tag:theconversation.com,2011:/global/topics/polio-free-19289/articlesPolio-free – The Conversation2021-09-08T07:07:36Ztag: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/1050122018-10-19T10:37:35Z2018-10-19T10:37:35ZSewage surveillance is the next frontier in the fight against polio<figure><img src="https://images.theconversation.com/files/241330/original/file-20181018-67194-xbcd3i.jpg?ixlib=rb-1.1.0&rect=128%2C261%2C3311%2C2322&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Monitoring sewage for virus allows for a quick public health response if any polio is detected.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Pharmawater-Factories/169f4ff3a4c24e7781780a5422328838/10/0">AP Photo/Matt Rourke</a></span></figcaption></figure><p>The world is at the brink of eradicating polio. <a href="http://polioeradication.org/where-we-work/polio-endemic-countries/">Only three countries</a> now have ongoing transmission: Nigeria, Afghanistan and Pakistan. And in 2017, there were <a href="http://polioeradication.org/news-post/working-toward-a-polio-free-future-2017-in-review/">only a couple dozen cases</a> of paralytic wild polio reported worldwide – a massive decrease from the estimated <a href="http://polioeradication.org/polio-today/history-of-polio/">350,000 cases reported across 125 countries in 1988</a>. Development of the polio vaccine and global vaccination efforts are at the heart of this monumental public health achievement.</p>
<p>Epidemiologists typically detect polio transmission based on reported cases of acute flaccid paralysis (AFP). The World Health Organization certifies a country as polio-free if there are no reports of AFP for three years. But AFP is a severe outcome that <a href="http://www.who.int/news-room/fact-sheets/detail/poliomyelitis">occurs in a very small fraction</a> of polio infections. It’s just the tip of the iceberg – one case of AFP indicates substantial underlying polio transmission in a population. </p>
<p>This is why now, as the world approaches the final stages of polio eradication, environmental surveillance becomes key. Looking for poliovirus in sewage is more sensitive than counting up cases of AFP. It can detect virus shed in the feces of non-paralyzed people infected with polio – what epidemiologists call the silent circulation of polio.</p>
<p>Environmental microbiologists have <a href="https://doi.org/10.1146/annurev.mi.49.100195.002333">studied pathogens in sewage for decades</a>, but its use as a public health surveillance tool is relatively new. As epidemiologists who specialize in modeling the spread of disease, we wondered if we could estimate the intensity of infection in a population by analyzing counts of virus in its sewage. The discovery of <a href="https://www.health.gov.il/PublicationsFiles/ICDC_317.pdf">polio transmission in Israel in 2013</a> – the <a href="http://polioeradication.org/where-we-work/polio-free-countries/">first in that country since 1988</a> – provided a way for us to test whether our model, coupled with environmental surveillance data from different parts of the world, could be used to assess how much silent transmission is still happening globally.</p>
<h2>Characterizing a polio outbreak in Israel</h2>
<p>Given all the progress made toward polio eradication, it was disturbing to realize <a href="https://doi.org/10.2807/1560-7917.ES2013.18.38.20586">polio was actively being transmitted</a> <a href="https://doi.org/10.2807/1560-7917.ES2014.19.7.20708">in Israel in 2013</a>. A sewage surveillance system – set up in 1989 by the Israeli health department to detect poliovirus – sounded the alarm. The Ministry of Health worked quickly to vaccinate the public, and fortunately none of the infections resulted in paralysis.</p>
<p>To track polio in human waste in Israel, samples are automatically collected from sewage trunk lines and treatment plants approximately weekly. Back at the country’s Central Virology Laboratory, they’re checked for poliovirus.</p>
<p>Most of the positive sewage samples during the 2013 outbreak came from the Negev region of Israel, and most of those from predominantly Bedouin communities. <a href="https://doi.org/10.1126/science.342.6159.679">Based on molecular characteristics of the virus</a> isolated from the sewage, scientists know that the virus originated in Pakistan, then traveled into the region, diverging into Egypt, Israel and Syria. For a virus, even tightly guarded geopolitical borders are fluid.</p>
<p>To understand what kept the polio transmission going, we needed to better characterize Bedouin movement patterns. Where people travel provides pathways for them to potentially spread the virus. For example, larger Jewish communities such as Beer Sheva are economic hubs; Bedouins from communities throughout the region travel there daily. In addition, many communities send children to regional schools, another potential hub of transmission.</p>
<p>Poor sanitary conditions provide an important route for the poliovirus to move from host to host – remember, infected people excrete viable virus in their feces. Epidemiologists knew surprisingly little about the water and sanitation infrastructure of these Bedouin communities, beyond that they were highly variable and often poor compared to nearby Jewish communities.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/241329/original/file-20181018-67164-ll836t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/241329/original/file-20181018-67164-ll836t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/241329/original/file-20181018-67164-ll836t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/241329/original/file-20181018-67164-ll836t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/241329/original/file-20181018-67164-ll836t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/241329/original/file-20181018-67164-ll836t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/241329/original/file-20181018-67164-ll836t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/241329/original/file-20181018-67164-ll836t.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">Where people encounter sewage-contaminated water, they may also be exposed to poliovirus.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Mideast-Gaza-Sewage-Crisis/92540e8fc91a4c66874e104b9671480c/8/0">AP Photo/Khalil Hamra</a></span>
</figcaption>
</figure>
<h2>Creating a model for how polio spread</h2>
<p>The Central Virology Laboratory and Ministry of Health recognized the potential in their data, but no one had developed a theory to convert environmental surveillance into public health metrics. Because of <a href="https://scholar.google.com/citations?user=PJAQ7AQAAAAJ&hl=en&oi=ao">our</a> <a href="https://sph.umich.edu/faculty-profiles/eisenberg-joseph.html">experience</a> <a href="https://scholar.google.com/citations?user=RhyNk3EAAAAJ&hl=en&oi=sra">in</a> modeling environmentally transmitted infectious diseases, we met with Central Virology Laboratory and Ministry of Health officials on the ground during the later stages of the epidemic and began collaborating on a new approach to the problem.</p>
<p>A mathematical model allows epidemiologists to use what we know about a situation’s underlying biological mechanisms to better interpret or extract more information from data. We knew a number of things in this case: the relative levels of poliovirus in various communities’ sewage over time, the coverage of the vaccination campaigns, and the differences in transmission between the wild virus and the attenuated vaccine virus. Our goal was to come up with a model that would explain how the disease was transmitted through the population in Israel that would match the observed changes in sewage polio levels over time.</p>
