[Senate Hearing 105-883]
[From the U.S. Government Publishing Office]
S. Hrg. 105-883
GLOBAL ERADICATION OF POLIO AND MEASLES
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HEARING
before a
SUBCOMMITTEE OF THE
COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE
ONE HUNDRED FIFTH CONGRESS
SECOND SESSION
__________
SPECIAL HEARING
__________
Printed for the use of the Committee on Appropriations
Available via the World Wide Web: http://www.access.gpo.gov/congress/
senate
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COMMITTEE ON APPROPRIATIONS
TED STEVENS, Alaska, Chairman
THAD COCHRAN, Mississippi ROBERT C. BYRD, West Virginia
ARLEN SPECTER, Pennsylvania DANIEL K. INOUYE, Hawaii
PETE V. DOMENICI, New Mexico ERNEST F. HOLLINGS, South Carolina
CHRISTOPHER S. BOND, Missouri PATRICK J. LEAHY, Vermont
SLADE GORTON, Washington DALE BUMPERS, Arkansas
MITCH McCONNELL, Kentucky FRANK R. LAUTENBERG, New Jersey
CONRAD BURNS, Montana TOM HARKIN, Iowa
RICHARD C. SHELBY, Alabama BARBARA A. MIKULSKI, Maryland
JUDD GREGG, New Hampshire HARRY REID, Nevada
ROBERT F. BENNETT, Utah HERB KOHL, Wisconsin
BEN NIGHTHORSE CAMPBELL, Colorado PATTY MURRAY, Washington
LARRY CRAIG, Idaho BYRON DORGAN, North Dakota
LAUCH FAIRCLOTH, North Carolina BARBARA BOXER, California
KAY BAILEY HUTCHISON, Texas
Steven J. Cortese, Staff Director
Lisa Sutherland, Deputy Staff Director
James H. English, Minority Staff Director
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Subcommittee on Departments of Labor, Health and Human Services, and
Education, and Related Agencies
ARLEN SPECTER, Pennsylvania, Chairman
THAD COCHRAN, Mississippi TOM HARKIN, Iowa
SLADE GORTON, Washington ERNEST F. HOLLINGS, South Carolina
CHRISTOPHER S. BOND, Missouri DANIEL K. INOUYE, Hawaii
JUDD GREGG, New Hampshire DALE BUMPERS, Arkansas
LAUCH FAIRCLOTH, North Carolina HARRY REID, Nevada
LARRY E. CRAIG, Idaho HERB KOHL, Wisconsin
KAY BAILEY HUTCHISON, Texas PATTY MURRAY, Washington
TED STEVENS, Alaska ROBERT C. BYRD, West Virginia
(Ex officio) (Ex officio)
Majority Professional Staff
Bettilou Taylor
Mary Dietrich
Minority Professional Staff
Marsha Simon
Administrative Support
Jim Sourwine and Jennifer Stiefel
C O N T E N T S
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Page
Opening remarks of Senator Dale Bumpers.......................... 1
Eliminating polio throughout the world........................... 1
International strategy........................................... 3
Statement of David Satcher, M.D., Ph.D., Assistant Secretary for
Health and Surgeon General, Public Health Service, Department
of Health and Human Services................................... 3
Decrease in cases of poliomyelitis............................... 4
Struggles faced in Southeast Asia................................ 5
Effective vaccine against measles................................ 6
Prepared statement Dr. David Satcher............................. 7
Statement of Erbahim M. Samba, M.D., regional director, Regional
Office for Africa, World Health Organization................... 13
World Health Organization........................................ 13
Winning the battle against polio................................. 14
Prepared statement of Dr. Erbahim M. Samba....................... 15
Human and natural resources to sustain everybody................. 22
Statement of Herbert A. Pigman, chairman, polio eradication
advocacy task force, the Rotary Foundation, Rotary
International.................................................. 22
Oral polio vaccine............................................... 23
Prepared statement of Herbert A. Pigman.......................... 24
Biographical sketch.......................................... 29
Statement of Dr. Bill Foege, former Director, Centers for Disease
Control........................................................ 30
Lessons from polio............................................... 31
Spreading of measles............................................. 32
Prepared statement of Dr. William Foege.......................... 33
When to stop manufacturing polio vaccine......................... 36
Smallpox vaccine and stockpiling................................. 36
Two polio vaccines............................................... 37
Eradication programs............................................. 37
Civil strife..................................................... 37
HIV and AIDS..................................................... 38
Polio eradication................................................ 38
Rotarians........................................................ 39
Eradicate measles................................................ 39
GLOBAL ERADICATION OF POLIO AND MEASLES
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FRIDAY, SEPTEMBER 23, 1998
U.S. Senate,
Subcommittee on Labor, Health and Human
Services, and Education, and Related Agencies,
Committee on Appropriations,
Washington, DC.
The subcommittee met at 10:34 a.m., in room SD-124, Dirksen
Senate Office Building, Hon. Dale Bumpers, presiding.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Office of the Surgeon General
STATEMENT OF DAVID SATCHER, M.D., Ph.D., ASSISTANT
SECRETARY FOR HEALTH AND SURGEON GENERAL
opening remarks of senator bumpers
Senator Bumpers. The committee will come to order.
First let me thank Chairman Specter for calling today's
hearing to discuss the eradication of polio and measles
throughout the world. I know he shares my commitment to improve
preventive health care for children and to make investments
necessary to ensure that all children have ready access to
vaccines that protect them from illness and death. Over the
past several years, the chairman's mark has included
significant funding increases for the Centers for Disease
Control to carry out its program to eradicate polio and
measles. Under his leadership and that of Senator Harkin, the
entire subcommittee has supported these efforts in a bipartisan
way and today we look forward to hearing some very good news
regarding how our investment in polio eradication is about to
pay off.
eliminating polio throughout the world
There are fewer than 800 days left before we reach the goal
of eliminating polio throughout the world by the end of the
year 2000. That victory will mark the second time in history we
have been able to eradicate an infectious disease. The first
was the eradication of smallpox, a disease that claimed
millions of lives through the centuries. As recently as the
1950's, smallpox was killing over 2 million people each year,
despite the fact that an effective vaccine for the disease had
been in use since 1796. Smallpox eradication began in 1967. The
campaign required 11 years to complete and cost nearly $300
million--$200 million from countries with endemic smallpox and
an additional $100 million from international donors. The
United States was the largest international contributor with a
total investment of $32 million, and that investment has repaid
itself many times over. Beyond the humanitarian benefits of
eliminating this vicious killer, we have enjoyed tremendous
economic benefits. The United States alone has recouped the
equivalent of its entire investment every 26 days since the
disease was eradicated.
The polio effort began in 1988 when the World Health
Assembly endorsed the program and set the year 2000 as the
target date for global eradication. Thus far, the campaign has
been a very dramatic success story. Today, four out of every
five of the world's children receive polio vaccine. Over the
past 10 years, polio cases have been reduced by over 90
percent, and today more than 150 nations report no polio. All
countries in the western hemisphere have been polio-free since
1991 and all countries in Europe and the western Pacific
region, including China, Vietnam, and Cambodia, have been
polio-free for 1 or more years.
In my view, the program's achievements are the result of a
model public/private partnership. Rotary International began
working on immunization programs in the early 1980's, and when
the World Health Assembly endorsed the polio eradication
program in 1988, Rotary became the primary private sector
partner in the campaign. We estimate that Rotary will have
contributed $450 million by the end of the year 2000, the
largest private contribution to a public health initiative in
history.
In a combined effort with the health ministries in each
country, Rotary, UNICEF, World Health Organization, and CDC
have mobilized thousands of volunteers to recruit, educate,
transport, and vaccinate children in a mass campaign strategy.
The scope of the program is enormous. In 1997 alone, more than
450 million children in 80 countries were vaccinated against
polio through the use of mass campaigns. And the partners have
enjoyed unparalleled success in densely populated areas where
the risk of disease has been high. During India's first
campaign in 1996, more than 87 million children were vaccinated
by 100,000 volunteers over one 3-day period.
The last frontier for the program is Africa, where the
polio campaign faces formidable challenges. Efforts there have
been hindered by poverty, civil conflicts, and logistical
problems in vaccine delivery. Even with these barriers, the
program has enjoyed significant success in many areas of the
continent. National immunization days have been conducted in
over 35 African countries and put a real dent in the number of
polio cases.
Experts in the field, including one Betty Bumpers who
participated in a mass campaign in West Africa earlier this
year, have all returned with the same message: We can win the
war against polio and Africa will put us over the top for the
year 2000, but only if we intensify our efforts in Africa over
the next 2 years. This means more funding from all the donors
and more logistical support for programs that are conducted in
countries racked by civil conflict and supply shortages.
As was the case with smallpox, the rewards will far exceed
the costs. The United States alone will reap annual savings of
over $230 million, and worldwide savings will exceed $1.5
billion every year. More importantly, we will have conquered a
disease responsible for crippling millions of children in our
history.
Finally, we have set the stage for our next campaign: the
eradication of measles worldwide. Regional efforts to eliminate
measles have already begun, and an international effort is on
the horizon. Historically, measles has killed more children
than any other infectious disease. Even today it is responsible
for 1 out of every 10 deaths in children under age 5. I can
remember when Dr. Satcher was in my office 3 or 4 years ago and
gave me that statistic. I was absolutely staggered. Think of
it: 1 out of every 10 deaths in children under age 5 caused by
a preventable disease.
international strategy
Many leaders in the public health field believe that we
should begin planning an international strategy over the next 2
years so that resources can be easily shifted from the polio
effort to a measles campaign once polio is eradicated.
We are privileged to have a very distinguished panel this
morning to educate us on the polio and measles efforts. Dr.
David Satcher has been a leader in the polio effort during his
tenure as Director of CDC and more recently as Surgeon General.
Dr. E.M. Samba, whom I want to personally thank for his
courtesy and hospitality to Betty, is with us this morning. He
is head of the World Health Organization in Africa and I am
confident will be responsible for winning the final battle of
the campaign when polio is eradicated there over the next 2
years. Mr. Herb Pigman heads the Rotary International polio
program, and even though he is the only nonphysician on the
panel, has probably visited and participated in more polio
campaigns across the world than any doctor or nurse in the
entire public health care system. Dr. Bill Foege, former
Director of the CDC and longtime advisor to the Congress and
leader in the international health community, brings us the
wisdom of his experience with smallpox, polio, and measles
eradication.
Gentlemen, I welcome all of you and thank you very much for
taking your time to travel here, prepare your testimony, and
enlighten the rest of us.
For lack of a better system, let me just suggest that we
start on the right with Dr. Foege.
summary statement of dr. david satcher
Dr. Foege. Thank you, Senator Bumpers.
Senator Bumpers. Wait just a moment.
[Pause.]
Senator Bumpers. I am sorry. Staff always prevails.
[Laughter.]
Dr. Satcher, you are uno numero. [Laughter.]
Dr. Satcher. Well, thank you very much. I certainly
understand the logic of starting from your right. [Laughter.]
I am delighted to be a part of this very outstanding panel.
I am David Satcher, Assistant Secretary for Health and Surgeon
General of the United States.
Senator Bumpers, I just want to say, before I officially
begin my testimony, how much it means to me to be here today
and to be a part of this panel. I want to thank you for your
tireless and effective efforts in support of the health of the
citizens of this country and throughout the world. Your wisdom
and foresight have helped reach unprecedented achievements,
especially in the area of immunization, and we are grateful. As
Director of the CDC, I came to respect your integrity,
appreciate your commitment, and admire your insights into
issues surrounding immunizations.
This will probably be my last opportunity to testify before
you in Congress, and I will miss you greatly but I will always
appreciate the outstanding work that you have done as a Member
of the Congress of the United States. Thank you.
Senator Bumpers. Thank you, Dr. Satcher.
Dr. Satcher. I will be brief because this is an outstanding
panel, and I would just like to support some major points that
you have made: No. 1, about the rationale for polio
eradication; two, the status of our efforts to eradicate this
disease; and three, to talk about the issue of measles
eradication and where we are with that consideration and
developments related to that.
Often when we talk about the rationale for eradicating
polio, we speak of it from the standpoint of the financial
gains. And they are significant in terms of being able to save
on the costs of immunizations in this country and throughout
the world. That is an important consideration, the fact that
this was, in fact, a cost effective effort. But I believe it is
fair to say that the opportunity which we have to prevent pain
and suffering and unnecessary deaths in this country and
throughout the world should be our overriding consideration.
We are a Nation that invests over $1 trillion a year in our
health care system, and we are predicting that by the year
2007, we will be spending over $2 trillion. We spend only about
1 percent of that amount on population based prevention.
Because of that, I think it is critical to point out that there
is no better investment that we could make than to prevent this
disease throughout the world and the necessity for immunizing
against it.
So, I think the rationale is really clear. We have the
technical ability to eradicate this disease. We have
demonstrated that. We eliminated this disease in the Western
Hemisphere. We have not had a case since 1991. As we speak, our
colleagues from the Pan American Health Organization are
meeting down the street. They played a great role in
eliminating this disease from the Western Hemisphere and
demonstrating, in fact, that it can be eradicated from the
world.
In terms of the status of polio eradication, I would just
like to point to some very important charts, and that was the
first one. [Laughter.]
decrease in cases of poliomyelitis
The number of reported poliomyelitis cases by year
worldwide. Beginning in 1988 when the World Health Organization
declared its commitment to eradicate this disease, there has
been an 85- to 90-percent decrease in the reported cases of
poliomyelitis by year. As you know, we do not report every
case. We know that there are many cases of polio that are not
reported, but using an epidemiological model, we can estimate
the number of cases from the number of cases that are reported.
So, this is a dramatic story of success in the efforts to
eradicate polio in the world, and it reflects a great reduction
in pain and suffering and deaths. Hundreds of thousands of
children who would have died from polio have been saved because
of this effort. I think that is the major message here.
You are very familiar with these charts, as are members of
the panel. In 1988, this disease was very common throughout the
world. The reports were very common. If you look at the color
of the charts, the red areas and the green areas especially,
the increase in the number of countries reporting no cases of
polio, when you compare 1988 with 1997, and the fact that today
we are struggling primarily in Africa, and primarily sub-
Saharan Africa, and Southeast Asia and making significant
progress.
I think if you look at India and what has happened in India
over the last few years, it is the most dramatic example of
what we can achieve. There has been in India more than a 90-
percent reduction in cases of reported polio since 1988. We
have really targeted in the last few years India. I was there
in 1996, December 7, when we immunized 120 million children
against polio.
But I also gained on that occasion a new kind of respect
for Rotary International. I was aware of all of their financial
investment, but on that particular day, 57,000 Rotarians were
in the streets throughout India getting children out to be
immunized. The commitment of this organization throughout the
world and the way it has coordinated its efforts has really
been something to behold. It is a unique kind of public health
partnership that we enjoy, and I commend Rotary International
for their commitment and effective operations.
