Comment
Substantial progress has been made in the effort to eradicate polio. In 1988, the year the eradication effort began, an estimated 350 000 people were paralysed by poliovirus infection, which was regarded as endemic in 125 countries. By contrast, in 2014, 359 cases were detected worldwide, and only three countries are currently deemed endemic: Pakistan, Nigeria, and Afghanistan.1 Further progress has been made, particularly in Nigeria, which as of June 17, 2015, has not seen a case of polio caused by wild viruses since July 24, 2014, or a case of circulating vaccine-derived poliovirus type 2 since Nov 16, 2014.1 Nevertheless, eradication is a very unforgiving goal. One infection anywhere is one infection too many, and it is crucial that we reach zero infections as soon as possible. Countries with ongoing transmission can serve as reservoirs to export virus and infect countries that are polio free, further threatening eradication. The areas most affected by polio have seen substantial conflict and insecurity, making delivery of vaccines to these populations difficult. Much of the focus on achieving eradication in these areas has dealt with assuring vaccine is available to populations living there. Not only must vaccine be available, but there also needs to be public demand for vaccination, something that might not be pronounced in some of the last reservoirs for poliovirus transmission. In The Lancet Infectious Diseases, Gillian SteelFisher and colleagues2 explore beyond operational barriers to quantify caregiver perceptions regarding polio vaccination in these troubled areas. Concerns about insecurity potentially thwarting successful polio eradication cannot be overstated. In 2014, 85% of the world’s cases of wild poliovirus occurred in Pakistan.1 Exportations from Pakistan, along with those from Cameroon and Syria, prompted the International Health Regulations Emergency Committee to declare the situation a public health emergency of international concern in 2014 and vaccination recommendations for travellers were instated.3 Although access has recently improved, in June, 2012, Taliban groups in Pakistan banned vaccination for more than 350 000 children in parts of the Federally Administered Tribal Areas (FATA).4 Targeted attacks against polio workers in FATA, Khyber Pakhtunkhwa
province, and Karachi have further compromised implementation of mass campaigns, a key strategy in the interruption of transmission of wild poliovirus. In the past, some states in Northern Nigeria have seen widespread refusal of polio vaccine because of rumours such as western plots of sterilisation, deliberate HIV infection, or chemical contamination.5 Although Nigeria has not reported wild polioviruses in over 10 months, insecurity could potentially compromise surveillance and detection of viruses. Surveillance systems in these regions must be strong enough to assure that if polioviruses are circulating, they will be detected. However, the marked recent success reported from Nigeria could mean that some of the key barriers, including parental acceptance of vaccines, have been overcome. SteelFisher and colleagues used a rigorous multistage cluster polling design and face-to-face interviews in their study, which resulted in three major findings in the comparison of higher-conflict and lower-conflict areas. First, their results confirmed the operational challenges that prevent vaccination teams from reaching areas fraught with armed conflict and civil unrest. Second, the study reported differences in caregiver understanding of polio disease and trust in vaccination efforts between higher-conflict and lower-conflict areas. Third, caregivers identified local priorities that, if addressed, could provide an indirect method of addressing gaps in trust of government vaccination efforts. Targeted communication efforts and enhanced training of health workers in vaccination programmes are additional ways to ensure vaccines reach every child in need. Surveys in conflict areas are inherently difficult because regions that are inaccessible due to security concerns often remain unreached in the sampling frame. Unfortunately, barriers that prevent health workers from reaching children also prevent interviewers from reaching the population of interest. The investigators reason that higher-conflict and lower-conflict areas in the study sample might be more similar than they are in reality, thus the study might underestimate the differences between them. The study might overstate caregiver support for vaccination and underestimate resistance, further illustrating discrepancies. Caregiver attitudes in higherconflict areas can have an important role in assuring
