Polio and confidence

Maryn McKenna writes about a new report (PDF) on polio eradication at Wired's SuperBug blog. The report comes from the Independent Monitoring Board (IMB) of the Global Polio Eradication Initiative (GPEI). The GPEI has existed for 23 years now, and while they've made much progress (polio cases are down 99% since the campaign started) the campaign has repeatedly missed the deadlines it sets for itself for eradication. The latest goal is to interrupt polio transmission worldwide by 2012, and despite a recent infusion of funding and enthusiasm the campaign is -- according to the IMB -- likely to miss yet another of its own goals. McKenna writes, "Possibly the biggest problem, the board concludes, is a get-it-done optimism so ingrained in the 23-year effort that it cannot acknowledge when things are not working." She quotes the report to the same effect:

The Programme has an established narrative of positivity – a pervading sense of "nearly there". The danger comes in how the Programme deals with information that does not sit well with this narrative. We have observed that the Programme:

• Is not wholly open to critical voices, perceiving them as too negative – despite the fact that they may be reporting important information from which the Programme could benefit.
• Tends to believe that observed dysfunctions are confined to the particular geography in which they occur, rather than being indicative of broader systemic problems.
• Displays nervousness in openly discussing difficult or negative items.

This report is likely to ruffle some feathers as the public discussion regarding polio eradication often suffers from the same dearth of criticism. One reason for that -- and likely for GPEI's own "get-it-done optimism" -- seems to be that polio eradication is an epic high-stakes gamble. If we can do it the benefits are huge: no more polio, and less need for continued vaccination (though much of the projected cost-savings are predicated on the idea that the US and other countries will stop polio vaccination, which is highly unlikely given fears of vaccine-derived strains or bioterrorism). But if we can't do it then it might be better to spend resources on some other priority in global health; spend some lesser amount on polio, allow a bit of resurgence (but not too much), and focus resources on other vital needs. Thus the real battle is over the general donor consensus around whether polio eradication will be achieved soon. As soon as the global health donor community decides that eradication isn't actually possible, that belief will become a self-fulfilling prophecy.

Avoid immunization, go to jail. Eek.

Via Foreign Policy:

In Nigeria, avoiding a shot could mean going to jail

As Bill Gates unveiled his plan this week to rid the world of polio, health officials in the northern Nigerian state of Kano announced their own assault on the disease. "The government will henceforth arrest and prosecute any parent that refuses to allow health workers to vaccinate his child against child-killer diseases, particularly polio," said a health ministry official.

This news, which was announced at the outset of the government's four-day vaccination campaign targeting six million children, marks a shift in government policy toward immunization programs in the north of the country. Nigeria's polio vaccination program stalled for more than a year after Muslim leaders raised doubts over the inoculations' safety in the summer of 2003 -- resulting in bans issued by some northern state governments....

I'm not familiar with every vaccination law in the world, but this seems like a first to me. If not a first, at least an exception to the norm. I don't like this more coercive approach. If you have enough resistance to a policy that you feel you need to threaten jail time, then actually making that threat -- and following through on it -- seems likely to breed more resistance.

I think governments can and should both incentivize vaccination and make it difficult to avoid without a really good reason. Any government policy should make it easier to get vaccinated against childhood diseases than avoid vaccination, because having a fully-vaccinated population is a classic public good. I like the fact that most states in the US have opt-out provisions for religious objections to vaccination, but I also think that states should not design a policy such that getting that exemption is simpler -- in terms of time and money -- than getting a child vaccinated, as is the case in many states.

But threatening to throw parents in jail? Way too heavy-handed to me, and too likely to backfire.

CIA's despicable Pakistan vaccination ploy

Via Conflict Health, The Guardian reports that the "CIA organised fake vaccination drive to get Osama bin Laden's family DNA":

In March health workers administered the vaccine in a poor neighborhood on the edge of Abbottabad called Nawa Sher. The hepatitis B vaccine is usually given in three doses, the second a month after the first. But in April, instead of administering the second dose in Nawa Sher, the doctor returned to Abbottabad and moved the nurses on to Bilal Town, the suburb where Bin Laden lived.

