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Africa and Pakistan Face Polio Outbreaks, in Blow to Global Fight

Friday, August 23, 2013

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The global effort to eradicate polio, a disease that has been on the brink of extinction for years, is facing serious setbacks on two continents. The virus is surging in Somalia and the Horn of Africa, which had been largely free of cases for several years. And a new outbreak has begun in a part of Pakistan that a warlord declared off limits to vaccinators 14 months ago.

The African outbreak began in May with just two cases of polio paralysis: one in Mogadishu, Somalia’s capital, and another in the huge Dadaab refugee camp in Kenya, where thousands of Somalis have fled fighting between Islamic militants, clan militias, government troops and African peacekeepers.

Now there are 121 cases in the region; last year, there were only 223 in the world.

The new Pakistan outbreak is in North Waziristan, near the frontier with Afghanistan. It is in an area where a warlord banned polio vaccinations after it was disclosed that the C.I.A. had staged a hepatitis vaccination campaign in its hunt for Osama bin Laden. The warlord, Hafiz Gul Bahadur, banned all efforts until American drone strikes ended.

Although only three North Waziristan children have suffered polio paralysis since then, even one case shows that the virus is in the area and could spread.

The new outbreaks may delay a recently announced $5.5 billion plan to eradicate polio by 2018. Nonetheless, public health officials still believe that, with enough local political will and donor money, they can prevail by using techniques that have worked before.

To prevent the disease from reaching Mecca during next month’s hajj, Saudi Arabia has tightened its rules. Pilgrims from any country with polio cases must be vaccinated at home and again on arrival. Last year, nearly 500,000 pilgrims were vaccinated on arrival, Dr. Ziad A. Memish, the Saudi deputy health minister, said recently.

The Pakistan outbreak is particularly frustrating because eradication had been going steadily forward despite the killings in December of nine vaccinators for which some blamed the Taliban.

Public health officials had counted themselves lucky that despite simultaneous vaccination bans in North and South Waziristan, no polio virus was known to be circulating in the 250,000 children in those areas. Vaccination posts were set up on nearby highways and on buses and trains. Urban hospitals packed the vaccine on ice for families willing to smuggle it back to neighbors. But it was not enough.

“The equation is simple,” said Dr. Elias Durry, emergency coordinator for polio eradication in Pakistan for the World Health Organization. “Where you can immunize, the virus goes away. Where you can’t, the virus gets in, and it will paralyze these poor kids.”

Dr. Durry said he hoped that parents whose children were paralyzed would speak up at local decision-making councils, called shuras, that are common in tribal areas, and possibly put pressure on warlords to rescind the ban.

The Taliban warlord in South Waziristan, Maulvi Nazir, was killed by a drone strike in January.

Before the Waziristan outbreak, Pakistan had seen only 24 cases this year, about as many as it had at the same point in 2012. Most were around Karachi and Peshawar, where last year’s killings of the vaccinators took place and where resistance to vaccines is highest.

The Somali outbreak is different. There is little opposition to the vaccine itself, said Dr. Bruce Aylward, the W.H.O. assistant director general for polio. In several Muslim countries, including Pakistan, the drive has been hurt by rumors that the vaccine sterilizes girls or contains the virus that causes AIDS or pork products.

But, he said, many cases are in areas south of Mogadishu where the Shabab, a militant group, operate. The group opposes mass campaigns because it believes the sight of thousands of vaccinators going house to house would undercut its claim to rule those areas.

“It’s all about control,” Dr. Aylward said.

Instead, the campaign negotiates with local chiefs and midlevel Shabab members to hold small drives.

Other tactics have changed, too: children of any age, and sometimes adults, get the drops, and drives are held twice a month instead of every three months.

Refugee camps face other obstacles. Large ones often have lawless areas on their fringes where vaccinators may fear to work because of predatory criminals.

“When this started, I said, ‘Brace yourself for hundreds of cases,’ ” Dr. Aylward said, because he knew that few children born in the last five years had been immunized.

Still, he said he believed this outbreak could be beaten because it echoed the one that plagued the region from 2005 to 2007. It also began in Mogadishu, and it spread as far as Yemen and Eritrea and paralyzed about 700 children before multiple mass vaccination rounds snuffed it out. Kenya, Yemen and Ethiopia are already planning those with help from Geneva.

Somalia is so dangerous for health workers that Doctors Without Borders pulled out of the country this month after 22 years there. But polio officials hope their campaign will not be targeted, largely because it creates thousands of temporary paying jobs for “volunteer” vaccinators.

In Mogadishu in July, President Hassan Sheik Mohamud publicly took polio drops at an event encouraging parents to vaccinate.

Asha Ali, 38, a mother of four, changed her attitude. “I was thinking the vaccine might sicken our children,” she said. “I realized later that it was good.”

Hamdi Hashi, 26, said she accepted it “because I don’t want this serious disease to cripple my children.”

But Habow Madey, in a different Mogadishu neighborhood, said her husband had forbidden vaccination, believing it causes “a mysterious disease.”

Mohammed Ibrahim contributed reporting from Mogadishu, Somalia.


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