www.thelancet.com/infection Published online July 13, 2015 http://dx.doi.org/10.1016/S1473-3099(15)00008-0
Fareed Khan/AP/Press Association Images
Overcoming barriers to polio eradication in conflict areas
Lancet Infect Dis 2015 Published Online July 13, 2015 http://dx.doi.org/10.1016/ S1473-3099(15)00008-0 See Online/Articles\ http://dx.doi.org/10.1016/ S1473-3099(15)00178-4
1
Comment
vaccination is achieved and further behavioural research in this area is needed. Obliteration of the last remaining cases of wild poliovirus infection in places such as Pakistan and Nigeria is a global priority, yet locally, more pressing concerns might be equally, if not more, essential to immediate survival. As identified in the study, clean water, energy, unemployment, and education are challenges that communities face daily. Addressing these issues will not only improve the quality of life and outlook for people in these countries, but will also gain their trust in other government programmes, such as health care. In 2014, Zulfiqar Bhutta commented: “Providing polio vaccines as part of a package of health services is a better way to engage local communities and religious leaders than through a narrow, polio-specific programme”.6 Thus, viewing polio eradication through a holistic child-health-focused lens might produce a larger overall effect. The Global Polio Eradication Initiative (GPEI) has recognised the importance of using polio resources to address other health burdens. The Polio Eradication and Endgame Strategic Plan for the period 2013–18 has “legacy planning” as a fundamental component.7 However, even before full eradication, it might be helpful to use the polio infrastructure to address other community concerns. The study by SteelFisher and colleagues presents an important, and sometimes neglected, facet of the challenges of polio eradication by shedding light on caregiver opinions and barriers beyond logistics. The study quantifies that individuals who are reached have the potential to form a solid base of vaccine acceptance and advocacy. This finding further supports the need to
2
address political issues to improve the reach of health workers in these countries. However, if a vaccine reaches a parent who is then hesitant to accept the intervention, efforts are lost and transmission continues. Until war itself is eradicated, public health programmes will continue to face challenges in reaching children in conflict areas, a serious barrier when it comes to interrupting transmission of infectious disease. Until then, we must focus on understanding and maintaining the trust of the communities we can reach. Only through a comprehensive understanding of vaccine delivery in the context of complex situations can we attain this lofty goal. Julie R Garon, *Walter A Orenstein Division of Infectious Diseases, Emory University School of Medicine, 1462 Clifton Rd NE, Rm 446, Atlanta, GA 30322, USA [email protected] We have received grants from the Bill & Melinda Gates Foundation. 1
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3
4
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Global Polio Eradication Initiative. Data and monitoring. Polio this week: wild poliovirus list. http://www.polioeradication.org/Dataandmonitoring/ Poliothisweek/Wildpolioviruslist.aspx (accessed June 10, 2015). SteelFisher GK, Blendon RJ, Guirguis S, et al. TThreats to polio eradication in high-conflict areas in Pakistan and Nigeria: a polling study of caregivers of children younger than 5 years. Lancet Infect Dis 2015; published online July 13. http://dx.doi.org/10.1016/S1473-3099(15)00178-4. WHO. WHO statement on the meeting of the International Health Regulations Emergency Committee concerning the international spread of wild poliovirus. May 5, 2014. http://www.who.int/mediacentre/news/ statements/2014/polio-20140505/en/ (accessed June 10, 2015). Alexander JP, Zubair M, Khan M, et al. Progress and peril: poliomyelitis eradication efforts in Pakistan, 1994–2013. J Infect Dis 2014; 210 (suppl 1): S152–61. Michael CA, Ogbuanu IU, Storms AD, et al. An assessment of the reasons for oral poliovirus vaccine refusals in Northern Nigeria. J Infect Dis 2014; 210 (suppl 1): S125–30. Bhutta ZA. Polio eradication hinges on child health in Pakistan. Nature 2014; 511: 285–87. Global Polio Eradication Initiative. Polio eradication & endgame strategic plan 2013–2018. http://www.polioeradication.org/Portals/0/Document/ Resources/StrategyWork/PEESP_EN_US.pdf (accessed June 10, 2015).
