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1
HEALTH NEWS
OCTOBER 23, 2018 / 7:15 PM / 8 DAYS AGO

Vaccine confidence low in

Europe, raising disease
outbreak risk
Kate Kelland
•
•

LONDON (Reuters) - Low levels of public confidence in

vaccines in the European Union are pushing immunization
rates down and the number of disease outbreaks up,
according to an expert report on Tuesday.

Recent outbreaks of measles – the highest number in the EU

for seven years – are a sign of the immediate impact of
declining vaccine coverage, the report said, and should
prompt governments to act to boost vaccine awareness and
confidence.

The report, published by the European Commission and

compiled by a team of scientists led by Heidi Larson, a
professor and director of the Vaccine Confidence Project at
the London School of Hygiene & Tropical Medicine, found
differing trends in vaccine confidence across EU member
states.

Some – including France, Greece, Italy and Slovenia – have

become more confident in vaccine safety since 2015, while
others, such as Czech Republic, Finland, Poland and Sweden,
have become less confident.

The EU’s health commissioner Vytenis Andriukaitis said the

report’s findings showed “the need for EU action”.

He noted that Europe has lower confidence in the safety of

vaccines than other regions of the world, and that seven out
of the 10 countries with the lowest vaccine confidence in the
world are in Europe - France, Greece, Italy and Slovenia.

“This is partly due to the rising influence of diverse anti-

vaccine groups that spread misleading information through
the internet or in political fora,” he said. “Their influence
should make us all cautious.”

The report found that vaccine trust among medics is linked to

confidence among members of the public, and that while
family doctors generally have higher levels of confidence,
there are worrying signs of mistrust even in the medical
community.

Some 36 percent of family doctors surveyed in Czech

Republic and 25 percent in Slovakia do not agree that the
measles, mumps and rubella (MMR) vaccine is safe, and 29
percent and 19 percent respectively do not believe it is
important, the survey showed.

The report found that since 2010, coverage of measles

immunization - defined as a first dose of a measles-
containing vaccine such as MMR - has fallen in 12 EU
countries: Bulgaria, Croatia, Czech Republic, Estonia,
 Finland, Greece, Lithuania, Netherlands, Poland, Romania,
Slovakia and Slovenia.

Vaccine confidence was defined in the report as trust in the

effectiveness and safety of vaccines and in the healthcare
system that delivers them.

Confidence in, and demand for, vaccines is influenced by a

number of factors, including the importance, safety, and
effectiveness of the shots. Larson said monitoring that
confidence over time can be an important barometer of
emerging issues that countries may need to act on.

Larson noted that across the EU, confidence in flu vaccines

is lower than trust in the MMR shot.

This is “perhaps in part due to the efficacy of the flu vaccine

changing year to year” she said, but also because “there is a
low perception of the various serious risks of influenza”.

Another concerning trend, Larson said, was increasing

hesitancy among doctors to recommend flu vaccines to
pregnant women: “This is worrying as the group is
considered very high risk for serious complications when it
comes to flu.”

Reporting by Kate Kelland; Editing by Raissa Kasolowsky

Our Standards:The Thomson Reuters Trust Principles.
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31-2004

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2013.

(MMWR. Update of vaccine derived polio virus-worldwide, APRIL 2011-June 2012 X 4!Zj

www.cdc.gov

Lorraino Nino, Jane F. Seward. Vaccine policy changes and epdidomecology of poliomyelitis in X 5!Zj

the United States (JAMMA Oct 13 2004, Vo. 292 No. 14)

Kathleen MO Pelly, Elias Durry. The effect of mass immunication compaigns and new oral X 6!Zj

polio virus vaccine on the incidence of poliomyelitis in Pakistan and Afghanisatan, 2001-2011;

retrospective analysis (The Lanncet.com published online July 4, 2012)

(Vaccine - Associated poliomyelitis in Pakistan. Virology blog 20 December, 2012)X7!Zj

John FM, The Bumpy Road to Polio Eradication. N ENGL J MED: June 2010; 362; 25: X 8!Zj

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of Medicine March 21, 2013 Vol. 368 No. 13)

Ali Jaffer Mohammad: Fractional Doses of inactivated polio virus in Oman: New England X 10!Zj

Journal of Medicine (June 24, 2010). Vol. 362, No. 25

From: Journal of Pakistan Medical Association <jpmaofficial@gmail.com>
Sent: Saturday, October 26, 2013 2:33 PM
To: salman imtiaz
Subject: Rejection of Article No: 352-2013.

