December 9, 2013
On November 26th, the World Health Organization announced it had documented two additional cases of polio in Aleppo and the Damascus suburbs in addition to 15 documented cases in the eastern province of Deir e-Zor in late October.
The first appearance of the disease in Syria since 1999, the continued breakdown of Syria’s medical services and government blockades of rebel-held area are all inhibiting vaccination against the incurable disease, which can paralyze a child under age five within an hour. The disease shows symptoms in just one of 200 infected children, making it difficult to contain as seven million Syrians are currently internally displaced or have fled the nation as refugees.
To combat the outbreak, UNICEF and the WHO are kicking off the second part of a campaign Monday to vaccinate 23 million children across the Middle East, including 2.2 million in Syria.
Oliver Rosenbauer is a spokesperson at the World Health Organization’s Global Polio Eradication department, which is documenting and responding to polio outbreaks in Syria and the horn of Africa, as well as combatting the disease in Pakistan, Afghanistan and Nigeria, where it is in endemic.
He spoke with Syria Direct’s Elizabeth Parker-Magyar about the virus’s origins in Pakistan and why he believes the polio outbreak is a problem “not only for Syria but right across the entire region.”
Q: I’ve read that only one in 200 children who carries polio actually shows symptoms. Does this mean the number of carriers is significantly higher than the World Health Organization’s 17 confirmed cases?
A. That’s right. That’s the nature of the disease. So if you have 200 children or individuals who haven’t been vaccinated and who are all infected with polio, you’re going to see one case with symptoms, and the other 199 are not going to have any symptoms at all. So they won’t even know that they are infected with the polio virus. And of course as they travel, they can bring the polio virus with them without even knowing it. By the time we find a single case, the horse is out of the barn, so to speak, we have to assume that there’s widespread transmission.
That’s why we have this recognition that this is not a problem for Deir e-Zor province, where most of the cases have been reported from, but with all the large-scale population movements happening right across the Middle East. This is really a Middle East problem. There’s a real risk that this could spread to other areas, and that’s why the response that’s being planned is not for that particular province, it’s not only for Syria,but right across the entire region.
A Syrian child receives drops of a polio vaccine.
Q: So to clarify – if you confirm 10 cases, there are 2,000 carriers? The WHO is only confirming cases where children are actually showing symptoms.
A. That’s right, the other 2,000 people, or 1,990 people, are not going to have symptoms but they could be carriers.
Q: How fast does polio typically spread and how serious is this outbreak? How does this compare to other outbreaks, and is there a critical number at which the outbreak is unable to be contained?
A. Well, I mean, outbreaks — we consider a single case an outbreak because of what we’ve talked about, you have 200 other infections. It’s very widespread. In terms of how long it can circulate, it all depends how quickly you build up immunity levels. Polio eradication from a medical point of view is not particularly complicated – if you vaccinate enough kids, the virus disappears.
What is complicated is that in some areas kids are not getting vaccinated, for whatever reason. The polio virus doesn’t much care what those reasons are. Because of conflict, you have access problems, in other areas it’s a lack of infrastructure, in other areas it’s community resistance – whatever the reason is, that’s where the challenge lies for polio eradication…Trying to root out what those causes are and trying to come up with ways to overcome those problems, to make sure that all children are vaccinated.
In Syria, right up until 2010, you had pretty good vaccination coverage, upwards of 90 percent of the population was fully immunized. Since 2010 that number is down to less than 70 percent now. What we could be dealing with is a base immunity that is relatively strong overall through the broad population age groups with an immunity gap in children under the age of two years. If we look at the cases, medically confirmed, they are all very young, they are all under two years. So that would make sense from that point of view.
There are many factors that will come into play as to how long this will last, but ultimately it’s really a question of can you fill that immunity gap?
Q: I hadn’t heard they were all under two. We’re hearing from doctors in rebel-controlled areas that government forces are preventing the entry of medicines.Has WHO been able to observe and treat across conflict lines?
A. Treating is very difficult, because of the nature of polio, actually. That’s one of the things that makes it very tragic, really there’s no cure, no treatment for it. The main goal right now is to vaccinate as many children as you can, to try to prevent the illness from happening in the first place.
Like I said, this needs to happen now right across the region, in Syria, in those areas which are controlled by the government, as well in contested areas. What we’re trying to do is coordinate with all humanitarian actors who are on the ground so that the vaccine reaches those areas. It’s not enough to make sure the vaccine actually reaches the district, it has to reach the children.
So in areas which are protected and a little bit cut off that makes it naturally much more difficult. What we seem to have is a very strong commitment that this needs to happen, because everyone recognizes it is not going to stay in Deire–Zor, already it has spread to Aleppo, it has spread to Damascus, and unless you immunize children right across whatever political lines you want to talk about, this thing is not going to stop and it will spread.
Q: I’ve seen a few reports blaming militants coming into Syria for bringing polio with them. Is there any way to trace the strain of polio in Syria? Can you trace it from a specific place in the world?
A. We trace the strains, for sure, genetically. Every polio virus we find, we look at where else it is found. The strain in Syria was last seen in the sewage system of Cairo, Egypt 12 months ago. There were no cases in Egypt, but it was in the sewage system, somewhere. Given that only humans carry the polio virus, it means someone was infected with polio virus.
That particular strain was linked to Pakistan. The strains that are currently in the Middle East, the origin is Pakistan. How it got into the Middle East, we don’t know. What’s clear is that it’s been in the Middle East, somewhere, in the past year.
It’s been there already, and wasn’t being picked up, which means probably there were surveillance gaps somewhere in the region, which is a further concern. That would further underscore the need to do a cross-regional response to this. How it specifically got to that area, we will never know. But we do know it came from Pakistan.
The only way to get rid of the risk of polio is to continue to try to eradicate it in the remaining endemic areas. That’s the point we’re trying to get across – outbreak response absolutely needs to happen, but at the same time, the world also needs to continue the push in the endemic areas.
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