It is going to be difficult to go the rest of the way. I
was a long distance runner in college. I really was not that
good, so you did not hear about me. [Laughter.]
But I learned something, and that is, I learned that it
does not matter how great your stride or how well you run the
first one-half or the first two-thirds or three-fourths of the
race. If you do not finish, you are a failure.
And I believe we have come to the point now where the issue
is, are we committed to finishing this race to eradicate polio?
We know we can do it. We have demonstrated that we can do it,
but I think we run the risk, if we are not careful, of slowing
down and not finishing the race by the year 2000. So, I think
it is really critical that we make the commitments, financial
and otherwise, to finish this task.
struggles faced in southeast asia
This chart demonstrates some of the struggles that we face
in Southeast Asia and in Africa especially. Even though this is
from Afghanistan, the fact of the matter is that some of the
things we take for granted in terms of communication and
transportation systems or the ability to preserve and move the
vaccine from place to place, all those issues become very
difficult, especially when you put on top of that often wars
and conflicts of various kinds that make it very difficult for
people to come together and implement national immunization
days.
Those are some of the things we are facing now in terms of
the logistics and the operations. We can overcome those
barriers. We have demonstrated that and I think we will,
working together, overcome them and complete the task of
eradicating polio. The benefits are tremendous and certainly
Dr. Foege who played such a critical role in the eradication of
smallpox probably appreciates that better than anyone in terms
of working very hard to accomplish the eradication of disease
and then seeing the benefits of it play out over the years.
As a leader in public health and all of the challenges that
we are facing, I appreciate the fact that the effort to
eradicate polio has really helped us to develop an
infrastructure, a global infrastructure that we would not
otherwise have in place. The importance of epidemiological and
laboratory surveillance in terms of monitoring the progress of
eradicating the disease and all of those systems that we have
put in place in order to carry out this effort will benefit us
tremendously, not only as we approach other diseases such as
measles, but the whole challenge of global emerging infectious
diseases.
I am meeting with our partners in eight nations throughout
the world now in terms of trying to make sure that we have in
place systems to deal with new and emerging infectious
diseases. We are learning a lot from our experience in the
eradication of polio. We have laboratories in place. We have
trained people in place. We have systems in place that we would
not have if it were not for this effort. So, the benefits are
just tremendous.
effective vaccine against measles
Well, I will just say a few words about measles because I
am sure that is going to be discussed by my colleagues. As you
pointed out, measles is still a very important disease, still
responsible for the deaths of almost 1 million children a year
in the world and almost 37 million cases of measles in the
world.
We have a very effective vaccine. We know that we can
eliminate this disease because in this country, for example, we
have seen dramatic declines in measles over the last several
years. In the past 5 years, we have averaged only about 400
cases, and last year we had, I think, a total of 138 cases in
this country. It looks like we are going to have fewer than
that this year, my colleagues from CDC tell me.
So, I think it is very clear that we can eliminate this
disease, we can eradicate it, and I think on the horizon is the
prospect of moving forward after we finish polio. If we do not
finish the job with polio, I think the hope of being successful
with measles and other diseases is not very great. So, we have
got to finish polio, but I think after we have finished it, it
looks like the prospects of eradicating measles are very real
and that we should pursue that. We are already working very
hard.
Again, PAHO has been very successful in dealing with
measles. To a great extent the reason we have had so few cases
in this country is there have been so few cases in the Western
Hemisphere. Now, last year we did have an outbreak in Brazil,
and that demonstrated the importance of being diligent in terms
of pursuing these diseases. But I think it is very clear that
as we complete the task of polio, we can look to eradicating
other diseases in the world and controlling emerging infectious
diseases.
prepared statement
So, I am very pleased to be a part of this panel and very
pleased to join you in reviewing our commitment to the
eradication of polio and look forward to, even in your
retirement from the Congress, working with you and Mrs. Bumpers
as we continue to work toward a world that is free of polio and
safe from other infectious diseases. Thank you.
Senator Bumpers. Dr. Satcher, thank you very much for that
wonderful, articulate, and enlightening statement.
[The statement follows:]
Prepared Statement of Dr. David Satcher
Good morning. Mr. Chairman and members of the Subcommittee, I want
to thank you for your invitation to testify at this important hearing
on the eradication of polio and control or elimination of measles. I am
Dr. David Satcher, Assistant Secretary for Health, Department of Health
and Human Services (HHS) and Surgeon General of the United States.
Mr. Chairman, like myself, some people in this room may remember
the fearful time in the 1940's and 1950's when thousands of Americans
were paralyzed by polio every year. Today, the Department is assisting
the World Health Organization (WHO) in the worldwide effort to
eradicate poliomyelitis by the year 2000. Ultimately, global polio
eradication is the most cost-effective and permanent way to protect the
United States from imported polio cases. No single country can be safe
from polio until all countries are free of polio.
Within HHS, the Centers for Disease Control and Prevention (CDC)
has lead responsibility for global polio eradication and measles
elimination programs. I would like to briefly address the following:
The rationale for global polio and measles initiatives, progress toward
global polio eradication, partnerships, and challenges, and the status
of efforts to develop and implement a global measles elimination plan.
rationale for global polio eradication and measles elimination
initiatives
Diseases do not recognize national boundaries; therefore,
international disease eradication and elimination activities are
essential in protecting Americans from the threat of imported disease.
Eradication is the permanent reduction to zero of the worldwide
incidence of infection caused by a specific agent. Eradication creates
an environment where intervention measures are no longer needed.
Elimination is the reduction to zero of the incidence of infection in a
defined geographic area.
Although the United States has been free from indigenous polio
since the early 1970's, polio cases resulting from imported polio virus
occurred during the late 1970's, and such events remain a threat in the
1990's, although, thankfully, a diminishing one. Virtually all measles
cases in the United States are now directly or indirectly imported from
other countries. By contrast, no American has suffered from smallpox
since global eradication was reached in 1977.
Successful eradication programs save significant amounts of money.
The global eradication of smallpox in 1977, with support from the
Department and the U.S. Agency for International Development (USAID),
proved to be a remarkably good economic investment for public health. A
total of $32 million was spent by the United States over a 10-year
period in the global campaign to eradicate smallpox. The entire $32
million has been recouped every 2\1/2\ months since 1971 when routine
smallpox vaccination was discontinued in the United States by saving
the costs of smallpox vaccine preparation and administration, medical
care, quarantine and other direct and indirect costs. According to an
April 1998 General Accounting Office (GAO) report, ``Infectious
Diseases: Soundness of World Health Organization Estimates for
Eradication or Elimination,'' the cumulative savings from smallpox
eradication for the United States is $17 billion. The report also
estimates the real rate of return on the smallpox investment for the
United States to be 46 percent per year since smallpox was eradicated.
Achievement of global polio eradication will offer benefits similar
to those realized by smallpox eradication. More than $230 million will
be saved annually in the United States alone when polio eradication is
achieved and polio vaccination is stopped. Globally, more than $1.5
billion will be saved annually.
Disease eradication also dramatically reduces the global burden of
disability and death resulting from disease. Smallpox eradication
eliminated the suffering of an estimated 10- to 15-million people a
year and saved the lives of 1.5 million people per year. The polio
eradication initiative is eliminating the burden, disability and death
related to polio. Since 1988, several million children worldwide who
would have been paralyzed were not because of the dramatic reductions
in polio virus transmission. More than 100,000 children who would have
died from polio, were saved.
Successful disease eradication initiatives also benefit the broader
spectrum of public health.
Disease surveillance systems established for eradication
initiatives can be used for other important public health efforts. For
example, polio surveillance systems in Latin America were helpful in
determining the scope of cholera outbreaks in the early 1990's.
Eradication initiatives provide models for appropriate and feasible
laboratory networks. For example, the global polio laboratory network
(87 virology labs) developed for polio eradication is a model for
global infectious disease laboratory surveillance.
Capacity-building required for successful eradication initiatives
leads to improvements in public health planning, logistics, training,
and communications. For example, the global polio eradication
initiative has helped the expansion of computer capacity and
development of health information systems in developing countries.
Quite importantly, the success of polio eradication activities is
increasing the enthusiasm for immunization and other public health
programs by local and political officials.
global polio eradication
Basic strategies for polio eradication
WHO has defined four basic strategies for polio eradication. They
are:
(1) Achievement and maintenance of high routine immunization
coverage levels among children with at least three doses of polio
vaccine. When a high percentage of children are vaccinated, disease
incidence is reduced and eradication becomes feasible.
(2) Development of sensitive systems of epidemiologic and
laboratory surveillance for suspected cases of poliomyelitis.
Eradicating polio requires a system to detect, investigate and report
every possible case of polio. Disease surveillance is a critical
component of any disease eradication program. Two stool specimens are
collected from every suspected polio case for testing in a virology
laboratory for the presence of polio virus.
(3) Implementation of National Immunization Days (NIDs)--mass
immunization campaigns that aim to vaccinate every child in a country
(generally children less than 5 years of age) in as short a time as
possible, usually within one to a few days, to rapidly stop the spread
of polio virus. Because not all children are reached by the routine
immunization system and not all children are fully protected by the
doses they have received, NIDs target all children less than 5 years of
age, regardless of their prior immunization status. This strategy
provides the additional advantage of boosting the intestinal immunity
among previously protected children, providing a further barrier to the
circulation of polio viruses in the community. Two doses of polio
vaccine are administered to all children with an interval of 4- to 6-
weeks between doses. Because the oral polio vaccine does not require a
needle and syringe to administer, volunteers with minimal training can
serve as vaccinators during NID's, thus vastly increasing the number of
vaccinators well beyond the existing staff of the country's ministry of
health and facilitating completion of NIDs within a short period of
time.
(4) Implementation of ``Mopping-Up'' Immunization Campaigns. These
are localized campaigns conducted in the final stages of polio
eradication in a country, which are targeted to high-risk areas where
polio virus circulation still persists. In order to reach every child,
polio vaccine is carried from house to house rather than having
children come to a central immunization station. As with the NID's, two
doses of polio vaccine are administered to all children less than five
years of age, regardless of prior vaccination history, with an interval
of 4- to 6-weeks between doses.
Progress toward achievement of global polio eradication
Extraordinary progress continues toward achieving the goal of
global polio eradication by the year 2000. Reported cases have declined
by more than 85 percent since the initiative was launched in 1988.
(Attachment I) A significant portion of the world has become polio-free
since 1988. (Attachments II and III) All countries of the Americas have
been polio-free since 1991, and virtually all countries in Europe and
the Western Pacific Region (including China) have been polio-free for 1
or more years.
In addition to this progress, notable reductions in polio cases
have occurred in other countries. For example, laboratory-confirmed
polio in the European Region declined to less than 10 cases in 1997
following three years of synchronized NIDs in 10 polio-endemic
countries in the Region. Also, India has experienced the most dramatic
declines in reported polio cases. In 1988, India documented a total of
24,257 cases. The number of cases fell dramatically to a total of about
2,300 cases in 1997, a decrease of more than 90 percent. In Indonesia,
three years have passed since the last laboratory-confirmed cases of
polio. Furthermore, the number of polio cases in Viet Nam has declined
from 557 cases in 1992 to zero cases in the last 12 months.
The polio eradication initiative has provided a tremendous example
of global cooperation and action. More than 450 million children in 80
countries worldwide were vaccinated against polio in National
Immunization Days (NIDs) in 1997, which is approximately two-thirds of
the world's children less than 5 years of age. NIDs in India in January
1998 involved deployment of 2 million volunteers to vaccinate over 130
million children in a single day. The polio-endemic countries of South
Asia, including India, Bangladesh, Myanmar, Nepal and Indonesia, have
conducted NID's for 2 or more years. In December 1997 and again in
January 1998, six countries (Bangladesh, Bhutan, India, Myanmar, Nepal,
and Thailand), in an unprecedented display of international
coordination for health, conducted simultaneous NID's in which 165
million children were vaccinated in each round. India's new National
Polio Surveillance Project works with a national laboratory network and
has greatly improved India's surveillance during the past 12 months.
More than 100 persons have been hired whose main job is to find polio
virus wherever it may be to guide further eradication efforts. Current
efforts to eradicate polio involve continuing polio NIDs, improving
polio surveillance, and strengthening routine immunization programs.
The fight against polio is taking place in some of the most
difficult locations, including those in the countries of Sudan, and
Somalia. Despite the challenges of war, famine, extremes of weather,
and a lack of roads or other infrastructure, polio immunization days
were implemented in Southern Sudan from February through April of this
year. New strategies to deliver the vaccine were developed including a
unique process that uses vaccine temperature monitors to ensure the
potency of polio vaccine in the absence of refrigerators. Small
aircraft were rented to bring personnel, educational materials, and
polio vaccine to the most remote areas.
Only last month, polio immunization days were conducted in Southern
Somalia. Somalia health workers and volunteers, under the leadership of
experts from WHO, United Nations Children's Fund (UNICEF), and CDC,
successfully vaccinated more than 1 million children, many of whom had
not received any health services for more than 8 years.
Partnerships to eradicate polio by the year 2000
Collaboration among Rotary International, WHO, UNICEF, USAID, the
Task Force for Child Survival and Development, CDC, and the governments
of Australia, Denmark, Japan, the United Kingdom, and other countries
has been unique among public health initiatives for the unprecedented
level of cooperation, the magnitude of private-sector contributions and
the amount of funds raised. It is estimated that Rotary International
will have contributed hundreds of millions of dollars by the end of the
polio eradication initiative. Rotary International's contribution is
the largest private contribution to a public health initiative in
history.
A further example of the outstanding partnerships that are
operating in this highly successful initiative is the joint effort
required for NIDs in Afghanistan. Vaccine was transported by donkeys
that carry loads of polio vaccine, packed to keep it cold, along
mountainous terrain to remote vaccination stations. Under the direction
of WHO, the vaccine was provided with CDC and Rotary International
funds, procured and shipped to Afghanistan by UNICEF, prepared for
distribution within the country using an action plan developed by WHO,
UNICEF, and Afghanistan national staff of the Ministry of Health, and
transported to its final destination within Afghanistan by Afghans
using whatever local transportation was available. (Attachment IV)
Challenges for the final days of polio eradication
Although polio eradication remains feasible by the year 2000,
``business as usual'' will not get the job done. While all of the
partner organizations involved in the effort are impressed with the
tremendous progress which has been made, the program is at a critical
stage with just over two years remaining before the end of the target
year 2000 and much work remains to be done. It is critical to achieve
eradication as close as possible to the target date, because: (1) the
longer that it takes to complete the global effort, the longer that
NIDs and other resource-intensive polio eradication activities will
continue to be required in those countries which are already polio-
free; (2) there is potential for fatigue in eradication efforts in
those areas that have already been successful, thereby jeopardizing the
entire eradication initiative. The partner organizations participating
in the eradication initiative are convinced that the established
strategies, when fully implemented, will achieve eradication.
