Some ethical issues arising from polio eradication programmes in India

The World Health Organisation's programme for the eradication of poliomyelitis as currently practised in India raises many ethical issues. In this paper we concentrate on just two. The first is the balance to be struck between the risks and benefits generated by the eradication programme itself. The issue of risks and benefits arises in relation to the choice between two different vaccine types available for polio programmes: oral polio vaccine (OPV) and inactivated polio vaccine (IPV). OPV is the vaccine currently used in the eradication campaign in India. We argue that given the current risks/benefits profile of this vaccine, there is an urgent need to review the programme and take remedial action to address existing problems (at least in India). The second issue we discuss is the fact that there is little effort to gain the informed consent of the parents of vaccinated children, as they are not currently told about the potential limitations of OPV or the possibility of vaccine-induced harm. We suggest that such a policy might be justifiable, given the importance of polio eradication, but only if there is a system of compensation for vaccine-induced harm as part of the eradication programme itself. There is a real danger that if these issues are not addressed then public trust in the eradication programme and vaccination programmes as a whole will be lost.     

A vision of a world without polio: the OPV cessation strategy.

Once the eradication of wild poliovirus has been confirmed, the public health benefits of routine immunization with OPV will no longer outweigh the burden of disease either due to paralysis caused by OPV (vaccine associated paralytic polio), or by outbreaks caused by circulating vaccine-derived polioviruses. The eventual cessation of OPV use in routine immunization programmes worldwide will become necessary to assure a lasting eradication of polio. As the world moves towards polio eradication and its certification, preparations are therefore being intensified for OPV cessation, and the risk management framework for safe OPV cessation is being put in place. The framework includes bio-containment of all known poliovirus and potentially infected substances, development of an international stockpile of oral polio vaccine, ensuring a mechanism for continued global surveillance and response for polio after eradication has been certified, and national policies if countries decide to continue vaccinating with inactivated polio vaccine (IPV). It is ironic that the vaccine on which the world has depended for polio eradication will itself become a risk to eradication once the transmission of wild poliovirus has been interrupted. Final preparations for the eventual global and simultaneous cessation of OPV will require the same level of international cooperation and coordination that has brought the world to the verge of polio eradication.     

First decade (1950-1960) of studies and trials with the polio vaccine.

The chronology of the development of polio vaccines following the first human trials of attenuated poliovirus vaccine in 1950 is described by me as a witness to the first decade of trials and tribulations following my discovery of polio vaccine in 1950. Mass vaccination trials are considered to be the most important phase of the discovery of oral polio vaccine (OPV). These took place in the Belgian Congo, Poland, Croatia, Switzerland, and finally in the former Soviet Union. By 1960, approximately 13 million individuals had been vaccinated with the Koprowski oral polio vaccine and over 11 million with the Sabin vaccine.     

Control of poliomyelitis by pulse immunisation in Vellore,India.

In a simple study into the control of polio in the Third World a town was divided into 16 zones and pulses or oral polio vaccine given at one station in each zone, after extensive publicity about the campaign. Some 62% of children received three doses of the vaccine and the incidence of polio fell dramatically over the study period. It is suggested that this method is applicable to similar communities because it is cheap, effective, and able to be extended to unimmunised communities when resources allow.     

Immunological effectiveness of a 2d revaccination against diphtheria performed at intervals extended up to 7-10 years

The present article deals with the data on the duration of antidiphtheria immunity, induced by the primary cycle of immunization with adsorbed DPT vaccine, with the aim of considering the problems of optimizing the immunization schedule for children. The prolongation of the interval before the second booster immunization to 7-10 years produces no negative influence on the effectiveness of immunization. Besides, the study has shown that after the main complex of immunizations with adsorbed DPT vaccine protective immunity to diphtheria is retained in 90.3-96.8% of children covered by this study for 9-10 years. These data point to high immunological effectiveness of adsorbed DPT vaccine and to the possibility of prolonging the intervals between booster immunizations to 10 years, as well as decreasing the number of booster immunizations in the immunization schedule for children.     

Hypotheses and facts

The book, The river, is based on assumptions and not facts. Oral polio vaccine was produced entirely in rhesus monkey kidney cell cultures. Allegations that it was produced in chimpanzee kidneys at the Wistar Institute in Philadelphia or, alternatively, that the vaccine was made in the then Belgian Congo in chimpanzee kidney has no basis in fact. As the only witness to the historical events leading to the development of oral polio vaccine, I have demonstrated in this paper the truthful facts excluding any link between oral polio vaccine and human immunodeficiency virus.     