<p><a href="https://doi.org/10.1073/pnas.1808798115">Using new analytical methods, we estimated</a> that in Rahat, the largest predominantly Bedouin community that sustained significant transmission, 56 percent of the at-risk population – primarily children under 10 – was infected.</p>
<p>Positive polio samples from the environment only alert public health officials that transmission is happening. Our model provides additional information about how many people were infected. Without a model, researchers would have no way of estimating the extent of the outbreak – the poliovirus in the sewage could have been collected from many people shedding a little or a few people shedding a lot. But because outbreaks follow recognizable patterns, the dynamic changes in polio concentration can actually tell us a lot about how the disease is moving through the population.</p>
<p>There is always uncertainty in model predictions, so corroboration with multiple data sources is important. In this outbreak, we were able to compare to crude estimates of infection <a href="https://doi.org/10.1016/j.jcv.2015.03.005">based on community stool samples</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/241328/original/file-20181018-67188-bvk2aq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/241328/original/file-20181018-67188-bvk2aq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/241328/original/file-20181018-67188-bvk2aq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/241328/original/file-20181018-67188-bvk2aq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/241328/original/file-20181018-67188-bvk2aq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/241328/original/file-20181018-67188-bvk2aq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=508&fit=crop&dpr=1 754w, https://images.theconversation.com/files/241328/original/file-20181018-67188-bvk2aq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=508&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/241328/original/file-20181018-67188-bvk2aq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=508&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Administering vaccine at the first signs of silent circulation can quickly stop a nascent polio outbreak.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Pakistan-Polio/8320416c5eed42848a273fb9bf454231/29/0">AP Photo/K.M. Chaudary</a></span>
</figcaption>
</figure>
<h2>Monitoring environment for silent transmission</h2>
<p>As we approach the final stages of polio eradication, environmental measures will become the only feasible way to detect polio transmission. And this silent spread of the virus must be halted to fully eradicate the disease. Waiting until there’s a paralytic case means there’s a lot of polio around and containing it with vaccination efforts becomes more difficult.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"888401952656297987"}"></div></p>
<p>Environmental surveillance efforts are growing in all three polio-endemic countries. Indeed, since the success seen in Israel in identifying and quickly containing transmission by administering oral polio vaccine, many countries have <a href="http://polioeradication.org/news-post/expansion-of-environmental-surveillance-for-poliovirus-aiding-in-regional-eradication-efforts/">begun to implement polio environmental surveillance</a>. WHO is working toward developing <a href="http://polioeradication.org/wp-content/uploads/2016/07/WHO_V-B_03.03_eng.pdf">organized environmental surveillance standards</a> akin to the well-established standards for acute flaccid paralysis.</p>
<p>Beyond polio, environmental surveillance can and should be extended to other infectious diseases shed into sewage – enteroviruses, typhoid and cholera are prime candidates. Epidemiologists can then use modeling approaches to translate surveillance data to describe population patterns, allowing public health officials to respond rapidly to outbreaks.</p><img src="https://counter.theconversation.com/content/105012/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marisa Eisenberg receives funding from the National Institutes of Health and National Science Foundation. </span></em></p><p class="fine-print"><em><span>Andrew Brouwer receives funding from the National Institutes of Health. </span></em></p><p class="fine-print"><em><span>Joseph Eisenberg receives funding from the National Institutes of Health. </span></em></p>Polio can be circulating through a community long before anyone is paralyzed. Monitoring sewage for the virus lets public health officials short-circuit this ‘silent transmission.’Marisa Eisenberg, Associate Professor of Complex Systems, Epidemiology, and Mathematics, University of MichiganAndrew Brouwer, Research Investigator in Epidemiology, University of MichiganJoseph Eisenberg, Professor and Chair of Epidemiology, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/905802018-03-23T10:31:39Z2018-03-23T10:31:39ZInching closer to a world without polio<figure><img src="https://images.theconversation.com/files/211471/original/file-20180322-165571-ymubad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">What will it take to finish polio off in the last three countries where it persists?</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Pakistan-Fighting-to-Vaccinate/6be7219ce1464481af4fdcf431f11bca/3/0">AP Photo/B.K. Bangash</a></span></figcaption></figure><p>At its height in the 1940s and ‘50s, <a href="https://www.cdc.gov/features/poliofacts/">polio paralyzed more than 35,000 Americans every year</a>. But thanks to vaccines as well as good hygiene and sanitation practices, polio has largely been forgotten in the developed world.</p>
<p>Now, even in less-developed regions, it’s close to being wiped out entirely. But there are still challenges to overcome before polio can join smallpox as a virus that has been eradicated worldwide. </p>
<p>With the support of the <a href="http://polioeradication.org">World Health Organization</a>, the <a href="https://www.gatesfoundation.org/What-We-Do/Global-Development/Polio">Bill & Melinda Gates Foundation</a> (a strategic partner of The Conversation US that provides funding for The Conversation internationally), <a href="https://my.rotary.org/en/take-action/end-polio">Rotary International</a> and others, public health workers and volunteers work tirelessly and in dangerous conditions to vaccinate every one of the world’s children. The number of polio cases globally dropped from 350,000 in 1988 to <a href="http://www.who.int/mediacentre/factsheets/fs114/en/">just 37 in 2016</a>. Thirty years ago, polio was regularly found in 125 of the world’s 190 or so countries. Today, only three countries continue to see regular cases: Pakistan, Nigeria and Afghanistan.</p>
<p>Of these, Pakistan is closest to becoming polio-free thanks to its persistent, innovative vaccination campaign programs. But its poor security, weak health system and lack of proper sanitation work against this effort.</p>