While the vast majority of the costs of polio eradication is borne
by the polio-endemic countries themselves, enhanced leadership and
continued support from the major partner organizations and governments
of the industrialized countries will be crucial at this critical phase
for successful completion of the eradication program on schedule. About
$170 million has been committed by partners in 1998.
During the next 2 years, the global polio eradication activities
will intensify to reach the needed peak of effort. However, global
shortfalls will increase in the years 1999 and 2000 without greater
commitment of resources on the part of the partner organizations and
governments. WHO estimates that the 1999 global shortfall is $131
million, and the year 2000 global shortfall is $116 million. These
global shortfalls are due both to the lack of financial commitment by
partners beyond a 1-year period, and a real shortfall of expected
funds. Similar to the smallpox eradication campaign, the provision of
adequate resources is important for finalizing efforts. Since the final
stages of eradication efforts are often the most difficult and resource
intensive, the year 2000 goals can only be met if adequate and timely
partner commitments of the needed resources are made.
Despite the extraordinary progress towards polio eradication,
progress in Africa has not kept pace with progress in other regions.
Rapid and complete implementation of the recommended polio eradication
strategies is urgently needed. Completion of special initiatives in
war-torn areas such as the Democratic Republic of Congo, Liberia, and
Sierra Leone is essential to bringing the polio eradication program to
a successful and timely conclusion. Additional funding from donor
organizations and governments will also be required to support polio
eradication activities in Africa.
Recent events that have threatened eradication of polio by the year
2000 include the tragic loss of life caused by the bombing of the U.S.
Embassy in Nairobi, Kenya. NIDs in Kenya were postponed by one week
nationwide and for one month in Nairobi. In subsequent developments,
the CDC epidemiologist in Pakistan had to be evacuated last month.
Necessary travel restrictions on U.S. Government employees traveling to
some African countries will increase the difficulty of placing staff in
long- and short-term positions there. Also, the eruption of civil war
again in Democratic Republic of Congo suspended NIDs scheduled for
August and September. It is important to remember, however, that
smallpox eradication was achieved in Africa in 1977 despite similar
impediments.
The legacy of polio eradication will not only be the prevention of
millions of cases of paralysis, permanent disability, and deaths, but
also a victory for global public health, with the demonstration that
diverse groups throughout the world can work together toward a common
goal. The successful conclusion of this initiative will have
substantial implications for other public health initiatives, the
strengthening of national health services and the credibility of
national and international organizations. Stopping polio vaccination
alone will save approximately $1.5 billion annually on a global basis
in perpetuity. The polio eradication program will leave stronger
immunization programs worldwide, improved capacity for disease
surveillance, a functioning global laboratory network, and the momentum
to tackle other major pubic health problems, including measles.
global measles control and elimination
Progress toward measles elimination
Despite the availability of a highly effective vaccine, measles
causes one million deaths annually and accounts for more child deaths
than any other vaccine-preventable disease. (Attachment V) One out of
every 10 deaths in children less than 5 years old is caused by measles,
a preventable disease. Virtually all cases of measles in children in
the United States are now the direct or indirect result of measles
imported from Europe, Asia, or Africa.
Global measles eradication would result in significant economic
benefits for the United States. CDC estimates that more than $50
million annually in measles vaccine costs alone would be saved in the
United States following a successful measles elimination initiative and
termination of measles immunization. Additional savings would accrue
from the prevention of hospitalizations and medical costs if future
measles epidemics in the United States were eliminated. For example,
hospitalization and other medical costs exceeded $100 million during
the measles resurgence in the United States during the period 1989-91.
Although there is not yet consensus for a global measles
eradication initiative, the Department fully supports regional measles
elimination goals and accelerated measles control as a step toward a
global initiative. If regional measles elimination goals continue to be
successful, we hope that a global measles initiative will be launched
as the polio eradication program comes to a successful conclusion.
A tremendous amount of progress toward establishing a global
measles initiative has already occurred. In 1994, the Pan American
Sanitary Conference endorsed the goal of measles elimination in the
Western Hemisphere by the year 2000. Implementation of an immunization
strategy combining high routine coverage with at least one dose of
measles vaccine and periodic mass campaigns vaccinating all children in
target age groups regardless of prior receipt of measles vaccine, has
led to a greater than 90-percent reduction of measles cases in the
Western hemisphere from 1990 to 1997. (Attachment VI) For more than a
year, measles transmission has been interrupted in Mexico, the
Caribbean, all countries of Central America, and some in South America,
including Colombia, Chile, and Peru. The importation of measles into
the United States from countries in Latin America has virtually
disappeared.
In addition to the ongoing measles initiative in the Americas,
other WHO regions are taking action. The Eastern Mediterranean Region
of the WHO has established a regional measles elimination initiative.
Countries in this region that have already conducted mass vaccination
campaigns designed to interrupt measles transmission include: Oman,
Kuwait, Jordan and Bahrain. Saudi Arabia, Syria, Tunisia, Qatar and the
United Arab Emirates are planning similar activities in 1998-1999. In
addition, the European Region of WHO is considering adopting a regional
measles elimination initiative. England and Wales conducted a highly
successful mass vaccination of school-aged children in 1994 which has
resulted in elimination of indigenous measles. Romania experienced the
largest measles outbreak in Europe in 1997 and is planning a mass
vaccination campaign among school-aged children, starting in October
1998. Other countries that have established national measles
elimination initiatives include Australia, New Zealand, South Africa
and several other southern African countries.
Partnerships
The partnerships that will be required to accelerate measles
control and achieve the eventual goal of measles eradication are being
developed using the polio eradication model. Strong relationships are
being developed among CDC, WHO, UNICEF, USAID, the International
Federation of the Red Cross and Red Crescent Societies, and the
American Red Cross.
Challenges
Many experts have concluded that global measles eradication is
biologically feasible. However, the eradication of measles will be a
more difficult challenge than either polio or smallpox eradication. The
highly infectious nature of the measles virus and the complex
logistical and operational requirements of conducting mass immunization
campaigns using an injectable vaccine (rather than an orally
administered vaccine as with polio), and ensuring safety of injections
in developing countries, make this a unique challenge. Another major
challenge will be harnessing the political will globally to move
forward. This is particularly relevant for many developed countries in
Western Europe and Asia that have not accepted measles as a serious
health burden and thus have not made prevention of measles a high
priority.
Refinement of the technical strategies (e.g., vaccination,
surveillance) for measles eradication may also be needed. Although we
have achieved a tremendous amount of success with measles prevention
and control, outbreaks still occur. In 1997, a measles outbreak in
Brazil affected more than 20,000 individuals, primarily young adults.
Investigations are ongoing to determine the reasons for the outbreak
and what additional prevention strategies may be required for adults.
Despite the importance of measles as a public health problem in the
United States and worldwide, it is critical that the global public
health community focus on finishing polio eradication before embarking
on a more difficult and expensive measles eradication initiative. As we
continue our efforts to eradicate polio by the year 2000, we are
carefully considering how we can best achieve global measles
eradication. The major challenges to measles eradication include: (1)
developing the political and financial commitment within countries and
regions, and at the global level to strive for measles eradication; (2)
developing the technology and logistics to safely deliver measles
vaccine in mass vaccination campaigns; (3) building consensus in the
clinical and public health communities that the time is right for a
measles eradication initiative; and (4) finalizing a timetable for
measles eradication that is synchronized with polio eradication
activities.
conclusion
The public health, financial and humanitarian benefits of
eradication programs offer a compelling rationale for continued U.S.
Government support of such initiatives. The smallpox eradication
program and the ongoing polio eradication initiative best document that
these potential benefits can be realized. However, for polio
eradication it should again be stated that ``business as usual'' will
not get the job done. Efforts must be extended to ensure success. While
recognizing that appropriate caution is needed, the United States must
also be willing to be ambitious and farsighted, even when some
questions remain unanswered. Simply stated, the eradication of polio
would be a remarkable gift to the children of the 21st Century.
NONDEPARTMENTAL WITNESSES
STATEMENT OF EBRAHIM M. SAMBA, M.D., REGIONAL DIRECTOR,
REGIONAL OFFICE FOR AFRICA, WORLD HEALTH
ORGANIZATION
Senator Bumpers. Dr. Samba, let me just say we are most
honored to have you here. As I said, Betty talked more about
you when she got home than she did about what she was doing
over there. [Laughter.]
She was immunizing children, but she did not know what she
was doing. She was scared she was going to overdose some of
them, and the doctors assured that was not possible.
In any event, thank you very much for being with us. Please
proceed.
Dr. Samba. Thank you very much, Senator Bumpers.
For me this is an inspiration, again coming this morning.
My colleagues behind me said, have you been here before? I
said, yes, I have been here many times when I was director of
the River Blindness Control Program. We used to come here to
solicit your support, which we got. You were lead supporters
and I am very pleased to tell you, sir, that we have won that
battle. Nobody--nobody--risks being blind of that disease in
west Africa today, thanks to you, thanks to your continued
support.
Senator Bumpers. Dr. Samba, if I may interrupt you, this
would be a very good time--and I know Dr. Foege will
wholeheartedly agree. Jimmy Carter, the President of the United
States, as you remember, from 1976 through 1980, deserves an
awful lot of credit for the success of that program. I
appreciate very much your mentioning it. Most people do not
understand what river blindness is.
Dr. Samba. That is right. Indeed, when I took over the
regional office of the World Health Organization in 1995, we
were looking for another challenge. Too many challenges in
Africa, but a challenge that we can win. And we looked at the
example of the United States and the Western Hemisphere, and we
said the World Health Organization has declared that polio
should and could be eradicated, but Africa was way behind.
We took up the challenge. We appealed to our partners,
Rotary, the United States, including CDC-Atlanta, and I went
around to some donors. And it is amazing how many of them said,
is the United States involved? And we said, yes. So, they
joined in. The United Kingdom, Germany, and many others.
World health organization
And today, since we started in January 1995, of the 46
African countries in the World Health Organization that did not
have any polio eradication campaign, today 36 have had a
national immunization day, even Angola where there has been
civil war raging for years. We managed to convince the
belligerents to lay down their arms and participate in the
national immunization days against polio, and we succeeded in
vaccinating over 90 percent of the targeted children.
As you have heard, sir, as Dr. Satcher has heard, we can
win but until we cross the finishing line--and in Africa the
finishing line is very tough indeed. No roads, no boats.
Sometimes we have to wear life jackets and wade our way through
hazardous rivers, avoiding crocodiles to cross over to
vaccinate all the children. But we know this is worth it
because, as Dr. Satcher said, we have been able to put down in
place mechanisms that can lead us to fight other battles in
Africa. And there are so many.
Recently Dr. Satcher, when he was Director of CDC, came to
my office in Brazzaville and we crossed over the Congo River to
Kinshasa to celebrate our defeat of ebola. I came here to this
house to thank the United States Government and to inform my
friends in the United States what we have done in protecting
them from ebola because ebola killed 70 percent of Africans. I
said, no disease will wipe out all Africans. Because we have
lived with them, some of us have immunity, but here in the
United States, you eat sterile food, your water is clean and
potable, even your source in preparing them are sterilized. Any
disease that can wipe out 70 percent of Africans will probably
wipe out 100 percent of Americans. And from the area where
ebola was in Kitwe to Kinshasa, a few hundred miles, and there
are daily flights from Kinshasa to Paris, to Zurich, and
between Zurich and the United States in a matter of hours.
Winning the battle against polio
So, together we are convinced that we can win the battle
against polio, and unless the last bastion of polio in Africa
is eliminated, the whole world is at risk. So, we are here in
this partnership, a noble partnership, led by the United States
of America. This is why I am here today. I arrived a few days
ago. I will be leaving tomorrow.
We come to follow, to salute you. Mrs. Bumpers was in
Africa a few months ago in my office, and she inspired us. I
said to her, we are going to return the compliment. We are
going to visit you and thank you and thank your husband, and
through Mr. and Mrs. Bumpers, thank the population of the
United States for helping us together eradicate polio, which is
doable. We can win. We are convinced, but it is going to be
very difficult. It is going to cost a bit more.
After polio, already in southern Africa in some parts of
Africa where polio has not been reported for the past 5 years,
measles has come to replace polio in our eradication campaign.
Similar principles, very slight modifications, dedicated,
committed collaborators, sufficient resources, good will, and
your support. We will win. We can win. We are going to win.
prepared statement
The objective of my mission here today therefore is to
thank you for the support you have always given Africa, for the
support you continue to give. Senator Bumpers, Dr. Satcher said
you are going to be missed. All the world will miss you. We
hope and pray, when you retire from the Senate, you will be
invigorated and you will have so much reserve energy, we invite
you to Africa to collaborate with us to continue our battle
against disease, suffering for the whole of humanity.
Thank you, sir, for this privilege.
[The statement follows:]
Prepared Statement of Dr. Ebrahim M. Samba
polio eradication and measles control/elimination initiatives in the
who african region
Mr. Chairman and distinguished Senators, the World Health
Organization [WHO] and its Regional Office for Africa appreciate the
opportunity to brief the Subcommittee on the initiatives to eradicate
polio and to control measles in the African Region. This statement
describes the progress and challenges to date, particularly in the
areas of polio vaccination, surveillance for acute flaccid paralysis
(AFP), and mobilization of funding, resources, and partnerships to
support the Polio Eradication Initiative in the African Region.
polio eradication
Situation analysis
Throughout the 1980's, 4,000 to 5,000 clinical cases of
poliomyelitis were reported annually in the WHO African Region.\1\
Experience in the field showed that this figure reflected severe under-
reporting, representing perhaps only 10 percent of all cases that
occurred in reality. The annual number of reported cases fell to 1,500
to 2,000 during the first half of the 1990's, presumably as a result of
the increasing impact of routine vaccination activities. This number
represented almost one-half of all polio cases reported in the world.
In 1997, only 883 clinical cases of polio were reported through the
routine reporting systems in Member States in the African Region.
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\1\ The WHO African Region consists of forty-six WHO Member States:
Algeria, Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Cape
Verde, Central African Republic, Chad, Comoros, Congo, Cote d'Ivoire,
Democratic Republic of the Congo, Equatorial Guinea, Eritrea, Ethiopia,
Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia,
Madagascar, Malawi, Mali, Mauritania, Mauritius, Mozambique, Namibia,
Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Seychelles,
Sierra Leone, South Africa, Swaziland, Togo, Uganda, United Republic of
Tanzania, Zambia, and Zimbabwe.
