1. VACCINES: PAST, PRESENT, AND FUTURE

2. Starry Night or Deadly Virus?

3. Variola Virus Smallpox signs and symptoms  Fever  Significant discomfort  Headache  Severe fatigue  Severe back pain  Vomiting  Characteric rash  Prognosis:  Fatality rate of ~33%  Permanent and severe scarring  Blindness can result http://www.mayoclinic.org/diseases-conditions/smallpox/basics/complications/con-20022769

4. TRANSMISSION  Airborne transmission – rapid spread  Direct person-to-person contact  Ventilation system  Contact with infected items  Potential: terrorist weapon  In 2014— Forgotten vials of live variola virus at the U.S. National Institutes of Health! http://www.mayoclinic.org/diseases-conditions/smallpox/basics/complications/con-20022769

5. TREATMENT AND PREVENTION  No cure exists  Antibiotic treatment for secondary infection  Vaccination- highly critical http://www.mayoclinic.org/diseases-conditions/smallpox/basics/complications/con-20022769

6. Smallpox History Smallpox may have been the cause of death for Rameses V 3,200 year-old mummy http://www.nature.com/news/infectious-diseases-smallpox-watch-1.15115

7. Smallpox History- Chinese vaccination, 1000 AD http://www.historyofvaccines.org/content/timelines/smallpox

8. SMALLPOX HISTORY  1796: Edward Jenner, physician from the UK, demonstrated that those inoculated with cowpox had immunity to Variola virus  World’s first vaccine! Nelson and Masters Williams, 2014

9. VACCINATION HISTORY  1885: Louis Pasteur developed rabies vaccine  1890: Antitoxins for diphtheria and tetanus were discovered by Emil von Behring and Shibasaburo Kitasato http://www.nhs.uk/conditions/vaccinations/pages/the-history-of- vaccination.aspx

10. VACCINATION HISTORY: ADVANCES IN 20 TH CENTURY  1920s: Wide availability of diphtheria, tetanus, whooping cough, and tuberculosis vaccines  1955: Polio vaccine become available in UK  1966: WHO – Smallpox Eradication Programme  1980: Smallpox eradicated!  1965 – 2000: Significant reductions in child mortality in sub-Saharan Africa, in part related to increased access to immunization http://www.nhs.uk/conditions/vaccinations/pages/the-history-of- vaccination.aspx http://www.ncbi.nlm.nih.gov/books/NBK2296/

11. UNICEF State of the World’s Children Report, 2008

12. VACCINATION: SUCCESS AND FAILURE IN 20 TH CENTURY Nelson and Masters Williams, 2014, p.273

13. UNICEF State of the World’s Children Report, 2008

14. GOALS OF VACCINATION CAMPAIGNS  Broad and continued coverage of immunizations among young children  Immunization schedule as early as possible  WHO Expanded Program on Immunization:  Diphtheria, tetanus, pertussis, polio, measles mumps, and rubella (BCG and yellow fever in some cases)  Vaccinations in the US:  Hepatitis B, diphtheria, tetanus, pertussis, Hib, polio, measles, mumps, rubella and varicella Nelson and Masters Williams, 2014

15. Nelson and Masters Williams, 2014, p.281

16. Immunization Schedule, Saudi Arabia

17. VACCINATION COVERAGE – U.S. EXAMPLE  U.S. vaccination coverage; 5 year olds, 2013  M edian 2-dose MMR vaccination coverage was 94.7%  Range = 81.7% in Colorado to ≥99.7% in Mississippi  26 states and DC did not report meeting the Healthy People 2020 target of 95% coverage for 2 doses  Median DTaP vaccination coverage was 95.0%  Range = 80.9% in Colorado to ≥99.7% in Mississippi http://www-ncbi-nlm-nih-gov.ezp-prod1.hul.harvard.edu/pubmed/25321068

19. VACCINATION COVERAGE – SAUDI ARABIA EXAMPLE  Saudi Arabia vaccination coverage for MMR (2004)  Random selection of children ranging in age from kindergarten through secondary school  children who attended school or the well baby clinic in Jeddah  Coverage = 99%  Variation was observed for prevalence of antibodies http://www-ncbi-nlm-nih-gov.ezp-prod1.hul.harvard.edu/pubmed/16432596

21. VACCINATION STUDIES  Vaccine efficacy: randomized controlled trial  Combination of vaccine efficacy and program performance: observational studies  Case-control  Cohort  Cross-sectional  Prevalence ratio = % protective antibody – vaccinated % protective antibody – unvaccinated  Vaccine effectiveness (VE) = 1- Prevalence ratio (PR) Nelson and Masters Williams, 2014

22. VACCINATION STUDIES  Observational studies- need to account for potential error, such as confounding  Potential confounders: age, sex, socioeconomic status, etc. Nelson and Masters Williams, 2014

23. Nelson and Masters Williams, 2014, p.289

24. Nelson and Masters Williams, 2014, p.295

26. GLOBAL POLIO ERADICATION INITIATIVE (GPEI)  WHO – eradicate polio by the year 2000  Challenges  3 serotypes exist, do not share cross-immunity  Several doses of IPV or OPV are needed  Factors related to low coverage:  Community resistance  Difficulty in linking vaccine initiative to other immunization programs  Failure to engage high risk populations Nelson and Masters Williams, 2014

27. BARRIERS TO POLIO ERADICATION  Failure to vaccinate – low coverage  Vaccination failures  OPV – lower immunogenicity and effectiveness in tropical climates  Trivalent OPV – lower efficacy compared to monovalent vaccine Nelson and Masters Williams, 2014

28. GPEI – MOVING FORWARD  A 99% reduction is not an option, according to the WHO: “As long as a single child remains infected, children in all countries are at risk of contracting polio”  2009/2010 – 23 previous polio free countries were reinfected due to import of polio virus Nelson and Masters Williams, 2014, p.297

29. Nelson and Masters Williams, 2014, p.298

30. GROUP DISCUSSION  Based on your reading of Foege’s article on smallpox eradication, what are some strategies that can be used to eradicate polio?  Are there any strategies used in eradication of smallpox that may not be as useful in eradicating polio?  Are there additional concerns that need to be taken into account for polio that were not part of the smallpox eradication campaign? Nelson and Masters Williams, 2014, p.297