WHO Reports Polio Setback

At the same time that some countries are complaining that the polio vaccine is dangerous, the World Health Organization announced in January that new cases of polio had been discovered in two African countries where WHO had previously labeled the disease as eradicated.

Polio cases were discovered in both Benin and Cameroon in early January, apparently having spread from Nigeria. Nigeria still experiences about 300 cases of polio annually and Muslim leaders in northern Nigeria have led a local fight against the polio vaccine saying it contains hormones that are used to sterilize girls.

Sources:

West Africa Polio Cases a Setback for WHO’s Eradication Plan. UN Wire, January 12, 2004.

UN says polio is spreading to countries where it had been eradicated. Press Release, United Nations, January 9, 2004.

WHO Launches Cholera Vaccination Test in Mozambique

In January the World Health Organization announced it was launching its efforts at mass vaccination against cholera using a new oral vaccine against the disease.

For this demonstration project, WHO is focusing on Mozambique which has been hit particularly hard by the disease in recent years. In 1999, it reported 45,000 cases out of a world total that usually hovers between 100,000-200,000 annually.

The vaccination project will focus on the city of Beria and will vaccinate about 50,000 of the half million people living there against the disease. WHO will be able to gauge the success of its efforts there in early 2005.

Should the vaccine prove effective, it is likely to play a key role in reducing worldwide cholera incidence.

Source:

WHO launches first oral-vaccination cholera campaign. UN Wire, January 15, 2004.

Mozambique mass campaign tests the theory. Press Release, World Health Organization, January 14, 2004.

Article Critical of World Health Organization’s Anti-Malaria Approach

Amir Attaran, who has been highly critical of donor organization’s approach to malaria control, published an opinion article in The Lancet in January arguing that “institutional inadequacies” in the World Health Organization’s anti-malaria efforts impede the organization’s ability to save lives from the disease.

Specifically, Attaran argues that by favoring expensive traditional malaria therapies over newer, more effective — but more expensive –treatments such as artemisinin combination therapies, the WHO is guilty of the equivalent of “medical malpractice.”

Attaran notes that WHO itself concedes that the drugs it using in Africa are growing increasingly ineffective,

WHO now writes of “global malaria control . . . being threatened on an unprecedented scale” by continued use of outdated drugs such as chloroquine, which is ineffective in most parts of Africa, and sulfadoxine-pyrimethamine, which is becoming so. For example, in East Africa, surveillance and clinical trial data show that up to 64% of patients given chloroquine and 45% given sulfadoxine-pyrimethamine will fail treatment, and those figures are climbing.

When treatment failure becomes so frequent, malaria deaths rise greatly, especially in children. In West Africa (Senegal), results of a 12-year community-based study showed that the onset of chloroquine resistance at least doubled childhood malaria death risk, and in some sites, increased it up to 11-fold in the youngest children. In East and southern Africa, the proportion of children dying from malaria doubled as chloroquine and later sulfadoxine-pyrimethamine resistance took hold from the 1980s to the 1990s, even as deaths from other causes declined. Elsewhere in Africa, chloroquine resistance increased the proportion of admissions to hospital and deaths from malaria by two-fold to four-fold.

Moreover, Attaran argues,

The superiority of ACT is now so established that of the five treatments WHO recommends for drug resistant P falciparum malaria, four are ACTs (the other is a “short-term solution” for countries that cannot use ACT immediately).3 ACT is now the preferred policy for WHO and the Roll Back Malaria campaign as a whole:

“Recently WHO has formulated policy that elevates combination drug therapy to preferred first therapy for all malaria infections in areas where P falciparum is the predominant infecting species of malaria. Combination therapy (CT) with formulations containing an artemisinin compound (ACT) is the policy standard . . .”22

However, WHO violates its own policy standard regularly. Most African countries reluctantly cling to chloroquine, sulfadoxine-pyrimethamine, or the insignificantly better combination of chloroquine and sulfadoxine-pyrimethamine, because ACT is ten times more expensive and, therefore, unaffordable to them.2,23 When those same countries seek financial aid from the Global Fund for AIDS, Tuberculosis, and Malaria (GFATM) to purchase ACT, they are forcefully pressured out of it by governments such as the USA, whose aid officials say that ACT is too expensive and “not ready for prime time”.24 WHO acquiesces to this pressure to cut costs, and despite a policy that names ACT as the gold standard of treatment, WHO signs its approval when GFATM funds cheap but ineffective chloroquine or sulfadoxine-pyrimethamine to treat P falciparum malaria.