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For programmatic purposes, the WHO African Region was divided into
four epidemiological blocks--Central, Eastern, Southern and Western--to
ensure that eradication activities could be tailored to the specific
needs of groups of countries. In addition, a separate, fifth
epidemiological block was formed by four large countries, each of which
has suffered difficult circumstances in recent years: Angola, DR Congo,
Ethiopia and Nigeria. These four countries represent major reservoirs
of wild polioviruses in the African Region and are believed to spread
polio to neighbouring countries.
In order to achieve polio eradication, countries in the African
Region have adopted and continue to implement four major strategies
recommended by WHO: (1) achieving and sustaining high routine
vaccination coverage with oral polio vaccine (OPV); (2) implementing
mass vaccination campaigns, known as National Immunization Days (NIDs);
(3) establishing effective surveillance of suspected polio cases (that
is, surveillance of all cases of acute flaccid (floppy) paralysis
(AFP)); and (4) carrying out mopping-up activities as indicated by
surveillance data.
Tremendous progress has been made to date in the Eastern and
Southern African epidemiological blocks. Supplemental vaccination
through National Immunization Days (NIDs) conducted in all countries of
these two blocks appear to have had a significant impact on the
circulation of ``wild'' polioviruses. NIDs aim to cover a high
proportion of the under-5 child population of a given area with two
doses of oral polio vaccine about a month apart. Despite increasingly
sensitive surveillance based upon the clinical, epidemiological and
virological investigation of AFP cases, wild polioviruses (that is,
those which are not associated with the vaccine) have not been isolated
in continental Southern Africa since 1995. A similar picture has
emerged in Eastern Africa since 1997.
Wild polioviruses continue to circulate in Central and Western
Africa and the four large countries. The fact that polioviruses were
detected after one or even two series of NIDs in some of these
countries indicates that polio-free status will be more difficult to
achieve in those areas.
Routine vaccination
Routine vaccination coverage with three doses of oral polio vaccine
(OPV3) among infants under 1 year of age reached 54 percent in the WHO
African Region in 1997. This represented no increase as compared with
the previous year. Coverage rates varied considerably by
epidemiological block in 1997: 39 percent for Central Africa, 59
percent for Eastern Africa, 74 percent for Southern Africa, 57 percent
for Western Africa, and 45 percent for the four large countries in
difficult circumstances. Factors which limit the achievement of high
routine vaccination coverage in certain countries include poor access
to health services, high drop-out rates, occasional shortages of
vaccine and deficiencies in the refrigerated transport or cold chain
system including fuel and power shortages and lack of transport.
Although supplemental vaccination through NIDs is critical for the
eradication of poliomyelitis, doses supplied through NIDs do not
replace routine vaccination of infants with OPV. Therefore, the
importance of educating and mobilizing communities to bring their
infants to health facilities, outreach clinics and mobile units for
routine vaccination has been strongly emphasized.
It is widely recognized that routine vaccination benefits
substantially from the implementation of NIDs. NIDs have increased
political commitment and support for the whole Expanded Program on
Immunization (EPI) from country-based and external partners. Additional
resources become available which benefit EPI in general and may be used
for strengthening planning and managerial capacities of health staff,
and provision of additional equipment such as refrigerators and cold
boxes. NIDs provide excellent opportunities for advocacy, social
mobilization and increasing community awareness about target diseases
and the benefits of immunization. Furthermore, it has been observed in
many countries, for example Angola, that the success of NIDs increases
the morale of health workers, especially where routine vaccination
coverage was poor.
National immunization days
The first series of National Immunization Days (NIDs), the biggest
ever conducted in Africa, was implemented in 31 countries of the
African Region in 1996 early 1997. Over 74 million children below five
years of age were targeted. More than 55 million (74 percent) children
received OPV in the first round and about 60 million (80 percent) in
the second round of NIDs. The majority of countries achieved remarkable
results in vaccinating their target population with OPV: 26 countries
(84 percent of the 31 countries that participated) had 80 percent or
greater coverage in at least one round and 20 (65 percent) achieved 80
percent or greater coverage in both rounds.
The second series of NIDs involved 36 countries between March 1997
and March 1998. These were the first NIDs for seven countries: Burundi,
Guinea, Guinea-Bissau, Madagascar, Mali, Niger and Senegal. Two
supplemental OPV doses were received by 85 million children under age
five. Immunization coverage was reported at 80 percent or greater for
both NID rounds except in the Central African Republic (77 percent and
82 percent), Equatorial Guinea (76 percent and 99 percent), Kenya (79
percent and 82 percent), Lesotho (67 percent and 65 percent),
Mozambique (65 percent and 75 percent), Nigeria (72 percent and 95
percent), Rwanda (73 percent and 75 percent) and South Africa (81
percent and 76 percent). It is hoped that the three countries which
have yet to conduct nation-wide NIDs--DR Congo, Liberia and Sierra
Leone--will do so in 1998. Those countries in West Africa where wild
polioviruses have reappeared since the first series of NIDs will
require four rounds of OPV (2 rounds of NIDs, 2 rounds of house-to-
house ``mopping-up'') if the goal is to be achieved by the year 2000.
NIDs reached over 80 percent of children under five years of age in
a number of countries where less than 50 percent of infants had
previously received routine OPV3, such as Angola, Burkina Faso,
Cameroon, Central African Republic, Chad, Mauritania and Niger.
Particularly noteworthy is the success achieved in Angola. This
country immunized 71 percent and 80 percent of its target population in
the first and second rounds in 1996 and 83 percent and 90 percent in
1997, respectively. This is especially remarkable since routine
coverage in Angola was below 40 percent. NIDs resulted in increased
collaboration between all national and international partners.
Initiated by the Government, this important initiative has also
involved UNITA, WHO, Rotary, UNICEF, UN Peacekeeping Forces and the
private sector. It was the first time that the Government and UNITA
worked together to improve health of their young compatriots. The
challenge now is to extend EPI in general and NIDs in particular into
those districts which remain inaccessible due to security problems.
Furthermore, a number of countries have utilized the opportunity to
include with OPV during NIDs the administration of other vaccines or
health interventions, for example, measles vaccine and vitamin A
supplementation. Although the inclusion of an injectable vaccine like
measles vaccine adds technical and logistical complexity to the
operation, the additional cost of including measles vaccine is less
than that of a separate measles vaccination campaign.
Although this support from external and country-based international
agencies and NGOs was important, the remarkable success of NIDs was
mainly achieved due to high-level political commitment, technical
competence and experience of national health authorities and health
staff, through the effective planning and coordination of activities.
The implementation of NIDs demonstrated the tremendous potential of the
health sector and communities to undertake joint activities, and
effective coordination between governments, external and country-based
partners. NIDs resulted in remarkable strengthening of inter-sectoral
and inter-agency coordination and cooperation, and boosted the
revitalization or formation of national EPI inter-agency coordination
committees.
Disease surveillance
The major task of countries implementing polio eradication
activities is to prove that the circulation of wild polioviruses, whose
presence in stool specimens of patients with AFP is considered
definitive proof of confirmed polio, has been interrupted. This only
can be done if all AFP cases are promptly detected, reported and
investigated, and if adequate stool specimens are properly collected
and shipped to a laboratory where they can be reliably cultured for
poliovirus.
The WHO African Regional Polio Laboratory Network currently
comprises three regional reference laboratories in Central African
Republic, Ghana, and South Africa and ten national and inter-country
laboratories. A further two national laboratories (Ethiopia and
Maidugari/Nigeria) are in the process of being certified. National
laboratories process stool specimens and identify serotypes from AFP
cases, and regional reference laboratories confirm the identity of
polioviruses isolated by national laboratories and determine whether
the viruses are wild or vaccine-derived.
In 1997, all but twelve countries of the African Region (Angola,
Burundi, Congo Gabon, Equatorial Guinea, Eritrea, Liberia, Mali,
Mauritania, Mozambique, Rwanda and Sierra Leone) submitted specimens to
the regional polio network laboratories. All stool specimens collected
from AFP cases in Eastern and Southern African countries in 1997 were
laboratory negative for wild poliovirus.
In 1997 and 1998, wild polioviruses were, however, isolated from
specimens collected in DR Congo and a number of countries mainly
situated in Central and Western Africa, including countries which had
conducted NIDs (Angola, Benin, Burkina Faso, Central African Republic,
Chad, Cote d'Ivoire, Ghana, Nigeria and Senegal). Partial genomic
sequencing shows that many wild poliovirus isolates from countries
surrounding the DR Congo originate in the DR Congo.
The performance of AFP surveillance in many countries of the
African Region, although it has markedly improved, still remains
inadequate for the purposes of official certification of polio-free
status. National surveillance systems need to be further strengthened
to increase their reliability and effectiveness. One critical task is
to sensitize medical professionals to the polio eradication initiative
and its proven strategies, in order to help them understand the need to
report and investigate AFP cases whose final diagnosis may eventually
be other than poliomyelitis.
The establishment of a system for AFP surveillance in Africa has
laid the foundation for the development of integrated infectious
disease surveillance throughout the continent. The provision of
resources including staff, transport and communications tools will
facilitate the inclusion of surveillance of other priority or epidemic
diseases such as measles, cholera, dysentery, meningitis and
haemorrhagic fevers.
Funding
During 1996 and 1997, over US$65 million were provided by Rotary
International, USAID, the U.S. Centers for Disease Control and
Prevention (CDC), the Government of Japan, vaccine manufacturers and
other partners for implementation of the two series of NIDs and disease
surveillance in the African Region. The United States of America is
playing a significant role in supporting the Polio Eradication
Initiative in the African Region. In 1996-97, the U.S. Government not
only disbursed US$34.5 million--that is, over half of all external
funds for NIDs and surveillance of EPI target diseases--through USAID
and CDC but also provided consultants to assist countries in planning
and implementation of these activities. This important external
financial support acted as a catalyst for national political and
financial commitments, and stimulated preparations for NIDs, local fund
raising, and resource mobilization in the majority of countries.
The cost of NIDs was estimated from a study conducted in Southern
Africa at approximately US$0.50 to 0.60 per child vaccinated with two
OPV rounds. However, the actual NIDs cost may be slightly higher, since
infrastructure, staff, funds and in-kind contributions were provided by
national governments, country-based international agencies,
nongovernmental organizations (NGOs) and other partners, including the
private sector and local communities.
Funding requirements for polio eradication activities in the WHO
African Region during 1999-2001 are summarized in Annex 1.
Political commitment, advocacy and social mobilization
In July 1996, African Heads of State and Government at the Thirty-
Second Ordinary Session of the OAU Summit in Yaounde, adopted a
Declaration on Polio Eradication in Africa. This declaration urges all
Member States to take immediate and concrete steps to urgently address
the problem of poliomyelitis and give their full political support to
polio eradication as a matter of top priority. The African leaders
confirmed their strong determination to make Africa free of polio and
committed themselves to fully support the implementation of the polio
eradication strategies recommended by the World Health Organization.
The Declaration states that adequate human, financial and material
resources, both local and external, be mobilized to support polio
eradication activities in Africa.
The Yaounde Declaration on Polio Eradication in Africa was
instrumental in obtaining the highest-level political commitment and
support for the Polio Eradication Initiatives in the African Region.
A ``Committee for a Polio-Free Africa'', chaired by President
Nelson Mandela and with high-level representation from around the
continent, was created to strengthen political advocacy and social
mobilization for polio eradication, and met for the first time in South
Africa in August 1996.
A region-wide ``Kick Polio out of Africa'' campaign was launched in
August 1996 in South Africa by President Mandela with participation of
the Members of the ``Committee for a Polio-Free Africa'' (the First
Ladies of Congo, Ghana and Nigeria, General Toumane Toure, former
President of Mali, and senior officials representing Rotary
International, WHO, OAU, UNICEF and USAID) at the first meeting of the
Committee.
NIDs were especially successful in countries where this political
commitment was attained. The role of Heads of State and Government and
First Ladies was critical in ensuring that NIDs receive necessary
attention and support, not only from external international and donor
agencies and organizations but, most importantly, from various
governmental sectors, as well as country-based agencies, non-
governmental organizations (NGOs) , the private sector and communities
themselves. In many countries, Heads of State and Government
demonstrated their support for NIDs by addressing the nation through
the mass media and by participation in launching ceremonies. In a
number of countries First Ladies served as patrons for the NIDs and
other polio eradication activities.
The three First Lady Members of the ``Committee for a Polio-Free
Africa'' have remained very active in advocacy and social mobilization
activities in preparation for NIDs in their respective countries. The
First Lady of Mozambique was also particularly active in the promotion
of NIDs in that country in 1998.
The success of NIDs continues to be made possible by the very
effective social mobilization campaigns carried out by each country,
with support from the highest-levels political leaders and other
opinion makers within countries, and advocacy from WHO and other
partners. To consolidate and share this experience widely, an advisory
group on social mobilization was established in the WHO African Region
with the membership of all major partners. The campaign's soccer-linked
theme in conjunction with its slogan and logo have now become widely
accepted and powerful tools for advocacy. The advisory group has
planned and implemented various regional activities such as the
activities during the Cup of African Nations contest in 1998.
The challenge is to maintain the interest and commitment for polio
eradication and to extend it to all EPI activities to ensure that all
partners play their part and contribute effectively to achieving this
important goal.
Partnership
A strong and effective partnership has been created to support the
Polio Eradication Initiative in the African Region with the leadership
of the WHO Regional Office. The major partners are the African
Governments, World Health Organization, Rotary International, UNICEF,
USAID, Centers for Disease Control and Prevention in Atlanta (USA),
Government of Japan, DFID (UK) and CIDA (Canada). The partners
participate in annual technical conferences of the African Regional
Task Force on Immunization, which are usually held in conjunction with
donor meetings of the Regional EPI Inter-Agency Coordination Committee.
Vaccine manufacturers also donated U.S. $600,000 worth of OPV for
polio eradication activities in Africa in 1997.
The Governments of Denmark, Finland, France, Germany and Ireland,
Rotary Clubs, the National Peace Corps Association (USA), national Red
Cross organizations, Swiss Development Corporation and private
companies, such as SmithKline Beecham, Rhone Poulenc, Barclays Bank,
Johnson & Johnson, Coca Cola and others, were involved in supporting
polio eradication activities in individual countries.
measles control/elimination
Since the introduction of measles vaccine in Africa, there has been
an estimated 56 percent reduction in measles cases and an estimated 77
percent reduction in measles deaths. However, the measles burden in
Africa remains the highest of any of the six WHO Regions, with an
estimated 9.2 million cases and 435,000 deaths in 1995. Studies have
shown that measles case fatality rates of 6 percent and higher continue
to occur.
Most of the deaths attributable to measles in Africa occur as a
result of various complications. It is estimated that approximately 5
percent to 30 percent of measles cases will have severe measles disease
and complications. The most common complication is bronchopneumonia,
followed by dehydration from diarrhea and vomiting. Some of the measles
cases also become malnourished. As much as half of all childhood
corneal blindness may result from measles complications in vitamin A
deficient children. Other complications include skin sepsis, purulent
conjunctivitis, blindness and otitis media which lead to deafness in a
small percent of children.