Christopher Albon of Conflict Health writes:

If true, the CIA’s actions are irresponsible and utterly reprehensible. The quote above implies that the patients never received their second or third doses of the hepatitis B vaccine. And even if they did, there is absolutely no guarantee that the vaccines were real. The simple fact is that the health of the children of Abbottabad has been put at risk through a deceptive medical operations by the Central Intelligence Agency. Furthermore, the operation undermines future vaccination campaigns and Pakistani health workers by fueling conspiracy theories about their true purpose.

Albon notes that the Guardian's source is Pakistan's ISI... but this McClatchy story seems to confirm it via US sources:

The doctor's role was to help American officials know with certainty that bin Laden was in the compound, according to security officials and residents here, all of whom spoke only on the condition of anonymity because they feared government retribution. U.S. officials in Washington confirmed the general outlines of the effort. They asked not to be identified because of the sensitivity of the topic.

The sensitivity of the topic? No kidding. This is absolutely terrible, and not just because the kids originally involved might not have gotten the second round of vaccine (which is bad) or because it will make the work of legitimate public health officials in Pakistan even harder (which is very bad). Vaccines are amazing innovations that save millions of lives, and they are so widely respected that combatants have gone to extraordinary lengths to allow vaccination campaigns to proceed in the midst of war. For instance, UNICEF has brokered ceasefires in Afghanistan and Pakistan for polio vaccine campaigns which are essential since those are two of the four countries where polio transmission has never been interrupted.

I hope I'm not overreacting, but I'm afraid this news may be bad for the kids of Pakistan, Afghanistan, and the rest of the world. Assuming the early reports are confirmed, this plot should be condemned by everyone. If US officials who support global vaccination efforts are going to control the damage as much as possible -- though it's likely much of it has already been done -- then there need to be some very public repercussions for whoever authorized this or had any foreknowledge. What tragic stupidity: a few branches of the US government are spending millions and millions to promote vaccines, while another branch is doing this. The CIA is out of control. Sadly, I'm not optimistic that there will be any accountability, and I'm fuming that my own country breached this critical, neutral tool of peace and health. How incredibly short-sighted.

Update: In addition to the Guardian story, Conflict Health, and McClatchy stories linked above, this NYTimes article offers further confirmation and the CNN piece has some additional details. Tom Paulson at Humanosphere, Mark Leon Goldberg of UN Dispatch, Charles Kenny of CGD, and Seth Mnookin all offer commentary.

Progress on Polio in Africa?

From the latest CDC Morbidity and Mortality Weekly Report: "Progress Toward Interrupting Wild Poliovirus Circulation in Countries with Reestablished Transmission -- Africa, 2009-2010" There are only four countries where polio is still "endemic" -- Afghanistan, Pakistan, India, and Nigeria. Combined the four endemic countries have about 23% of the world's population, though to be fair polio is only endemic in some portion of each country.

But the actual definition of "endemic" may not match with lay assumptions about that term. For polio, endemic countries are defined as those where transmission has never been broken. So a country where polio has been reintroduced -- and is now spreading on its own, without the need for additional introductions -- is by definition still not endemic. Thus, there's essentially a three-tiered system: a) endemic countries, b) countries with reestablished transmission, and c) countries without established transmission, which may have sporadic outbreaks from imported cases or from vaccine-derived polio.

The CDC report linked above provides an overview of polio in African countries. Between 2002 and 2009 several dozen previously polio-free countries had outbreaks of polio from strains imported from India or Nigeria. (The strain of polio in each outbreak is genetically typed, which means we can determine which known strain the new one is closest too, and thus from whence the outbreak came.) Of those countries, four--Angola, Chad, Democratic Republic of the Congo (DRC), and Sudan--had persistent transmission (more than one year) after re-importation of polio that occurred before 2009. One of the milestone of the Global Polio Eradication Initiative (GPEI) was that polio transmission would be interrupted in those four countries by the end of 2010. The conclusion of the MMWR report is that it has been stopped in Sudan, but not Angola, Chad, or DRC.