A warning from Tajikistan

The following post was written by Alanna Shaikh. Alanna is a global health professional who blogs at UN Dispatch and Blood and Milk. A polio outbreak is underway in Tajikistan. 12 people have died of the diseases since March. 32 cases of polio have been confirmed, and 171 cases of acute flaccid paralysis (a signal of possible polio) have been identified. That’s a full-fledged outbreak in a country with an 82% vaccination rate. Until this January, there hadn’t been a polio case in Tajikistan for 13 years; Tajikistan was certified polio-free in 2002.

Tajikistan should simply not be seeing a polio outbreak – an 82% vaccination rate is enough to achieve herd immunity and protect even the unvaccinated. And we know this is not one of the rare vaccine-caused outbreaks because the WHO has done genetic analysis on the polio strain – it is wild polio.

Something has gone wrong in the health sector in Tajikistan. There are several ways that the health system could fail on vaccination. Vaccine records could be inaccurate, causing unvaccinated children to be missed by the system. Or the cold chain is not being maintained and the vaccines are losing effectiveness – the oral polio vaccine is especially vulnerable to warm temperatures. Whatever happened, it’s a sign of health system weakness and the Ministry of Health of Tajikistan will need support to improve it.

This outbreak calls into question the disease eradication approach to public health. Tajikistan has shown genuine commitment to polio eradication and that commitment has not been enough. Without a health sector strong enough to ensure effective vaccination coverage, a single-disease focus just doesn’t work. That idea is slowly being accepted. Eradication proponent Bill Gates called the eradication approach into question in his annual letter, mentioning slow progress to date in Nigeria.

If disease eradication is not the key to promoting global health, what is? Successful immunization against dangerous childhood diseases requires the same basic health sector resources as fighting HIV, protecting maternal health, and preventing chronic illnesses: a sufficient number of trained staff, useful data and the ability to act of it, health infrastructure, and effective financing methods. Support for those resources therefore strengthens a nation’s health as a whole.

Moving to a health systems approach for supporting global health will maximize the impact of global health spending. Every dollar spent will battle more than one disease. A broad systems approach also directly supports the goals of disease eradication by making sure that health staff are available, and trained, to provide vaccinations, and that the logistical system is in place to keep vaccines cold.

A systems approach will also support the structures needed to maintain disease elimination. Even after polio has been eliminated from a region, vaccination for the disease needs to continue as long as it still exists in human patients anywhere. And surveillance is necessary to watch and prepare for new outbreaks of the disease, like the one we are seeing in Tajikistan.

Tajikistan’s polio outbreak is a warning sign. You can’t eliminate a disease without also building a health system that ensures the disease stays eliminated.