Article No: 352-2013

Title: "Polio vaccine and eradication of polio from Pakistan"

Dear Dr Salman Imtiaz,

Your above cited Article was reviewed by a specialist in the field and according to the comments provided,
your article cannot be considered for publication in the journal. Following are the comments:

Comments:
The article is not focused. As Polio is concerned, it is declared as national emergency in Pakistan. The
GOP has issued one important document titled: "National Emergency Action Plan" which contains
comprehensive line of action for eradication of Polio in Pakistan. It also contains provisions for social
mobilization activities to improve the uptake of services at national level. Furthermore many organizations
are also involved in advocacy, communication, and social mobilization activities in Pakistan addressing the
misconceptions for polio disease and oral polio vaccine. Furthermore all stakeholders including deputy
commissioners, Commissioners, and higher authorities are actively involved in polio eradication activities
in Pakistan. Therefore program is already there in Pakistan for the concerns mentioned in the article,
delimiting the public health importance of the article.
We regret to inform you that as per reviewer’s comments and editorial board’s
decision, the above-cited article does not qualify for publication in the JPMA.
We hope that you will appreciate our editorial decision does not reflect on the
quality of your work. Your interest in JPMA is highly appreciated.

Regards,

Dr Fatema Jawad
Editor In Chief
JPMA.
 Page 1 of 5

Brief Communication

Polio vaccine and eradication of polio from Pakistan

Eradication of poliomyelitis from Pakistan has now become a political issue

which took precious lives of many Pakistani healthcare workers. People are

skeptical about polio vaccine, like its constituents and contamination and an

accepted rumour that it is not to eradicate polio but to spread it. The recent

hijacking of polio campaign by CIA at Abbottabad, to catch Usama Bin

Laden1 and a feeling of “forced vaccination” strategy without getting

creditable answers to these apprehensions has further reinforced the suspicion.

An attempt is made for all those who encounter the oral polio vaccine to know

the factual position. There are two important issues, the contamination of oral

polio vaccine and the other is emergence of vaccine derived or vaccine related

polio virus causing poliomyelitis.

The polio vaccine was synthesized in 1951 and later in 1961 it was allowed for

human use in North America. The inventor used monkey kidneys to generate

the vaccine. After a year of invention, it was recognized that the vaccine is

contaminated with monkey virus, Simian Virus 40 (SV40) which is a potential

carcinogenic virus. Despite these crucial findings the use of vaccine was not

stopped by National Institute of Health, North America, rather the research

which focused on the virus and the vaccine was not allowed to be published2.

Now it is evident that the SV40 is associated with some human cancers like

mesothelioma, brain cancer, bone cancer and with lymphomas3,4. Although,

the preparation was either changed or virus was cleaned from the vaccine in
 Page 2 of 5

North America. The vaccine with the monkey preparation was in use in other

part of the world, in 1980 a Soviet Union preparation which was supplied to

South America, Asia and Africa was found contaminated with SV405.

One of the concerns of the people in Pakistan is that the vaccine is

contaminated with “something” which can harm the human being. Since these

questions were never addressed it increased the frustration and resulted in

violence which took the lives of the many polio workers. There is a need to

check these vaccines by private, as well as, at government level within

Pakistan for any contamination. In case contamination is identified, then, there

is a need to inform the factual position to the nation.

The use of oral polio vaccine to eradicate the disease is merely fighting fire

with fire, it will ultimately cause emergence of Vaccine derived poliomyelitis.

To understand the issue, there is a need to have some background information.

