Friday, March 7, 2014

Conflict and Disease: Syria's Wild Polio 1 Outbreak and European Public Health Security

Update: "For the first time ever, the World Health Organization on Monday declared the spread of polio an international public health emergency that could grow in the next few months and unravel the nearly three-decade effort to eradicate the crippling disease. The agency described the current polio outbreaks across at least 10 countries in Asia, Africa, and the Middle East as an "extraordinary event" that required a coordinated international response. It identified Pakistan, Syria and Cameroon as having allowed the virus to spread beyond their borders, and recommended that those three governments require citizens to obtain a certificate proving they have been vaccinated for polio before traveling abroad." See: http://www.foxnews.com/health/2014/05/05/who-declares-polio-international-public-health-emergency/?intcmp=latestnews






"Detection and control of emerging infectious diseases in conflict situations are major challenges due to multiple risk factors known to enhance emergence and transmission of infectious diseases. These include inadequate surveillance and response systems, destroyed infrastructure, collapsed health systems and distribution of disease control programs, and infection control practices even more inadequate than those in resource-poor settings, as well as ongoing insecurity and poor coordination among humanitarian agencies."  Michelle Gayer, Dominique Legros, Pierre-Formenty and Maire A. Connonlly seehttp://wwwnc.cdc.gov/eid/article/13/11/06-1093_article.htm*** 


In 1980, the World Health Organization (WHO) declared smallpox, the first disease in human history, eradicated. Smallpox is the only disease to have been eradicated and only two repositories the Center for Disease Control and Prevention in Atlanta, Georgia and Vector in Novosibirsk, Russia maintain live viral strain collections.Wild Polio Virus, was the next scheduled disease to face eradication. Unfortunately, the recent polio outbreak in Syria serves as a reminder that conflict and war severely impact vaccination campaigns and eradication strategies leaving the most vulnerable open to the spread of this horrific disease. While ample polio vaccine exists, other diseases such as smallpox, avian flu, highly pathogenic strains of Category A agents, typically considered suitable for weaponization are not maintained in significant global stockpiles to contain a pandemic outbreak and in some instances not even an epidemic. It takes nearly ten years and around one billion US dollars to bring a vaccine onto the market. While war and disease often go hand in hand and conflict disease is not a new topic, changes in the demographics of war, terrorism and emerging disease pose a critical nexus that until very recently was not fully appreciated. The recently reported outbreak of Wild Polio Virus 1 (WPV1), serves as a reminder of the effect of war and terrorism on emerging and re-emerging highly pathogenic disease. The transmissible Polio virus had long been eradicated in all but three countries: Pakistan, Afghanistan and Nigeria. Its re-emergence in Syria, the likely result of Pakistani fighters entering Syria to fight against the regime of Bashar al Assad, is among several potentially life threatening diseases facing not only Syrian populations and refugee camps, but due to modern air travel and high numbers of fighters returning to Europe, the global community as a whole.see: http://www.redorbit.com/news/health/1113001691/polio-virus-confirmed-syria-origin-pakistan-threats-111313  


polio vaccine


In a November 11th report, the WHO, under the direction of the United Nations, confirmed that genetic sequencing showed the isolated viruses were most closely related to environmental samples pulled from Egypt in December 2012. Interestingly enough, those samples had in fact been linked to the poliovirus circulating in Pakistan. see: http://www.redorbit.com/news/health/1113001691/polio-virus-confirmed-syria-origin-pakistan-threats-111313/   


Highly pathogenic and transmissible diseases do not respect national boarder, any outbreak of a contagious pathogenic agent, given modern air travel, presents health risks to the wider global community. In protracted and post conflict situations, populations may have high rates of illness and mortality due to breakdown of health systems, flight of trained staff, failure of existing disease control programs and destruction of infrastructure. These populations may be more vulnerable to infection and disease because of high levels of malnutrition, low vaccine coverage, or long term stress. See: http://wwwnc.cdc.gov/eid/article/13/11/06-   Moreover, with significant numbers of fighters returning to Europe from conflict in Syria, communities once considered to have relatively high herd immunity, due to previous vaccination, are likely to see outbreaks of polio, a disease recently scheduled for and nearly eradicated by WHO. WPV3 has possibly been eradicated, WPV2 was eradicated in 1999, but WPV1 remains endemic in countries with poor public health infrastructures. See:  http://www.polioeradication.org/tabid/488/iid/336/Default.aspx#sthash.U3cWLlcw.dpuf Chris Maher, Senior Scientist for Polio Eradication at the World Health Organization made the following observation published in the Global Polio Eradication Initiative website:http://www.polioeradication.org/tabid/488/iid/336/Default.aspx#sthash.U3cWLlcw.dpuf 

"The danger with WPV3 is that it is less virulent than WPV1, Maher explained. It causes cases at a rate of approximately 1 in 2,000 infections, compared with 1 in 200 infections for WPV1. Causing fewer cases is a good thing of course, but it also means that the virus can transmit more widely and longer, without being detected. "It's a sneaky virus, in that sense, so we have to be cautious not to let it surprise us." Maher said. The other challenge is that the last known remaining WPV3 reservoirs (Khyber Agency in Pakistan, and Bomo and Yobe states in Northern Nigeria), are areas where access is compromised due to insecurity. Undetected circulation therefore cannot be fully ruled out. Efforts are ongoing to address these and other challenges, as part of national emergency action plans being implemented in both countries. see:  http://www.polioeradication.org/tabid/488/iid/336/Default.aspx#sthash.U3cWLlcw.dpu 

"It is vital that we work in areas which offer opportunities beyond war zones as well to contain highly pathogenic diseases at the earliest identification such as refugee camps and neighboring nations, which often witness the influx of large numbers of refugees. In the case of WPV1 outbreak in Syria, Europeans are at greater risk due to the numbers of fighters returning to Europe. while this may seem to be a straight forward counter terrorism issue, it is also a European public health issue with potentially global health consequences. Increasing public health infrastructures in nations such as Turkey and Lebanon will likely help reduce risk of spread, it is not nearly enough." http://www.polioeradication.org/tabid/488/iid/336/Default.aspx#sthash.U3cWLlcw.dpu 

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