At the Reaching the Last Mile Forum in Abu Dhabi on November 19, 2019, Bill Gates (second from the … [+]
Courtesy of Reaching the Last Mile
Last year, 2019, was an eventful and “good news-bad news” year for both polio viruses and efforts to get rid of these nasty viruses that have been paralyzing and killing people for thousands of years. If you haven’t figured it out yet, good news for humans is bad news for the viruses and vice-versa.
The good news (for humans, that is) included two major announcements in the latter half of 2019. One came in October: two of the three wild polio virus strains have now been eliminated, leaving wild polio virus type 1 (WPV1) as the only wild strain circulating in the world. The other two wild strains, wild polio virus type 2 (WPV2) and wild polio virus type 3 (WPV3), have been declared eradicated in 2015 and last year, respectively.
The other announcement came the following month on November 19 at the Reaching the Last Mile (RLM) Forum in Abu Dhabi: donors around the world have pledged $2.6 billion more towards efforts to eradicate polio. This included $160 million from His Highness Sheikh Mohamed bin Zayed Al Nahyan, Crown Prince of Abu Dhabi, who hosted the Forum and $1.08 billion from the Bill & Melinda Gates Foundation.
Unfortunately for humans, the virus had some cause in 2019 to celebrate as well. First of all, wild polio virus 1 made a bit of a comeback. According to the United Nations (UN) News, while there were only 28 reported cases of polio from WPV1 in 2018, the count surged to 113 in 2019, as of mid-December. This obviously is going the wrong direction.
A health worker administers a polio vaccine to a child, out of Kabul Afghanistan. Afghanistan, … [+]
Secondly, a known risk of one of the two currently available types of polio vaccines, the oral polio vaccine (OPV), has been a growing problem. If you down with OPV, you are putting several drop of liquid into your mouth that includes weakened but still alive polio viruses. This is quite different from the other available vaccine, the inactivated polio vaccine (IPV), which is a shot that includes only viruses that are essentially dead and cannot cause polio. While the attenuated live viruses in the OPV aren’t supposed to cause polio, they can re-invigorate and revert to their disease-causing dastardly versions. Recently, countries in Africa, the Eastern Mediterranean, South-East Asia and the Western Pacific have experienced outbreaks of such re-invigorated polio viruses derived from the OPV.
This World Health Organization (WHO) video explains how these vaccine-derived polio viruses can emerge:
The final piece of bad news was the assistance that the polio viruses have continued to get from humans. Yes, humans. In 2019, some humans have continued to spew anti-vaccination propaganda not backed by scientific evidence. This has essentially served as good PR for the polio viruses, hindering efforts to vaccinate people around the world.
All of this should make 2020 a very interesting and important year for the ongoing humans versus polio viruses saga. Indeed, humans have certainly come a long way since 1988, when the WHO, the Pan American Health Organization (PAHO), the U.S., Centers for Disease Control and Prevention (CDC), UNICEF, and Rotary International agreed to launch efforts to halt polio transmission throughout the world, as a Smithsonian timeline shows. This has evolved into the Global Polio Eradication Initiative (GPEI) which formulated the so-called “polio endgame”: the goal to eradicate the disease from the world.
This endgame has nothing to do with the Avengers, the Infinity Stones, or the quantum realm, but instead is an ambitious goal that has been the focus of polio efforts around the globe. Eradicate is different from eliminate, which is different from control. Eradicating polio would mean completing getting rid of the disease so that vaccination is no longer necessary. Eliminating polio would mean that the disease is no longer seen, but polio vaccination would have to continue to keep the disease from returning. Control just means keeping the disease at reasonably low levels, with “reasonably” being somewhat of a subjective term.
Of course, eradication would be preferable. It would be the best safeguard against human foolishness, such as humans telling other humans to not get vaccinated, the one thing scientifically proven to prevent polio, which can be a devastating disease. After all, we’ve seen what happened to measles in recent years. Measles was considered eliminated from the U.S. in 2000 after years of getting the population vaccinated. But alas, such new hope soon became the measles virus strikes back. Anti-vaccination propaganda has helped the measles virus go from a problem that we thought had been eliminated to making a major comeback.
However, if you want to eradicate a disease like polio, it don’t come easy, to re-purpose the name of a Ringo Starr song. Quite the opposite, it do come very, very, very difficultly. In fact, progress can be a lot harder the closer you get to the endgame goal. As they say when you are running a marathon, delivering a package, or trying frantically to waddle to a bathroom, the “last mile” can be the most difficult.
That’s because the earlier part of any disease eradication program typically focuses on the “low hanging fruit,” the goals that are easier to achieve, such as vaccinating the bulk of people who are willing and can be readily reached. This then leaves people who are harder to vaccinate, because they are in more remote locations, are generally neglected, don’t regularly interact with the health care system, or are resistant to getting vaccinated. As Helen Clark, the 37th Prime Minister of New Zealand from 1999 to 2008, explained, “these can include the poorest of the poor. The people who remain affected are the most vulnerable, the hardest to reach. Reaching them then requires a huge effort.” The virus can then continue to play hide-and-go-seek in these populations and locations. Anti-vaccination propaganda gives more cover and only makes the job of vaccinating to the harder-to-vaccinate even harder.