<p>The lessons infectious disease preparedness and response researchers <a href="https://scholar.google.com/citations?user=0M6hB44AAAAJ&hl=en&oi=ao">like</a> <a href="http://bush.tamu.edu/scowcroft/fellows/">us</a> are learning in Pakistan, during what’s hopefully a final push against polio, will also apply elsewhere, as public health experts work to wipe out other infectious diseases around the world.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/211397/original/file-20180321-165577-1hppxsa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/211397/original/file-20180321-165577-1hppxsa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/211397/original/file-20180321-165577-1hppxsa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=458&fit=crop&dpr=1 600w, https://images.theconversation.com/files/211397/original/file-20180321-165577-1hppxsa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=458&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/211397/original/file-20180321-165577-1hppxsa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=458&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/211397/original/file-20180321-165577-1hppxsa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=575&fit=crop&dpr=1 754w, https://images.theconversation.com/files/211397/original/file-20180321-165577-1hppxsa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=575&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/211397/original/file-20180321-165577-1hppxsa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=575&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Transmission electron micrograph of polioviruses.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Polioviruses.jpg">Graham Beards</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>Polio in people and in the environment</h2>
<p>Wild poliovirus is not particularly hardy and can’t survive for long in the environment. If the virus cannot find an unvaccinated person to serve as its host, it will die. This fact means vaccination efforts can fully exterminate the virus by denying it a place to live in human hosts.</p>
<p>The world’s polio eradication campaign has already done away with <a href="http://www.who.int/features/factfiles/polio/en/">two of the three naturally occurring wild polioviruses</a>. Wild poliovirus type 2 was last seen in 1999, and there has not been a case of wild poliovirus type 3 since 2012.</p>
<p>Polio spreads primarily through water contaminated with the feces of an infected person. Where sources of drinking water come into contact with sewage waste – often the case in developing countries like Pakistan – the virus spreads easily.</p>
<p>To complicate matters, nearly <a href="https://www.cdc.gov/polio/us/hcp.html">3 out of 4 people</a> infected with the poliovirus never have any symptoms at all. So most carriers of polio never know they harbor the virus, or that they’re spreading it to others.</p>
<p>In addition, those who do have symptoms usually seem to have the flu, with fever, headaches, body aches and vomiting. <a href="http://www.who.int/mediacentre/factsheets/fs114/en/">In only around 1 percent of cases</a> do symptoms include temporary or permanent paralysis.</p>
<p>This means that it is possible for the virus to exist and spread in a community even when there are no diagnosed cases of polio. For that reason, public health workers use two different measures to gauge the success of a vaccination effort: the number of people diagnosed with polio, and how much of the virus is found in the environment.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/211472/original/file-20180322-165547-tj50x0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/211472/original/file-20180322-165547-tj50x0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/211472/original/file-20180322-165547-tj50x0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=440&fit=crop&dpr=1 600w, https://images.theconversation.com/files/211472/original/file-20180322-165547-tj50x0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=440&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/211472/original/file-20180322-165547-tj50x0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=440&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/211472/original/file-20180322-165547-tj50x0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=553&fit=crop&dpr=1 754w, https://images.theconversation.com/files/211472/original/file-20180322-165547-tj50x0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=553&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/211472/original/file-20180322-165547-tj50x0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=553&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A health worker gives a polio vaccine to a child at a railway station in Pakistan.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Pakistan-Polio-Workers-Killed/225c7743762a4f499b5d9e859e459621/8/0">AP Photo/Fareed Khan</a></span>
</figcaption>
</figure>
<h2>Cultural challenges</h2>
<p>In Pakistan, these two measures paint somewhat different pictures of disease eradication. The not-so-good news is that <a href="http://www.endpolio.com.pk/images/polio-briefer/Pakistan-Polio-Update-DECEMBER-2017.pdf">16 percent of the water sources tested in 2017</a> contain the polio virus, a slight increase from 2016 levels. </p>
<p>The better news is that from 2014 to 2017, the number of new polio cases <a href="http://www.endpolio.com.pk/images/polio-briefer/Pakistan-Polio-Update-DECEMBER-2017.pdf">dropped a whopping 97 percent</a>, from 306 cases to just eight. The country’s government, with the support of the international community, has vaccinated most Pakistanis, which no doubt accounts for the impressive drop in diagnosed cases. However, because vaccination is not universal, the virus persists in some regions of Pakistan and poses a threat to those who are not vaccinated or who have not received vaccination boosters as scheduled.</p>
<p>There are several cultural barriers to wiping out polio in Pakistan. Vaccinations are usually given at health clinics and transit points, where public health workers can make contact with a large share of the population. <a href="http://polioeradication.org/where-we-work/pakistan/">Mobile vaccination units</a> reach people in other locations, but cannot safely get to children in high-conflict areas.</p>
<p>In many of these areas, <a href="https://blogs.cdc.gov/global/2017/10/24/overcoming-obstacles-to-polio-eradication-in-pakistan/">armed militants refuse</a> to let public health officials vaccinate children, claiming that the polio vaccine is part of a <a href="https://doi.org/10.1186/s12992-016-0195-3">Western plot</a> to sterilize Muslims. In 2012, the Taliban, which remain in control in some mountainous areas, <a href="https://doi.org/10.1186/s12992-016-0195-3">imposed a ban on vaccinations</a>, which slowed the polio eradication effort. Furthermore, polio vaccine campaign workers have been targets of violence, as seen most recently in the <a href="https://www.nytimes.com/2018/01/22/health/polio-pakistan-killing.html">killing of a mother-daughter vaccination team in January</a> and an <a href="https://www.independent.co.uk/news/world/asia/pakistan-polio-vaccination-team-militants-ambush-two-dead-islamic-extremism-cia-osama-bin-laden-a8261931.html">ambush this past week in a remote tribal area</a> that killed two medical workers and wounded two others.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/211473/original/file-20180322-165580-t3l6u3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/211473/original/file-20180322-165580-t3l6u3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/211473/original/file-20180322-165580-t3l6u3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/211473/original/file-20180322-165580-t3l6u3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/211473/original/file-20180322-165580-t3l6u3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/211473/original/file-20180322-165580-t3l6u3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/211473/original/file-20180322-165580-t3l6u3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/211473/original/file-20180322-165580-t3l6u3.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">With armed security, a Pakistani health worker marks a house after administering polio vaccine.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Pakistan-Polio/12b58f7c0a8c472a81b772618b592a36/1/0">AP Photo/Shakil Adil</a></span>
