Failed vaccine campaigns are a global issue

The Guardian (UK) recently revealed that Central Intelligence Agency (CIA) agents working with Pakistani health officials arranged a vaccination drive using a hepatitis B vaccine made by Amson, a Pakistani manufacturer, with the ulterior motive of collecting DNA from suspected Bin Laden family members.1

Taliban-circulated rumors that Western vaccines are untrustworthy and may contain pig products already contribute to the Afghan/Pakistan border’s low vaccinations rates. In July alone, such rumors led parents there to refuse vaccinations for more than 16,000 children, according to Pakistani media.2 The CIA’s decision to use the cloak of public health and medicine may lend further credence to specious claims of government conspiracies.

Two historical public health lessons suggest the CIA’s DNA fishing expedition could have significant global health consequences as well. First, conspiracy theories have previously derailed vaccination campaigns and will now be harder to refute. Second, international travel efficiently spreads infectious diseases. Catastrophe can result when these two circumstances intersect.

In 2003, Nigeria had two-thirds of the world’s ~1,200 yearly cases when three northern states boycotted an ongoing polio vaccination campaign due to rumors that Western vaccines were laced with anti-fertility hormones or the AIDS virus.

Prior unethical clinical trials (e.g. Pfizer’s Trovan trial), domestic political power struggles and blowback from the “War on Terror” may all have contributed to the 11-month boycott, during which, polio spread throughout Nigeria and into 12 nearby countries previously declared polio-free, some likely via Hajj-associated travel. Worldwide over 1,500 children were left paralyzed by virus genetically linked to the outbreak. The cost of polio-related public health interventions during and after the boycott surpassed $500 million.3–5

Re-establishing trust with the Nigerian public, religious leaders and politicians required a substantial investment of time and effort at local, national and international levels, from the public health community and beyond. Although WHO scientific panels emphasized the vaccine’s safety and many Muslim leaders publicly endorsed it, Kano state did not reverse the boycott until a vaccine manufactured in Indonesia, a Muslim country, was identified.

Failed vaccine campaigns are not local issues. In an interconnected world, poor vaccine coverage anywhere is a weak link everywhere. Europe’s last smallpox outbreak exemplifies how a pocket of disease can spread through mass gatherings, particularly the Hajj. In 1970, an Afghan family contracted smallpox while travelling to the Shi’a holy city of Mashhad, Iran. Preoccupied with the 2,500-year anniversary of the Persian Empire, Iran ignored the smoldering epidemic, withheld epidemiological information from WHO, and refused their vaccine. Iran’s domestically produced vaccine was only 65% effective, allowing the outbreak to spread to thousands in Iran, Iraq and Syria.6

Returning from the Hajj in 1972, a Yugoslavian contracted smallpox while visiting Shi’a holy sites in Iraq before returning to Kosovo where 175 people became infected. Martial law, strict quarantine and the re-vaccination of over 18 million people eventually contained the outbreak, but with devastating economic consequences.6

While smallpox has been eradicated, polio remains endemic in Pakistan. The risk of spreading polio and measles at the Hajj or other pilgrimage sites remains significant despite vaccination requirements.7,8 Indeed, we have previously discussed how travel for mass gatherings can efficiently spread disease.9

Nigeria’s and Europe’s outbreaks remind us that small sparks can precipitate the re-emergence of vaccine-preventable diseases. Both polio and measles can spread easily if sports fans or pilgrims cross paths with failed vaccination campaigns.

Trust is critical for effective crisis response, particularly in Nigeria. The US should not squander trust, and the CIA’s actions have now brought Pakistani doctors, health officials and vaccine manufacturers under suspicion. If reaction to the CIA operation manifests as another Muslim vaccine boycott of similar proportions, speedy diplomacy and Indonesian vaccines might not be enough to avert disaster. Ironically, in attempting to protect Americans from terrorism, the CIA may ultimately expose them to collateral damage in the form of infectious diseases.­

Guest post written by David Scales MD, PhDa, Sumiko R Mekaru DVM, MVPMa,b, and John S Brownstein PhDa,ca. Computational Epidemiology Group, Children’s Hospital Informatics Program, Children’s Hospital Boston, Boston, USA b. School of Public Health, Boston University, Boston, USAc. Department of Pediatrics, Harvard Medical School, Boston, USA. Conflicts of interest: We declare that we have no conflicts of interest

Correspondence to: david.scales@childrens.harvard.edu

References

1.         Shah S. CIA organised fake vaccination drive to get Osama bin Laden’s family DNA. The Guardian (UK). July 11, 2011. URL: http://www.guardian.co.uk/world/2011/jul/11/cia-fake-vaccinations-osama-bin-ladens-dna accessed 16 Aug. 2011.

2.         Yusufzai A. Anti-polio drive in KP over 16,000 refusal cases recorded in July. Dawn. August 4, 2011. URL: http://www.dawn.com/2011/08/04/anti-polio-drive-in-kp-over-16000-refusal-cases-recorded-in-july.html accessed 16 Aug. 2011.

3.         Jegede AS. What led to the Nigerian boycott of the polio vaccination campaign? PLoS Medicine. 2007; 4(3): e73.

4.         Kaufmann JR, Feldbaum H. Diplomacy and the polio immunization boycott in Northern Nigeria. Health Affairs. 2009; 28(4): 1091.

5.         Renne E. Perspectives on polio and immunization in Northern Nigeria. Social Science & Medicine. 2006; 63(7): 1857-69.

6.         Tucker JB. Scourge: The Once and Future Threat of Smallpox. New York: Grove Press; 2002.

7.         Wilder-Smith A, Leder K, Tambyah PA. Importation of poliomyelitis by travelers. Emerging Infectious Diseases. 2008; 14(2): 351.

8.         Hull HF. In Response. Emerging Infectious Diseases. 2008; 14(2): 351-2.

9.         Khan K, Freifeld CC, Wang J, et al. Preparing for infectious disease threats at mass gatherings: the case of the Vancouver 2010 Olympic Winter Games. Canadian Medical Association Journal. 2010; 182(6): 579.

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