There are three types of polio viruses called wild polio virus 1, 2 & 3 (WPV1,

WPV2, WPV3). The oral trivalent vaccine, which was synthesized in the

beginning, was the combination of all three live attenuated viruses. The

vaccine was widely used throughout the world. In 1999 when WHO declared

that the world is free from WPV2, the second component was taken out from

the vaccine. Later on the manufacturers synthesized either isolated type 1 or

type 3 monovalent vaccines or single bivalent vaccine which is a combination

of the type 1 and type 3 polio viruses. The immunity for type 2 virus

weakened over the time and vaccine virus which was circulating in the

community attacked vulnerable population. Every year several outbreaks were

 Page 3 of 5

reported from all over the world like Yemen, Mozambique, Pakistan,

Afghanistan and India6.

Polio virus isolates have been categorized on the basis of extent they divergent

with the corresponding OPV strain like; Vaccine related polio viruses

(VRPVs) <1% divergent (PV1 and PV3) or <0.60% divergent (PV2). Vaccine

derived polio virus (VDPV) >1% divergent (PV1 and PV3) or > 0.60%

divergent (PV2). Wild Polio Viruses (WPV1, WPV2 and WPV3), no genetic

evidence of derivation from any vaccine strain. Vaccine derived polio virus

are further categorized as; (a) Circulating vaccine derived polio virus

(cVDPVs). When evidence of person-to-person transmission in the

community exists. (b) Immune vaccine derived polio virus (iVDPVs) which

are isolated from person with primary (B cell) immunodeficiency who are

prolonged VDPV infection. (c) Ambiguous vaccine derived polio virus

(aVDPVs) which are either clinical isolates from person with no known

immunodeficiency or sewage isolates whose source is unknown7.

Due to the complexity of polio virus and polio vaccine US government

changed its policy in 1997 and shifted to injectable polio vaccine to stop the

endless spreading of vaccine derived polio virus8. Ironically, this strategy was

not acquired in Pakistan rather a trial on a new oral polio vaccine (A bivalent

polio vaccine v/s monovalent polio vaccine) was conducted in northern areas

and Afghanistan to establish the efficacy of bivalent polio 1, 3 vaccines over

monovalent polio vaccine.10 There are strategies to combat this threat to

developing countries, and one of them is to switch to injectable form of polio

vaccine.9 One argument for the injectable polio vaccine is its high cost. The
 Page 4 of 5

issue of cost on using injectable is also addressed recently by Ali Jafar

Mohammd et al by using in the derived fractional disease (1/5th) of the normal

dose) of injectable polio vaccine and showed similar seroconversion11.

In conclusion, the doubts, suspicions and anger of the people should be

addressed to stop further violence, there is need to make serious efforts, at

least by checking the contamination of SV40, and having a clear plan for a

gradual shift from oral polio vaccine to injectable polio vaccine to protect the

people from vaccine derived polio virus.

 Page 5 of 5

References

1) Roberts LF, VanRooyen MJ. Ensuring Public Health Neutrality. N ENGL

J MED 368; 12: March 2013.

2) Debbie B and Schumacher J. The Virus and the Vaccine: The True Story
of a Cancer-Causing Monkey Virus Contaminated Polio Vaccine and the
Millions of Americans Exposed. Jim Schemacher. St Martin’s Press, 2004
ISBN 0-31-227874-1.

3) Vilchez RA, Madden CR, Kozinetz CA et al. Association between simian

virus 40 and non-Hodgkin lymphoma. The Lancet, Vol. 359 (9309);
March 2002: 817-823.

4) Hmeljak J and Cor A. Presence and role of Simian Virus 40(SV40) in

malignant pleural mesothelioma. Radiol oncol 2009; 43(1): 9-16.

5) Bookchin D. Vaccine scandal revives cancer fear. New Scientist July

2004; Issue 2455.

6) Vaccine-associated poliomyelitis in Pakistan. Virology blog; 20

December, 2012.

7) Update on Vaccine-Derived Polioviruses – Worldwide, April 2011–June

2012. Morbidity and Mortality Weekly Report (MMWR).
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6137a3.htm

8) Alexander LN, Seward JF, Santibanez TA et al. Vaccine Policy Changes

and Epidemiology of Poliomyelitis in the United States. JAMMA Oct
2004; Vol. 292(14): 1696-1701.
9) Sing SK. Oral polio vaccines: a matter for debate. Future Microbiol.
(2008) 3(4); 383-385.