Routine vaccination coverage with one dose of measles vaccine among
infants under one year of age remains persistently the lowest of all
the vaccines in the EPI. In 1997, 16 out of 46 countries in the WHO
Africa Region, representing 21 percent of the regional population,
failed to reach 50 percent routine vaccination coverage.
In accordance with national variations in routine vaccination
coverage, measles epidemiology and operational and financial
feasibility, WHO has developed and, in some countries, begun to
implement three sets of strategies designed specifically for three sets
of countries, with the following primary objectives: to reduce measles
mortality to accelerate measles control; or to eliminate measles
transmission.
To achieve these objectives, a careful mix of activities will be
implemented (see Table 1), including strengthening routine vaccination
services, supplemental measles vaccination, social mobilization,
surveillance and evaluation. The additional funds required to carry out
supplemental vaccination are presented in Annex 2.
TABLE 1.--PROPOSED MEASLES CONTROL/ELIMINATION STRATEGIES IN THE WHO AFRICAN REGION
----------------------------------------------------------------------------------------------------------------
Epidemiological characteristics Geographic areas Proposed strategies
----------------------------------------------------------------------------------------------------------------
Low routine coverage (<50 percent), West Africa and Central Reduction of measles deaths:
presumed high number of deaths (Case Africa, Angola, DR Congo, Achieve higher routine coverage with
Fatality Rate >4 percent). Ethiopia, Nigeria. measles vaccine;
Reduce measles deaths through measles
campaigns in urban, densely populated
rural areas and other high-risk areas
(target age group: children below 5
years of age);
Conduct periodic measles campaigns in
high risk areas with 2-3 year
intervals;
Collect aggregated surveillance data.
Medium routine coverage (50-75 East Africa, Algeria, Accelerated measles control:
percent), presumed low-medium number Madagascar, Mauritania, Achieve higher routine coverage with
of deaths (Case Fatality Rate 0.5-4 Mozambique. measles vaccine;
percent). Further reduce measles cases and deaths
through campaigns in high-risk areas
(target age group: children below 5 yrs
of age);
Conduct periodic measles campaigns in
high risk areas (frequency of campaigns
and target age group to be determined
by surveillance data);
Establish sentinel collection of case-
based data.
High routine coverage (>75 percent), Southern Africa............. Measles elimination:
presumed low number of deaths (Case Increase and sustain routine coverage
Fatality Rate <0.5 percent). with measles vaccine to above 90
percent;
Conduct ``catch-up'' measles campaigns
among children below 15 years of age;
Conduct periodic ``follow-up''
campaigns; and
Case-based surveillance including
laboratory investigation of cases.
----------------------------------------------------------------------------------------------------------------
conclusions
Less than 1,000 days remain to achieve the goal of polio
eradication by the end of the year 2000, as established by the Member
States of the World Health Organization in 1988, and endorsed by the
World Summit for Children in 1990.
In view of current trends, it appears that the polio eradication
goal is achievable in Africa. Marked progress is reported from Eastern
Africa, and there is justifiable confidence that Southern Africa is
close to being confirmed as polio-free. However, despite the remarkable
progress achieved, there is an urgent need to improve surveillance in
order to document the progress achieved to date. To accomplish the goal
by the target date, implementation of polio eradication strategies must
be accelerated, in particular, by establishing effective disease
surveillance systems. Financial and political support from all partners
for polio eradication in the African Region is particularly important
right now, in light of the success to date and the remaining challenges
to reaching the regional and global goals of polio eradication.
The eradication of poliomyelitis will not only prevent our children
from becoming crippled for life and reduce human suffering caused by
this terrible disease in Africa. It will also save an estimated US $1.5
billion per year worldwide, currently spent on immunization,
surveillance and rehabilitation of patients. After eradication, these
resources could be reprogrammed to address other emerging health
problems in Africa.
Measles remains significant among the major causes of childhood
morbidity and mortality in Africa. The lessons learned from the Polio
Eradication Initiative in the African Region will serve as critical
experience for the next vaccine-preventable disease control step.
Measles control and elimination in the African Region will require
further coordination of efforts and resources from all partners.
ANNEX 1.--FUNDS NEEDED FOR POLIO ERADICATION ACTIVITIES IN THE AFRICAN REGION
[U.S. dollars]
----------------------------------------------------------------------------------------------------------------
Budget line 1999 2000 2001
----------------------------------------------------------------------------------------------------------------
OPV for NID's................................................... 20,817,000 17,107,000 6,946,000
NID's operational costs......................................... 40,878,000 36,165,000 13,764,000
Mopping-up activities........................................... 19,875,000 19,875,000 19,875,000
Disease surveillance............................................ 8,395,000 8,582,000 8,960,000
Laboratory activities........................................... 810,000 664,000 739,000
Certification activities........................................ 102,000 140,000 175,000
Personnel (including duty travel and support)................... 9,067,000 8,880,000 9,324,000
Regional office/inter-country activities........................ 650,000 683,000 716,000
-----------------------------------------------
Subtotal.................................................. 100,594,000 92,096,000 60,499,000
===============================================
PSC............................................................. 6,608,000 6,010,000 3,166,000
-----------------------------------------------
Total..................................................... 107,202,000 98,106,000 63,665,000
===============================================
Grand total: U.S. dollars................................. 268,973,000 .............. ..............
----------------------------------------------------------------------------------------------------------------
ANNEX 2.--FUNDS NEEDED FOR MEASLES CONTROL/ELIMINATION ACTIVITIES IN THE AFRICAN REGION \1\
[U.S. dollars]
----------------------------------------------------------------------------------------------------------------
Budget line 1999 2000 2001 2002 2003 Total
----------------------------------------------------------------------------------------------------------------
Costs of vaccine and injection 1,674,993 6,209,330 5,511,090 8,763,394 8,063,125 30,221,932
equipment for supplemental
immunization......................
Operational costs of supplemental 1,486,680 5,511,240 4,891,500 7,778,160 7,156,620 26,824,200
immunization......................
Costs of injection safety and 495,560 1,837,080 1,630,500 2,592,720 2,385,540 8,941,400
evaluation/surveillance...........
----------------------------------------------------------------------------
Subtotal: Supplemental 3,657,233 13,557,65 12,033,090 19,134,274 17,605,285 65,987,532
immunization................
============================================================================
PSC................................ 475,440 1,762,495 1,564,302 2,487,456 2,288,687 8,578,380
----------------------------------------------------------------------------
Total........................ 4,132,673 15,320,145 13,597,392 21,621,730 19,893,972 74,565,912
----------------------------------------------------------------------------------------------------------------
\1\ Supplemental immunization.
Human and natural resources to sustain everybody
Senator Bumpers. Thank you very much, Dr. Samba, and thank
you very much for your kind words. It was a very powerful,
wonderful statement. I regret that 99 other Senators could not
have heard your testimony this morning. [Laughter.]
You know, there is not anything wrong with this country.
Indeed, there is not anything wrong with the world. We have the
assets and we have the human and natural resources to sustain
everybody in relative prosperity, but we simply miscue our
priorities and squander so much on misspent priorities. And you
have set that out with a great deal of specificity and very
graphically.
Again, I thank you very much for being with us.
Dr. Satcher. Senator Bumpers.
Senator Bumpers. Yes.
Dr. Satcher. Please allow me to apologize for having to
leave. As I said, the Pan American Health Organization is
meeting, and I have just been paged and told that we are
getting ready for a very important vote.
Senator Bumpers. That is quite all right.
Dr. Satcher. I am part of the U.S. delegation.
I am delighted to have been able to be here and to testify
in front of you once again about this very important issue and
to join my outstanding colleagues here. I am sure they can
answer any questions that you have. Thank you.
Senator Bumpers. Well, most of them were directed to you,
so we will see. [Laughter.]
STATEMENT OF HERBERT A. PIGMAN, CHAIRMAN, POLIO
ERADICATION ADVOCACY TASK FORCE, THE ROTARY
FOUNDATION, ROTARY INTERNATIONAL
Senator Bumpers. Mr. Pigman, once again welcome. Thank you
in advance for the magnificent job Rotary International has
done in bringing us really to this happy state. Please proceed.
Mr. Pigman. Thank you, Senator Bumpers. Rotary
International would like to thank your subcommittee for
conducting this hearing. It comes at a critical time in the
fight against polio. The virus may indeed be on the threshold
of extinction, but that final threshold is a formidable one,
and without the needed resources directed on a timely basis, we
could fail to reach the target in the year 2000.
I would like the privilege of joining my colleagues here in
commending you, Senator Bumpers. Throughout your distinguished
career, you have carried the torch for immunization both here
and abroad, and speaking on behalf of the 450,000 members of
Rotary in this country, we could wish for no greater advocate
of the rights of the children for a healthy start in life. We
thank you.
Polio eradication is one of the great public health
stories, and since that resolution by WHO 10 years ago, a
global partnership has developed and it includes the private
sector. The private sector has joined with health ministries
and their workers in polio endemic countries, and as you have
seen, the reported incidence of this disease has declined by 90
percent and now 160 nations are polio-free. Some 4 million
cases of polio have been prevented in this period, and victory
holds the promise of $1.5 billion in savings and $230 million
in this country alone.
Support for polio eradication by the private sector is
unprecedented, and I think it is instructive to question why
this has developed and furthermore what lessons are there for
the future of such collaboration.
The polio initiative presents an attractive case to the
private sector. It is a time-limited goal. It is an achievable
goal. We have an effective vaccine. We have a proven strategy,
the promise of future savings and future benefits in the fight
against other infectious diseases. Health workers in countries
all over the world soon awakened to the potential of their new
ally, the private sector, and they identified roles which play
to the strengths and the interests of the private sector. All
these I believe are positive factors in the decisions by the
private sector to get on board on polio eradication, and it has
been a fruitful marriage.
Oral polio vaccine
Three pharmaceutical firms have donated 100 million doses
of oral polio vaccine. Another has contributed $1 million to
support polio virology labs in Africa. Corporations are lending
advertising know-how to convey the message of immunization. In
support of national immunization days, they have deployed
private helicopters, jets, vehicles. They have printed posters,
provided faxes and fuel, megaphones, and meals, all with the
aim that the war on polio in their particular country shall not
fail for the want of a horseshoe nail.
Rotary, as a service club organization, has helped to tap
this private sector potential because we ourselves are the
private sector. We comprise business and professional leaders
in 159 countries and our 1.2 million members try to lead by
example. Since the PolioPlus Program began in 1985, Rotary has
committed $313 million for vaccine, social mobilization, and
laboratory support in 119 nations. We support a core of
experts, some of whom are here today, who are leading the polio
fight at WHO headquarters in Geneva and in regional offices.
Very recently $5 million has been contributed by cooperating
clubs to fund polio laboratories in a dozen countries. We will
invest, as you have said, Senator Bumpers, at least $425
million in polio by the year 2005 when we celebrate Rotary's
100th anniversary in a polio-free world.
This financial support was welcome. It is needed, but of
even greater value are the millions of hours invested by
Rotarians and friends and others in volunteer service. They
constitute an army of workers on the front lines, and in
stretching out a hand of help to health workers, they help them
stretch their nation's health dollars. Some 150,000 Rotarians
and their friends have turned out for each of India's national
immunization days, and in many countries, members of Rotary
chair the national and regional interagency coordinating
committees which help health ministries to plan and execute
strategies.
Rotary also is advocating the benefits of polio eradication
to the leaders of donor governments, some 30 other governments.
This effort has helped to produce more than $500 million in
polio specific grants in the last 5 years, and I am very proud
to say as a citizen of this country that the United States has
contributed 40 percent of this total, or $201 million, toward
polio eradication overseas.
We wish to commend your subcommittee for the recommended
increase of $20 million for polio needs in Africa. These funds
are vitally needed not only for fiscal year 1999, but also for
the year 2000.
The task of delivering oral polio vaccine to children faces
enormous problems in many parts of Africa, as Dr. Samba has
testified. Civil conflict, poor roads, uncertain communication,
unpaid health workers, shortages of transportation and
refrigeration, and a weak but rapidly improving surveillance
system.
The good news is that national immunization days against
polio in Africa have achieved remarkable results despite these
obstacles. The health workers of these countries need these
additional resources. Furthermore, they merit the encouragement
which such special help will bring them. New funds will buy
needed vaccine, fuel, training, extend surveillance capacity.
But, moreover, they will trigger new private support. Rotary
has committed $92 million to the program needs of 47 African
nations, and that continent continues to have our highest
priority.
In closing, Senator Bumpers, I would like to emphasize that
private sector collaboration in the war on polio, for which I
have provided a few examples, has implications which transcend
the victory over a single infectious disease. The private
sector has responded to an appeal by leaders of the public
health community. They have asked for help in winning a war
that can be won, a war that can eliminate forever a terrible
disease.
prepared statement
Now we are allied in a mutual testing ground. The goal is
in sight, and all partners, governments of polio endemic
nations, donor governments, and the private sector, must stay
the course and keep the resources flowing. Victory over polio
will prove to have many lasting benefits, but I believe one of
the most important benefits may well be that the value of
childhood immunization will engrave itself on the corporate
social conscience and nurture the realization that in the long
run healthy kids are the future of a healthy global economy.
Thank you for this opportunity to testify, Senator.
Senator Bumpers. Thank you very much, Mr. Pigman.
[The statement follows:]
Prepared Statement of Herbert A. Pigman
Mr. Chairman, members of the subcommittee, Rotary International
thanks you for the opportunity to participate in this hearing as a
representative of the non-governmental, private sector community, a
sector which has emerged as a key partner in the global effort to raise
immunization levels among the children of this world.
We particularly wish to commend Senator Bumpers for his leadership
in immunization, both here in the United States and in the
international arena. Early in his distinguished career he recognized
the value of investing in immunization. He has worked assiduously
toward this end, with the great support and participation of Mrs.
Bumpers. Newborns around the world could wish for no greater advocates
of their right to a healthy start in life.
I will address in particular one theme of this hearing: the
importance of public and private sector collaborative efforts in
achieving the world-wide eradication of polio, and its implications for
measles eradication and other public health goals. The global program
to eradicate poliomyelitis provides an outstanding example of how a
public/private partnership can be forged and sustained, producing
dramatic results.
The international team which is attacking this dreaded, crippling
disease includes among its public sector the World Health Organization,
UNICEF, the U.S. Centers for Disease Control and Prevention, the U.S.
Agency for International Development and counterpart agencies in other
donor nations, and the health ministries and workers in the countries
where the battle against polio continues. Chief among the private
sector is Rotary International, the service club organization of over
1.2 million business and professional leaders in 29,000 communities in
159 countries.
