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POST 00937E : THINKING THE UNTHINKABLE
Follow-up on Posts 00917E, 00923E and 00931E
8 June 2006
__________________________________________________________
This posting contains five contributions to the discussion. The first
comes from Patrick Isingoma (mailto:[email protected]) from
Uganda, followed by that of Anthony Battersby (mailto:[email protected])
from the United Kingdom, who responds to Stan Foster. The third is from
Hans Everts (mailto:[email protected]) from WHO/HQ who responds to Anthony
and Mogens in a previous posting. The fourth is from Nasim Ahmed
(mailto:[email protected]) and the last comes from Julie Milstien
(mailto:[email protected]) from France/United States.
For your information, we are also sending four relevant documents to this
discussion again thanking Bob Davis and Evelyn Chege fros having shared
them through Tech Updates. These are :
1. The draft text of WHA resolution on Polio Eradication adopted at the
last World Health assembly at the end of May (attached herewith : 27K)
2. Country Comments on Polio Eradication, World Health Assembly, May
2006 (attached herewith : 81K)
3. Update on WHA outcomes on polio eradication by Bruce Aylward,
Director of PEI (attached herewith : 26K)
4. Polio Eradication in Nigeria : Status, Priorities and Plans, by Alex
Gasasira from WHO, dated 22 May 2006. This is a slideshow and as it is
rather heavy (460K), you can download it directly from the following link
if you are interested to view it.
Http://www.technet21.org/PolioEradicati ... sasira.ppt
_________________________________
I have read the open discussion between Bob ,Mogens and others about Polio
Eradication.
Polio eradication may not be as easy as it was for smallpox. The cost
benefits of polio eradication may also be difficult to assess. Polio
eradication seems to be difficult in areas where the routine immunisation
was either not there or completely at a low pace.
The structures of Polio eradication has been used widely in the Health
Sector (The Cascade training, the multi-sectoral approach, etc) have been
copied to benefit other programs(at least here in Uganda we have borrowed
this principles for Injection Safety Project)
On the statement "As importantly is the time that country staff have to
spend and which therefore means that they are not available for other
health responsibilities. This burden falls entirely on national
governments, " True, districts talk about it, but if we look closer, there
is always the problem of last minute planning and individualisation of
programs which overloads a few people busy with many redundancies at lower
levels. Can we blame lack of adequate and timely planning, other than the
programs that usually come into the districts?
You will also realise that in developing countries like Africa, a lot of
time is spent on Malaria and similar diseases. So tagging polio or similar
efforts to these diseases will encourage countries to budget more on all
programs.
Patrick Isingoma
Waste Management Advisor,
Injection Safety Project,
Kampala, Uganda
----------------------------
Claude,
I would like to respond to Stan Foster's three questions. Before doing so
it is instructive to recap on the original resolution of 1988
The WHA resolution specified that the task of eradicating polio should be
achieved "in ways that strengthen national immunization programs and
health infrastructure". The WHA resolution also stated that polio
eradication should only be undertaken by countries that had achieved 70%
or more for routine coverage of OPV3. From the start achievement and
maintenance of 90% routine infant immunization coverage was stated to be a
key WHO strategy for polio eradication. WHO also estimated that the
additional external resources needed to eradicate polio would be $155 million.
In the wake of UCI and the subsequent collapse of immunization services in
some countries, it must have been clear that the original conditions for
polio eradication were unachievable. Were the original caveats to the
resolution ever formally changed? Were the implications of changing them
explained to the countries where their achievement was unlikely? When was
it explicitly made clear to member states that the original cost estimate
was wrong by several orders of magnitude?
The great worry for me is that, as I said before, wise heads are saying
that the objective is unachievable. If the epidemiology does not support
eradication then why is eradication still being pursued?
Now to Stan's questions :
1. The response from a number of eminent specialists in the field (see
Mark Miller et al, Leslie Roberts and Isao Arita) is that technically,
logistically and I would add economically, it is not possible to eradicate
polio.
