No One Is Safe Until Everyone Is Safe? Reporting a Polio Outbreak at Snail’s Pace
Bill Gates meeting with Pakistani President Arif Alvi in Islamabad during a visit to Pakistan on 17 February

ISLAMABAD – The timing couldn’t have been worse. 

On the same day that Bill Gates, completed his maiden visit to Pakistan to cheer on the country’s progress towards polio eradication, WHO and Malawi health authorities announced that a small child thousands of kilometers away in Malawi had been ill with polio – infected by a Pakistani strain of wild poliovirus (WPV type-1).   

WHO officials hastened to say that the polio case in the 3-year-old girl in Lilongwe, diagnosed after she experienced an onset of paralysis, did not threaten Africa’s hard-earned  “polio free” status – because it was an “imported case” of the deadly virus.  It was only after repeated queries by Health Policy Watch, that WHO acknowledged that neither the young girl or her family members had recently traveled to Pakistan – meaning that she became infected locally.   

But in fact, the particular genetic strain of the wild poliovirus that popped up in Lilongwe Malawi, hasn’t even been seen in Pakistan since 2019, Pakistani authorities there later stated – raising questions about if and how the virus may indeed be circulating more widely now in the African country.  

It was only in August 2020 that Africa was declared free of wild poliovirus.  Pakistan is getting closer to that goal as well. 

But the surfacing of a Pakistani wild poliovirus strain in Africa, underlines the challenges still faced to global elimination of polio – not to mention control and elimination of other diseases. And if more cases of wild poliovirus occur in Malawi, the whole continent’s wild polio-free status could be threatened – even if WHO is loath to state that publicly.   

Three month delay in WHO announcement of Malawi polio outbreak   

The other conundrum raised by the episode is one of timing – the apparent three-month long delay in identifying and reporting the wild poliovirus case.

The WHO African Regional Office announcement took place on 17 February 2022. But the child’s polio symptoms were first reported in November, 2021. 

“The three-year-old girl in Malawi experienced onset of paralysis on 19 November 2021, and stool specimens were collected for testing on 26 and 27 November,” stated a Global Polio Elimination Initiative report, also dated 17 February 2022.

“Sequencing of the virus conducted in February by the National Institute for Communicable Diseases in South Africa and the U.S. Centers for Disease Control and Prevention confirmed this case as WPV1,” the GPEI statement continued.   

So far, no one has been able to explain why there was a three-month delay in sequencing the virus and announcing the case – when new SARS-CoV2 variants were being identified by the same laboratories within days or weeks.  

But only four days later, WHO Director General Dr Tedros Adhanom Ghebreyesus commended Malawi’s President Lazarus Chakwera for  “rapid action and transparency” in responding to the outbreak.

Analogue era of reporting – in digital age

A similar pattern occurred last October, when WHO reported a Ziki outbreak in India – four months after a cluster of new cases actually occurred and were diagnosed.

It raises, once more, again thorny questions, once more, about the snail’s speed at which national governments report, laboratories examine and WHO publicly releases sensitive “disease outbreaks news” – that national governments may find embarrasing. 

Fault lines in the chain of alert and response have come under heightened scrutiny during the COVID pandemic – something The Independent Panel described it as an “analogue” system operating in a digital age.

WHO’s alert and response system “seems to come from an earlier analogue era and needs to be brought into the digital age,” observed panel co-chair Helen Clark, former Prime Minister of New Zealand, in a media briefing on 21 January 2021. 

The SARS-CoV2, the virus was probably circulating in Wuhan for weeks, if not months, before the first public report was made by Wuhan health authorities on 31 December 2019, experts now believe. After the first public reports, it took WHO another full month to declare an international health emergency, Clark noted.     

Imported case – but circulating locally  

Another issue raised is how you define an “imported” case of a disease.

When WHO described the Malawi polio case as “imported” that meant that “laboratory analysis shows that the strain detected in Malawi is linked to the one that has been circulating in Sindh Province in Pakistan”, WHO African Regional Office,  Dr. Modjirom Ndoutabe, told Health Policy Watch, in an interview.

Neither the child nor her parents had been to Pakistan, he affirmed.

“When we are talking about importation, it will be an adult passive vector who traveled from an infected country to the polio-free country,” he explained. Laboratory analysis of the virus strain showed that it is genetically linked to a wild poliovirus found circulating in Pakistan in 2019, Ndoutabe added.

