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Testimony on Eradication of Polio and Control or Elimination of Measles by David Satcher, M.D., Ph.D.
Assistant Secretary for Health and Surgeon General of the United States
U.S. Department of Health and Human Services

Before the Senate Committee on Appropriations, Subcommittee on Labor, Health and Human Services, Education and Related Agencies
September 23, 1998

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