2. I do not know where the figure of 250,000 lame children Stan quotes
comes from, what is certain is that many tens of thousands of children in
Nigeria have died as a result of routine health services being neglected
because all available time and attention was being spent on polio
eradication. The British Medical Journal, 26 May 2006 states "Half a
million children a year die of AIDS through lack of drugs. These are drugs
like co-trimoxazole that at a cost of 2 pence a day have been shown in
Zambia to reduce mortality in HIV infected children by 43%."
Doubtless it would be possible to quantify the burden of avoidable disease
around the world that has resulted from the focus on polio eradication and
subsequent neglect of routine services. So my reply to Stan's second
question is: What is the human cost to individuals, families, and
communities if we do not reach and maintain the 90% coverage originally
set by WHO?
The answer to Stan's third question is contingent on the answer to the
first, i.e. Is it technically and economically practical to eradicate polio?
We all strive to reach goals, in the process of striving new knowledge is
gained and lessons learned. The result may show that the original goal was
not the right one. We are now at the point where we need to reassess the
goal for PEI.
It would be tragic if in some years hence with more billions spent on PEI
it was finally acknowledged that the goal was wrong. We need answers to
the questions which Stan has asked.
Wise and experienced heads have already answered Stan's first question we
need to heed their answer and act accordingly.
I hope others will respond to this important debate, silence will not make
the issue go away.
Anthony
----------------------------
I will not go into the financial arguments. The given extrapolation from
smallpox to polio is an oversimplifications aimed at winning votes.
About the switch from eradication to control, imagine the world asking a
mountain climber to climb a mountain that was never conquered before. What
do you think our climber will respond, when at a few meters below the top
he is requested not only to stop climbing, but to hold on and stay where
he is indefinitely. He will rightly answer that he should either reach the
top, or go back down, but that there is no way he can stay where he is.
The eradication activities took us where we are now, with only 4 endemic
countries left. To keep us here indefinitely would require regular
supplementary immunization activities in the currently endemic countries,
in countries with outbreaks and in countries with low routine coverage. To
monitor this all, would require an excellent surveillance system.
Unfortunately the reality is, that in the absence of disease, surveillance
would soon weaken, and importations in polio free areas would not be
detected timely.
In other words, the costs for staying where we are, would on a yearly
basis be only little less than the current costs for eradication, but it
would eternalise them. It would simply eternalise the agony.
If large scale supplementary immunization would stop, we would face a
pandemic in a few years, aggravated by the built up of susceptibles,
affecting higher age groups, with higher case fatality. Yemen and
Indonesia only gave a pre-taste of what would happen if supplementary
immunization stops with polio virus circulating anywhere in the world.
To be fully honest, I find the call for switching to control rather ironic
and slightly naive, completely missing the point that consolidating the
gains without completing the job, is simply not sustainable. It is
ethically refutable and operationally impossible. The choice is between
achieving the goal or sliding back into the pre eradication era.
Mogens, you ask for new approaches and strategies. How about these:
1) monovalent OPV is now used in many parts of the world and represents
close to 50% of global requirements. The vaccine practically did not exist
1.5 years ago;
2) in Niger impregnated bed nets were distributed during a polio NID;
3) Nigeria is currently trying out integrated campaigns with other
vaccines, soap, bed nets or other items;
4) a policy to reach new-borns with OPV is being developed in India;
5) special strategies are being developed for transit and underserved
populations in India, Pakistan and elsewhere;
6) the minimum npAFP rate was increased from 1 to 2 to increase
surveillance sensitivity and be more in line with the reality;
7) laboratory techniques have evolved to get more speedy results of stool
tests.
This is not all and covers only recent developments. Far from ignoring the
difficult phase we are in, we are very keen for ideas, which may help us
to make the last steps.
You say : "Routine immunization is then often neglected", but the poor
quality of routine immunization was where the need for repeated campaigns
started. Not only was routine in those areas neglected long before the
campaigns started and is the negligence the very reason for the necessity
to repeat campaigns, but the campaigns helped in many places to draw the
attention to the problem of poor quality routine.
