Comment
Inactivated polio vaccine launch in Nepal: a public health milestone On Sept 18, 2014, as part of the Global Polio Eradication Initiative (GPEI), Nepal became the first GAVIsupported country in the world to introduce one dose of inactivated poliomyelitis vaccine (IPV) into routine immunisation schedules at 14 weeks. The launch at Tribhuvan University Teaching Hospital, Kathmandu, is a significant step, but there are challenges ahead. Introduced in 1955, IPV was the first vaccine against polio—its discovery was a great advance in public health.1 Yet, it was eventually the oral polio vaccine (OPV) that became the world’s preferred vaccine because of lower cost, ease and safety of production, a simple route of oral delivery, and its efficacy in stopping virus circulation.2,3 OPV was included in routine immunisation programmes, and the GPEI still uses OPV extensively in supplementary immunisation activities in efforts to eradicate polio. Since 1988, the global incidence of polio has fallen by more than 99%.4 However, in rare cases, OPV can cause vaccineassociated paralytic poliomyelitis (2–4 cases per million birth cohort per year) and circulation of vaccine-derived poliovirus.5 OPV contains certain live attenuated strains of the virus that can sometimes mutate and revert to virulent vaccine-derived poliovirus (mostly type 2 poliovirus), as opposed to IPV which contains fully inactivated or killed strains. As long as live attenuated strains are used in polio vaccines, final eradication cannot occur. IPV therefore mitigates risks posed by OPV. New evidence from India also suggests that when IPV is given to OPV-vaccinated individuals, better immunity is achieved.6 It is no coincidence that Nepal is the first of 72 planned GAVI-funded countries to introduce IPV. After stopping polio transmission in 2000 and responding effectively to subsequent importations from India, the last case was in 2010.7,8 Nepal also has a high-performing immunisation programme, with coverage rising from 43% in 1990 to 90% in 2012.9 The immunisation programme has strong political commitment, and effective partnerships between government, civil society, and international organisations including WHO, UNICEF, Rotary International, GAVI, and USAID. Professional associations have had a pivotal role: the Nepal Paediatric www.thelancet.com/lancetgh Vol 2 November 2014
Society and the Society of Public Health Physicians Nepal were advocates for the introduction of IPV. But there are challenges ahead with IPV introduction, and carefully crafted and field-tested communication efforts are needed to explain the issues to the public and professionals alike. First, the introduction of the new vaccine is to be used alongside an existing vaccine for the same disease. One dose of IPV is to be introduced in parallel with OPV to particularly bolster immunity to type 2 poliovirus (type 2 causes most of the current vaccine-related problems). Subsequently there will be a switch in the kind of OPV from that containing type 1, 2, and 3 poliovirus (trivalent OPV) to one without type 2 (bivalent OPV). Once virus circulation has been stopped everywhere, OPV can be withdrawn. The science is complex and a challenge to explain to the medical profession and caregivers. In Nepal, media outlets gave an early sense of how the lay public could respond to IPV. One noted that IPV was “the latest antidote to polio” and reported an expert as saying that it “[boosted] immune system big time”.10 Another source ran with the headline: “Polio vaccination to be intravenous”,11 perhaps confusing the inactivated strains in IPV given intramuscularly. Second, in most countries, new vaccines mean either more injections in a given immunisation session, or more sessions. Multiple injections at the same time pose logistical and communication challenges, and have opportunity costs. Health professionals might worry about parental concerns and caregivers might in some circumstances object to more injections for a distressed child.12 Alternatively, increasing the number of visits could lead to increased dropout rates. IPV is best given at 14 weeks. But to avoid three injections at 14 weeks (IPV, pneumococcal conjugate vaccine, and pentavalent vaccine [diphtheria, tetanus, pertussis, hepatitis B, and Haemophilus influenzae type b]), Nepal has decided to give the second dose of pneumococcal conjugate vaccine at 10 weeks, despite it being potentially less effective than at 14 weeks. Third, currently in south Asia about 8 million children have not had a third dose of diphtheria, tetanus, and pertussis vaccine in their first year of life9—these are e627
Comment
often the most deprived and hardest to reach groups. In Nepal, reaching children in remote mountainous areas poses particular challenges. Addition of new vaccines, without improving and expanding the supply chain, risks stretching public health systems to the limit. Finally, in Nepal the success of polio eradication has resulted in public support for immunisation; communities play their part to ensure every child is vaccinated. For governments like Nepal’s, IPV introduction might be mainly about the start of final polio eradication by working towards removing live attenuated polio vaccines. But the public might already regard polio as eradicated and not understand the need for IPV. The Maldives is planing to be the next country in south Asia to introduce IPV. After that, the rest of the region is due to follow, including Bangladesh, Pakistan, Afghanistan, and India. All have significant public health challenges. It is crucial that countries share lessons learned as IPV is rolled out, including how to address its challenges.
