation surfaced in northern Nigeria</a> about the effectiveness and safety of polio vaccines. This misinformation led some people in the area to refuse or delay polio vaccines. Vaccination coverage dropped, resulting in widespread polio outbreaks in northern Nigeria and beyond. Such misinformation has gained traction on <a href="https://gh.bmj.com/content/5/10/e004206">social media</a>. </p>
<p>Avoiding vaccination even when it’s available is referred to as <a href="https://www.thinkglobalhealth.org/article/vaccine-hesitancy-escalating-danger-africa">vaccine hesitancy</a>. Polio vaccine hesitancy poses significant risks not only for the hesitant people, but also the wider community. It could prevent African communities from reaching thresholds of vaccination coverage necessary to keep polio out of Africa. If a single child remains infected with polio virus in any part of the world, children in all countries are at risk of contracting the disease.</p>
<h1>Long-term rewards</h1>
<p>Africa’s health systems are much stronger because of the investments made. Countries were supported to make life-saving gains. These included increasing access to health care in the most remote places, strengthening routine vaccination systems, and ensuring strong disease surveillance. </p>
<p>Polio’s legacy must be built on to achieve <a href="https://www.africakicksoutwildpolio.com/the-legacy-of-polio-eradication-in-africa/">other major health goals</a>.</p><img src="https://counter.theconversation.com/content/148857/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Charles Shey Wiysonge does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The polio eradication programme in Africa directly combated a severe debilitating disease. But it also provided a platform for broader healthcare services on the continent.Charles Shey Wiysonge, Director, Cochrane South Africa, South African Medical Research CouncilLicensed as Creative Commons – attribution, no derivatives.