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I declare that I have no competing interests.

the priority. These problems include still-rampant malnutrition, poor water and sanitation, and eventually lifestyle behaviours underlying noncommunicable disease and injury. Unfortunately most people conceive of universal health coverage as universal clinical care access. Hopefully, Bangladesh will conceive of universal health coverage in a larger sense that continues to put health itself, rather than medical care, at the forefront. I declare that I have no competing interests. The views expressed do not necessarily reflect those of USAID.

James D Shelton [email protected] USAID, Washington, DC 20523, USA 1

Jon E Rohde [email protected] James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh 1

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Chowdhury AMR, Bhuiya A, Chowhury ME, Rasheed S, Hussain Z, Chen LC. The Bangladesh paradox: exceptional health achievement despite extreme poverty. Lancet 2013; 382: 1734–45. Jolly R, ed. Jim Grant: UNICEF visionary. Florence, Italy: UNICEF Innocenti Research Centre, 2001.

Health achievement in Bangladesh as described by Chowdhury and colleagues 1 has indeed been exceptional. But it is ironic that universal health coverage is portrayed as the eventual desired culmination of that progress. Whereas universal health coverage is something of a diffuse concept,2 in practice it typically appears predominantly to mean access (coverage) to the full range of clinical, largely curative medical care. In contrast, as Chowdhury and colleagues1 describe, Bangladesh has successfully taken a rather different course: one that emphasises prevention and non-clinical outreach, community, and social marketing approaches, prioritising such interventions as oral hydration, family planning, vitamin A supplementation, and immunisation. Whereas medical care is important, clearly problems largely outside the medical realm but amenable to further public health approaches must remain www.thelancet.com Vol 383 March 22, 2014

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Chowdhury AMR, Bhuiya A, Chowhury ME, Rasheed S, Hussain Z, Chen LC. The Bangladesh paradox: exceptional health achievement despite extreme poverty. Lancet 2013; 382: 1734–45. O’Connell T, Rasanathan K, Chopra M. What does universal health coverage mean. Lancet 2014; 383: 277–79.

Chowdhury and colleagues1 provided a remarkably positive review of Bangladesh’s health systems performance and health outcomes, in which maternal and child health status improved throughout the country. The authors noted that disease burden shifted rapidly from communicable to non-communicable disease (NCD); however, they overlooked the economic burden of these illnesses and health financing performance. Although some developments have been observed in health-care service delivery in Bangladesh, to date, the health financing system remains very poorly designed. More than twothirds of total expenditure is privately financed through out-of-pocket payments. Households in Bangladesh are facing the highest incidence of financial catastrophe (18%) among the Asia-Pacific region and more than 12% of households are forced to adopt distress financing to pay for health care related to major communicable diseases and chronic NCDs.2,3 Despite these enormous challenges, the Government of Bangladesh has neither taken comprehensive action

nor made any concrete future plans to adopt health insurance schemes in their health financing system. Although Bangladesh has a similar sociodemographic profile to countries such as Vietnam and Sri Lanka, these countries’ social insurance systems are now being extended and the burden of out-of-pocket payment has declined significantly since the introduction of these insurance systems,4 whereas in Bangladesh there is no national health insurance nor is the private insurance market well developed. Only small NGO-based insurance schemes exist, and they have not reduced the burden of out-of-pocket payments.5 Therefore, the government should give more attention to NCD management programmes and incorporate health insurance in health financing systems.

Shafiqul Alam/Demotix/Corbis

confidence, hope, and determination. Whereas simultaneously confronting the multiple and sometimes overwhelming challenges of a comprehensive programme can lead to low coverage, low morale, and a pervasive sense of failure. The substantial achievements of Bangladesh, against great odds, are based on a willingness to take problems one at a time and a commitment to reach everyone with the solution. If this is “vertical programming” then so be it. Examples of planned development efforts that have succeeded on this scale are not so many that we can ignore an approach that has manifestly worked.

I declare that I have no competing interests.

Md Mizanur Rahman [email protected] Population Science and Human Resource Development, University of Rajshahi, Rajshahi 6205, Bangladesh; and Department of Global Health Policy, University of Tokyo, Tokyo, Japan 1

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Chowdhury AM, Bhuiya A, Chowdhury ME, Rasheed S, Hussain Z, Chen LC. The Bangladesh paradox: exceptional health achievement despite economic poverty. Lancet 2013; 382: 1734–45. Rahman MM, Gilmour S, Saito E, Sultana P, Shibuya K. Health-related financial catastrophe, inequality and chronic illness in bangladesh. PloS One 2013; 8: e56873. Rahman MM, Gilmour S, Saito E, Sultana P, Shibuya K. Self-reported illness and healthcare payment coping strategies in Bangladesh. Bull World Health Organ 2013; 91: 449–58. Lagomarsino G, Garabrant A, Adyas A, Muga R, Otoo N. Moving towards universal health coverage: health insurance reforms in nine developing countries in Africa and Asia. Lancet 2012; 380: 933–43. Werner WJ. Micro-insurance in Bangladesh: risk protection for the poor? J Health Popul Nutr 2009; 27: 563–73.