10) O’Reilly KM, Durry E, Islam O et al. The effect of mass immunization
campaigns and new oral poliovirus vaccines on the incidence of
poliomyelitis in Pakistan and Afghanistan, 2001-11: a retrospective
analysis. www.thelancet.com July (2012) http://dx.doi.org/10.1016-
S0140-6736(12)60648-5

11) Mohammed AJ, AlAwaidy S, Bawikar S, et al. Fractional Doses of

Inactivated Poliovirus Vaccine in Oman. N ENGL J MED 362 (25); June
2010: 2351-2359.
BMJ

Decision Letter (BMJ.2014.017536)

From: rhurley@bmj.com
To: salman_imtiaz@hotmail.com
CC: salman_imtiaz@hotmail.com
Subject: BMJ.2014.017536 Manuscript Decision Personal view
Body: 10-Mar-2014

Dear Dr. imtiaz

# BMJ.2014.017536 entitled "Polio vaccine and eradication of polio from Pakistan"

Thank you for sending us your paper. We read it with interest but I regret to say that
we have decided not to publish it in the BMJ. We would be happy to consider a
revision, however, that takes into account the comments below.

The issue is important as Pakistan is one of the last countries left for polio eradication,
and more so in the context of killings of polio health workers. Nevertheless, we felt the
article needs more substance that can be relied on. Some points below:

1) Need to give the context of polio eradication in Pakistan. At what stage is the
campaign; what have been the challenges historically (with references if available);
what is the vaccination coverage and how many cases of vaccine-derived polio virus
have been observed.

2) The killings have been recent, I think. So I am not sure the doubts and fears about
OPV are the sole reason for the violence, which the author states may be curbed by
building trust. Aren't the killings more recent and instigated by the CIA operations?
The number of killings and which parts of Pakistan may be mentioned.

3) They state people fear the vaccine is contaminated with ‘something’ that can harm
the human being. Can they support this more? Are there qualitative studies from
Pakistan or among Muslims elsewhere on people’s perceptions about OPV, and why
they may refuse? I am aware in India there have been instances of Muslim
communities refusing to vaccinate their children due to the belief that it may sterilize
them or harm them, and is being done to decrease their population. There have been
initiatives to work with Muslim clerics to address these fears. I read that in Nigeria it
has been similarly difficult among Muslims with their leaders accusing this is a
Western initiative to decrease their numbers and infect them with HIV. And they also
rejected tests which showed no contamination.
 May the author provide some of this background as referenced sources?

4) There is a lot of information on development of the vaccine. Some of it, I feel, is

just pulled from text, and seems out of context to the issue on hand. For instance,
they mention SV40 in a vaccine in Soviet Union. How is it linked to the present day
vaccine? I worry if these may just aggravate unfounded fears if not adequately
explained. Likewise, the author mentions administering OPV is treating ‘fire with fire’
due to the emergence of vaccine-derived poliomyelitis. Can this be substantiated with
numbers of cases or hard evidence? As it reads now, all efforts worldwide are in vain
otherwise.

5) As I understand, injectables are better than OPV as they don’t contain a live strain
and hence have a lesser chance of vaccine derived poliomyelitis. However, cost and
feasibility of implementation on a national scale are challenges, both of which factors
OPV scores on. However, in the final leg, injectables are deemed necessary, and India
is contemplating that switch. So when the author says the US shifted to injectable but
tried newer oral forms in other countries, again, some evidence would be useful
especially considering costs, feasibility, and scale.

The danger is it would just perpetrate the fear that substandard vaccines are being
given to them, and further threaten the vaccination campaign.

We receive over 8000 submissions a year and accept less than 10%. We do therefore
have to make hard decisions on just how interesting an article will be to our general
clinical readers, how much it adds, and how much practical value it will be.

Thank you for considering BMJ for the publication of your article. I am sorry to
disappoint you on this occasion, and I hope the outcome of this specific submission
will not discourage you from the submission of future manuscripts.

Best wishes

Yours sincerely

Richard Hurley
rhurley@bmj.com

If you elected during submission to send your article on to another journal the article
will be transferred in 5 working days. If you intend to appeal against this decision
please notify us before then.
The journal(s) (if any) you have selected at submission are: BMJ Open
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office: papersadmin@bmj.com
Date Sent: 10-Mar-2014

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