Aug 04, 2012 Volume 380 Number 9840 p447 – 536
Polio vaccines and the eradication of poliomyelitis
Philip D Minor
In The Lancet, Kathleen O’Reilly and colleagues1 describe their findings from a case-control analysis of vaccination history data from children in Pakistan and Afghanistan, in which they estimated the clinical effectiveness of oral monovalent, bivalent, and trivalent poliovirus vaccines (OPVs) specifically related to type 1 poliomyelitis—a topic that might seem esoteric to those outside the poliomyelitis community. However, these results provide an example of the need to tailor immunisation programmes to epidemiological circumstances, particularly where the goal is eradication.
The effect of mass immunisation campaigns and new oral poliovirus vaccines on the incidence of poliomyelitis in Pakistan and Afghanistan, 2001–11: a retrospective analysis
Kathleen M O’Reilly, Elias Durry, Obaid ul Islam, Arshad Quddus, Ni’ma Abid, Tahir P Mir, Rudi H Tangermann, R Bruce Aylward, Nicholas C Grassly
Pakistan and Afghanistan are two of the three remaining countries yet to interrupt wild-type poliovirus transmission. The increasing incidence of poliomyelitis in these countries during 2010—11 led the Executive Board of WHO in January, 2012, to declare polio eradication a “programmatic emergency for global public health”. We aimed to establish why incidence is rising in these countries despite programme innovations including the introduction of new vaccines.
We did a matched case-control analysis based on a database of 46 977 children aged 0—14 years with onset of acute flaccid paralysis between Jan 1, 2001, and Dec 31, 2011. The vaccination history of children with poliomyelitis was compared with that of children with acute flaccid paralysis due to other causes to estimate the clinical effectiveness of oral poliovirus vaccines (OPVs) in Afghanistan and Pakistan by conditional logistic regression. We estimated vaccine coverage and serotype-specific vaccine-induced population immunity in children aged 0—2 years and assessed their association with the incidence of poliomyelitis over time in seven regions of Afghanistan and Pakistan.
Between Jan 1, 2001, and Dec 31, 2011, there were 883 cases of serotype 1 poliomyelitis (710 in Pakistan and 173 in Afghanistan) and 272 cases of poliomyelitis serotype 3 (216 in Pakistan and 56 in Afghanistan). The estimated clinical effectiveness of a dose of trivalent OPV against serotype 1 poliomyelitis was 12·5% (95% CI 5·6—18·8) compared with 34·5% (16·1—48·9) for monovalent OPV (p=0·007) and 23·4% (10·4—34·6) for bivalent OPV (p=0·067). Bivalent OPV was non-inferior compared with monovalent OPV (p=0·21). Vaccination coverage decreased during 2006—11 in the Federally Administered Tribal Areas (FATA), Balochistan, and Khyber Pakhtunkhwa in Pakistan and in southern Afghanistan. Although partially mitigated by the use of more effective vaccines, these decreases in coverage resulted in lower vaccine-induced population immunity to poliovirus serotype 1 in FATA and Balochistan and associated increases in the incidence of poliomyelitis.
The effectiveness of bivalent OPV is comparable with monovalent OPV and can therefore be used in eradicating serotype 1 poliomyelitis whilst minimising the risks of serotype 3 outbreaks. However, decreases in vaccination coverage in parts of Pakistan and southern Afghanistan have severely limited the effect of this vaccine.
Poliovirus Research subcommittee of WHO, Royal Society, and Medical Research Council.