</figcaption>
</figure>
<p>In order to overcome some of the challenges, members of the eradication campaign <a href="https://doi.org/10.1186/s12992-016-0195-3">have coordinated vaccination efforts</a> with military operations. When a large military offense in 2015 pushed the Taliban out of the northern provinces of Pakistan, it <a href="https://www.rotary.org/en/new-polio-strategy-working-pakistan">cleared the way</a> for hundreds of thousands of children to receive vaccination. </p>
<p>High illiteracy rates, extreme poverty and religious beliefs also can cause <a href="https://doi.org/10.1186/s12992-016-0195-3">parents to refuse vaccines</a> – in Pakistan and elsewhere – for their children. In these instances, education and outreach are vitally important. Helping parents <a href="https://doi.org/10.1073/pnas.1504019112">understand the dangers of disease</a> may help overcome misinformation about the vaccine and increase positive association with vaccination, as it has in the United States. </p>
<h2>Pharmaceutical challenges</h2>
<p>Public health officials have <a href="https://www.cdc.gov/vaccines/vpd/polio/index.html">two types of polio vaccine</a> in their medical supply kit: an oral vaccine and an inactivated vaccine. Both are necessary to eradicate polio. The <a href="http://www.who.int/biologicals/areas/vaccines/polio/ipv/en/">oral vaccine</a> is made from live weakened virus. The inactivated version is made with dead virus.</p>
<p>The oral vaccination <a href="http://www.virology.ws/2015/09/10/why-do-we-still-use-sabin-poliovirus-vaccine/">works significantly better</a> against naturally occurring poliovirus, known as wild poliovirus. Additionally, the administration method – being given by mouth – is thought to increase vaccine uptake because it does not require an injection.</p>
<p>The body builds immunity from this live vaccine, and then can withstand the virus if exposed to it in the future. Countries where polio is present must use the oral vaccine in order to eliminate wild poliovirus because the inactivated vaccine does not <a href="https://www.pakistankakhudahafiz.com/understanding-polio-eradication-campaign-pakistan/">stop its transmission</a> since it <a href="http://www.virology.ws/2015/09/10/why-do-we-still-use-sabin-poliovirus-vaccine/">produces lower levels of mucosal immunity</a>. </p>
<p>Though necessary, using the live oral vaccine comes with some challenges. For example, it can cause <a href="http://www.who.int/features/qa/64/en/">vaccine-derived</a> cases of polio, which include <a href="https://www.sciencedirect.com/science/article/pii/B9781437716047004231">cases of paralysis</a>. In this unfortunate and extremely rare scenario, the vaccine meant to prevent a terrible illness directly transmits it. Of the 10 billion doses of oral polio vaccine administered since 2000, there have only been <a href="http://www.who.int/features/qa/64/en/">760 cases</a> of vaccine-derived polio. </p>
<p>Though the oral vaccine is vital to the eradication of wild poliovirus, its use must be discontinued as soon as the wild virus is wiped out. Otherwise, it runs the risk of hindering complete eradication by <a href="http://www.virology.ws/2015/09/10/why-do-we-still-use-sabin-poliovirus-vaccine/">perpetuating existence of poliovirus in the environment</a> through human excrement and continuing to introduce new vaccine-derived cases of the disease. </p>
<p>Once Pakistan is declared free of wild poliovirus, the eradication campaign must switch to using the inactivated vaccine.</p>
<p>Because the inactivated vaccine provokes a weaker immune response, it doesn’t effectively disrupt transmission of wild poliovirus. But it does <a href="https://doi.org/10.15585/mmwr.mm6649a4">protect against</a> the weaker vaccine-derived poliovirus, and it doesn’t contribute to vaccine-derived cases. Once the only remaining strains are vaccine-derived, inactivated vaccines can be used to completely wipe out the disease.</p>
<p>It is likely that a world without polio may not be too far off in the future — and then infectious disease researchers can make use of the lessons learned in Pakistan as they move the fight to other diseases elsewhere around the world.</p><img src="https://counter.theconversation.com/content/90580/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 organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Pakistan had only eight new diagnoses of polio in 2017. The virus’ days look numbered – but health workers have their work cut out for them to eradicate the devastating disease once and for all.Christine Crudo Blackburn, Deputy Director, Pandemic & Biosecurity Policy Program, Scowcroft Institute of International Affairs, Bush School of Government and Public Service, Texas A&M UniversityMorten Wendelbo, Research Fellow, American University School of Public AffairsLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/456042015-08-13T04:57:54Z2015-08-13T04:57:54ZA polio-free world is in sight: what’s needed to wipe out the last 1%<figure><img src="https://images.theconversation.com/files/91453/original/image-20150811-11068-1igsocv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Afghanistan and Pakistan are the only two countries that still have endemic levels of polio.</span> <span class="attribution"><span class="source">Parwiz/Reuters</span></span></figcaption></figure><p>The next three years are crucial in the global fight to eradicate the last 1% of polio cases and contain the virus across the world. But it will only become a reality with a combination of intensive vaccination campaigns and high-level surveillance to trace and monitor each polio case and circulating viruses. </p>
<p>Central to achieving this is the polio eradication and endgame strategic plan 2013 to 2018. The plan belongs to World Health Assembly’s Global Polio Eradication Initiative. It was developed to eliminate and contain all wild, vaccine-related and <a href="http://www.polioeradication.org/Polioandprevention/Thevaccines/Oralpoliovaccine(OPV).aspx">sabin</a>, which is a live but weakened strain, of the polioviruses by 2018. </p>
<p>Since the <a href="http://www.who.int/mediacentre/news/releases/2010/polio_eradication_20100616/en/">initiative</a> was launched by the assembly in 1988, the number of polio cases have reduced by 99%. The remaining 1% of cases can be found in the two countries with endemic polio – Pakistan and Afghanistan. Nigeria was the third polio-endemic country until July 2015, when it recorded one full year with no new cases.</p>
<p>Polioviruses belong to the family of viruses that infect the human gastrointestinal tract and cause diseases of the nervous system. It is caused by one of three related wild polioviruses: poliovirus types 1, 2 and 3 or as a result of a poliovirus derived from a <a href="http://www.who.int/features/qa/64/en/">vaccine</a>. </p>
<p>The vaccine-derived poliovirus develops when the weakened vaccine-virus given to a child during immunisation is excreted in areas with bad sanitation. It then circulates.</p>
<p>Although wild poliovirus type 2 was eradicated worldwide in 1999, the majority of reported cases are from vaccine-derived poliovirus outbreaks associated with type 2 wild poliovirus. </p>
<h2>Challenges in the plan</h2>
<p>Eliminating this last 1% of polio cases requires two main strategies in the plan: immunisation and surveillance. Its immunisation arm aims to achieve a high level of immunity across all populations while the surveillance arm picks up new cases. </p>