Should we use oral polio vaccine in Europe? The eradication of polio, the ultimate goal set by WHO in 1988, has not been achieved despite massive use of oral polio vaccine (OPV). Polio is still endemic in Afghanistan, Nigeria, and Pakistan, and circulation of wild 1037

Correspondence

poliovirus has recently been reported in Syria and Israel. “Polio risk looms over Europe”, warned Declan Butler,1 surveillance and vaccination rates are suboptimal in many European countries, and there is a risk for transmission of polio to Europe from Syria or Israel.2 Since 2005, only inactivated polio vaccine (IPV) has been used for routine childhood immunisation in Israel. Although no paralytic cases were reported in the country, in February, 2013, environmental surveillance suggested wildtype poliovirus 1 transmission.3 Therefore, a nationwide supplementary immunisation with bivalent OPV targeting children was instituted. Recently, the Israeli Ministry of Health decided to re-introduce OPV into the national immunisation schedule. If OPV was recommended for Europe, it will be a cause for concern. Most European countries use only IPV for immunisation and eradication of polio. IPV vaccination provides good individual protection against polio and, if the vaccination rate is sufficiently high, unvaccinated individuals are also protected by herd immunity. By contrast, a suboptimal vaccination coverage using OPV might be disastrous, since circulating OPV strains might revert to virulent poliovirus as seen in Haiti.4 IPV-vaccinated individuals, like unvaccinated individuals, might excrete wild poliovirus during an outbreak—as seen in Israel.3 However, the duration of excretion is inversely related to the serum titres of virus neutralising IgG and IgA antibodies, the higher the titre, the shorter the excretion period. 5 OPV stimulates protective intestinal immune responses, but does not eliminate faecal excretion and transmission of virus. The presence and circulation of vaccine virus complicates the polio surveillance programme. Polio eradication demands elimination of both wild type and vaccine-derived virus. 1038

Europe has been free of polio since 2002, and the threat of epidemics no longer seems a reality. Therefore, a high vaccination acceptance rate can only be achieved by information about the risk of epidemic polio. Vaccine virus reverting to virulence at OPV mass vaccination will unavoidably cause vaccine-derived polio cases, which would affect acceptance rates negatively. We want to emphasise that IPV immunisation is preferable because many of the problems associated with OPV will be avoided and ask the European Centre for Disease Prevention and Control6 to carefully consider the choice of vaccine before any recommendations in Europe are set. We declare that we have no competing interests.

Erik Lycke, Lars O Magnius, *Helene Norder [email protected] Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden (EL); Karolinska Insitutet, Stockholm, Sweden (LOM); and Department of Clinical Microbiology-Virology, Sahlgrenska University Hospital, Gothenburg 41345, Sweden (HN) 1

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Butler D. Polio risk looms over Europe. Cases in Syria highlight vulnerability of nearby countries to the viral disease. Nature 2013; 502: 601–02. Eichner M, Brockmann SO. Polio emergence in Syria and Israel endangers Europe. Lancet 2013; 382: 1777. European Centre for Disease Prevention and Control. Wild-type poliovirus 1 transmission in Israel—what is the risk to the EU/EEA? http:// ecdc.europa.eu/en/publications/Publications/ polio-risk-assessment-transmission-in-Israel. pdf (accessed March 6, 2014). Kew O, Morris-Glasgow V, Landaverde M, et al. Outbreak of poliomyelitis in Hispaniola associated with circulating type 1 vaccinederived poliovirus. Science 2002; 296: 356–59. Buisman AM, Abbink F, Schepp RM, Sonsma JA, Herremans T, Kimman TG. Preexisting poliovirus-specific IgA in the circulation correlates with protection against virus excretion in the elderly. J Infect Dis 2008; 197: 698–706. Celentano LP, Lopalco PL, Huitric E, Coulombier D, Giesecke J. Polio and the risk for the European Union. Lancet 2014; 383: 216–17.

Authors’ reply

transmission in Israel and Syria.1 They outline the reasons why European countries should use inactivated polio vaccine (IPV) for routine vaccination. ECDC fully supports the recommendation by Global Polio Eradication Initiative to replace oral polio vaccine (OPV) with IPV for routine vaccination.2 Already, among the 28 European Union (EU) Member States, and Iceland and Norway, only one country routinely uses OPV and that is for a single booster dose at 6 years, after a child has been fully vaccinated with IPV.3 ECDC has also stated that IPV can be used in the control of limited outbreaks in the EU where vaccine coverage, sanitation standards, and hygiene levels are high. These opinions have been published in an ECDC technical report and in the conclusions of a technical experts meeting that was convened by ECDC in November, 2013.4,5 The use of OPV in the EU would be warranted in a polio outbreak where there is evidence of sustained person-toperson transmission or continuous environmental contamination. We agree with Lycke and colleagues that polio eradication demands elimination of both wild and vaccine derived virus. We declare that we have no competing interests.

Elizabeth A Bancroft, Paloma Carrillo-Santisvere, *Lucia P Celentano, Niklas Danielsson, Johan Giesecke [email protected] European Centre for Disease Prevention and Control, Stockholm SE-171 83, Sweden 1

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Erik Lycke and colleagues call upon the European Centre for Disease Prevention and Control (ECDC) to carefully consider the choice of polio vaccine before making recommendations for Europe in light of recent identification of poliovirus

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Celentano LP, Lopalco PL, Huitric E, Coulombier D, Giesecke J. Polio and the risk for the European Union. Lancet 2014; 383: 216–17. Global Polio Eradication Initiative. Polio eradication and endgame strategic plan 2013–2018. http://www.polioeradication.org/ Resourcelibrary/Strategyandwork.aspx (accessed Feb 12, 2014). European Centre for Disease Prevention and Control. Vaccine schedule. http://vaccineschedule.ecdc.europa.eu/Pages/Scheduler.aspx (accessed Feb 12, 2014). European Centre for Disease Prevention and Control. Detection and control of poliovirus transmission in the European Union and European Economic Area. http://ecdc.europa.eu/ en/publications/Publications/polio-detectioncontrol-EU.pdf (accessed March 6, 2014).

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Should we use oral polio vaccine in Europe?

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