Electroporation-Mediated Immunization of a Candidate DNA Vaccine Expressing Dengue Virus Serotype 4 prM-E Antigen Confers Long-Term Protection in Mice

Dengue fever, caused by dengue viruses(DENVs), is a widespread mosquito-borne zoonotic disease; however, there is no available anti-dengue vaccine for worldwide use. In the current study, a DNA vaccine candidate(pV-D4 ME) expressing prM-E protein of DENV serotype 4(DENV-4) was constructed, and its immunogenicity and protection were evaluated in immunocompetent BALB/c mice. The pV-D4 ME candidate vaccine induced effective humoral and cellular immunity of mice against DENV-4 in vivo when administered both at 50 μg and 5 μg through electroporation. Two weeks after receiving three immunizations, both doses of pV-D4 ME DNA were shown to confer effective protection against lethal DENV-4 challenge. Notably, at 6 months after the three immunizations, 50 μg, but not 5 μg, of pV-D4 ME could provide stable protection(100% survival rate) against DENV-4 lethal challenge without any obvious clinical signs. These results suggest that immunization with 50 μg pV-D4 ME through electroporation could confer effective and long-term protection against DENV-4, offering a promising approach for development of a novel DNA vaccine against DENVs.     

Cold chain monitoring of OPV at transit levels in India: correlation of VVM and potency status

We have conducted a study to analyze monitoring of the cold chain of 674 OPV field samples collected at four different levels of vaccine distribution viz., immunization clinics, district stores, hospitals and Primary Health Centers (PHC) from states of Uttar Pradesh, Madhya Pradesh, and Delhi. The study design included: collection and scoring of vaccine vial monitor (VVM) status of the samples and testing for total oral polio virus concentration (TOPV) by standard WHO protocol. Ten samples each were exposed to 25 degrees C and 37 degrees C, and 10 samples as controls were kept at -20 degrees C. VVM were scored daily till they attained grade 4 and each sample was subsequently subjected to potency testing for individual polio serotypes 1, 2 and 3, and TOPV.Of the 674 samples tested it was observed that: samples from immunization clinics and district stores had an acceptable VVM score of grade 1 and 2; however the probable risk that a sub potent vaccine could have been administered was 2.15%. In 2.5% samples received from district stores vaccine had a VVM score of grade 3 (i.e., discard point), although vaccine when tested was found to be potent (i.e., leading to the vaccine wastage). With exposure to higher temperatures, VVM changed score to grade 2 and 3 when the vaccine was kept at 25 degrees C/37 degrees C, and the titres of individual serotypes 1, 2 and 3 and TOPV were beyond the acceptable limits.Important observations at the different levels of vaccine distribution network and correlation of VVM and potency status of OPV are discussed in the paper which will be of help to the EPI program managers at different transit levels.     

Use of Mobile Information Technology during Planning,Implementation and Evaluation of a Polio Campaign in South Sudan

Background

Use of mobile information technology may aid collection of real-time, standardised data to inform and improve decision-making for polio programming and response. We utilised Android-based smartphones to collect data electronically from more than 8,000 households during a national round of polio immunisation in South Sudan. The results of the household surveys are presented here, together with discussion of the application of mobile information technology for polio campaign planning, implementation and evaluation in a real-time setting.

Methods

Electronic questionnaires were programmed onto Android-based smartphones for mapping, supervision and survey activities during a national round of polio immunisation. National census data were used to determine the sampling frame for each activity and select the payam (district). Individual supervisors, in consultation with the local district health team, selected villages and households within each payam. Data visualisation tools were utilised for analysis and reporting.

Results

Implementation of mobile information technology and local management was feasible during a national round of polio immunisation in South Sudan. Red Cross visits during the polio campaign were equitable according to household wealth index and households who received a Red Cross visit had significantly higher odds of being aware of the polio campaign than those who did not. Nearly 95% of children under five were reported to have received polio immunisation (according to maternal recall) during the immunisation round, which varied by state, county and payam. A total of 11 payams surveyed were identified with less than 90% reported immunisation coverage and the least poor households had significantly higher odds of being vaccinated than the most poor. More than 95% of households were aware of the immunisation round and households had significantly higher odds of being vaccinated if they had prior awareness of the campaign taking place.

Conclusion

Pre-campaign community education and household awareness of polio is important to increase campaign participation and subsequent immunisation coverage in South Sudan. More emphasis should be placed on ensuring immunisation is equitable according to geographic area and household socio-economic index in future rounds. We demonstrate the utility of mobile information technology for household mapping, supervision and survey activities during a national round of polio immunisation and encourage future studies to compare the effectiveness of electronic data collection and its application in polio planning and programming.     