<p>To achieve the two elements, a combination of innovations may be required. The innovations need to be applied in the most challenging conditions and should be tailored for each country and its settings.</p>
<p>Currently, <a href="http://www.polioeradication.org/Polioandprevention/Historyofpolio.aspx">2.5 billion children</a> across the world have received vaccination against polio.</p>
<p>The challenges holding back immunisation include:</p>
<ul>
<li><p>political unrest;</p></li>
<li><p>dealing with misinformation that the polio vaccine causes sterility and/or AIDS;</p></li>
<li><p>the banning of healthcare workers from vaccinating certain communities; or</p></li>
<li><p>attacks on healthcare workers distributing vaccine, as has been the case in Nigeria and Pakistan.</p></li>
</ul>
<p>In 2003, the polio vaccination was stopped in parts of northern Nigeria. This caused a polio outbreak in six other countries. In Pakistan, the Taliban have launched several attacks on healthcare workers trying to vaccinate children. </p>
<p>Today, problems still persist in Pakistan. And recently, a church in Kenya started a misinformation <a href="http://www.christiantoday.com/article/boycott.polio.vaccine.say.kenyas.catholic.bishops/60587.htm">campaign</a>.</p>
<h2>Why surveillance is important</h2>
<p>Polioviruses replicate in the intestine of infected people and are shed in high numbers in faeces. As a result, the virus is found in sewage and faecally contaminated water sources. Active surveillance is important to identify residual pockets of the poliovirus. These inform the areas where the supplementary immunisation campaigns are required. </p>
<p>Most people infected with polioviruses have inapparent or mild disease but a small percentage will develop polio. To successfully eliminate the disease, it is important that experts monitor both the virus’ transmission and the characteristics of people who have contracted the disease. </p>
<p>There are two aspects of surveillance. Within the global initiative, the gold standard for surveillance is the monitoring of cases of <a href="http://medical-dictionary.thefreedictionary.com/Acute+flaccid+paralysis">acute flaccid paralysis</a>, or weakness in the limbs, in children under 15. Once this is picked up, further investigation needs to be done in the immediate community. </p>
<p>But in regions where the surveillance for the acute flaccid paralysis is either low or absent, alternate surveillance is needed. Here, environmental surveillance must be applied at sites where the virus is suspected to persistently circulate or can be reintroduced. This entails monitoring the sewage in high-density urban populations.</p>
<p>The benefit of this strategy was seen in 2013 when wild poliovirus was detected in the sewage in southern and central Israel and the West Bank. No cases of polio were reported but the poliovirus found was related to viruses present in Egypt and Pakistan. This early warning prompted an additional immunisation programme to prevent a potential outbreak of polio. </p>
<h2>Towards the end goal</h2>
<p>Until 2018, there will be continuous environmental surveillance of the poliovirus in polio-endemic areas of Pakistan, Afghanistan and the recently cleared Nigeria. Virologists will try to identify residual transmission and new importations. They will also monitor the switch from the vaccine that treats all three wild polioviruses to the one which treats only two. The third has been eradicated.</p>
<p>This strategy provides an important passive and non-invasive supplementary surveillance system to monitor circulating polioviruses in non-endemic countries and countries still using oral polio vaccines. This was shown in Israel.</p>
<p>Eliminating polio worldwide is achievable. But the success or failure of the global initiative depends on political and social will and adequate funding. </p>
<p>Since 1988, more than <a href="http://www.polioeradication.org/Polioandprevention/Historyofpolio.aspx">US$9 billion</a> has been invested into the global polio eradication initiative. Although more money is needed for the plan to be implemented until 2018, donor fatigue and anti-vaccine movements, such as those in Nigeria and Pakistan, could derail the process. This could cause a public health crisis. </p>
<p>But with adequate immunisation and the surveillance of both acute flaccid paralysis and the environmental factors, the polio-free status of the non-endemic countries can be maintained. This will also ensure that the transmission of polio in endemic countries is identified and interrupted.</p><img src="https://counter.theconversation.com/content/45604/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maureen Taylor receives funding from water utilities (Rand Water, Midvaal Water, Sedibeng Water), the National Research Foundation, Water Research Commission and the Poliomyelitis Reseatch Foundation.</span></em></p>Eradicating the last 1% of polio cases in the world requires an endgame plan centred on immunisation and surveillance.Maureen Taylor, Professor of Virology , University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/456882015-08-11T04:19:26Z2015-08-11T04:19:26ZThe legacy benefits from Africa’s fight against polio<figure><img src="https://images.theconversation.com/files/91166/original/image-20150807-27582-dhcw9j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Nigerian commissioner for health of Bauchi state, Sani Malam, administers a polio vaccine to a child during an immunisation drive.</span> <span class="attribution"><span class="source">EPA/Deji Yake</span></span></figcaption></figure><p>The campaign to eradicate polio in Africa has had a number of positive spinoffs for the health sector on the continent. Chief among these have been community involvement, multi-disciplinary partnerships, improved health care and the strengthening of health systems. </p>
<p>For decades, polio took a heavy toll on both children and adults. Before the development of two polio vaccines in the 1950s and the 1960s, about half a million people a year were <a href="http://www.who.int/mediacentre/factsheets/fs114/en/">paralysed</a> or died. Today, more than 10 million people who would otherwise have been paralysed by <a href="http://www.who.int/mediacentre/factsheets/fs114/en/">the virus</a> are able to walk because of these vaccines. </p>
<p>Globally, more than <a href="http://www.polioeradication.org/portals/0/document/resources/strategywork/economiccase.pdf">US$9 billion</a> has been ploughed into polio eradication since the the 1980s. This has resulted in more than <a href="http://www.polioeradication.org/Polioandprevention/Historyofpolio.aspx">2.5 billion</a> children being immunised against polio. The Global Polio Eradication Initiative estimates that it has already generated benefits worth $27 billion through its vaccination campaigns and the deaths it averts. The administration of vitamin A during these campaigns has also helped. </p>
<p>But in addition to the humanitarian and financial benefits, anti-polio campaigns have also had a positive impact on health services and the development of health infrastructure. </p>
<h2>A more involved community</h2>
<p>The greatest positive impact has been in community mobilisation and multi-disciplinary partnerships. These are inseparable pillars of primary health care and two strategies that have proved the most difficult to implement. </p>
<p>Within community mobilisation, the main elements are strengthening existing community organisations, using educational campaigns and advocating the involvement of political and <a href="http://www.unicef.org/immunization/polio/index_49028.html">community leaders</a>. Through the polio eradication campaigns, these approaches have been successfully adopted by other health programmes. </p>
