Belgian parents face jail over non-vaccinated children

The Associated Press today reported on a fascinating story out of Belgium, where two sets of parents were sentenced to five months in prison as a result of failing to vaccinate their children against polio. The story notes that Belgium and France are the only two countries to require polio vaccination as a matter of national law. (Recall that U.S. vaccination requirements occur at the state level, and include various exemption protocols.) The parents' jail terms have been delayed to allow them another opportunity to vaccinate their children. Fines equivalent to approximately $8,000 were also assessed.

The website of the Belgian Federal Public Service includes information on polio and notes that it is the only mandatory vaccine in Belgium.

The story brings to mind the controversial jail threat levied against parents of unvaccinated children in Prince George's County, Maryland, last fall. (Our coverage here.)

According to this WHO website, there have been a total of three confirmed cases of polio in Belgium since 1980, the last occurring in 1989. (For comparison, there were 1307 cases worldwide in 2007 according to the Global Polio Eradication Initiative, the vast majority found in India and Nigeria.) Authorities in Belgium would likely point to the scarcity of polio cases as evidence supporting a strong vaccination requirement.

Threatening (or imposing) imprisonment is perhaps the most forceful tool at the disposal of public health authorities. It is unclear from the AP story whether such action is appropriate here or whether these measures should be reserved for more imminent threats to public health than the comparative minor threat of polio in Belgium given the very high vaccination rate overall.

MMWR: Flu recommendations and polio eradication update

Several interesting items related to vaccination appear in today's issue of MMWR. Among them:

-- A revision to the ACIP document "Prevention and Control of Influenza," an expansive review of all aspects of seasonal flu vaccination guidance and related data. Notable in this updated version is additional encouragement aimed at promoting influenza vaccination of health care workers as well as information on the composition of the 2007-08 vaccine.

-- A report on worldwide progress toward polio eradication, as of May 2007. The number of polio-endemic countries remains at four (Pakistan, Afghanistan, Nigeria, and India) with the vast majority of the 1,997 cases reported in 2006 occurring in Nigeria (1,123) and India (676). Global vaccination coverage stands at 78%, a number that is well over 90% in the Americas but far lower in Nigeria (39%) and India (58%). Those interested in polio eradication should visit our previous posts about polio, which include several items discussing the merits and challenges associated with pursuing eradication.

Debate on continuing polio eradication efforts

That's what is being reported in this AP story from last week: "Experts reconsider goal of ending polio." The debate centers on whether efforts should be centered on containment -- polio is endemic in four countries and affects roughly 2,000 people a year -- or a continuation of the quite costly eradication program now entering its 19th year. Eliminating these remaining cases has proven to be far more difficult than smallpox eradication, which was accomplished in half as much time.

The story highlights an interesting and important debate among experts within the WHO, the infectious disease community overall, and leaders from the countries still affected by the disease.

Of note is the nearly-4,000 word feature published nearly a year ago in the New York Times on the challenges of polio eradiation, which we wrote about here.

Friday round-up: HPV vaccine parental acceptance, bird flu vaccine allocation, and more

• The May 2006 issue of Pediatrics includes an interesting study of parental beliefs and attitudes on HPV and HPV vaccination, comparing groups receiving an information sheet on the topic versus those without it. The paper, from Dempsey, et al., is titled "Factors that are associated with parental acceptance of human papillomavirus vaccines: A randomized intervention study of written information about HPV." (117:1486-1493; free abstract, subscription required for full text) Their findings, in short: those receiving the information sheet performed better on a knowledge assessment, but there was no statistically significant difference in vaccine acceptability between the two groups. Here's the press release on the paper from the University of Michigan (the lead author's institution.)

• This story from National Geographic's website discusses a paper in the current issue of Science on how best to ration limited vaccine supply in the event of a pandemic. The paper, titled "Who should get influenza vaccine when not all can," is written by Ezekiel Emanuel and Alan Wertheimer of the NIH, though they note the opinions expressed are solely their own. (312:854-855; subscription required for full text.) In the paper, the authors challenge the current plan to allocate limited supplies of vaccine, which they refer to as the 'save-the-most-lives principle.' Their alternative? A modified 'life-cycle principle' that values giving everyone a chance to pass through various life stages while, overall, still maintaining public order. It's an interesting idea, and one that leads to a radically different ranking of which groups would receive vaccines first. Well worth reading.

• Another paper of note in this week's Science: "Is polio eradication realistic?" by Arita, et al. (312:852-854; subscription required). The authors propose that "the time has come for the global strategy for polio to be shifted from 'eradication' to 'effective control.'"

CDC update on global polio eradication efforts

The latest MMWR reports on progress made over the past 15 months in the quest to eradicate polio worldwide. Among the details included:

• The number of polio-endemic countries now stands at 4 (Afghanistan, India, Nigeria, and Pakistan), down from 6 as recently as February 2006 (Egypt and Niger have been dropped from the list.)
• India and Pakistan are moving closer to eradication, with a 50% decrease in cases over the past year.
• Nigeria remains the primary nation of concern (as we've written about previously). 41% of cases worldwide (799 of 1,948) occurred in Nigeria, and 94% of global cases were caused by viruses originating in northern Nigeria.
• Worldwide infant vaccination levels are estimated at 80%, but are much lower (as expected) in polio-endemic countries. The number is only 39% in Nigeria overall, and lower still in provinces with higher rates of polio transmission.

Today's report comes a month after an extended feature in the New York Times on polio eradication efforts, which we previously discussed here.

The challenges of polio eradication

Today, the New York Times launched on its front page a five-part series titled "On the Brink". The series will focus on diseases...

"...that are extinct in the developed world but stubbornly persistent in some poor nations. As the diseases hover on the brink of eradication, doctors and scientists face daunting obstacles as they struggle to finish the job."

Today's piece is an extensive, 4,000 word examination of the quest to eradicate polio worldwide. We've written previously about polio eradication efforts. The Times piece elaborates on how rumored safety concerns, public suspicions of government motives, and questions over the continued necessity of vaccination have hampered the push toward eradication. While the story discusses only polio in the developing world, these objections sound all but identical to common criticisms of any vaccination campaign, developing world or otherwise. An excerpt:

"Since [1988], some two billion children have been vaccinated, cutting incidence of the disease more than 99 percent and saving some five million from paralysis or death, the World Health Organization estimates.

But six years past the [2000] deadline [for polio eradication], even optimists warn that total eradication is far from assured. The drive against polio threatens to become a costly display of all that can conspire against even the most ambitious efforts to eliminate a disease: cultural suspicions, logistical nightmares, competition for resources from many other afflictions, and simple exhaustion. So monumental is the challenge, in fact, that only one disease has ever been eradicated -- smallpox. As the polio campaign has shown, even the miracle of discovering a vaccine is not enough."

It's an excellent piece that offers a glimpse at the staggering complexity of mounting an effective vaccination campaign on a global scale.

Also of note is this sidebar piece on the merits of disease eradication as a public health goal.

Meanwhile, on the other side of the world...

While those of us in the U.S. and elsewhere debate 'behavioral disinhibition' and the effects (or lack thereof) of vaccine preservatives, this story notes that simply organizing an effective polio vaccination campaign is the focus of government officials in Nigeria. Despite being off the U.S. radar for decades (with the exception of a few cases among those unvaccinated), polio is still a concern in many parts of Africa and Asia, nowhere more so than Nigeria, according to this WHO site.

The story from Nigeria explains that government efforts for widespread polio vaccination (and hopefully, eradication) face a number of challenges. Chief among them? What else, controversies over vaccine safety.