This was confirmed by Pakistan’s Dr. Rana Mohammad Safdar, Director General of the Ministry of National Health Services. However, the same virus strain has not been seen in Pakistan since 2020, he told Health Policy Watch

“Origin is, of course Pakistan, but remains to be investigated where it survived as hidden circulation,” Safdar said.

Heading off a wider outbreak 

An oral polio vaccine is administered to a child.

Meanwhile, WHO’s African Region polio coordinator, Ndoutabe, admitted that the virus “may be spreading silently”, elsewhere in the environment. 

Just one infected child can contaminate water sources, as well as other people who come into contact an infected persons stool – and the virus can also multiply and thrive in untreated sewage, he observed.

If the virus indeed spreads further, then it could compromise the recently-gained status of Africa being free of wild poliovirus Type 1.  That, in additon to the vaccine-derived polio cases that some 16 African countries continue to battle.    

In the wake of Malawi’s polio case, the Global Polio Eradication Initiative (GPEI) team based at WHO’s Brazzaville Regional Office is deploying a team to Lilongwe to support coordination, surveillance, data management, communications, and operations, WHO said.  

Ndoutabe  expressed confidence that Malawi health authorities could head off a wider outbreak, saying: “We can stop it very quickly with excellent vaccine campaigns.” 

Gates – Pakistan faces ‘hardest phase’ of eradication effort 

Meanwhile, in his first-ever visit last week to Pakistan, Gates, the billionaire philanthropist and co-chair of the Bill and Melinda Gates Foundation (BMGF), declared that not a single case of wild poliovirus has been reported in that country in the last fourteen months.

“It has been over a year since wild polio paralyzed a child in Pakistan, presenting an incredible opportunity to stop this disease for good,” Gates said in a tweet. 

Malawi’s case aside, Pakistan and Afghanistan are the only countries left in the world still struggling to eliminate wild poliovirus. 

Officials at Pakistan’s ministry of National Health Services Regulation and Coordination told Health Policy Watch that they believe Pakistan is indeed very close to eradicating the wild polio virus Type 1 that remains endemic in the country  – although the virus continues to be identified in stool samples collected by surveillance in a few sites in the country’s northwestern province.

“Two samples in the south of province Khyber Pakhtunkhwa were tested positive in December while all other sites were negative,” a senior official said, asking to remain anonymous. 

This was formally confirmed by a BMGF statement about Gates’ visit and meeting with Pakistan’s President Arif Alvi, and Prime Minister Imran Khan.  The BMGF statement noted that “wild poliovirus was detected in sewage samples in Khyber Pakhtunkhwa, a province located in the northwestern region of the country, in December 2021”.

During his visit, Gates commended Pakistan’s commitment to “the hardest phase” of the eradication effort. 

“This is the final, and hardest, phase of the eradication effort, but by keeping up the momentum and staying vigilant, Pakistan has an opportunity to make history by ending polio for good,” he said.

Vaccine hesitancy and reaching children in areas of civil unrest 

Children in Pakistan display their finger nail died purple – proof they have been vaccinated against polio.

Other challenges include vaccine hesitancy and reaching children in insecure areas, said the BMGF and Pakistani government statements.

Dr Shahzad Baig, the coordinator of the health ministry’s National Emergency Operations Center (NEOC) – highlighted the need to halt virus circulation in border areas shared by Pakistan and Afghanistan – in the throes of crisis and with refugees crossing the border daily. 

Against that landscape, Pakistan’s Polio Eradication Programme continues to work closely with Afghanistan’s new Taliban government in efforts to halt poliovirus transmission across shared corridors and amongst highly mobile population groups, Baig underlined. Reversing years of vaccine hesitancy, the new Afghan leaders have committed to continue polio vaccination efforts on their side of the border. See related Health Policy Watch story. 

Baig also commended the growing synergies between the activities of WHO-supported Expanded Programme on Immunization (EPI) and Polio Eradication Programme (PEI) – to carry out routine vaccination campaigns that offer multiple health services at the same time.

In 2022, for instance, targeted polio vaccination campaigns across all four provinces in Pakistan will be followed by health camps that offer communities free routine vaccinations, nutrition services, and referrals to health facilities.

Image Credits: UNICEF Pakistan, Pakistan, President's Media Team , WHO.

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