<p>Involving the community ensures two things. First, people are motivated to bring their children to be vaccinated during mass campaigns. They also continue to bring their children for routine vaccination visits after the campaigns. </p>
<p>Second, these communities become actively involved in the campaigns. They often help deliver vaccines, maintain the vaccine cold chain and avail their own resources to campaigns, forming an active part of the vaccine supply chain. </p>
<p>In Nigeria, for example, community members donated money, used their vehicles, volunteered their time and availed personal resources for these operations. On occasion, this cost them their own lives. Many vaccinators in Nigeria were <a href="http://europe.newsweek.com/polio-related-murders-kill-more-disease-itself-287880">killed</a> in targeted assassinations. </p>
<p>A good proportion of vaccine storage equipment used in immunisation programmes across Africa, such as cold stores, freezers and refrigerators as well as transporting equipment such as coolers, vaccine carriers and ice packs, were procured in the polio eradication initiative. </p>
<h2>Improved health care services</h2>
<p>Polio eradication has helped raise the profile of the public health sector. It has done this by creating a renewed demand for vaccination services, resulting in higher routine vaccine coverage. </p>
<p>But the model has also shown innovative ways to deliver health services. For example, to increase the coverage of vaccine in security-affected states in Nigeria, federal and state governments developed a specific <a href="https://www.rotary.org/myrotary/en/polio-vaccinators-make-significant-headway-nigeria">strategy</a> in those parts of the country. Known as “hit and run”, local vaccinators would move into a rural area in the morning, vaccinate children speedily and leave as soon as possible.</p>
<p>Some health programmes have taken on features developed for the polio eradication initiative, such as:</p>
<ul>
<li><p>setting up partnerships between agencies, disciplines and sectors;</p></li>
<li><p>engaging the media and improving communication systems to reach entire populations;</p></li>
<li><p>increasing community involvement;</p></li>
<li><p>creating innovative knowledge management systems;</p></li>
<li><p>improving programme management capacity; and</p></li>
<li><p>establishing high-quality disease surveillance. </p></li>
</ul>
<p>It has also helped to pinpoint gaps and weaknesses in health service delivery and in many cases helped to fill these gaps. This includes strengthening the <a href="http://www.unicef.org/immunization/polio/index_49025.html">supply chain</a> processes.</p>
<p>And like the campaign to eliminate smallpox, the global polio campaign also brought health services to under-serviced populations, such as children trapped in war zones. In the lead-up to the Muslim religious holiday Eid earlier this year, a <a href="http://www.polioeradication.org/mediaroom/newsstories/Children-Reached-with-Polio-Vaccines-in%20Yemen/tabid/526/news/1259/Default.aspx#sthash.AI43xqQl.dpuf">humanitarian pause</a> allowed 50,000 children to receive polio vaccines in Yemen.</p>
<h2>Towards a polio-free world</h2>
<p>Important lessons were also learnt at the international level. The World Health Organisation has successfully brought together an unprecedented <a href="http://www.polioeradication.org/AboutUs.aspx">global team</a>. It includes governments, other UN agencies, non-governmental organisations, community groups, the business community and religious organisations. </p>
<p>A new strategic plan has been <a href="http://www.polioeradication.org/Resourcelibrary/Strategyandwork.aspx">developed</a> to ensure successful worldwide eradication of polio by 2018. The plan was created along with polio-affected countries, donors and national and international advisory bodies. It is the first plan designed to eradicate all types of the polio disease from wild poliovirus to vaccine derived polioviruses.</p>
<p>Once polio is eradicated, the world can celebrate the delivery of a major global public good benefiting all equally. But most importantly, success will mean that no child will ever again endure the misery of lifelong <a href="http://www.polioeradication.org/Polioandprevention/Historyofpolio.aspx">polio paralysis</a>.</p><img src="https://counter.theconversation.com/content/45688/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 positive impact of the polio eradication initiatives on the continent can be felt across the health sector in other health programmes.Charles Shey Wiysonge, Professor of Clinical Epidemiology at the Faculty of Medicine and Health Sciences, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/449322015-08-07T04:40:34Z2015-08-07T04:40:34ZWhy Nigeria took so long to get non-polio endemic status<figure><img src="https://images.theconversation.com/files/91012/original/image-20150806-5233-1utpree.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A health worker vaccinates children with drops of polio vaccine in a classroom in Lagos, Nigeria. </span> <span class="attribution"><span class="source">Reuters/George Esiri</span></span></figcaption></figure><p>For both Nigeria and the continent, the country’s removal from the list of polio endemic countries is a huge step towards Africa complying with the global goal of becoming polio free by <a href="http://www.polioeradication.org/Portals/0/Document/Resources/StrategyWork/PEESP_CH0_EN_US.pdf">2017</a>. The goal is part of the World Health Assembly’s Global Polio Eradication Initiative, to deliver a polio-free world in the next three years.</p>
<p>Until now, Nigeria was one of only three countries in the world on the ignoble list of polio endemic countries. The other two were Pakistan and Afghanistan. The list contains the countries that have never interrupted the transmission of polio. To be removed from the list you must have no polio for at least one year. And to be declared polio free, the World Health Organisation needs to certify that the country has had no new cases of the wild poliovirus reported for three successive years. If Nigeria continues its current trend, it could be declared polio free by 2017. </p>
<p>But considering the resources that have been pumped into polio eradication in Nigeria and the detailed prevention strategy in place in the country, Nigeria could have been declared polio free 10 years ago.</p>
<p>Nigeria’s move off the list of polio endemic countries leads us to three questions: Firstly, why did it take Nigeria so long to get to this stage? Secondly, what led to Nigeria’s sudden achievement? And third and most importantly, what must Nigeria continue to do to ensure that the country is finally free of polio?</p>
<h2>The challenges around polio</h2>
<p>In 2008, Nigeria alone accounted for <a href="http://www.who.int/csr/don/2008_06_18/en/">86%</a> of all the polio cases on the continent. The other cases came from Niger, Congo, Senegal, Angola and Chad.</p>
<p>There are two reasons the country was the epicentre of the virus at the time. One relates to immunisation. The country’s national <a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5926a2.htm">immunisation programme</a> performed sub-optimally. There was an abysmally low number of routine immunisations during this period.</p>
<p>But the main stimulus for a high number of polio cases came in 2003. It was a call by a front line medical practitioner and a prominent member of the Supreme Council for Sharia in Nigeria to boycott anti-polio vaccinations in the country’s <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4098042/">northern states</a>. The call followed fears that the polio vaccine had been contaminated with <a href="http://edition.cnn.com/2003/WORLD/africa/10/27/nigeria.polio.reut/">anti-fertility steroids</a>. </p>