. . .

These are very obvious errors of scientific and medical judgment; and although WHO might be expected to spearhead a corrective intervention, the evidence suggests that it instead exacerbated the errors. In Kenya, Ethiopia, and Uganda, WHO’s country representatives reviewed the funding proposals in which inappropriate drugs were sought–and signed their approval. Those signatures follow a declaration that WHO “has participated throughout the . . . process” of developing the proposal to GFATM, and that it “reviewed the final proposal and [is] happy to support it”.31-33

These decisions are indefensible. For WHO and GFATM to provide chloroquine and sulfadoxine-pyrimethamine treatments in the countries we cite as examples at least wastes precious international aid money, and at most, kills patients who have malaria. If one takes the measured increase in childhood malaria mortality that follows P falciparum drug resistance (two-fold to 11-fold) and extrapolates it to populations in which GFATM is funding chloroquine or sulfadoxine-pyrimethamine despite resistance (more than 100 million people in the four countries we name), then at least tens of thousands of children die every year as a direct result. Those patients who survive will often become much sicker and require retreatment, at some further expense of time and money. We do not exaggerate to state that, based on the outcomes, there is no ethical or legal difference that separates them from conduct otherwise condemned as medical malpractice (compare the case in which a doctor or pharmacist who, like these institutions, knowingly furnished treatments that failed perhaps 80% of the time, while withholding the alternatives as “too expensive”).

WHO responded with a letter to Lancet saying that it does encourage use of ACT, but that its high cost has hampered efforts to distribute it in Africa,

Although progress is encouraging, there are still major challenges to the adoption of ACTs, especially sustainable financing. Although with growing demand a price decrease can be expected in the coming years, the cost of growing the raw ingredient, Artemisia annua, means that ACTs will remain relatively expensive. Governments need to trust that sustainable funding from the Global Fund and other sources will be available before they can make the commitment–of up to US$2 per head per year–of switching to ACTs. WHO and its partners are developing a new mechanism to facilitate access to quality medicines and other products for malaria control. WHO will continue to work with the public and private sectors, and major institutions such as the Global Fund, to make ACTs more widely available through lowered costs, increased access, and technical cooperation.

The bigger problem is that so little money is devoted worldwide to fighting malaria.

Sources:

WHO, the Global Fund, and medical malpractice in malaria treatment. Amir Attaran, et al, The Lancet 2004; 363: 237-40.

Response to accusations of medical malpractice by WHO and the Global Fund. Fatoumata Nafo-Traoré, The Lancet 2004; 363.

WHO Release Report on Maternal Mortality Around the World

In October the World Health Organization released its estimates of the continued prevalence of maternal mortality. WHO estimates that worldwide 529,000 women die during childbirth.

Not surprisingly, 95 percent of those childbirth deaths occur in Africa and Asia, while only about 2,500 maternal deaths (less than one percent of the world total) occurred in developed countries.

In the United States, for example, the risk of dying during childbirth was 1 in 2,500. In Sweden it reached an astounding low of 1 in 29,800. But in places like Afghanistan and Sierra Leone, the risk was 1 in 6, while in Angola, Malawai and Niger the risk was 1 in 7.

In the developed world, the lifetime risk of a woman dying during childbirth as 1 in 2,800, while in developing countries it was 1 in 61. For Africa as a whole, the life time risk was 1 in 20.