www.thelancet.com/infection Published online July 13, 2015 http://dx.doi.org/10.1016/S1473-3099(15)00008-0
Substantial progress has been made in the effort to eradicate polio. In 1988, the year the eradication effort began, an estimated 350 000 people were paralysed by poliovirus infection, which was regarded as endemic in 125 countries. By contrast, in 2014, 359 cases were detected worldwide, and only three countries are currently deemed endemic: Pakistan, Nigeria, and Afghanistan.1 Further progress has been made, particularly in Nigeria, which as of June 17, 2015, has not seen a case of polio caused by wild viruses since July 24, 2014, or a case of circulating vaccine-derived poliovirus type 2 since Nov 16, 2014.1 Nevertheless, eradication is a very unforgiving goal. One infection anywhere is one infection too many, and it is crucial that we reach zero infections as soon as possible. Countries with ongoing transmission can serve as reservoirs to export virus and infect countries that are polio free, further threatening eradication. The areas most affected by polio have seen substantial conflict and insecurity, making delivery of vaccines to these populations difficult. Much of the focus on achieving eradication in these areas has dealt with assuring vaccine is available to populations living there. Not only must vaccine be available, but there also needs to be public demand for vaccination, something that might not be pronounced in some of the last reservoirs for poliovirus transmission. In The Lancet Infectious Diseases, Gillian SteelFisher and colleagues2 explore beyond operational barriers to quantify caregiver perceptions regarding polio vaccination in these troubled areas. Concerns about insecurity potentially thwarting successful polio eradication cannot be overstated. In 2014, 85% of the world’s cases of wild poliovirus occurred in Pakistan.1 Exportations from Pakistan, along with those from Cameroon and Syria, prompted the International Health Regulations Emergency Committee to declare the situation a public health emergency of international concern in 2014 and vaccination recommendations for travellers were instated.3 Although access has recently improved, in June, 2012, Taliban groups in Pakistan banned vaccination for more than 350 000 children in parts of the Federally Administered Tribal Areas (FATA).4 Targeted attacks against polio workers in FATA, Khyber Pakhtunkhwa
province, and Karachi have further compromised implementation of mass campaigns, a key strategy in the interruption of transmission of wild poliovirus. In the past, some states in Northern Nigeria have seen widespread refusal of polio vaccine because of rumours such as western plots of sterilisation, deliberate HIV infection, or chemical contamination.5 Although Nigeria has not reported wild polioviruses in over 10 months, insecurity could potentially compromise surveillance and detection of viruses. Surveillance systems in these regions must be strong enough to assure that if polioviruses are circulating, they will be detected. However, the marked recent success reported from Nigeria could mean that some of the key barriers, including parental acceptance of vaccines, have been overcome. SteelFisher and colleagues used a rigorous multistage cluster polling design and face-to-face interviews in their study, which resulted in three major findings in the comparison of higher-conflict and lower-conflict areas. First, their results confirmed the operational challenges that prevent vaccination teams from reaching areas fraught with armed conflict and civil unrest. Second, the study reported differences in caregiver understanding of polio disease and trust in vaccination efforts between higher-conflict and lower-conflict areas. Third, caregivers identified local priorities that, if addressed, could provide an indirect method of addressing gaps in trust of government vaccination efforts. Targeted communication efforts and enhanced training of health workers in vaccination programmes are additional ways to ensure vaccines reach every child in need. Surveys in conflict areas are inherently difficult because regions that are inaccessible due to security concerns often remain unreached in the sampling frame. Unfortunately, barriers that prevent health workers from reaching children also prevent interviewers from reaching the population of interest. The investigators reason that higher-conflict and lower-conflict areas in the study sample might be more similar than they are in reality, thus the study might underestimate the differences between them. The study might overstate caregiver support for vaccination and underestimate resistance, further illustrating discrepancies. Caregiver attitudes in higherconflict areas can have an important role in assuring
