It’s hard to imagine things getting any worse for people trapped in Syria’s vicious civil war, but the World Health Organization (WHO) has issued an alert that it has received reports of a polio outbreak in that devastated country’s Deir Al Zour province. The alert notes that wild poliovirus type 1 (WPV1) has been isolated from ten of the cases under investigation, and final genetic sequencing results are pending to determine the origin of the isolated viruses. Wild poliovirus had last been detected in the Syrian Arab Republic in 1999.
The WHO says Syria’s Ministry of Health confirms that it is treating this event as a cluster of ‘hot’ cases, pending final laboratory confirmation, and an urgent response is currently being planned across the country. The agency notes that Syria is considered at high-risk for polio and other vaccine-preventable diseases due to the current situation there, which has killed upwards of 100,000 and displaced millions of people. A surveillance alert has been issued for the region to actively search for additional potential cases, supplementary immunization activities in neighboring countries are currently being planned.
Most of the new Syrian cases are in very young persons (below two years of age), who are believed to have been un- or under-immunized. The WHO says estimated immunization rates in the Syrian Arab Republic have declined from 91 percent in 2010 to 68 percent in 2012, but that an already-planned large-scale supplementary immunization activity (SIA) was launched there on October to vaccinate 1.6 million children against polio, measles, mumps and rubella in both government-controlled and contested areas. A larger-scale outbreak response across Syria in and neighboring countries is anticipated to begin this month and will last for at least six to eight months depending on the area and based on evolving epidemiology. However, given the current situation in Syria, with frequent population movements across the region and subnational immunity gaps in key areas, the WHO warns that risk of further international spread of wild poliovirus type 1 across the region is considered to be high. A surveillance alert has been issued for the region to actively search for additional potential cases, and the WHO’s International Travel and Health that all travelers to and from polio-infected areas be fully vaccinated against polio.
Ironically, news of this new Syrian polio outbreak broke just after the Global Polio Eradication Initiative marked World Polio Day 2013 on October 24, announcing that since 1988, when the forty-first World Health Assembly adopted a resolution for the worldwide eradication of polio, cases have decreased by over 99% from an estimated 350,000 cases in more than 125 endemic countries then, to 223 reported cases in 2012 In 2013, and only three countries in the world remaining polio-endemic: Nigeria, Pakistan and Afghanistan, and even there, cases were down 40 percent year-over-year. Polio is one of only four diseases that require a country to notify the World Health Organization when new cases are diagnosed.
And now Syria? Unhappily, polio has now joined a constellation of diseases that are re-emerging there with a vengeance as a consequence of what has become a war of attrition and a concomitant breakdown in infrastructure and public health control measures. Commenting on this new outbreak, Houston-based neglected tropical diseases expert and advocate Dr. Peter Hotez notes that “Polio is one of many tropical and childhood infections now emerging out of Syria, along with cutaneous leishmaniasis, dengue, measles, and others. Poverty, human migrations, and conflict are the major forces promoting neglected tropical diseases.”
Dr. Hotez is America’s leading advocate for, and an internationally recognized expert on, tropical diseases and vaccine development. He is director of the Sabin Vaccine Institute and Texas Children’s Hospital’s Center for Vaccine Development, operated in partnership with Baylor College of Medicine’s pediatrics department. Dr. Hotez is also the Texas Children’s Hospital Endowed Chair of Tropical Pediatrics and serves as chief of the Section of Pediatric Tropical Medicine, Professor of Pediatrics and Molecular Virology & Microbiology, and the fellow in Disease and Poverty at the James A. Baker III Institute for Public Policy at Rice University, as well as being the founding dean of the new National School of Tropical Medicine at Baylor College of Medicine, Co-Editor in Chief of the medical journal PLOS Neglected Tropical Diseases, and author of a new book: Forgotten People, Forgotten Diseases (ASM Press).
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In an interview with Pacific Standard magazine’s Michael Todd this week , Dr. Hotez observed that: “By the time you see a case of clinically apparent paralytic polio, that means there’s at least a hundred other people who are probably infected. It’s made it that much more difficult to eliminate and eradicate. Syria has just become a public health disaster.”
In an opinion piece published by Al Jazeera last August, Dr. Hotez says that recent flare-ups of conflict in Egypt, Iraq, Libya, Pakistan, Syria, Tunisia, Yemen, and elsewhere in the Middle East may have sufficiently destabilized national and international public health control measures to a point where several tropical diseases have either emerged and are sickening large populations in the region, with the situation in war-torn Syria being the most dramatic example, where an estimated half-million of some five million children under age five have not been fully vaccinated for polio.
In the Al Jazeera op-ed, Dr. Hotez reports that several mosquito-transmitted virus infections have also become important public health problems in the region, citing recent estimates of six million cases of dengue fever occurring in Egypt in 2010 — a metric equalling more than seven percent of that country’s population, as well as almost 14 million cases reported that year in Pakistan. He observes that Dengue has also emerged in Saudi Arabia, Syria, and Yemen, and that additionally Rift valley fever has also appeared in both Saudi Arabia and Yemen — the first time that particular mosquito-transmitted viral infection has been seen outside of Africa. He also notes that there is growing concern that such viral infections could affect pilgrims entering Saudi Arabia during the Hajj pilgrimages this coming fall, as could the new MERS coronavirus that has caused international concern about its potential to become a global pandemic, or the recently-discovered Alkhurma hemorrhagic virus, both of which were first detected and identified in Saudi Arabia. He observes that In cases of prolonged conflict, destabilized communities, human migrations, and a collapse of public health infrastructure synergize with endemic poverty to promote emergence of epidemic diseases, with breakdowns in animal control and veterinary public health infrastructure also contributing to emergence of infections transmitted from animals.