Not surprisingly, the World Health Organization fond that lack of access to quality medical care was the major cause of most maternal deaths.

Source:

Africa childbirth deaths ‘unacceptable’. The BBC, October 20, 2003.

Fears of Polio Vaccine Grip Nigeria

The World Health Organization’s goal of eradicating polio worldwide by 2005 ran into a major obstacle in October 2003 when three Nigerian states suspended polio vaccination over fears that the vaccine could cause AIDS, cancer and infertility.

The largely-Muslim northern states of Kaduna, Kano and Zamfra ordered a stop to a WHO-sponsored vaccination program. Reuters quoted Dr. Datti Ahmed, president of Nigeria’s Supreme Council for Sharia Law, as saying,

A lot of documents have come into our possession indicating there are grave doubts and concerns about the safety of the oral polio vaccine being used in Nigeria. We therefore called on the authorities to suspend the immunization program and investigate these fears.

WHO representatives dismissed such objections saying the polio vaccine was safe.

Unfortunately, Nigeria is one of only 7 countries where the disease is still prevalent and many children there are not vaccinated. Authorities worry that the disease could expand from Nigeria into surrounding countries. According to WHO representative Dr. David Heymann,

In some parts of Nigeria, only 13 percent of children have been vaccinated, largely because of the fears about it that have been disseminated. Nigeria is now exporting the disease. It has already cost Nigeria’s five neighbors $13 million to launch their own campaigns against it and that could go up to $20 million if it is confirmed that Chad has cases.

The government set up a group to test the polio virus, but that group dealt another setback to the polio eradication in January when it issued results claiming it found high levels of estrogen in the polio vaccine which would render those who received the vaccine infertile.

Both the WHO and the Nigerian state dismissed these claims, but WHO’s efforts to vaccinate children in Nigeria appears to have been severely set back which bodes ill both for the children there who are unnecessarily exposed to the risk of contracting polio as well as neighboring states and the rest of the world that would like to see polio eradicated.

Source:

Health experts losing battle to promote polio vaccine in Nigeria. AFP, Friday January 9, 2004.

Nigeria orders polio vaccine tests. Associated Press, October 29, 2003.

Nigeria debates polio campaign. Anna Borzello, The BBC, December 22, 2003.

New WHO Chief Pledges to Make Polio Eradication a Priority

Newly installed World Health Organization director-general Jong-wook Lee pledged to step up efforts to eradicate polio by 2005, but the WHO might not have the funds to follow up on Lee’s pledge.

In a July press release, Lee said,

Polio eradication is a top priority. I want to see this disease gone once and for all. We have eliminated it from almost every country in the world. Now is the time to boost our action and resolve, and wipe it out everywhere. I am immediately upgrading WHOÂ’s capacity to support India, Nigeria, Pakistan and Egypt in their efforts to immunize every child against polio.”

Lee appointed SARS expert David Heymann to head up WHO’s polio eradication efforts who noted the dangers of not eradicating polio as soon as possible,

Just as with SARS, polio knows no boundaries. In January, a child was paralyzed by polio in Lebanon for the first time in ten years. That virus travelled from India. Unless we stop transmission in the remaining polio-endemic countries, polio will spread to other countries and paralyze children, potentially reversing the gains already made.

But the WHO is also begging for money, claiming that it needs an additional $210 million for polio eradication efforts or it might have to scale back its efforts to fight the disease.

In 2002, there were less than 2,000 reported cases of polio worldwide and the disease is only present in seven countries. Lee argues it would be well worth the money to eradicate the disease worldwide once and for all.

Source:

WHO faces $210M shortfall in polio fight. Jonathan Fowler, Associated Press, July 29, 2003.

WHO steps up polio fight. The BBC, July 29, 2003.

New WHO Director-General steps up global polio eradication effort, as polio threatens other countries. Press Release, World Health Organization, July 29, 2003.

World Health Organization seeks eradication of polio by 2005. Lawrence K. Altman, New York Times, July 29, 2003.