<p>The resulting boycott brought the wobbly national polio eradication programme to a total collapse. As a result, the average annual reported polio cases shot up from 400 between 1998 and 2002 to 750 cases after the 2003 call. By 2006, there were over <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4098042/">1100 new cases</a> of polio that year.</p>
<p>Frantic national and international efforts were made to end the boycott. This included a resolution being adopted at the 61st World Health Assembly in <a href="http://www.who.int/mediacentre/events/2008/wha61/journal5/en/">2008</a> calling on Nigeria to reduce the risk of international spread of poliovirus by ensuring that all children in the north of the country were vaccinated against polio. The special and negative mention Nigeria received at the global level appeared to have <a href="http://www.polioeradication.org/content/polionews/polionews31.pdf">moved the country</a> in the right direction for achieving polio eradication.</p>
<h2>What Nigeria did right</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/90885/original/image-20150805-22478-yc209g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/90885/original/image-20150805-22478-yc209g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=411&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90885/original/image-20150805-22478-yc209g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=411&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90885/original/image-20150805-22478-yc209g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=411&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90885/original/image-20150805-22478-yc209g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=517&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90885/original/image-20150805-22478-yc209g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=517&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90885/original/image-20150805-22478-yc209g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=517&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Volunteer Health officials wait to immunise children at a school in Nigeria’s capital in 2010.</span>
<span class="attribution"><span class="source">REUTERS/Afolabi Sotunde</span></span>
</figcaption>
</figure>
<p>The polio eradication strategy was twofold. Firstly, traditional and community leaders, civil society organisations and women groups were brought into the polio eradication activities to encourage the community to <a href="http://www.polioeradication.org/mediaroom/newsstories/Partnering-with-religious-schools-to-fight-against-polio-in-Nigeria/tabid/526/news/774/Default.aspx">“own”</a> the initiative.</p>
<p>Secondly, emergency operations centres were established in Abuja and six Northern states. Through these centres real-time and detailed information was gathered about the eradication programme in key endemic states. This meant any new polio cases were rapidly detected and the appropriate approach could be co-ordinated in these states. </p>
<p>The system was further enhanced with an accountability framework for team members and groups involved. Individuals, and not just the system or organisation, were held responsible and accountable for their performance.</p>
<p>The system proved so successful that they were deployed and used to control the 2014 <a href="https://theconversation.com/how-nigeria-beat-the-ebola-virus-in-three-months-41372">ebola outbreak</a> in Nigeria.</p>
<h2>The road to become polio-free</h2>
<p>Nigeria still has some distance to go to polio free status. It must be continuously stressed that the end of polio is only in sight and at the end of a two year tunnel. On two previous occasions - in 2007 and 2011 - Nigeria shifted focus from polio eradication to electioneering <a href="http://www.polioeradication.org/mediaroom/newsstories/Maintaining-Momentum-in-Nigeria-is-Crucial-for-a-Polio-free-Africa/tabid/526/news/1205/Default.aspx">campaigns</a>. As a result, polio resurged. </p>
<p>For the country to achieve a polio free status, it requires two things: a sustained political commitment to polio eradication and a massive operation with adequate funding and meticulous co-ordination. Nigeria’s progress against polio over the last few years has been a combination of this grand coordination and attention to small-scale detail. </p>
<p>All levels of government need to implement routine immunisation. Insecurity in the northeast part of the country has left many settlements in the area inaccessible to health workers. Access to these areas will be critical. </p>
<p>Nigeria cannot afford to be complacent. The current government must build on the achievement of the past government and sustain political commitment to eradicating not only polio and controlling other infectious diseases that still plague the country. Adequate funding must be provided to sustain and expand the operations of emergency operations centres to every state, with adequate funding and management by qualified staff.</p>
<p>Had Nigeria done what was right regarding the polio eradication initiative and routine immunisation, none of these Nigerians would have been maimed, incapacitated and paralysed forever by polio. This is the poignant message for the world, of Nigeria’s current non-polio endemic status, and a reason to ensure polio free status by 2017 and forever.</p><img src="https://counter.theconversation.com/content/44932/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>Nigeria’s strategy to eliminate polio was so effective that it was duplicated to deal with ebola. So why did the country take so long to get off the list of polio-endemic countries?Oyewale Tomori, President , Nigerian Academy of ScienceLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/447862015-08-05T04:48:45Z2015-08-05T04:48:45ZAfrica is within reach of being declared a polio free region<figure><img src="https://images.theconversation.com/files/90746/original/image-20150804-11977-1wq5rxx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Senegalese Mamou Tiang, who suffers from polio, begs for money outside a bank on a sidewalk in the capital Dakar. </span> <span class="attribution"><span class="source">Nic Bothma/EPA</span></span></figcaption></figure><p>More than 20 years after North and South America eliminated the threat of polio, sub-Saharan Africa is finally on the brink of being declared polio-free. Last month the region marked <a href="http://www.polioeradication.org/">one year</a> without a new polio case following the last case in Nigeria on 24 July 2014. If no new cases are reported for another three years, Africa will be certified polio-free by late <a href="http://www.unicef.org/immunization/polio/">2018</a>. </p>
<p>Polio has maimed and killed hundreds of thousands of people across the globe. Polio paralysis has caused physical suffering, life-long dependency, loss of productivity and placed a heavy burden on poor families.</p>
<p>As a result of the use of two vaccines developed more than 50 years ago the annual number of polio cases has globally dropped by more than <a href="http://www.who.int/mediacentre/factsheets/fs114/en/">99%</a> from about half a million in the 1980s to only 34 so far in 2015. But eliminating the last 1% of cases of polio is still proving to be a challenge. </p>
<p>Currently, only parts of two countries in the world remain polio-endemic – <a href="http://www.polioeradication.org/Infectedcountries.aspx">Pakistan and Afghanistan</a>. </p>
<h2>The workings of the poliovirus</h2>