Dr. Hotez, who testified last June in a presentation regarding Neglected Tropical Disease (NTD) R&D Funding before the United States House of Representatives Committee on Foreign Affairs Subcommittee on Africa, Global Health, Global Human Rights and International Organizations Hearing , says in his Al Jazeera piece that prompt global action is needed in order to contain, and prevent further spread and emergence of diseases in the Middle East, and that while certainly, United Nations agencies, especially the WHO, have a key role to play in terms of convening health ministers from the region and implementing meaningful disease control measures, the newly-launched US State Department Office of Global Health Diplomacy should also be mobilised in order to identify how the United States Government, possibly in partnership with research universities and institutes, could provide important technical assistance for disease control and elimination, but also to promote international and diplomatic cooperation across the region for this purpose. He observes that some of the wealthier Middle Eastern countries, such as Kuwait, Qatar, Saudi Arabia, and United Arab Emirates also need to shoulder responsibility both in terms of providing technical assistance and financial support for such efforts, warning that further delays could have permanent and long-lasting destabilizing consequences for this already volatile region.
According to the WHO, Polio (poliomyelitis) a highly infectious disease caused by a virus invades the nervous system, and can cause total paralysis in a matter of hours. The virus enters the body through the mouth and multiplies in the intestine. There are three types of poliovirus and many strains of each type. Once it enters the central nervous system, the polio virus invades the motor neuron cells that control muscles for swallowing, circulation, respiration, and the trunk, arms, and legs. It hijacks the cell’s assembly process, making thousands of copies of itself in hours, then killing the cell and spreading to infect other cells. Initial symptoms include fever, fatigue, headache, vomiting, stiffness in the neck and pain in the limbs. Polio mainly affects children under five years of age. One in 200 infections leads to irreversible paralysis, with some 5% to 10% of paralyzed victims dying when their breathing muscles become immobilized.
In the United States, polio was the most notorious disease of the 20th century until AIDS appeared, the most famous polio victim being U.S. president Franklin Delano Roosevelt, who was partially paralyzed by it. On April 12, 1955, it was announced that Jonas Salk, using March of Dimes donations from millions of people, had developed a vaccine to prevent polio. Nowadays, polio is widely considered in the developed West to be a disease of the past. A 2005 Smithsonian National Museum Of American History exhibit on the disease put it decidedly in the past tense: “Whatever Happened to Polio?”
There are three types of poliovirus: 1, 2, and 3. Type 1 being the most virulent and common. Type 2 polio virus has not been detected anywhere in the world since 1999. There is no cure for polio, which can only be prevented. Polio vaccine, given multiple times, can protect a child for life. There are two different types of polio vaccine, one using inactivated (killed) viruses, and the other using live but attenuated, or weakened, viruses. Jonas Salk was the leading proponent of the killed virus type, and Albert Sabin became the foremost proponent of the attenuated virus approach. Today, Salk’s IPV vaccine is the most commonly used in the United States and Europe, involving an injected shot. Sabin’s OPV is given orally in drop form, and used in global efforts to stop polio transmission.
Both the Salk and Sabin vaccines are “trivalent” ie: effective against all three virus types. A person who gets polio is immune to future infection from the virus type that caused the polio. Nearly all vaccine used in the global campaign is the Sabin type oral live virus form, which has the advantages of being much cheaper than injected vaccine, and not requiring highly trained medical personnel to administer every dose. Instead, one doctor or nurse can supervise many volunteers, making it possible to carry out massive vaccinations. These countrywide campaigns are called National Immunization Days and occur on two days about six weeks apart.
However, the WHO says that as long as a single child remains infected, children in all countries are at risk of contracting polio, and that failure to eradicate polio from its last remaining strongholds could result in as many as 200 000 new cases every year, within 10 years, all over the world. Polio is one of just four diseases requiring WHO notification when new cases are diagnosed. In most countries, the global effort to eradicate polio has expanded capacities to tackle other infectious diseases by building effective surveillance and immunization systems.
A new Polio Eradication and Endgame Strategic Plan 2013-2018 has been developed in consultation with polio-affected countries, stakeholders, donors, partners and national and international advisory bodies. The new Plan was presented at a Global Vaccine Summit in Abu Dhabi, United Arab Emirates, at the end of April 2013, and is the first plan to eradicate all types of polio disease simultaneously – both due to wild poliovirus and due to vaccine-derived polioviruses. Global leaders and individual philanthropists signaled their confidence in the Plan by pledging three-quarters of the Plan’s projected US$5.5 billion cost over the six years, also calling upon additional donors to commit upfront the additional US$1.5 billion needed to secure a lasting polio-free world.