www.thelancet.com/infection Published online July 13, 2015 http://dx.doi.org/10.1016/S1473-3099(15)00008-0
Fareed Khan/AP/Press Association Images
Overcoming barriers to polio eradication in conflict areas
Lancet Infect Dis 2015 Published Online July 13, 2015 http://dx.doi.org/10.1016/ S1473-3099(15)00008-0 See Online/Articles\ http://dx.doi.org/10.1016/ S1473-3099(15)00178-4
1
Comment
vaccination is achieved and further behavioural research in this area is needed. Obliteration of the last remaining cases of wild poliovirus infection in places such as Pakistan and Nigeria is a global priority, yet locally, more pressing concerns might be equally, if not more, essential to immediate survival. As identified in the study, clean water, energy, unemployment, and education are challenges that communities face daily. Addressing these issues will not only improve the quality of life and outlook for people in these countries, but will also gain their trust in other government programmes, such as health care. In 2014, Zulfiqar Bhutta commented: “Providing polio vaccines as part of a package of health services is a better way to engage local communities and religious leaders than through a narrow, polio-specific programme”.6 Thus, viewing polio eradication through a holistic child-health-focused lens might produce a larger overall effect. The Global Polio Eradication Initiative (GPEI) has recognised the importance of using polio resources to address other health burdens. The Polio Eradication and Endgame Strategic Plan for the period 2013–18 has “legacy planning” as a fundamental component.7 However, even before full eradication, it might be helpful to use the polio infrastructure to address other community concerns. The study by SteelFisher and colleagues presents an important, and sometimes neglected, facet of the challenges of polio eradication by shedding light on caregiver opinions and barriers beyond logistics. The study quantifies that individuals who are reached have the potential to form a solid base of vaccine acceptance and advocacy. This finding further supports the need to
2
address political issues to improve the reach of health workers in these countries. However, if a vaccine reaches a parent who is then hesitant to accept the intervention, efforts are lost and transmission continues. Until war itself is eradicated, public health programmes will continue to face challenges in reaching children in conflict areas, a serious barrier when it comes to interrupting transmission of infectious disease. Until then, we must focus on understanding and maintaining the trust of the communities we can reach. Only through a comprehensive understanding of vaccine delivery in the context of complex situations can we attain this lofty goal. Julie R Garon, *Walter A Orenstein Division of Infectious Diseases, Emory University School of Medicine, 1462 Clifton Rd NE, Rm 446, Atlanta, GA 30322, USA [email protected] We have received grants from the Bill & Melinda Gates Foundation. 1
2
3
4
5
6 7
Global Polio Eradication Initiative. Data and monitoring. Polio this week: wild poliovirus list. http://www.polioeradication.org/Dataandmonitoring/ Poliothisweek/Wildpolioviruslist.aspx (accessed June 10, 2015). SteelFisher GK, Blendon RJ, Guirguis S, et al. TThreats to polio eradication in high-conflict areas in Pakistan and Nigeria: a polling study of caregivers of children younger than 5 years. Lancet Infect Dis 2015; published online July 13. http://dx.doi.org/10.1016/S1473-3099(15)00178-4. WHO. WHO statement on the meeting of the International Health Regulations Emergency Committee concerning the international spread of wild poliovirus. May 5, 2014. http://www.who.int/mediacentre/news/ statements/2014/polio-20140505/en/ (accessed June 10, 2015). Alexander JP, Zubair M, Khan M, et al. Progress and peril: poliomyelitis eradication efforts in Pakistan, 1994–2013. J Infect Dis 2014; 210 (suppl 1): S152–61. Michael CA, Ogbuanu IU, Storms AD, et al. An assessment of the reasons for oral poliovirus vaccine refusals in Northern Nigeria. J Infect Dis 2014; 210 (suppl 1): S125–30. Bhutta ZA. Polio eradication hinges on child health in Pakistan. Nature 2014; 511: 285–87. Global Polio Eradication Initiative. Polio eradication & endgame strategic plan 2013–2018. http://www.polioeradication.org/Portals/0/Document/ Resources/StrategyWork/PEESP_EN_US.pdf (accessed June 10, 2015).
www.thelancet.com/infection Published online July 13, 2015 http://dx.doi.org/10.1016/S1473-3099(15)00008-0