<p>Polio is a communicable disease caused by one of three related wild polioviruses: poliovirus types 1, 2 and 3. It attacks at any age but mainly affects children under five. The virus typically enters the body through the mouth and multiplies inside the gut. Initially it manifests as flu-like symptoms. Once established, it enters the bloodstream and attacks the central nervous system. As it proliferates, it destroys nerve cells which stimulate muscles. These nerve cells cannot be renewed and affected muscles no longer function. The virus circulates silently at first, possibly infecting up to 200 people before the first case of paralysis surfaces. </p>
<p>Immunity against polio comes from either natural infection, which is when one recovers from polio or is immuned against contracting the disease through vaccination. There are two polio vaccines which are highly effective. The first is an injectable vaccine developed in the 1950s, the second an oral vaccine developed in the 1960s. </p>
<p>Of the three poliovirus types, type 2 was successfully eradicated in 1999 and worldwide cases of the other types are down to the lowest levels ever.</p>
<h2>The plan to eradicate polio</h2>
<p>In <a href="http://www.who.int/ihr/polioresolution4128en.pdf">1988</a> the World Health Assembly, which governs the World Health Organisation, adopted the Global Polio Eradication <a href="http://www.who.int/mediacentre/news/releases/2010/polio_eradication_20100616/en/">Initiative</a>. </p>
<p>The strategy was developed as a result of the success in eradicating smallpox in the 1970s, because of the similarities in the spread of the viruses. Like smallpox, polio only attacks humans. Polio viruses also only survive for a very short time in the environment and there are no animal or insect reservoirs that carry them. Similar to smallpox, polio can be eradicated and an effective vaccine is available. Once a person is immunised against it, immunity is life-long. </p>
<p>The polio strategy included widespread routine vaccinations, mass vaccination campaigns and a rapid response to polio cases. But the most critical element of the strategy is surveillance - in the community and the laboratory - to find polio cases that may have been ignored or initially overlooked.</p>
<p>Surveillance in the community needs to involve both the general public and health care workers. Health care workers need to report all cases where children experience abrupt weakness in the limbs, even if the weakness is presumed to be triggered by an injection. Community leaders need to report any newly paralysed children in their communities to health care services.</p>
<p>In the laboratory, the specific polio virus is identified and its source determined. Without this high-quality surveillance it would be difficult to locate where and exactly how the poliovirus is circulating or to confirm when its transmission has been stopped. </p>
<h2>Making Africa a polio-free region</h2>
<p>Countries are certified to have eradicated polio only if no cases of the wild poliovirus are reported for three successive years. There must be documented evidence from high-quality surveillance which shows this. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/90747/original/image-20150804-11971-lorn0j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/90747/original/image-20150804-11971-lorn0j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=408&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90747/original/image-20150804-11971-lorn0j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=408&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90747/original/image-20150804-11971-lorn0j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=408&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90747/original/image-20150804-11971-lorn0j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=513&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90747/original/image-20150804-11971-lorn0j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=513&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90747/original/image-20150804-11971-lorn0j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=513&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A child receives an oral polio vaccination.</span>
<span class="attribution"><span class="source">epa.eu</span></span>
</figcaption>
</figure>
<p>Currently, four fifths of the world’s population live in regions certified to be polio-free. In 1994, the Americas were certified polio-free, followed by the Western Pacific region in 2000. Europe received its certification in June 2002 and the South-East Asian region in March 2014. </p>
<p>In 1996 African heads of state resolved to stamp polio out of Africa. Then South African President <a href="http://www.mandela.gov.za/mandela_speeches/1996/960802_polio.htm">Nelson Mandela</a> launched the three-year “Kick Polio out of Africa” campaign. But by <a href="http://www.unicef.org/immunization/files/The_Story_of_the_End_of_Polio.pdf">2000</a>, wild poliovirus was still circulating in Egypt, Niger, and Nigeria. The situation worsened when the polio vaccination was stopped in <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001405">northern Nigeria</a> for religious reasons. As a result, polio transmission spread from the area to eight other African countries in 2003. </p>
<p>Poliovirus continued to circulate in Africa until last year. But the number of affected countries has steadily been decreasing. In 2004 there were 14 countries that had polio outbreaks. These included Benin, Botswana, Burkina Faso, Cameroon, Central African Republic, Chad, Côte d’Ivoire, Egypt, Ethiopia, Guinea, Mali, Niger, Nigeria, and Sudan. In 2011, this dropped to 12. Last year, there were only five African countries with polio outbreaks: Nigeria, Cameroon, Equatorial Guinea, Ethiopia, and Somalia. </p>
<p>In all these outbreaks, the common factor was the country’s failure to immunise. The reasons for this failure varied from one outbreak to another, but in each case there was a group of non-vaccinated people that enabled the poliovirus to seed itself and spread far and wide. </p>
<p>The size of the unimmunised population ranged from small isolated groups which refused vaccination for religious or <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001405">cultural reasons</a> to entire birth cohorts in areas like Somalia experiencing <a href="http://www.emro.who.int/polio/polio-news/wild-poliovirus-somalia-may-2013.html">humanitarian emergencies</a>. </p>
<h2>The endgame around polio</h2>
<p>As long as a single child remains infected, children in all countries are at risk of contracting polio. </p>
<p>While the humanitarian benefits of polio eradication in Africa will be immeasurable, efforts have been made to quantify the financial savings that can be anticipated. </p>
<p>The World Health Organisation estimates that once polio is eradicated and vaccination halted, global savings from vaccination, treatment costs, and rehabilitation will amount to nearly <a href="http://www.ncbi.nlm.nih.gov/books/NBK11763/">US$2 billion</a> a year. </p>
<p>African countries should start careful polio legacy planning now to ensure that most of that money is redirected to other health programmes.</p><img src="https://counter.theconversation.com/content/44786/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>It’s been one year since the last polio case was reported in Africa. If the continent keeps this up, it could be declared polio free by 2018.Charles Shey Wiysonge, Professor of Clinical Epidemiology at the Faculty of Medicine and Health Sciences, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.