Over the past 13 years, this global team--unprecedented in the
history of public health--has applied innovative strategies to reduce
the reported cases of polio by 90 percent. The polio virus is on the
threshold of extinction, and we are surrounding it in its final
stronghold: sub-Saharan Africa. If adequate financial resources
continue to flow to this program, there is great optimism that we will
see the last case of polio by the end of the target year 2000. This
virus, which once crippled or killed some 600,000 people annually,
mostly children, will join the smallpox virus as the second to be
eradicated from the planet. In addition to immeasurable human benefits,
the world will save at least $1.5 billion every year in the cost of
vaccine and its administration, when polio immunization is no longer
needed. There will be lasting benefits in the form of a stronger
infrastructure for the delivery of vaccines against other infectious
diseases.
The strategy, the successes, and the challenges remaining to the
global polio eradication campaign have all been reviewed by my
distinguished colleagues who are testifying today. I would like to take
this opportunity to point out that Rotary holds these men in great
esteem, for their vision of a world without polio. Dr. Satcher, Dr.
Foege and Dr. Samba are all recipients of Rotary's Polio Eradication
Champion award, for their leadership in the international partnership
which is making the ``Target 2000'' dream a reality.
On behalf of Rotary International and the 400,000 American
Rotarians, I would also like to express our deep gratitude to this
Subcommittee for its staunch support of the CDC's international polio
eradication efforts over the past several years. In particular, I would
like to thank the Subcommittee for the recommended increase of $20
million for fiscal year 1999. The CDC has accomplished so much with the
funds you have allocated them to date. This additional appropriation
will help make it possible to eliminate polio in Africa by the end of
the year 2000. As may be seen in the appendix to this document, the
United States' generosity has fueled the rapid progress. US
appropriations in the last three fiscal years total $201 million, or 40
percent of the major polio-specific grants of all donor nations. These
monies have been deployed most effectively by the CDC and USAID, which
are spearheading America's fight against polio. Few investments are as
risk-free or can guarantee such an immense return. Rotary greatly
appreciates your personal leadership and continued support of the CDC's
program and ``Target 2000.''
the polio eradication strategy works
Polio, like smallpox before it, can be eradicated because humans
are the only host for the virus. At the 1988 World Health Assembly, the
nations of the world resolved to see the last case of polio by the end
of the year 2000, with certification of eradication by the year 2005.
This is possible because we have a proven strategy. In 1994, the entire
Western Hemisphere was certified free of polio. Every country which can
effectively implement WHO's polio eradication strategy can expect to be
polio-free within three to four years. We must make certain that every
country is able to do this, because if we fail in any one country, we
fail world-wide.
Although polio-free since 1979, the United States currently spends
at least $230 million annually to protect its newborns against the
threat of importation of the polio virus. This threat is real. In 1996,
for example, a polio outbreak in Albania, caused by an imported virus,
killed and crippled dozens of people and spread to neighboring Greece
and Yugoslavia. Once polio is eradicated and immunization against it
can be ceased, America will save this amount every year. Eradicating
the disease in the 50 countries where it remains clearly benefits the
American people.
rotary's role in the global partnership
Thanks in large measure to United States support, the international
effort to eradicate polio has made tremendous progress during the past
year: 160 countries now polio-free; polio apparently gone from the
Western Pacific, and virtually eliminated in Europe; solid improvements
in polio surveillance and the global laboratory network; National
Immunization Days (NIDs) conducted or scheduled in all polio-endemic
African nations. Rotary is proud to have played a role in these many
successes. Rotary's contribution to the international effort is
fourfold: funding, volunteerism, laboratory and surveillance support,
and advocacy for polio eradication.
Funding.--When the PolioPlus Program began in 1985, Rotary
initially intended to raise $120 million to provide oral polio vaccine
(OPV) for all the newborns in the developing world for a period of five
years. Rotarians responded with $247 million, more than double the
original fund-raising goal. Since then, Rotary has committed additional
resources, and by the year 2005, when we expect to celebrate the
certification of polio's eradication, Rotary International will have
expended over $425 million on the effort--the largest private
contribution to a public health initiative ever. Of this, $313 million
has already been allocated for polio vaccine, operational costs,
laboratory surveillance, cold chain, training and social mobilization
in 119 countries, including $92 million to date for 47 African nations.
Over the past year, realizing the increased role which external donors
need to play in order to ensure that polio eradication is not
jeopardized due to lack of resources, The Rotary Foundation has
allocated an additional $40 million to its PolioPlus Fund. But Rotary's
contribution goes beyond the financial.
Volunteerism.--Around the world, Rotarians and their friends and
families have contributed millions of hours to polio immunization and
eradication efforts in their nations and communities. Rotarians are
active at all levels of the campaign--international, regional, national
and local. They work together with their national ministries of health,
UNICEF and WHO, and with health providers at the grass-roots level.
They help to plan and implement the National Immunization Days, to
publicize the campaigns, to transport vaccine, to staff immunization
posts, and to help track children who may have missed the immunization.
In Angola, for instance, Rotarians helped negotiate a cease-fire in
order to immunize children, and led a campaign to solicit corporate
jets, helicopters and vehicles to move vaccine through Angola's land-
mine infested countryside. The Government has been so impressed by
Rotary's ability to negotiate with the factions and build consensus
that the President of Angola has approached Angolan Rotarians to
solicit Rotary's assistance in convening a national peace conference.
In India, 70,000 Rotarians and the 100,000 additional volunteers they
were able to mobilize were critical to the success of the NIDs, during
which 130 million children were immunized on one day--the largest
single public health event in history.
Laboratory and surveillance support.--Rotary is committed to
strengthening the network of international, regional and national
laboratories which is necessary to investigate suspected polio cases.
We have made grants to fund laboratory equipment, personnel, and
training of virologists, and through our PolioPlus Partners program
have enabled Rotarians in polio-free countries to make direct, specific
contributions to the global eradication of polio, by adopting
laboratory and social mobilization projects in polio-endemic countries.
Rotary districts in America, Canada and Japan have funded polio
laboratories in Cote d'Ivoire, Kenya, Madagascar, Nigeria, Senegal,
Zambia, and 6 other African nations, in some cases providing all the
equipment and materials necessary to get the lab functioning. In
addition, Rotarians in polio-endemic countries are involved in
surveillance for suspected polio cases at the local level, actively
looking for any child with the tell-tale signs of paralysis and fever
and informing the appropriate health authorities. In the 1980's,
Rotarians worked with the Brazilian Pediatrics Association to educate
12,000 Brazilian pediatricians about the need to report suspected polio
cases. During the last stages of the eradication campaign in the
Americas, Rotarians in several countries even offered substantial
rewards to citizens reporting confirmed polio cases.
Advocacy.--For the past 3 years, The Rotary Foundation's Polio
Eradication Advocacy Task Force has coordinated Rotarian efforts to
inform both governments and the private sector about the benefits to
all nations of global polio eradication, and the urgent need for all to
increase their commitment to the Target 2000 goal. Advocacy also means
building the political will to eradicate polio in those countries of
the world in which it still exists. Many of you may be familiar with
our efforts here in the USA--we have testified before your Subcommittee
and others, and held events to celebrate progress in the polio
eradication campaign and United States leadership of the international
partnership. But you may not be aware that Rotarians are engaged in
similar activities in over 25 other nations around the world.
Australia, Belgium, Canada, Denmark, Germany, Japan and the United
Kingdom are among those countries which have followed the United
States' lead in increasing their commitment to Target 2000. In these
and other countries, Rotarians have been taking the message to
parliamentarians, foreign aid agencies, and heads of state. Over the
past three years, Rotarians have played a role, sometimes greater,
sometimes lesser, in decisions by their governments to commit some $500
million in new funds for international polio eradication. We hope to
maintain this momentum until polio is eradicated, and also step up
efforts to solicit the support of international corporations and other
private sector sources.
The examples I have cited above are just a few of the reasons why
United Nations Secretary General Kofi Annan has called Rotary's
PolioPlus Program ``A shining example of the achievements made possible
by cooperation between the United Nations and non-governmental
organizations.''
private sector support for polio eradication
The Polio Eradication Initiative has been strongly supported by the
private sector, most notably at local levels. Corporate involvement has
often resulted from efforts by Rotarians to engage private sector
partners for the highly visible and popular National Immunization Days.
A few examples are provided below:
Financial contributions.--Lederle Laboratories donated US$1 million
over a 3-year period to support the development of the Polio Laboratory
Network in Africa. During the polio eradication initiative in Latin
America, a fast-food chain donated a fixed amount of the proceeds from
each item sold in their restaurants in several countries.
Vaccine.--The largest corporate contribution for polio eradication
to date has been the donation by Chiron, Pasteur-Merieux, and
SmithKline Beecham of 100 million doses of oral polio vaccine to WHO,
over a 3-year period. These three companies the principal suppliers of
OPV to UNICEF. The vaccine is valued at US$8 million and is targeted to
African countries, where the need is greatest. Connaught Laboratories
also donated 1 million doses of OPV through Rotary in 1996.
Advertising and social mobilization.--Within the private sector,
particularly corporations, there are considerable resources and
expertise for ``communications.'' A number of corporations and media
organizations have supported polio eradication by providing advertising
to inform and motivate parents regarding NIDs. Local and national firms
have paid for print and electronic media announcements on NIDs. They
have also paid for more traditional forms of advertising and social
mobilization, including posters, banners and mobile megaphone
announcements. One striking example of this approach was the free
television advertising provided by a major household products company
in Turkey. During the weeks leading up to the NIDs, the last 10 seconds
of each of their television commercials was an NID announcement. This
advertising was provided without cost to the Ministry of Health.
Transportation.--Transportation of vaccine, vaccinators and
laboratory specimens is another area where local private sector support
has been substantial. Soft drink companies have transported vaccine
from central storage facilities to villages where it was used in NIDs.
In some cases this was accomplished during regular deliveries and with
minimal cost to the company. Local companies and individuals have also
contributed the use of vehicles for the short period of time needed to
transport vaccinators and vaccine to the immunization clinics. In one
country an oil company donated gasoline for vehicles for an NID.
Finally, in the Philippines, an express-delivery company donated the
service of delivering laboratory specimens from provincial health
centers to the central laboratory in Manila.
Facilitating NID's immunization clinics.--Corporate sponsors have
assisted with NIDs immunization clinics in many countries. For example,
several major food companies in the Philippines offered their
restaurants as immunization posts during NIDs, while companies in Egypt
donated food for the immunization teams. Companies have also donated
balloons, candy and other small items to be given to children as a
reward for being immunized. T-shirts, aprons, pins, baseball caps and
other items bearing NIDs logos have been donated by corporate sponsors
to increase the visibility of the NIDs and serve as a reward for health
workers.
Other approaches to the private sector.--In addition to the
successful examples of private/public sector collaboration for polio
eradication outlined above, Rotary and WHO have made approaches to a
number of other corporations at both the national and international
levels. These include approaches to a major soft drink manufacturer, a
large mining concern, an oil company, an automobile manufacturer and a
computer manufacturer, asking them to consider donations of money and/
or materials.
africa: the key to global success
The task of delivering oral polio vaccine to children faces
enormous problems on the African continent. These include civil
conflict, poor roads, uncertain communication, shortages of
transportation, unreliable refrigeration facilities, lack of
sufficiently trained personnel to plan and manage National Immunization
Days, and a weak system of surveillance.
Despite these obstacles, however, the countries of Africa have made
remarkable strides in polio immunization. These countries need and
merit special assistance in their fight against polio. Thus Rotary
International strongly endorses the recommendation of this Subcommittee
in providing an additional $20 million for Africa's needs in fiscal
year 1999, supplementing the planned deployment of $47.2 million by the
CDC. Furthermore, Rotary International hopes that such an amount can be
included in the President's budget for fiscal year 2000.
The additional $20 million would go to three areas of need: $6
million for oral polio vaccine for NIDs, $5 million for NID operational
support in difficult countries, and $9 million for developing the
surveillance systems which are critical to the eradication strategy.
These areas of expenditure all provide additional opportunities for
private sector support on national and local levels. Increased funding
for the polio campaign is critical for eradication of the virus by the
year 2000.
the legacy of polio eradication
The global Polio Eradication Initiative learned much from the
successful campaign to eradicate smallpox, and in turn the polio
eradication effort is teaching the public health experts important
lessons which will help other disease control and elimination programs.
Firstly, increased political and financial support for childhood
immunization has many documented long-term benefits. Polio eradication
is helping countries to develop public health and disease surveillance
systems useful in the control of other vaccine-preventable infectious
diseases. Already, much of Latin America is free of measles, due in
part to improvements in the public health infrastructure implemented
during the war on polio. As a result of this success, measles has been
targeted for elimination in the Americas by the year 2000, and it is
anticipated that measles can be eradicated world-wide. The disease
surveillance system--the network of laboratories, computers and trained
personnel built up during the Polio Eradication Initiative--is now
being used to track measles, Chagas, neonatal tetanus, and other viral
diseases.
The campaign to eliminate polio from communities has led to
increased public awareness of the benefits of immunization, creating a
``culture of immunization'' and resulting in increased usage of primary
health care and higher immunization rates for other vaccines. It has
identified and eliminated barriers to immunization. It has improved
public health communications and taught nations important lessons about
vaccine storage and distribution, and the logistics of organizing
nation-wide health programs. Lastly, the unprecedented cooperation
between the public and private sectors serves as a model for other
public health initiatives. In this regard, Rotary applauds two service
club organizations: Kiwanis International for its work with UNICEF to
eliminate Iodine Deficiency Disorders (IDD) worldwide, and Lions Clubs
International which is working with WHO's Blindness Prevention
Programme to eliminate onchocerciasis (river blindness) and other
causes of blindness.
Humankind is on the threshold of victory against polio, and we must
not miss this window of opportunity. Poliomyelitis will be the second
major disease in history to be eradicated, but not the last. The world
celebrated the eradication of smallpox in 1979, and no child anywhere
in the world will ever suffer from smallpox again. The annual global
savings of nearly $1 billion per year in smallpox immunization and
control costs far exceed the approximately $300 million that was spent
over ten years to eradicate the disease. The United States was a major
force behind the successful eradication of the smallpox virus, and has
recouped its entire investment in smallpox eradication every 2\1/2\
months since 1971. Even greater benefits will result from the
eradication of polio, and after that, measles and other infectious
diseases which kill and maim millions of children every year.
Polio eradication is an excellent example of truly cost-effective
foreign assistance. It is estimated that the world will ``break even''
on its investment in polio eradication--saving the more than $1.5
billion now spent annually on routine polio vaccination--only 2 years
after the virus has been vanquished and immunization against it can be
ceased. The financial and humanitarian benefits of polio eradication,
which will accrue forever, will be a gift to the children of the
twenty-first century.