Plasmid DNA vaccine encoding prostatic acid phosphatase is effective in eliciting autologous antigen-specific CD8+ T cells

Prostatic acid phosphatase (PAP) is a prostate cancer tumor antigen and a prostate-specific protein shared by rats and humans. Previous studies indicated that Copenhagen rats immunized with a recombinant vaccinia virus expressing human PAP (hPAP) developed PAP-specific cytotoxic T cells (CTL) with cross reactivity to rat PAP (rPAP) and evidence of prostate inflammation. Viral delivery of vaccine antigens is an active area of clinical investigation. However, a potential difficulty with viral-based immunizations is that immune responses elicited to the viral vector might limit the possibility of multiple immunizations. In this paper, we investigate the ability of another genetic immunization method, a DNA vaccine encoding PAP, to elicit antigen-specific CD8+ T cell immune responses. Specifically, Lewis rats were immunized with either a plasmid DNA-based (pTVG-HP) or vaccinia-based (VV-HP) vaccine each encoding hPAP. We determined that rats immunized with a DNA vaccine encoding hPAP developed a Th1-biased immune response as indicated by proliferating PAP-specific CD4+ and CD8+ cells and IFNγ production. Rats immunized with vaccinia virus encoding PAP did not develop a PAP-specific response unless boosted with a heterologous vaccination scheme. Most importantly, multiple immunizations with a DNA vaccine encoding the rat PAP homologue (pTVG-RP) could overcome peripheral self-tolerance against rPAP and generate a Th1-biased antigen-specific CD4+ and CD8+ T cell response. Overall, DNA vaccines provide a safe and effective method of generating prostate antigen-specific T cell responses. These findings support the investigation of PAP-specific DNA vaccines in human clinical trials.     

Next Generation Inactivated Polio Vaccine Manufacturing to Support Post Polio-Eradication Biosafety Goals

Worldwide efforts to eradicate polio caused a tipping point in polio vaccination strategies. A switch from the oral polio vaccine, which can cause circulating and virulent vaccine derived polioviruses, to inactivated polio vaccines (IPV) is scheduled. Moreover, a manufacturing process, using attenuated virus strains instead of wild-type polioviruses, is demanded to enhance worldwide production of IPV, especially in low- and middle income countries. Therefore, development of an IPV from attenuated (Sabin) poliovirus strains (sIPV) was pursued. Starting from the current IPV production process based on wild type Salk strains, adaptations, such as lower virus cultivation temperature, were implemented. sIPV was produced at industrial scale followed by formulation of both plain and aluminium adjuvanted sIPV. The final products met the quality criteria, were immunogenic in rats, showed no toxicity in rabbits and could be released for testing in the clinic. Concluding, sIPV was developed to manufacturing scale. The technology can be transferred worldwide to support post polio-eradication biosafety goals.     

Manufacturing and supply of monovalent oral polio vaccines.

A new polio vaccine was developed, produced and licensed by sanofi pasteur at the request of the World Health Organization (WHO) for mass immunization campaigns in endemic countries such as Egypt. The new vaccine, monovalent oral polio vaccine 1 or mOPV1, is currently used in Egypt as a critical part of a new WHO strategy to end polio type 1 transmission by the end of the year 2005 (types 2 and 3 polioviruses have already been eliminated from Egypt). To answer this specific need, an urgent program was mounted by Sanofi pasteur to manufacture 50million doses for Egypt, in close collaboration with WHO and National Regulatory Agencies (France and Egypt). The joint efforts between manufacturer, regulators and the WHO resulted in the quickest ever vaccine development and licensure and WHO pre-qualification. The production of mOPV was based on existing tOPV but with appropriate "change control" procedures to assure the quality of the product, and to distinguish mOPV from tOPV. Key success factors included clear and careful definition of the project; close collaboration between manufacturer, regulators and WHO; and commitment and motivation of staff. As a result, development and production of mOPV1 vaccine were carried out in a drastically reduced time period, leading to the release and delivery of the first 15 million doses of mOPV1 in April 2005.     

Gaps in scientific knowledge for the post eradication world.

There are significant gaps in the understanding of polio and polio vaccines which have programmatic importance even after 50 years of vaccine use. This paper considers four: the effect of strains used in the manufacture of IPV on safety and efficacy, the reasons for the safety of the Sabin strains, the nature and detection of long-term excreters of poliovirus and the basis for the cessation of virus excretion.     