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The opinions expressed in this paper are solely those of the authors and do not necessarily represent the official position of UNICEF. We declare no competing interests. © Copyright Hasman et al. Open access article published under the terms of CC BY-NC-ND. 1 2
3
4
5 6 7 8
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Andreas Hasman, Hendrikus C J Raaijmakers, *Douglas J Noble
11
UNICEF Regional Office for South Asia, Lekhnath Marg, PO Box 5815, Kathmandu, Nepal (AH, DJN); and UNICEF Nepal Country Office, UN House, Pulchowk, Kathmandu, Nepal (HCJR) [email protected]
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Oshinsky, David M. Polio: an American story. New York: Oxford University Press, 2005. Offit, Paul A. The Cutter incident: how America’s first polio vaccine led to the growing vaccine crisis. New Haven and London: Yale University Press, 2007. Global Polio Eradication Initiative. Oral polio vaccine (OPV). http://www. polioeradication.org/Polioandprevention/Thevaccines/ Oralpoliovaccine(OPV).aspx (accessed Sept 22, 2014). Global Polio Eradication Initiative. Polio eradication and endgame strategic plan 2013–2018. http://www.polioeradication.org/resourcelibrary/ strategyandwork.aspx (accessed Oct 8, 2014). WHO. Polio vaccines: WHO position paper. Wkly Epidemiol Rec. 2014; 89: 73–92. JJafari H, Deshpande JM, Sutter RW, et al. Efficacy of inactivated poliovirus vaccine in India. Science 2014; 345: 922–25. Kew O. Reaching the last one per cent: progress and challenges in global polio eradication. Curr Opin Virol 2012; 2: 188–98. WHO. WHO vaccine-preventable diseases monitoring system: 2014 global summary. http://apps.who.int/immunization_monitoring/ globalsummary/countries?countrycriteria%5Bcountry%5D%5B%5D=NPL (accessed Sept 22, 2014). UNICEF South Asia. Improving children’s lives, transforming the future: 25 years of child rights in South Asia. http://generation25.org/wp-content/ uploads/2014/09/Improving-Children-s-Lives-Transforming-the-Future. pdf (accessed Sept 22, 2014). Anon. Nepal becomes first in SE Asia to administer IPV. Republica Sept 18, 2014. http://www.myrepublica.com/portal/index.php?action=news_ details&news_id=83400 (accessed Sept 22, 2014). Anon. Polio vaccination to be intravenous. EKantipur Sept 16, 2014. http:// www.ekantipur.com/2014/09/16/capital/polio-vaccination-to-beintravenous/395118.html (accessed Sept 22, 2014). Wallace AS, Mantel C, Mayers G, Mansoor O, Gindler JS, Hyde TB. Experiences with provider and parental attitudes and practices regarding the administration of multiple injections during infant vaccination visits: lessons for vaccine introduction. Vaccine 2014; 32: 5301–10.