We have given our climber new gear and hope. All he needs is a final push
to reach the top. Without that, his hands will soon lose grip on the rope
and he will fall down a whole lot faster than he climbed up. There is no
"hang on mate, we will catch you when you land."
Hans Everts
WHO Geneva
Technical officer EPI
------------------------------
Dear Technet 21,
I have been following with interest several key issues, questions etc
raised in the presentation of "Thinking the Unthinkable" from my
colleagues Anthony, Mogem Munk, Bob Davis and wisdom of Stan Foster. I
could not remain silent and preferred to express my personal views on
operational issues related to Polio Eradication, Routine EPI, Special
initiatives on measles control and eradication, Elimination of neonatal
tetanus through mass vaccination. All the above intervention leads to
reduction of mortality and morbidity and may lead to eradication. Polio
eradication remains the global priority and huge amount of resources has
already been put in place. The question still remains whether with the
present strategy the elimination goal could be achieved. No one will
question funding requirement if and when polio is eradicated from the
earth as in the case of smallpox.
NIDs and SNIDs no doubt put lots of pressure on the health infrastructure
in the underdeveloped countries particularly in Africa. My recent
experiences in South Sudan and North Sudan shows the tremendous pressure
on the system, where manpower is in acute shortage and PHC infrastructure
is not in place. It is a logistical nightmare to move man and material to
every corner of the country, where security is a major concern because of
ongoing internal conflict. Situation is no better in other conflict and
war countries like Somalia and Congo. In addition to this the same
delivery system is required to deal with malaria, TB and HIV Aids. However
I still believe that if the current strategy for Polio eradication is
sound and correct, we should push for whatever the cost may be.
Though the benefit of Polio Eradication programme has created a large
amount of trained manpower and established a delivery system from central
to periphery level and established cold chain, there are immediate fallout
on the performance of routine EPI, primarily because of immediate
reduction of operational budget and lack of initiative. There is no doubt
that routine EPI should remain as the core of the entire immunization
programme, and sustaining a very high level of coverage needs to be
continued even the eradication of polio is achieved in the near future.
There are example of achieving more than 85 percent of coverage for
children under one year in Malawi, a very poor country in 1990 through
their PHC infrastructure. It was possible because of dedicated health
workers, government priority and outreach vaccination using pushbikes. At
the same time Oman with a very high coverage of 95 percent on polio
immunization faced a large polio outbreak in 1991-92. It seems to me that
routine vaccination performance is gradually diminishing in the face of
mass vaccination. It is definitely a matter of concern. Because of the
rising global energy cost, the operational cost of vaccination is bound to
increase substantially and it remains to be seen how the developed and
least developed countries will cope with.
I think we should continue this debate to clear our minds.
Regards to all Technet members
Nasim Ahmed
Former Sr. Programme Coordinator, UNICEF
--------------------------------
Dear Claude,
I have read with interest all the discussion on polio eradication - a goal
that I have been intimately involved with since I joined WHO
(coincidentally in 1988, the date the WHA launched the initiative), and
even before then. So it is difficult to imagine that it might not succeed,
and very hard to argue with such a giant of public health as Stan Foster.
Nevertheless, I believe that WHO is going to have to address the issue of
whether, with all the knowledge we have now, polio eradication will be
feasible in our lifetime. Can WHO set a firm date and firm criteria for
when the effort would be stopped? While we are seeing increasing donor and
country resistance, I believe if there were truly a "drop dead" date, that
countries and donors would rise to the challenge with the needed resources.
The WHA has just reiterated its support for polio eradication, in memory
of Dr Lee Jong-Wook, who was the responsible officer for polio eradication
in the Western Pacific Region prior to coming to Geneva, and eventually
becoming WHO's Director-General. This would be a fitting memorial if it
will happen, and soon. My fear is that the polio eradication will
eventually end, "not with a bang, but a whimper." We can avoid that if
only we will.
Julie
Dr Julie Milstien
Montpellier, France
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