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Bruce Aylward¹

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¹Assistant Director-General, Polio, Emergencies and Country Collaboration, World Health Organization, Geneva, Switzerland.

The Eastern Mediterranean – crossroads of the world. Sitting for millennia on ancient, vital trade and travel routes, leaders here have faced a twofold challenge in protecting their people from the ravages of infectious diseases: first, the control of pathogens native to these lands and, secondly, the elimination of those pathogens which gain entry with travellers, traders and pilgrims. The most dangerous of this latter group are those organisms that enter the region silently, then spread widely before suddenly emerging with terrible consequences for the most vulnerable populations.

This past month, an ancient virus again re-emerged in the Middle East, more than a decade after most health leaders thought it had been vanquished there forever.

On 28 October 2013, the Minister of Health of the Syrian Arab Republic announced to his counterparts from 22 countries of the Eastern Mediterranean Region of the World Health Organization, that after a 15-year absence, polio was again paralysing and killing children in his country. Genetic sequencing showed that the virus had originated in Pakistan and already travelled to Egypt, Israel, the Gaza Strip and the West Bank over the previous 12 months.

Within 24 hours, the assembled Ministers declared this re-infection of the Middle East an emergency for the entire Eastern Mediterranean Region, calling for extraordinary joint action to combat this ancient scourge [1]. The Minister of Oman announced US$ 5 million in new financing for the effort, Saudi Arabia declared it would mobilize religious leaders to ensure that all parents understood their obligation to vaccinate their children, the United Arab Emirates reconfirmed their US$ 120 million pledge for polio made earlier this year; most striking, 7 countries immediately agreed to coordinate the vaccination of 22 million children over the subsequent 3 weeks, and again in December, to again vanquish polio in the Middle East. All countries called on Pakistan to rapidly access and vaccinate all of its children as a matter of urgency to stem the international spread of its viruses.

This decisive leadership and rapid emergency action builds on a long and illustrious history of infectious disease control, vaccination and, especially, polio eradication in the Eastern Mediterranean Region.

A few examples reinforce the striking accomplishments of this Region on its road to becoming polio-free.

When poliovirus roared out of northern Nigeria 10 years ago following the temporary suspension of oral poliovirus vaccine (OPV) in 2 states, nearly 2 dozen previously polio-free countries became re-infected and thousands of children were needlessly paralysed; Saudi Arabia led the world in boldly introducing new polio vaccination requirements for all travellers from polio-infected countries to protect pilgrims, travellers and Saudi Arabians alike [2]. When it appeared impossible to interrupt polioviruses in Egypt due to the very high population density, particularly in the mega-city of Cairo/Giza, that country led the world in innovation by commissioning the fast-track development and use of a new monovalent OPV (mOPV1); polio transmission there stopped almost immediately. In Afghanistan, the Ministry of Public Health courageously supported the painstaking work of negotiating vaccinator access to every corner of Kandahar and Helmand provinces; as of November 2013, the country passes its first anniversary with no child having been paralysed by an indigenous poliovirus^a.

As importantly, major regional institutions – including the Organization of Islamic Cooperation and the Islamic Development Bank – have brought their voices and resources to the effort to secure a polio-free world. Religious leaders, led by the Grand Imam of Al Azhar, have formed an Islamic Advisory Group for the Global Polio Eradication Initiative to ensure parents know that they are obligated to ensure all children are vaccinated and to ensure communities assure the safe passage and work of vaccinators.

This central role of the Eastern Mediterranean in polio eradication led global leaders in philanthropy, development and vaccinology to gather in Abu Dhabi in April 2013 to launch the new Polio Eradication & Endgame Strategic Plan 2013–2018 [3] and pay tribute to the commitment of the Region’s leaders to immunization and disease eradication.

The major unresolved threat to the Region’s deep commitment to complete polio eradication is now the decision by a handful of local leaders in parts of north-west Pakistan and south/central Somalia to withhold vaccination and protection from the devastating effects of this disease. As national and regional leaders launch their new emergency eradication effort to again eliminate polio in the Middle East, they must at the same time rapidly reconcile the concerns of local leaders in Pakistan and Somalia to restart vaccination in those areas.

2014 must be the year in which the Eastern Mediterranean conquers this ancient menace by backing this emergency response with the leadership, generosity, innovation, determination and diligence that has been characteristic of this Region’s work in polio eradication and which continues to inspire the entire Global Polio Eradication Initiative.

The first recorded image of polio in the world is from the Eastern Mediterranean, where the consequences of this disease were captured in a 5000 year-old stele from Egypt. There is absolutely no reason why the last image of polio should be from this Region.

References

1. WHO Regional Committee for the Eastern Mediterranean Resolution EM/RC60/R.3. Escalating Polio Emergency in the Eastern Mediterranean Region (http://applications.emro.who.int/docs/RC60_Resolutions_2013_R3_15136_EN.pdf, accessed 30 November 2013).
2. International travel and health. Geneva, World Health Organization (www.who.int/ith, accessed 30 November 2013).
3. Polio eradication and endgame strategic plan 2013–2018. Geneva, Global Polio Eradication Initiative, 2013 (http://www.polioeradication.org/Resourcelibrary/Strategyandwork.aspx, accessed 30 November 2013).

^a For the first time in history, all polio cases detected in Afghanistan in 2013 have been due to imported viruses (originating in Pakistan’s Federally Administered Tribal Areas or FATA).