Pakistan and Israel hit by polio setback

By Jon Boone, Harriet Sherwood and Sarah Boseley

North Waziristan cases follow militants' vaccination ban, while Israel starts mass inoculation after virus detected in sewage

The battle to eliminate polio has hit apparent setbacks in northern Pakistan, where new cases are being reported, and in Israel, where the discovery of the virus in the sewage system has led to a mass immunisation campaign. Fourteen suspected cases of polio have been discovered in Pakistan's insurgency-racked north-west, where Taliban militants have banned vaccination workers. Although the country is awaiting the result of tests on stool samples from the affected children, a surge in cases could strike a major blow to the government's intense efforts to exit the small group of nations that has failed to eradicate the disease. All but two of the children were from North Waziristan, the most troubled of the seven tribal "agencies" that comprise the Federally Administered Tribal Areas, a semi-autonomous region of Pakistan that borders Afghanistan and is a hotbed for militancy. The majority of strikes by the CIA's unmanned drone campaign occur in North Waziristan, a situation that last year prompted Taliban commander Hafiz Gul Bahadur to block the anti-polio campaign in the agency. Militants in other areas have enacted similar bans, saying they will lift them only when drone strikes end. In North and South Waziristan, more than 260,000 under fives have not been immunised since June 2012. In tribal, highly conservative parts of the country health workers are regarded with intense suspicion. Popular fears are often stoked by local religious leaders who claim the vaccines are part of a western plot to sterilise Muslims. Elsewhere in the country, monsoon floods, insecurity and a string of byelections have forced authorities to postpone a vaccination drive originally scheduled to begin on Monday. According to the global polio eradication initiative, 181 cases had been recorded worldwide this year between January and 13 August. A total of 71 were in Afghanistan, Nigeria and Pakistan, countries where the disease is endemic. Bruce Aylward, who leads the World Health Organisation's global polio eradication campaign, pointed out that the actions of Gul Bahadur were not in line with the expressed views of the Afghan Taliban, which published a statement on its website two months ago about the importance of vaccinating children against polio (with the rider that it should be done in a manner appropriate for Muslims). Aylward said some of the reported cases were false alarms, with tests showing that children's symptoms were not caused by the polio virus. But, he added, cases were inevitable. "This is one of the very few areas in the world that is affected by polio where there is no vaccination ongoing," he said. "The endgame in stopping transmission is getting vaccination into every affected area. If we are not vaccinating, we are not eradicating." Experts are hopeful that vaccination may resume. A year has passed since it was suspended, making it probable that the political impact will have diminished. And while a ban can continue indefinitely while there are no polio cases, local sensitivities may change if children become sick or are harmed by the disease. Aylward pointed to conflict-hit areas such as the Democratic Republic of the Congo and northern Nigeria, where vaccination has resumed. "In each case, with time and understanding for the consequences of their own children, it has been possible to get a dialogue," he said. Meanwhile, Israel has launched a mass inoculation programme, aimed at reaching more than a million under-10s over the next three months, after one of the three strains of polio was detected in the country's sewage system. No one in Israel has developed the virus since the discovery of type one in the south of the country earlier this year. It has since spread to sewage systems in the centre and the north. Type one was identified in neighbouring Egypt in December. Drops containing vaccine against types one and three of the virus are being administered orally at health clinics. Israel routinely immunises children against polio, but this campaign aims to boost the level of protection. About 182,000 children were inoculated in the first three days. A legal petition against the move, on the grounds that it was unnecessary and could be harmful, was dismissed by the high court. The last outbreak of polio in Israel was 25 years ago, and Aylward said the situation there is different to that in Pakistan. Like most countries that have eliminated polio, Israel has switched from oral drops to the inactivated poliovirus vaccine (IPV), which is injected. The IPV prevents the virus causing illness but, if children or adults contract it, it will still travel through the gut. Israel, which has excellent surveillance systems, discovered the virus in the sewage system in February, said Aylward, but that happens in many countries using IPV. What is unusual is that it did not disappear and has since been detected in other parts of the country. The virus in the sewage is not a threat to children who have been immunised, but it is to the estimated 6% who have not been. "So far, they have been lucky – there are no cases," said Aylward. Without the vaccination campaign, however, it would be surprising if cases did not occur.