Thank you for this opportunity to testify.
MAJOR POLIO-SPECIFIC GRANTS \1\
[In U.S. dollars]
----------------------------------------------------------------------------------------------------------------
Fiscal year--
------------------------------------------------ Total
1996 1997 1998 \2\
----------------------------------------------------------------------------------------------------------------
Australia..................................... 210,000 948,000 .............. 1,158,000
Belgium....................................... 5,100,000 .............. .............. 5,100,000
Canada........................................ 1,400,000 .............. 40,740,000 42,140,000
Denmark....................................... 40,000,000 6,000,000 .............. 46,000,000
European Union................................ 704,000 400,000 .............. 1,104,000
Finland....................................... 330,000 .............. .............. 330,000
Germany....................................... .............. 451,000 24,000,000 24,451,000
Italy......................................... 750,000 .............. .............. 750,000
Japan......................................... 22,430,000 25,720,000 10,228,000 58,378,000
Korea......................................... .............. .............. 900,000 900,000
Netherlands................................... .............. 248,000 .............. 248,000
Norway........................................ 2,120,000 700,000 .............. 2,820,000
Sweden........................................ 481,000 400,000 .............. 881,000
Switzerland................................... 177,000 1,300,000 .............. 1,477,000
United Kingdom................................ 78,600,000 1,550,000 31,160,000 111,310,000
USA........................................... 47,200,000 72,200,000 81,200,000 200,600,000
Vaccine manufacturers \3\..................... 9,000,000 .............. .............. 9,000,000
-----------------------------------------------------------------
Total................................... 208,502,000 109,917,000 \2\ 188,228,00 506,647,000
0
----------------------------------------------------------------------------------------------------------------
\1\ Grants in excess of US$100,000 intended primarily for polio eradication activities. These may be direct
bilateral grants to polio-endemic nations, or multi-lateral grants through international organizations such as
WHO or UNICEF. Some are for multiple years.
\2\ As of August 1998.
\3\ Donation from three European and one American vaccine manufacturer: 100 million doses of Oral Polio Vaccine
plus US$1 million.
Note: In addition to these polio-specific grants, many countries are supporting the WHO Expanded Programme on
Immunization, which combats several infectious diseases, among them polio.
______
Biographical Sketch of Herbert A. Pigman
general secretary of rotary international, 1979-86 and 1993-95
Herb Pigman served as General Secretary of Rotary International and
of The Rotary Foundation of Rotary International from 1979 to 1986 and
again from 1993 to 1995. As Rotary International's managing officer, he
supervised the Rotary International staff located at Rotary's World
Headquarters in Evanston, IL, USA, and service centers in eight other
countries.
He began his 35-year career with Rotary International in 1956 as an
editor of The Rotarian magazine. As Under Secretary from 1964 to 1975
he was responsible for Rotary's program development, publications, and
international meetings. From 1976 to 1978 he was executive assistant to
the president. In 1979 he was elected General Secretary, serving until
his retirement in 1986 after 30 years' service.
In 1986-89, he directed the Rotary International Immunization Task
Force for the PolioPlus Program. The Task Force helped to launch
Rotary's child immunization operations in 90 countries of Asia, the
Pacific, Latin America, and Africa. He was Rotary's liaison with
UNICEF, the World Health Organization, and with national health
ministers. More than 1 billion children in developing countries have
been immunized against polio with Rotary's help, an effort recognized
by the World Health Organization in the awarding of its Gold Medal.
He currently serves as chairman of the Polio Eradication Advocacy
Task Force, which encourages governments to commit financial resources
needed to eradicate polio by the year 2000. He is also a member of The
Rotary Foundation Permanent Fund Leadership Team.
He is a graduate and former trustee of Franklin College of Indiana,
from which he holds a degree in journalism and an honorary doctorate in
the humanities. He is a member of the Indiana Academy. He and his wife,
Betty, who have five children, live in rural Warren County, IN, where
he pursues farming and newspaper publishing. Herb is a past president
of the Rotary Club of Evanston, Illinois. He is a member and past
president of the Rotary Club of Boswell, IN, USA.
Rotary--a service organization
Senator Bumpers. It was only a few years ago I discovered
Rotary's role in this whole thing. One day I was going home for
the weekend, and Betty said, what is your schedule? And among
other things, there was a Rotary Club speech on the agenda, and
she said, do not forget to thank them. I said, thank them for
what? [Laughter.]
And that is when I first discovered Rotary as a service
organization in the very highest meaning of the word. Your work
on polio is probably not well known in the country, but it is
no less meaningful because of that. I want to again express my
personal gratitude to all Rotarians, all 450,000 of them, for
their commitment to this, and I hope they will stay committed
as we move from polio to measles.
STATEMENT OF DR. BILL FOEGE, FORMER DIRECTOR, CENTERS
FOR DISEASE CONTROL
Senator Bumpers. Dr. Foege, a close friend of mine and
Betty, for many, many years. Dr. Foege, we are most honored
that you could be with us this morning and please proceed.
Dr. Foege. Thank you, Senator Bumpers.
Unlike a marathon, we will not know the day we cross the
line with polio. We will only know afterwards. For example, it
was October 1977, a family entered a hospital in Somalia with
two small children. They both had smallpox. They asked
directions to the infectious disease ward, and a cook at the
hospital said, instead of giving directions, I will take you
there. In the few minutes that it took him to take that family
to the infectious disease ward, he got smallpox from one of
those children. We did not know that day that that was the last
time smallpox would be transmitted from one person to the next.
He recovered. No one got smallpox from him. That broke the
chain. It went right back to the very first human case. So, we
did not know that day. We will not know until sometime later
the day we have crossed the line on polio.
Senator Bumpers. Where was that, Dr. Foege?
Dr. Foege. In Somalia.
So, it was not only the first disease eradicated that day,
but it is the first time a body of medical knowledge actually
benefits everyone in the world and everyone who will ever be
born in the future. There are lots of lessons from smallpox. I
want to mention four of them.
One is the value of tenacity. You mentioned that the first
smallpox vaccination was in 1796, and you can understand why
people 150 or 160 years later would come to the conclusion
smallpox could not be terminated. Yet, a new look was taken, a
global approach was taken. People shared the value of smallpox
eradication, and hard work led to, 11 years later, smallpox
eradication. So, it is worth always taking new looks.
No. 2, the value of partnership and the possibility of
partnerships even during the cold war. We forget it was the
Soviets who first suggested smallpox eradication, and we found,
during the cold war because we had a health objective, we
learned how to work together and it had value beyond smallpox.
No. 3, the most refreshing lesson, I believe, was the
discovery that some things have to be done only once in the
entire history of the world. Smallpox vaccine had to be
developed only once. The eradication of the disease does not
have to be repeated. It is almost an afterthought to find out
it was such a good financial investment.
And No. 4, the value of U.S. leadership. USAID provided the
early smallpox eradication resources, and CDC actually provided
300 people to WHO over those 11 years. We get a return on that
investment in this country by having global and domestic health
people who really have a totally different view.
One strange outcome was the feeling by many people that
such a success could not be repeated, that this was unique. So,
while some things need be done only once, some lessons
apparently have to be relearned.
Some people in this room will recall that April day in 1955
when a press conference at the University of Michigan announced
that the Salk vaccine actually protected children against
polio. It is almost impossible to recreate the feeling of that
day, but the next day around the United States, simultaneously
and spontaneously, there were signs in store windows that said,
thank you, Dr. Salk.
Well, as you know, we struggled with the best mechanisms,
but we finally got it right, and 25 years after the vaccine was
introduced, we had the last outbreak in this country. But we
did not automatically go the next step and commit to global
eradication. It took a catalyst, and as we have heard
repeatedly this morning, that catalyst was Rotary
International. It was not just the resources that we have heard
about of millions of hours of work or millions of dollars. It
was their role as a collective conscience. Gandhi once said
that his interpretation of the Golden Rule is that he should
not be able to enjoy something denied to others, and Rotary
reminded us that we cannot enjoy having our children and
grandchildren free of polio unless we give all parents that
same joy.
I will never forget the day when Dr. Maseto, director of
the Pan American Health Organization, called a group of people
together to look at the science behind polio, and at the end of
the day, the scientific evidence was so compelling that he went
out on a limb by himself, the first person in WHO to say we
will eradicate polio. And he announced that it would be
eliminated from the Americas, and as we have heard, by 1991 it
was.
Lessons from polio
So, what are some of the lessons from polio?
No. 1, the scientific case is clear. The objective is
realistic, as we have heard, but we still have not fully
grasped the size of the effort which will be required in
Africa. In smallpox eradication, our first success was in west
and central Africa. It was a CDC/USAID effort and we
demonstrated what could be done with people who were realistic
but very motivated. The same can be done for polio in Africa,
but it will require more support I believe than people have
thought heretofore.
The key lesson is that we do not save money by just getting
by. You asked where the last case of smallpox was. It was in
Somalia. The smallpox eradication program put great effort into
Ethiopia, but not quite enough. Elimination from Ethiopia took
one month longer than it should have, and in that last month
smallpox was transmitted to Somalia and it took us 2 years of
hard effort to get it out of Somalia. That is my fear with
polio. If it takes 1 month, 6 months, 1 year too long than we
will have reimportations into Brazil or India or Burma.
We are at a crucial phase where a labor intensive effort is
required in Africa. The structure, as we have heard today, has
rapidly been put into place in that continent, and the next
step, and the last major step, should be to flood them with
help before anything can go wrong. If that is to be done, it
will be done because the United States decides to do it, giving
even more support to CDC to, in turn, give to UNICEF and WHO
and others. We can assure this country that that is a direct
investment in American children for all time.
A few closing words on measles. It is because of you and
your wife that we even raise the idea of measles eradication.
Your efforts on immunization in Arkansas were shared with
President and Mrs. Carter at a dinner at the White House in
1977. The next day I had a phone call from Joe Califano and he
said, we are going to have an immunization initiative in this
country.
Within a year, the results were so good we started asking
the question could we actually interrupt measles transmission
in the United States, and I can tell you many public health
people told me do not take that objective. You will only ruin
the credibility of CDC.
Spreading of measles
We did take that as an objective and we had weekly reviews.
One problem after another was uncovered. Military recruits
going to basic training would spread measles around the country
as they went home on furlough. That was solved by immunizing
all military recruits, whatever their past history was. Then
day care centers, colleges, one problem after another, until we
got down to the last barrier, and that turned out to be
importation of measles from other countries. We were having on
average two importations a week at that time. As Dr. Satcher
mentioned, PAHO has now done such a good job, that we have very
few importations from this hemisphere, but we can clearly say
we have interrupted transmission of measles in this country and
all of our cases are due to importation.
So, we have discovered that we are interrelated. It takes
more than a village to raise a child. It takes the entire
world, and if we are to protect American children, it will be
by getting rid of measles in the rest of the world.
What are the lessons we have learned from this?
Scientifically measles eradication can be done, and we have
shown that by getting rid of it in this country.
It will require tremendous effort. We should continue to
build the infrastructure for measles immunization, and we
should improve the tools. We should develop vaccines that are
heat resistant so we do not need the cold chain. We should
develop stealth vaccines that actually get by the maternal
antibody so you can give measles immunization in the first 9
months of life. And we should make measles vaccine a tugboat to
pull the entire immunization program to greatness. We should
some day make global measles eradication a legacy of the
Arkansas immunization program. Our best argument for measles
eradication will be made by finishing polio with all the speed
we can generate.
Permit me to end on a personal note. I no longer work for
the Government. I am nearing the end of my professional career
and, therefore, I feel free to say what I want. [Laughter.]
Senator Bumpers. Sort of like not running again.
[Laughter.]
Dr. Foege. At a time of great criticism of Government,
Government employees, and politicians, I can identify few
instances of social justice by groups other than Government. No
church group, no service club, no organization represents all
of us except Government. Our immunization successes in this
country have resulted from Government at its best by a desire
to protect every child individually and society collectively.
It is the result of politics at its best. And likewise, the
U.S. support of smallpox eradication, polio eradication, child
health, child immunization for the rest of the world, it is
enlightened self-interest, yes, but it also expresses our
understanding as Americans of a responsibility to the world and
to the future. As with the Marshall plan and the Point Four
Program, it is the U.S. Government at its best.
prepared statement
For years of giving us Government at its best and on behalf
of tens of millions and hundreds of millions of people who are
never invited to a hearing like this, I thank both you and Mrs.
Bumpers. Thank you.
[The statement follows:]
Prepared Statement of William Foege M.D., M.P.H
introduction
It is not possible to grasp the pace of health improvements in our
lifetime. When my parents were born, 15 percent of children in this
country died before their first birthday. Now the figure is less than 1
percent. Given his life expectancy at birth, my father was destined to
die in 1953. 20th Century medicine and science have given him both
quantity and quality of life, and at age 93 he enjoys a full life.
Likewise, global health gains stagger our imagination. The World
Bank has reported that health has improved more in the past 40 years
than in the previous 4,000. Global life expectancy has approached 65
and infant mortality rates for the world have been cut in half in the
past 35 years. But the gains cannot be mentioned without also noting
the increasing gaps between the haves and the have-nots, the rich and
the poor. Disease eradication efforts help to close that gap, providing
the same benefits for everyone.
smallpox
On an October day in 1977, a family arrived at a hospital in
Somalia with two small children. They both had smallpox. Asking for
directions to the infectious disease ward, they were escorted by a
hospital employee. In that brief period, the employee contracted
smallpox. But, no one acquired smallpox from him, thus breaking the
chain of smallpox transmission that went back to the very first human
case hundreds of years before. Not only was that the first disease
eliminated from the world, it was also the first time that a body of
medical knowledge benefited everyone living and everyone who would be
born in the future. It was truly social justice in the medical field.
Many lessons come from the smallpox eradication experience. I will
mention only four.
1. The value of tenacity.--Senator Bumpers mentioned that the first
smallpox vaccination was given in 1796. It is understandable that after
150 or 160 years people would conclude the disease could not be
eliminated. But after a new analysis, global agreement was reached, a
shared goal was defined and the hard work of 11 years led to
eradication.
2. The value of partnerships.--It was possible, even in the Cold
War, to develop effective partnerships with the Soviet Union. [Indeed,
we forget that it was the Soviets who originally suggested smallpox
eradication as a global goal.] The program gave us practice in working
together and this led to benefits beyond smallpox eradication.
3. But the most refreshing lesson for me was the demonstration that
some things need to be done only once in the history of the world.
Smallpox vaccine did not need to be developed a second time. The
eradication of smallpox did not have to be repeated. It is almost an
afterthought to find what a good financial investment it was.
4. The value of U.S. leadership. USAID provided the early resources
and the Centers for Disease Control and Prevention provided over 300
people to the World Health Organization for the eradication effort. The
U.S. got a return on that investment with global and domestic health
workers that had a different perspective and great skills.