www.thelancet.com/lancetgh Vol 2 November 2014
Inactivated polio vaccine launch in Nepal: a public health milestone On Sept 18, 2014, as part of the Global Polio Eradication Initiative (GPEI), Nepal became the first GAVIsupported country in the world to introduce one dose of inactivated poliomyelitis vaccine (IPV) into routine immunisation schedules at 14 weeks. The launch at Tribhuvan University Teaching Hospital, Kathmandu, is a significant step, but there are challenges ahead. Introduced in 1955, IPV was the first vaccine against polio—its discovery was a great advance in public health.1 Yet, it was eventually the oral polio vaccine (OPV) that became the world’s preferred vaccine because of lower cost, ease and safety of production, a simple route of oral delivery, and its efficacy in stopping virus circulation.2,3 OPV was included in routine immunisation programmes, and the GPEI still uses OPV extensively in supplementary immunisation activities in efforts to eradicate polio. Since 1988, the global incidence of polio has fallen by more than 99%.4 However, in rare cases, OPV can cause vaccineassociated paralytic poliomyelitis (2–4 cases per million birth cohort per year) and circulation of vaccine-derived poliovirus.5 OPV contains certain live attenuated strains of the virus that can sometimes mutate and revert to virulent vaccine-derived poliovirus (mostly type 2 poliovirus), as opposed to IPV which contains fully inactivated or killed strains. As long as live attenuated strains are used in polio vaccines, final eradication cannot occur. IPV therefore mitigates risks posed by OPV. New evidence from India also suggests that when IPV is given to OPV-vaccinated individuals, better immunity is achieved.6 It is no coincidence that Nepal is the first of 72 planned GAVI-funded countries to introduce IPV. After stopping polio transmission in 2000 and responding effectively to subsequent importations from India, the last case was in 2010.7,8 Nepal also has a high-performing immunisation programme, with coverage rising from 43% in 1990 to 90% in 2012.9 The immunisation programme has strong political commitment, and effective partnerships between government, civil society, and international organisations including WHO, UNICEF, Rotary International, GAVI, and USAID. Professional associations have had a pivotal role: the Nepal Paediatric www.thelancet.com/lancetgh Vol 2 November 2014
Society and the Society of Public Health Physicians Nepal were advocates for the introduction of IPV. But there are challenges ahead with IPV introduction, and carefully crafted and field-tested communication efforts are needed to explain the issues to the public and professionals alike. First, the introduction of the new vaccine is to be used alongside an existing vaccine for the same disease. One dose of IPV is to be introduced in parallel with OPV to particularly bolster immunity to type 2 poliovirus (type 2 causes most of the current vaccine-related problems). Subsequently there will be a switch in the kind of OPV from that containing type 1, 2, and 3 poliovirus (trivalent OPV) to one without type 2 (bivalent OPV). Once virus circulation has been stopped everywhere, OPV can be withdrawn. The science is complex and a challenge to explain to the medical profession and caregivers. In Nepal, media outlets gave an early sense of how the lay public could respond to IPV. One noted that IPV was “the latest antidote to polio” and reported an expert as saying that it “[boosted] immune system big time”.10 Another source ran with the headline: “Polio vaccination to be intravenous”,11 perhaps confusing the inactivated strains in IPV given intramuscularly. Second, in most countries, new vaccines mean either more injections in a given immunisation session, or more sessions. Multiple injections at the same time pose logistical and communication challenges, and have opportunity costs. Health professionals might worry about parental concerns and caregivers might in some circumstances object to more injections for a distressed child.12 Alternatively, increasing the number of visits could lead to increased dropout rates. IPV is best given at 14 weeks. But to avoid three injections at 14 weeks (IPV, pneumococcal conjugate vaccine, and pentavalent vaccine [diphtheria, tetanus, pertussis, hepatitis B, and Haemophilus influenzae type b]), Nepal has decided to give the second dose of pneumococcal conjugate vaccine at 10 weeks, despite it being potentially less effective than at 14 weeks. Third, currently in south Asia about 8 million children have not had a third dose of diphtheria, tetanus, and pertussis vaccine in their first year of life9—these are e627
Comment
often the most deprived and hardest to reach groups. In Nepal, reaching children in remote mountainous areas poses particular challenges. Addition of new vaccines, without improving and expanding the supply chain, risks stretching public health systems to the limit. Finally, in Nepal the success of polio eradication has resulted in public support for immunisation; communities play their part to ensure every child is vaccinated. For governments like Nepal’s, IPV introduction might be mainly about the start of final polio eradication by working towards removing live attenuated polio vaccines. But the public might already regard polio as eradicated and not understand the need for IPV. The Maldives is planing to be the next country in south Asia to introduce IPV. After that, the rest of the region is due to follow, including Bangladesh, Pakistan, Afghanistan, and India. All have significant public health challenges. It is crucial that countries share lessons learned as IPV is rolled out, including how to address its challenges.
