By Robert Fortner, special to Humanosphere
During high season for polio this year, Nigeria has seen only one case of paralysis caused by the wild virus – an achievement which, if viewed in isolation, can be hailed as a great global health success.
But the single-minded focus on polio eradication appears to have left routine immunization behind. Measles deaths spiked last year not only in Nigeria but globally.
Now, ironically, Nigeria’s exceptionally poor immunization system is obstructing the goal of polio eradication.
Polio eradication originally sprang from the idea of expanding routine immunization, a strategy that succeeded in Latin America. But in much of Africa, polio vaccination and routine immunization diverged. Polio eradication couldn’t wait, given a 2005 deadline that coincided with the centennial of Rotary International. Weak, needle-based immunization systems had to be leapfrogged. Oral polio vaccine, deliverable by armies of untrained children and adults, made that possible.
In Nigeria, polio spending over six years will reach $1.5 billion by 2018. These huge sums have been translated into high rates of successful polio vaccination coverage. In two years, starting in 2012, polio vaccination coverage rose above 80 percent or 90 percent in nearly all Local Government Areas (LGAs) in Nigeria.
Routine vaccination, however, has been and remains a wreck in Nigeria, among the worst in the world.
In stark contrast to the $1.5 billion for polio over six years, Nigeria has received only $357 million from GAVI (the Gates-initiated global immunization program) for routine immunization over the last 15 years. In 2012, as polio coverage took off, no country in the world had more children who received no vaccines at all than Nigeria: 3.4 million in a country of 160 million people. India, population 1.2 billion, missed only 3.1 million children completely. To the extent whipsawing estimates of Nigeria’s immunization rates can be trusted, routine coverage fell from 2009 to 2013.
About 2.7 million children in Nigeria have not been vaccinated against measles, perhaps contributing to a large measles outbreak there last year. It’s not just Nigeria. The single-minded pursuit of polio and inattention to other priorities such as measles is global. Measles deaths rose last year, up an estimated 24,000 to 146,000. Polio eradication hasn’t just de-emphasized routine immunization but militated against it directly:
“Where there is poor routine immunization structure you get competition between the routine system and polio eradication …” said Vance Dietz, the CDC’s chief of immunization systems strengthening, in a 2010 interview for the book by historian William Muraskin Polio Eradication and its Discontents.
Although the lethality and ubiquity of measles have always surpassed polio, the Bill & Melinda Gates Foundation has elevated polio eradication to the highest global health priority. The foundation is also a leading advocate for routine vaccination and its most influential funder. But Bill Gates has said he spends more time on polio than anything else. The Gates Foundation is not part of the Measles & Rubella Initiative.
However, routine vaccination not only prevents measles deaths, it plays a critical role in polio eradication. Nigerian parents are not keen to have their children dosed again and again with oral polio vaccine, as required for eradication.
Consequently, the eradication initiative began setting up “health camps” that provided more than just polio vaccine. According to the Independent Monitoring Board of the eradication effort, health camps were “a major part of Nigeria’s recent success” in battling polio. “Popular with communities, they attract big crowds, offer a wide range of health measures, and polio vaccine is readily accepted.”
But nationwide, health camps are too little, too late to make a meaningful difference in routine immunization. And although the impressive polio push has crushed wild type cases to only six cases this year, there’s a larger, under-recognized problem: 26 additional cases of polio caused by the oral polio vaccine itself. Oral polio vaccine contains live but attenuated virus which can mutate back into virulent form.
Transmission of vaccine-derived polio in Nigeria is spreading, with five additional cases recently popping up in five new places. Where routine immunization is strong, as in India when it purged itself of polio, the vaccine-derived virus can’t find a foothold.
As Gates Foundation program manager Apoorva Mallya put it, the difference between India and Nigeria is “likely better RI [routine immunization]coverage in India and perhaps a few more tOPV [trivalent oral polio vaccine]campaigns …” Defeating vaccine derived virus is not an insuperable task, but Nigeria wouldn’t face it if it had better routine immunization.
Eradication will require quitting the oral vaccine – which can sometimes flip back to virulence and cause polio – in favor of the inactivated, injected vaccine. However, as the Independent Monitoring Board (IMB) observed: “This only works if there are robust systems in place to actually deliver the vaccine.” Because Nigeria’s immunization infrastructure is far from robust, it is unclear how it will transition away from the oral vaccine.
The difficulty in rolling out the inactivated polio vaccine is global.
“Now we want routine immunization built up but there are real infrastructural gaps,” the CDC’s Olen Kew told William Muraskin in 2010. “There is a conflict between what we want done and what the reality on the ground is.”
The gaps remain. Today, plans call for all countries using oral polio vaccine to “introduce at least one dose of IPV [inactivated polio vaccine]in their routine immunization programs before the end of 2015.” However, Nepal became the very first country to do so in September. There is no possibility of all the nations of Africa, for example, adding IPV to routine vaccination by the end of next year.
According to Kew: “There is no escaping the fact that the gap between ideal and reality is a direct result of the decision to push for a global eradication program and not invest in strengthening the routine immunization systems.”
The polio eradication effort is taking the fall: “the major part of the program is focused on stopping polio transmission, and treats the routine immunization objective as a poor cousin,” wrote the IMB in its latest report. But the near-total erasure of polio from the planet resulted from exactly this strategy which the board now calls “short-sighted.”
The problem is not the program but the policy. The clearest way to reconcile the now conflicting goals of massive polio vaccine coverage and top-notch routine immunization would have been to make polio part of routine vaccination.
The IMB was slow to address routine immunization. Only in its tenth and most recent report explains that: “To accelerate the required improvement in integration, the IMB is recommending in this report that GAVI be invited to become a sixth core partner of the polio program…” According to the CDC’s Vance Dietz, however, “After 10 to 15 years of polio activities, polio should have adopted a policy of strengthening of EPI [Expanded Program on Immunization],” i.e. years ago, around the turn of the century.
Polio tops all other global health priorities even though its greatest champion acknowledges it barely merits pursuit. Smallpox, Bill Gates said, “was a good choice. Polio is a hard but reasonable choice.” Much better is malaria, which he characterized as “a very reasonable choice.” Polio is reasonable to Gates because it will provide a proof of concept for malaria eradication: “Polio we hope to get done by 2018,” he explained. “Then the credibility, the energy from that we will allow us to take the new tools we’ll have then and go after a malaria plan.”
Gates became concerned with polio and credibility when, in 2007, he and Melinda Gates switched the world’s malaria policy from control to eradication. In 2008, the foundation became and has remained polio eradication’s largest funder.
Malaria eradication was not possible in 2007, but advocates said: “we’ll use today’s tools today, and tomorrow’s tools tomorrow.” Seven years later, tomorrow’s tools are still on the drawing board. Malaria eradication is radically more ambitious than attacking polio, and the tools for it don’t exist. Meanwhile, polio eradication will slide past its 2018 deadline. The all out pursuit of polio costs $1 billion a year and has distorted health priorities including routine immunization and perhaps even the response to Ebola.
Brace for more. Gates doesn’t have new malaria tools to announce but he has set a timeline: “We Can Eradicate Malaria—Within a Generation.”
Robert Fortner, based in Portland, OR, is a science writer whose work has appeared in Scientific American, Ars Technica, and the Columbia Journalism Review. He is working on a book about Bill Gates, science and technology.