One disconcerting outcome was the feeling by many that such a
success could not be repeated, that it was unique.
polio
So, while some things need be done only once, some lessons
apparently have to be relearned.
Some here will remember that April day in 1955, when a press
conference at the University of Michigan caused absolute euphoria with
the announcement that the vaccine developed by Jonas Salk protected
children from polio. There was a spontaneous reaction with signs
appearing in store windows the next morning saying, ``Thank you, Dr.
Salk!''
We struggled in this country for the best mechanisms, but we
finally got it right. Our last outbreak occurred 25 years after the
vaccine was introduced.
But we did not automatically go the next step and commit to global
eradication. It took a catalyst and that catalyst was Rotary
International. It was not just their resources of millions of hours in
the field and millions of dollars that was important. It was also their
role as a collective conscience.
Gandhi once said that his interpretation of the Golden Rule is that
he shouldn't be able to enjoy something denied to others. Rotary
reminded us that we cannot enjoy having our children and grandchildren
free of polio unless we give all parents that joy.
I will never forget the day when Dr. Macedo, director of the Pan
American Health Organization, called together a group to review the
science of polio control. On hearing the scientific evidence, he
immediately went out on a limb, ahead of his colleagues, to announce
that polio would be eliminated from the Americas. And it was done by
1991.
What then are the lessons we take to from our polio eradication to
this date?
1. The scientific case is clear as larger and larger geographic
areas are freed of the disease.
2. The objective is still realistic.
3. But, we still haven't grasped the size of the effort required in
Africa. In smallpox eradication, our first success was in West and
Central Africa. It was a CDC/USAID effort that demonstrated what could
be done with realistic and well-motivated people. The same can be done
for polio in Africa, but it will require more support for the next two
years than we have given, or even imagined to date.
4. The key lesson is that we don't save money by just getting by.
In smallpox eradication we put great effort into the program in
Ethiopia but not quite enough. Elimination of smallpox took one month
too long. In the last month of smallpox in Ethiopia, the disease was
transmitted to Somalia, and it took an additional 2 years to rid
Somalia of the disease.
That is my fear with polio. If it takes one month, 6 months, 1 year
too long we may get re-importation into Brazil, India, or Burma.
We are now in a crucial phase, where a labor-intensive effort is
required in Africa. The structure has rapidly been put into place and
the next step (and the last major step), should be to flood them with
help before anything can go wrong.
If this is to be done, it will require the support of the United
States giving even more support to CDC to, in turn, provide assistance
to WHO, UNICEF and others.
We can assure Congress that it is a direct investment in American
children for all time.
measles
A few closing words on measles. It is because of you, Senator
Bumpers, and your wife, that we even raise the idea of measles
eradication.
Your efforts on immunization in Arkansas were shared with President
and Mrs. Carter at a dinner in the White House in 1977. The next day I
received a call from the Secretary of HHS, Joseph Califano, to inform
me that we were going to have an immunization initiative.
Within a year the results were so good that we began asking
ourselves if measles transmission could be interrupted in this country.
Many public health people advised against it saying it was not possible
and would serve only to impair the credibility of CDC. But we chose
that objective and began to have weekly reviews of progress. We found
one problem after another, from military recruits spreading the
disease, to problems in day care centers, colleges, sports events, etc.
But we solved each problem as it arose until the ultimate barrier
presented itself--importations from other countries.
We were experiencing two importations of measles in the average
week. Once again we were faced with the fact that everything in the
world is interrelated. If we want to protect American children from
measles we have to protect all children in the world from measles.
It doesn't just take a village to raise a child, it now takes the
entire world to raise a child. PAHO launched a very effective program
and importations from this hemisphere have been dramatically reduced.
We have now interrupted measles transmission in this country. All
cases now are due to importations.
What are the lessons?
1. We have demonstrated the science. Measles eradication is
possible.
2. It will require tremendous effort.
3. We should continue to build the infrastructure for measles
immunization. All children in the world need to be immunized.
4. But we should also improve the tools. We should strive for
vaccines that are heat stable in order to minimize the costly and
difficult cold chain. We should seek ``stealth'' vaccines that evade
maternal antibody, allowing immunization in the first 9 months of life.
5. We should make measles vaccine a tugboat to pull the entire
immunization program to even greater heights. All of the new vaccine
possibilities require an ever stronger immunization structure.
6. We should make global measles eradication the legacy of the
Arkansas immunization program.
7. Our best argument for measles eradication will be made by
eradicating polio with all of the speed we can generate.
Finally, permit me to end on a personal note. I no longer work for
the government; I'm near the end of my professional career; therefore,
I am free to say what I want.
At a time of great criticism of government, government employees
and politicians, I can identify few instances of social justice by
groups other than government. No church group, no service club, no
other organization represents all of us. Only government does that.
Our immunization successes in this country have resulted from
government at its best by a desire to protect every child individually
and society collectively. It is the product of politics at its best.
Likewise, the U.S. support of smallpox eradication, polio
eradication, child health, and child immunization for the rest of the
world, while we know it is enlightened self interest, it also expresses
our understanding, as Americans, of a responsibility to the world and
to the future.
As with the Marshall Plan, and the Point Four Program, it is the
U.S. Government at its very best.
For the years of giving us government at its best, and on behalf of
ten's and hundred's of millions who are never invited to a Senate
hearing, I thank you and Mrs. Bumpers.
Thank you.
when to stop manufacturing polio vaccine
Senator Bumpers. Dr. Foege, that statement can only be
described as beautiful, powerful, clear, representing the
highest and best values of citizens of this country. I cannot
tell you how impressed I am with it and how, once again, I wish
not just my colleagues in the Senate but every citizen in
America could hear that.
This is such an unbelievable success story, and at the same
time we have to recognize that the success just simply points
out how far we have to go and you have done that in your
statement.
Let me ask you three or four questions, Dr. Foege. No. 1,
how soon after the last case of polio can we safely quit
manufacturing polio vaccine?
smallpox vaccine and stockpiling
Dr. Foege. It is a difficult question to answer because as
with smallpox, we are now reasking the question 20 years later.
Should we be making smallpox vaccine and stockpiling it in case
something goes wrong?
With polio eradication, it will take us some time, some
years actually, of close surveillance and monitoring every
suspected case, every case of flaccid paralysis, to make sure
that there is no virus actually circulating in the population.
Then we have to make the decision do we stockpile vaccine even
if we do not use it. But we are talking about a period of
years, not a period of decades.
Senator Bumpers. How long has it been since the last case
of smallpox was reported?
Dr. Foege. It has been over 20 years since the last case.
Senator Bumpers. When did we discontinue manufacturing
smallpox vaccine? I assume we have discontinued it.
Dr. Foege. We have. We actually stopped giving smallpox
vaccine in this country before it was eradicated from the
world. That is how confident we were that eradication was going
to take place and that we could respond to an emergency.
Polio is more of a stealth virus that it can get into the
population without us knowing. So, we cannot do that with
polio. We have to continue right up until the last case and
then longer.
But we did stop making smallpox vaccine. We could do it
again without any problems if we had to.
Senator Bumpers. Oh, you could.
Dr. Foege. We could make it again. We do not have to have
smallpox virus to make the vaccine because the vaccine is
actually made from a vaccinia virus or a cowpox virus.
Senator Bumpers. At the time we chose vaccine for
international, worldwide eradication, was that the only vaccine
we had that was practical for such a big undertaking or did we
do it for another reason?
two polio vaccines
Dr. Foege. We, of course, had two polio vaccines and still
do: the inactivated polio vaccine that Jonas Salk developed
which is injected, and the oral vaccine that Dr. Sabin
developed which is taken by mouth. The decision was made to use
the oral vaccine because it was easier to use and because it
provides an immunity in the intestine of the person that is not
always achieved with the inactivated vaccine. So, it was
considered to be the better vaccine to use on a global basis.
In this country we now talk about using the inactivated
vaccine at the end of the campaign, but these decisions have
not been totally made as yet.
Senator Bumpers. Is it feasible or desirable to do more
than one global eradication at the same time?
Dr. Foege. We, of course, are doing two global eradication
programs right now, one for guinea worm and one for polio, and
we are talking at the same time about doing one for measles.
I think what happened after smallpox is we lost a certain
momentum because people were so convinced this was unique, they
did not automatically ask, OK, how do we use what we have done
to continue on something else?
eradication programs
I think it is probably useful to think in terms of always
doing one or two actual eradication programs and one or two
programs where you are building up to it. I would hope that
measles eradication will be so feasible that it will be almost
seamless to go from polio eradication to measles. So, yes, we
can do two at the same time.
Senator Bumpers. Where is guinea worm indigenous to, what
part of the planet?
Dr. Foege. Guinea worm used to be in areas south of the
Sahara in Africa and in Pakistan and in India. It has been
reduced by over 95 percent in just the last 8 or 9 years. Now
we are finding the problems that we fear with polio; that is,
in Sudan we are having difficulties with guinea worm because of
the political problems. You do not know what will happen with
social and political problems. It is another reason to do this
as fast as we can.
Senator Bumpers. Is the kind of civil conflict in some
African nations--maybe, Dr. Samba, I should address this
question to you. We have quite a few civil disturbances in
Africa, in various parts of Africa. What, if any, impact--I
know it is going to have some, but how difficult is it going to
be to continue with this schedule we are on to try to eliminate
polio, say, by the year 2000? I know, first of all, it
increases our cost because transportation is often interrupted
and so on, but just comment generally on that subject, if you
would.
civil strife
Dr. Samba. It is feasible because the civil strife does not
continue indefinitely. Like in Sierra Leone now we are starting
the polio eradication, in Liberia, in Niger. Even in Congo, we
got the stocks ready and within a week of starting, the civil
strife erupted, so we had to suspend. When the electricity was
stopped, we bought portable generators to preserve the vaccines
and so on. And in December we will restart again. In Angola, it
was during the civil strife that we managed to have over 90
percent vaccinations. We have been able to convince the warring
partners that health is in the interest of all concerned, and
even during civil strife, we have been able to carry on. It is
very difficult but it can be done.
HIV and AIDS
Senator Bumpers. Let me ask you a second question. Some
critics say that HIV and AIDS are much more critical to these
nations and this money could be better spent on trying to
control and even to treat HIV and AIDS. What is your thought on
that?
Dr. Samba. My impression, for what it is worth, I said
earlier, as a result of partnership, governments inside Africa,
governments outside Africa, the United States taking the lead,
civil society--in the case of river blindness, Merck, Sharp, &
Dome, a private enterprise--we have been able to win. With
polio we are on the way of winning. Smallpox we have won.
We are convinced that with the partnership, the dedication,
the commitment, increasing resources and knowledge, that with
AIDS we will win. We are already starting on an initiative in
Africa to complement the United States system on AIDS. For the
moment it is a big problem. It is increasing, but AIDS is
relatively new. We knew about it in the 1980's. It is much more
recent than polio and smallpox and river blindness.
Senator Bumpers. Are other nations in Africa trying to
assist with what a lot of people in this country consider
rather epidemic proportions of HIV and AIDS? Is the United
States involved in it, and if so, to what extent? Let me
rephrase the other question. Are other, for example, European
nations, Japan, wealthier nations, involved in trying to help
with HIV/AIDS problems in Africa?
Dr. Samba. Yes; indeed. The United States is involved.
Japan is involved. Britain, all western countries, all Asia, in
fact, are involved because the whole world is realizing more
than ever that with any epidemic anywhere in the world with the
type of mobility of human beings, no other country is safe. So,
it is in the interest of all concerned that the last bastion of
these diseases are attacked. They are all involved, sir.
Senator Bumpers. It is what we call enlightened self-
interest on an international basis.
Dr. Samba. Exactly.
Senator Bumpers. Mr. Pigman, do you think we would be able
to count on the Rotary Club, once we eradicate polio, to
continue with their assistance, say, in measles?
polio eradication
Mr. Pigman. That question is often asked, Senator Bumpers,
and I would respond by saying that when we named our program
back in 1985, we could have named it ``polio eradication'' or
we could have named it ``kick polio off the planet,'' but we
named it PolioPlus, the ``plus'' implying that our focus on
polio is aimed at raising the immunization levels against all
infectious diseases.
Now, we have an army currently deployed against polio.
Polio eradication is going to be their focus until the job is
done, but I would hope that we would not have disarmament.
Senator Bumpers. Well, I hope not too. I hope to be a
private citizen then, but I will do my best to weigh in with
such Rotarians as I have any influence with to make sure that
they continue their efforts.
Mr. Pigman. Thank you.
rotarians
Senator Bumpers. I find, incidentally, that Rotarians take
great personal satisfaction in what they have been able to
accomplish, and they are very proud of themselves. As I say, a
lot of service organizations are not service organizations at
all, but the Rotarians have shown that they really are truly a
service organization.
Mr. Pigman. Well, Senator, in defense of sister
organizations, we are very happy to see that such large service
organizations such as Kiwanis has tackled iodine disease
deficiency and Lions, vitamin A deficiency, et cetera. So, let
us hope that the partnership will only grow in the future.
Senator Bumpers. Dr. Foege, will there be any significant
change, up or down, in the cost of eliminating measles compared
to the cost of eliminating polio?
Eradicate measles
Dr. Foege. Measles is going to be a tougher disease to
eliminate, and my belief is that it will probably be somewhat
greater cost than polio. It is a very difficult disease to
contain. It spreads rapidly and it is going to take a massive
effort to eradicate measles, but it is doable.
Senator Bumpers. You do not think there is any question but
that measles ought to be the next effort I take it.
Dr. Foege. That is right. The figures that you gave, the
single most lethal agent in the world just a few years ago. It
is such a problem in Africa that I think we should do this, and
I think that we are getting experience now in how to improve
our infrastructure. So, there is no question in my mind that we
should do this, but that polio should be eradicated as a step
toward measles.
Senator Bumpers. I have a couple of technical questions
that I probably will submit in writing to you, Dr. Foege, just
for my own enlightenment and the members of the subcommittee,
about the possible shortfall of funds to make sure we finish
this.
conclusion of hearing
Well, let me just again thank you all very much for what I
know is a great effort to get here to be here for this. I have
been here 24 years, and I can tell you--and this is not to
flatter you--this has been one of the most enlightening,
gratifying hearings I have ever attended in my life. All of you
spoke so extremely well. Whether they read it or not, it will
be shared with all the members of the full committee, not just
the subcommittee. So, we will submit two or three questions in
writing, but again thank you all very much for coming.
The subcommittee will stand in recess subject to the call
of the Chair.
[Whereupon, at 11:39 a.m., Wednesday, September 23, the
hearing was concluded, and the subcommittee was recessed, to
reconvene subject to the call of the Chair.]
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