e628
The opinions expressed in this paper are solely those of the authors and do not necessarily represent the official position of UNICEF. We declare no competing interests. © Copyright Hasman et al. Open access article published under the terms of CC BY-NC-ND. 1 2
3
4
5 6 7 8
9
10
Andreas Hasman, Hendrikus C J Raaijmakers, *Douglas J Noble
11
UNICEF Regional Office for South Asia, Lekhnath Marg, PO Box 5815, Kathmandu, Nepal (AH, DJN); and UNICEF Nepal Country Office, UN House, Pulchowk, Kathmandu, Nepal (HCJR) [email protected]
12
Oshinsky, David M. Polio: an American story. New York: Oxford University Press, 2005. Offit, Paul A. The Cutter incident: how America’s first polio vaccine led to the growing vaccine crisis. New Haven and London: Yale University Press, 2007. Global Polio Eradication Initiative. Oral polio vaccine (OPV). http://www. polioeradication.org/Polioandprevention/Thevaccines/ Oralpoliovaccine(OPV).aspx (accessed Sept 22, 2014). Global Polio Eradication Initiative. Polio eradication and endgame strategic plan 2013–2018. http://www.polioeradication.org/resourcelibrary/ strategyandwork.aspx (accessed Oct 8, 2014). WHO. Polio vaccines: WHO position paper. Wkly Epidemiol Rec. 2014; 89: 73–92. JJafari H, Deshpande JM, Sutter RW, et al. Efficacy of inactivated poliovirus vaccine in India. Science 2014; 345: 922–25. Kew O. Reaching the last one per cent: progress and challenges in global polio eradication. Curr Opin Virol 2012; 2: 188–98. WHO. WHO vaccine-preventable diseases monitoring system: 2014 global summary. http://apps.who.int/immunization_monitoring/ globalsummary/countries?countrycriteria%5Bcountry%5D%5B%5D=NPL (accessed Sept 22, 2014). UNICEF South Asia. Improving children’s lives, transforming the future: 25 years of child rights in South Asia. http://generation25.org/wp-content/ uploads/2014/09/Improving-Children-s-Lives-Transforming-the-Future. pdf (accessed Sept 22, 2014). Anon. Nepal becomes first in SE Asia to administer IPV. Republica Sept 18, 2014. http://www.myrepublica.com/portal/index.php?action=news_ details&news_id=83400 (accessed Sept 22, 2014). Anon. Polio vaccination to be intravenous. EKantipur Sept 16, 2014. http:// www.ekantipur.com/2014/09/16/capital/polio-vaccination-to-beintravenous/395118.html (accessed Sept 22, 2014). Wallace AS, Mantel C, Mayers G, Mansoor O, Gindler JS, Hyde TB. Experiences with provider and parental attitudes and practices regarding the administration of multiple injections during infant vaccination visits: lessons for vaccine introduction. Vaccine 2014; 32: 5301–10.
www.thelancet.com/lancetgh Vol 2 November 2014