中国婴儿中脊灰母传抗体水平对两种疫苗免疫效果的影响

为了了解2月龄婴儿中针对脊髓灰质炎病毒的中和抗体水平,并探讨母传抗体对脊髓灰质炎减毒活疫苗(OPV)和灭活疫苗(IPV)免疫效果的影响。对416名2月龄婴儿分别接种OPV和IPV,采集免疫前后血清,用微量中和法检测血清中Ⅰ、Ⅱ、Ⅲ型脊髓灰质炎病毒中和抗体滴度,评价抗体GMT水平及4倍增长情况。检测结果显示,2月龄婴儿母传抗体Ⅰ、Ⅱ、Ⅲ型阳性率分别为45%、38.2%和17.5%,抗体GMT水平为9.0、8.1和5.2。经接种两组疫苗后,母传抗体阳性者与阴性者免后抗体GMT水平相比,OPV组无明显差异,IPV组阳性者略低于阴性者。在免前抗体滴度<1∶32人群中,OPV组免后抗体滴度4倍增长率及几何滴度增长倍数分别为:Ⅰ型93.6%、71.2;Ⅱ型98.2%、43.7;Ⅲ型91.7%、47.9;IPV组免后抗体滴度4倍增长率及几何滴度增长倍数分别为:Ⅰ型82%、9.4;Ⅱ型62.8%、5.1;Ⅲ型95.6%、11.7;在免前抗体滴度1∶32～1∶128人群中,OPV组Ⅰ型92.3%、23;Ⅱ型86.4%、13.9;Ⅲ型55.6%、4.1;IPV组Ⅰ型48%、2.5;Ⅱ型15%、0.9;Ⅲ型55.6%、2.7。目前中国2月龄婴儿免前脊灰抗体阳性率较高,尤其是Ⅰ、Ⅱ型。脊灰母传抗体对两种疫苗免疫效果有一定干扰,对IPV疫苗的影响较为明显。     

The Jezierski papers: live polio vaccine development in colobus monkey cells but not chimpanzee cells in the Belgian Congo, 1952-1958

A reading of ten relevant papers by Alexandre Jezierski provides evidence for the only attempt in Central Africa to develop a live oral polio vaccine (OPV) from growing reference wild polio strains to 210 passages in colobus monkey tissue culture, and experimental administration to about 25 humans. Chimpanzees were used as a human model, but their tissues or kidneys were absent from the passage and production line of the proposed vaccine. Thus, the implication published by Hooper that Jezierski had produced a candidate OPV that might have contained chimpanzee viruses, possibly simian immunodeficiency virus cpz or the precursor of human immunodeficiency virus-1 group M, is incorrect.     

消灭脊髓灰质炎行动现状分析及免疫策略建议

脊髓灰质炎曾在全球广泛流行和传播,严重危害儿童健康。自1988年世界卫生大会发起全球消灭脊髓灰质炎行动倡议以来,全球脊髓灰质炎防控工作取得显著进展,但消灭脊髓灰质炎工作仍面临重重挑战。在目前维持无脊髓灰质炎状态下,我国面临的主要问题是疫苗相关麻痹型脊髓灰质炎(vaccine associated paralytic poliomyelitis, VAPP)病例和脊髓灰质炎疫苗衍生病毒(vaccine-derived poliovirus,VDPV)病例的发生。为此,通过回顾消灭脊髓灰质炎工作取得的进展,总结不同国家或地区在消灭脊髓灰质炎过程中所采用的防控策略,尤其是不同国家或地区的脊髓灰质炎疫苗使用经验,分析消灭脊髓灰质炎最后阶段面临的挑战,进而提出应对策略和建议,即科学评价防控措施、适时调整脊髓灰质炎免疫策略、努力消除接种犹豫并提高疫苗接种率,这对早日实现根除脊髓灰质炎的目标是非常有必要的。     

The role of polio-vaccine in pleural mesothelioma--an epidemiological observation

From the Croatian Cancer Registry (period 1991-1997) 194 malignant pleural mesothelioma patients were collected. According to participation in polio vaccination mass campaign in 1961 that covered the entire Croatian population aged 3 months to 20 years, mesothelioma patients were divided in vaccinated (N=58), and non-vaccinated (N=136) subjects. Significantly higher percentage of those with a history of occupational exposure to asbestos was found in vaccinated (79%) compared to non-vaccinated group (63%). This is the opposite to what would be expected if potential SV40 contamination of polio vaccine used had a causative role in the development of the tumour. On the other hand, shorter latency period reflected by very high percentage of 45-year-old or younger mesothelioma patients in vaccinated group (15 out of 58), with all of them having a history of occupational asbestos exposure, raises a question for a possible enhancing effect of the vaccine used to asbestos exposure, if it was contaminated with SV40.     

A new rabies vaccine in public health practice in the USSR

A new antirabies vaccine prepared on the basis of virus grown in the ovine brain, purified from 85-90% of brain-tissue ballast substances and inactivated with beta-propilactone has been developed at the Moscow Research Institute of Viral preparations (USSR Acad. Med. Sci.). The preparation produces no neuro-allergenic effect in tests on guinea pigs. When injected to humans, the vaccine shows much lower reactogenicity than Fermi vaccine. High antigenic and immunogenic activity of the new vaccine has made it possible to work out a less intensive immunization schedule in comparison with that used for immunization with Fermi vaccine and nonconcentrated tissue-culture vaccine, viz. doses of 3 ml for 12 days or doses of 3 ml for 20 days with two booster immunizations. The preparation has been introduced into medical practice.