Helen Clark (right), former prime minister of New Zealand, spoke of the importance of cooperating … [+]
Courtesy of Reaching the Last Mile
Clark was one of the speakers at the “Reaching the Last Mile: Accelerating the Pace” forum. In this case, the “last mile” concurrently refers to the final stages of disease eradication and the last part of a journey that a vaccine and other supplies need to make to reach people who need them. This forum convened over 250 luminaries in global health, including Dr. Tedros Ghebreyesus, Secretary General of the WHO, and Bill Gates, billionaire philanthropist and Co-Chair of the Gates Foundation, to discuss the challenges of the last mile in disease eradication and elimination in general, not just for polio.
Clark emphasized that disease eradication and elimination efforts need to be looked at “through an equity lens,” meaning that a big part of the challenge is overcoming the huge inequities that exist in people’s access to healthcare and other resources. After all, if you don’t regularly interact with healthcare professionals, chances are you won’t get vaccinated and you won’t get rapidly diagnosed when you catch a disease like polio or malaria.
Clark mentioned other challenges such as “political, religious, and military conflict” that can prevent health care workers from doing their jobs. Just look at what happened to Rahane Lawal, a polio worker in Nigeria, who was awarded the Recognizing Excellence Around Champions of Health (REACH) Unsung Hero Award at the Abu Dhabi forum. While traveling by foot to different homes in a small town in Nigeria to talk to parents about the importance of vaccines, she’s had to navigate through areas plagued by terrorism and crime. In fact, she ended up being kidnapped and in the process watched her father-in-law get murdered by her captors. Yet, even after this awful experience, she continued her work, realizing the importance of combating polio and other vaccine-preventable diseases.
Clark said that people like Lawal, Dr. Richard Kojan, who won the REACH Game-Changing Innovator Award, and Olivia Ngou, who won the REACH Rising Champion Award, have “done the hard yards on combating diseases that very difficult to get on top of. We need to recognize such people. We need people to stay to stay the course [in trying to eradicate or eliminate diseases].”
Gates during his speech at the forum remarked that “polio persists in some of the most complex and challenging places on earth. In war zones inaccessible to vaccinators. Among migrant and nomadic populations on the move. In remote areas. In neighborhoods where some parents don’t want their children immunized. And in communities where the health system is so weak that it can’t provide basic health services like polio vaccines as part of routine immunization.”
He added that “As there are fewer and fewer cases of polio, detecting the virus becomes more difficult. Most people infected with it show no signs of paralysis, which means the virus can circulate silently for long periods of time before it is detected or causes paralysis in a child.”
This year, which is 2020 in case you are still writing 2019 on your checks, will be pivotal for polio eradication efforts in many ways. Policy makers, public health officials, researchers, health professionals, and others involved in the eradication efforts will have to find creative ways to vaccinate those who are still not vaccinated. This means going down with OPV in places where polio viruses are still actively transmitting because unlike the IPV, an oral vaccine goes directly to the intestines, where the polio virus can normally hang out and then spread to other people via poop. By going directly to the intestines, the OPV can generate immune responses in the intestines. The IPV, which generates a less comprehensive immune response, because it is injected into your arm or leg and doesn’t include live viruses, is thus reserved for locations where the polio virus is no longer actively transmitting.
To remember this, just think “Oh good” OPV prevents the virus from being in someone’s poop. Here is a WHO video on the OPV and IPV:
The need to continue using the OPV means that the global community has to figure out how to stop reverted OPV-derived polio viruses from emerging and spreading. As the earlier WHO video showed, making sure that everyone is vaccinated can help do this. However, in places where vaccination rates aren’t high enough, the threat of vaccine-derived polio viruses remains a problem. Therefore, the Gates Foundation has been funding efforts to develop new OPV’s that have viruses that don’t revert to polio-causing forms as readily as the viruses in the current OPV. Two such vaccine candidates are now in Phase I and II clinical trials. So depending on how these trials go and how much data will be enough to re-assure people that these vaccine candidates are effective and safe, they may be available sometime soon.
Nobody said that eradicating a disease would be easy. Smallpox was declared eradicated in 1980 only after countries around the world, include those that actively hated each other, cooperated over many years to get people vaccinated. Back then there wasn’t the same level of anti-vaccination ridiculousness as exists today. Eradicating polio will require true cooperation once again because there’s a reason why polio has been around for thousands of years. It is a tough pathogen. It’s a formidable foe. It won’t be overcome by supplements, diets, crystals, psychic mediums, or whatever anti-vaxxers are telling you to buy and take instead of getting vaccinated.
Remember, it wasn’t until the 1950’s when the OPV and IPV were first available that humans began getting the upper hand in the fight against this disease. Before that the disease would continue to paralyze and kill thousands in the U.S. each year. Polio may have seemed to be on the ropes in recent years, but as 2019 showed, the last mile is often the toughest.