Hope dims for polio eradication over coronavirus

*Childhood killer diseases set to surge as COVID-19 forces suspension of vaccination campaigns
*NPHCDA says outbreak should not affect immunisation, other routine primary care services
*Why end for Ebola will have to wait as new case emerges in Democratic Republic of the Congo

Nigeria’s hope of being fully certified free of the crippling Wild Polio Virus (WPV) by June 2020 might have gone with the winds as the novel coronavirus (COVID-19) pandemic has forced the World Health Organisation (WHO) to suspend vaccination campaigns.

Nigeria’s quest to be certified polio-free by the WHO was shifted from December 2019 to June 2020. The country was supposed be certified polio free after not reporting any case of wild poliovirus (WPV) for three years. The last case of polio in Nigeria was reported in August 2016.

Before the emergence of COVID-19, the target was threatened and the date was shifted because of the impact of circulating Vaccine-Derived Polio Virus type 2 (cVDPV2), poor rountine immunisation, insecurity in some parts of northern Nigeria, and rise in cases of polio in the remaining polio endemic countries- Pakistan and Afghanistan- and some parts of Africa.

But Head of GAVI, the Vaccine Alliance, Seth Berkley, described the dilemma facing global health organisations in the past few weeks. Berkley said they could either continue to support mass vaccination campaigns in poor countries and risk inadvertently helping to spread COVID-19—or recommend their suspension, inevitably triggering an upsurge of many other infectious diseases.

In the end, they chose the latter. As the journal Science reported penultimate week, the Global Polio Eradication Initiative on March 24 recommended suspending polio vaccination campaigns until the second half of the year. Two days later, the WHO’s Strategic Advisory Group of Experts on Immunisation (SAGE) issued a broader call, recommending that all preventive mass vaccination campaigns for other diseases be postponed. “Any mass campaigns would go against the idea of social distancing,” said Alejandro Cravioto of the National Autonomous University of Mexico’s faculty of medicine, who chairs SAGE.

But experts say the fallout from the wrenching decision will be huge and may last long after the pandemic subsides. It comes on top of the damage COVID-19 will do to the fragile health systems in many countries.

Mass vaccination campaigns against a host of diseases are already grinding to a halt in many countries. For many children, these campaigns are the only chance to get vaccines. Some 13.5 million have already missed out on vaccinations for polio, measles, human papillomavirus, yellow fever, cholera, and meningitis since the suspensions began, Berkley said. “I tell you those numbers will be much larger than what we see today.”

In the case of polio, more children will be paralysed in countries where polio is still circulating, and the virus will likely spread to countries that are now polio-free. The decision couldn’t come at a worse time. The polio eradication effort is already reeling from setbacks in Afghanistan and Pakistan, where the wild virus is surging, and in Africa, where outbreaks caused by the live polio vaccine itself are spiraling out of control. The programme will reassess the decision every two weeks.

A measles expert in in the Global Immunization Division of the U.S. Centers for Disease Control and Prevention (CDC), Robb Linkins, told Science that 23 countries have already suspended their measles campaigns, and as a result, 78 million children will miss out on the vaccine and 16 other countries are still deciding.

Linkins predicts tragic consequences. According to the WHO, in poor countries, the virus can kill three per cent to six per cent of those it infects, with malnourished children especially at risk. Measles infected an estimated 10 million and killed 140,000 in 2018, the last year for which numbers are complete. And because measles is incredibly contagious, case numbers could quickly surge following the suspensions.

Unlike the polio initiative, SAGE stopped short of recommending that countries halt campaigns to quell ongoing measles outbreaks, but it said they should carefully weigh the risk of an immediate response against that of a delayed one. For now, campaigns are continuing in the Democratic Republic of the Congo, where the world’s biggest outbreak has so far killed an estimated 6500 children—far more than the ongoing Ebola outbreak in that country—and sickened more than 340,000.

WHO, GAVI, and other health organisations stressed that routine immunisation of individual children at clinics must continue as much as possible during the coronavirus pandemic. But health systems in many countries were already stretched thin, and protective gear is often lacking. Berkley feared severe disruptions of routine immunisation if health workers are diverted to COVID-19 or become sick or die, or if parents are afraid to bring their children to a clinic.

Vaccines may run out as well. Some countries are already experiencing shortages as flights are grounded and borders close, Berkley said.

Executive Director of the Alliance for International Medical Action, Augustin Augier, said other essential health services would also be disrupted. Every year, ALIMA trains about 500,000 African mothers to diagnose acute, potentially fatal malnutrition in their children; those programs have been suspended. The knock-on consequences of the pandemic “will be much stronger and more lethal for the world’s most vulnerable populations,” Augier said.

Across all these programmes, the goal is to regain lost ground quickly once the pandemic is over. In the meantime, WHO says, countries should continue surveillance for vaccine-preventable diseases to figure out where pathogens are circulating and which children are most at risk. But that, too, is a challenge amid the fear and disruption from COVID-19.

Berkley sees some hope in the experience in West Africa after the 2014–15 Ebola outbreaks. “There was an unprecedented flow of finance and goodwill,” he said. “We did campaigns once Ebola was over and strengthened routine immunization. We not only recovered coverage levels, but exceeded them.” But that epidemic was largely confined to three countries with a combined population of fewer than 25 million people. This time, the entire world is affected.

But the National Primary Health Care Development Agency (NPHCDA), the body in-charge of mass and routine immunisations in Nigeria, has said all Primary Health Care Centres (PHCs) remain open throughout the country, including states with a lockdown order.

Executive Director, NPHCDA, Dr. Faisal Shuaib, told journalists that the outbreak of COVID-19 in the country should not affect the routine services provided by the PHCs and governments at the national, state and local levels have put in place measures for safe delivery of all Primary Health Care services at the PHC centres.

He urged pregnant women to continue to go to the PHCs nearest to them for antenatal care and child birth and parents and caregivers are encouraged to take their children for immunisation, growth monitoring and all other PHC related services. “Please ensure that you take along your hospital cards,” Shuaib said.

The public health expert advised all caregivers, health workers and Nigerians to obey all government guidelines on physical distancing, frequent hand washing with soap and running water, self isolation, among others throughout the period of COVID-19 outbreak.

Indeed, most hospitals are struggling to treat patients with other deadly conditions because of the rise in spread of COVID-19 in the country. One of the biggest hospitals in Nigeria, the Lagos University Teaching Hospital (LUTH) Idi-Araba, last week, said, “We have scaled down the admission of routine cases while all in-patients are being transferred to Block E for ease of care…”

The COVID-19 outbreak has distorted a lot of health services across the world. In order to reduce the effect of the distortion on health services among people in need of regular treatment, WHO has published guidance for countries on how to maintain essential health services even while responding to this crisis.

Meanwhile, according to a report published by the journal Nature, a new case of Ebola has been recorded in the Democratic Republic of the Congo (DRC). It was the first such report in 52 days, and came just two days before the WHO was set to declare the official end of the outbreak.

Already, clinicians and scientists on the frontline of that crisis have shifted their attention to COVID-19. But now, their efforts at the site of the Ebola outbreak must continue, too.

Experts have called the Ebola outbreak, which started in August 2018, one of the most complex health emergencies the world has ever seen because it occurred in a region of the DRC ravaged by decades of war and political instability. More than 2,270 people have died of Ebola — around two-thirds of the outbreak’s reported infections. In addition, armed groups injured more than 70 responders and people with the disease in targeted attacks.