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 1940s and 1950s 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 towards 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 1970s, polio cases resulting from imported polio virus occurred
during the late 1970s, and such events remain a threat in the 1990s,
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 ten-year period in the
global campaign to eradicate smallpox. The entire $32 million has been
recouped every 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
1990s.
- 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
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 two 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
one-year period, and a real shortfall of expected funds. The 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 Towards 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 five 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 1989-1991.
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 towards 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.