World Witnesses a Tumultuous Year while India Reports an Eventful Decade in the Long Story of Polio Eradication

With recent outbreaks in Syria and Horn of Africa, silent circulation of wild poliovirus type 1 (WPV1) in Israel, West Bank, and Gaza, and fresh spate of violence against vaccinators and their security personnel in Pakistan, the world is facing a turbulent final ascent to the summit of polio eradication. On the positive side, we may also be witnessing the end of wild poliovirus type 3 (WPV3) and defused programmatic crisis caused by funding gaps, while India registers third consecutive polio-free year. Having a cogent endgame plan 2013-2018, informed by some cardinal lessons learned from an eventful decade in India, is also a very significant development. Now, there is a parallel pursuit against WPV and vaccine-derived poliovirus (VDPV). Endgame would also involve integration of at least one dose of affordable inactivated polio vaccine (IPV) to up-scaled routine immunization (RI), switch from trivalent oral polio vaccine (tOPV) to bivalent oral polio vaccine (bOPV) in 144 countries before 2018, stockpiling of mOPV, and simultaneous global cessation of bOPV before 2020. Role of antivirals in post-eradication era is still unclear. Some specific threats emerging at this stage are as follows: Global buildup of new birth cohorts in non-endemic countries with weak RI and downscaled supplementary immunization activities (SIAs), tremendous pressure on peripheral health workers, and fatigued systems. Cultural resistance to transnational programs is taking a violent shape in some areas. Differential interpretations of ‘right to say no’, on both sides of the divide, are damaging a global cause. Amidst all these concerns, let us not forget to underline the sacrifice made by frontline vaccinators working in some of the most challenging circumstances.     

Increasing the duration of dual amoxicillin plus omeprazole Helicobacter pylori eradication to 6 weeks: a pilot study

Background and Aim: Helicobacter pylori infections have become increasingly difficult to treat as antimicrobial resistance has increased. The aim of this study was to test the hypothesis that a 6‐week dual regimen of amoxicillin 1 gm and omeprazole 20 gm therapy b.i.d. would cure at least 90% of treatment‐naïve H. pylori infections. Methods: This was an open‐label prospective pilot study in which treatment‐naïve subjects with active H. pylori infection (positive by two tests) received dual amoxicillin 1 g and omeprazole 20 mg, b.i.d. daily for 6 weeks. Success was accessed by urea breath test 4–6 weeks later. A tentatively effective therapy was defined as a per‐protocol treatment success of 90% or greater; treatment success of 80% or less was prespecified as unacceptable. Results: Sixteen patients were included in the study (14 men, two women) with an average age of 49 years. At 16 patients, the prespecified stopping rule of six treatment failures was achieved (i.e. the 95% confidence interval excluded achieving the required 90% success rate even if 50 patients were entered). As per protocol, enrollment was stopped. Per‐protocol and intention‐to‐treat treatment success were both 62.5% (95% confidence interval, 35–84%). Compliance was greater than 99%. Five patients (31%) reported side‐effects, all of which were mild and none interrupted therapy. Conclusion: Despite the theory and pre‐existing data from Japan, in the USA, prolonging the duration of dual amoxicillin‐PPI therapy did not improve treatment outcome in 90% or more of our patients.     

根除老年人消化性溃疡合并幽门螺旋杆菌感染的治疗策略

目的对质子泵抑制剂（PPI）或铋剂三联疗法作为初治方案以及序贯疗法或四联疗法作为补救方案根除老年人消化性溃疡（PUA）合并幽门螺旋杆菌（Hp）感染的疗效进行比较。方法2009年7月至2010年7月间261例胃镜下尿素酶法诊断的PUA合并Hp感染患者,随机采用PPI三联疗法、铋剂三联1周疗法进行根除,观察治疗过程中不良反应发生率。PUA患者经上述抗Hp治疗后继续4周抗溃疡治疗,停药1月后复查胃镜并比较两种方法对Hp根除率及溃疡愈合率的疗效差异。对于首次三联疗法根除Hp失败者,随机应用10日序贯疗法和PPI、铋剂四联1周疗法再次行Hp根除。观察疗程中不良反应发生率,停药1个月后采用”C呼气试验观察Hp根除率。统计分析采用符合方案（PP）群组分析和意向治疗（ITT）群组分析。结果相比于铋剂三联疗法,PPI三联疗法Hp根除率（ITT：77．7％vs62．6％;PP：79．5％v564．1％;P〈0．05）及溃疡愈合率（ITT：78．5％vs64．9％;PP：80．3％vs66．4％;P〈0．05）高,不良反应发生率无明显差异（1TT：10．8％vs16．8％：PP：11．0％vs17．2％;P〉0．05）。对于首次三联疗法失败者以10日序贯疗法补救,Hp根除率较高（ITT：84．6％vJ61．5％;PP：86．8％v563．2％;P〈0．05）,且不良反应发生率较四联疗法低（ITT：12．8％VS35．9％;PP：13．2％VS36．8％;P〈0．05）。结论PPI三联1周疗法进行Hp感染根除可作为PUA患者首选,有较高的溃疡愈合率和Hp根除率;首次根除失败者可优先改用10日序贯疗法进行补救。     

Serological Detection of Antibodies to Peste des Petits Ruminants Virus in Large Ruminants

Peste des petits ruminants (PPR) is an economically important disease of small ruminants with a rapidly expanding geographical distribution. Peste des petits ruminants virus may manifest in a variety of ways with disease ranging from acute to subclinical. We investigated the exposure of large ruminants to PPRV in areas where the virus is endemic in the small ruminant population by assessing the serological status of groups of animals. This study focused on the Punjab province of Pakistan as an area where the virus is endemic and where mixed farming practices occur enabling close interactions between small and large ruminant populations. An overall PPR seropositivity was detected in 10.0% of cattle and 14.16% of buffaloes. Following an assessment of serological profiles in large ruminants within different age groups, a maximum seroprevalence was observed in cattle (17.5%) and buffaloes (22.5%) over 2 years of age indicating the potential utility of sampling large ruminant populations for PPR serosurveillance. The large ruminants sampled between one and two years of age had similar levels of seropositivity within populations with 11.2% and 16.2% of animals being seropositive, respectively. Current PPR vaccination strategies do not enable the differentiation between infected and vaccinated small ruminants, and as such, the serological surveillance of sheep and goats is of little value. When considering eradication programmes for PPRV, this factor is of great significance. However, where large and small ruminants are farmed together, serological surveillance of large ruminants may provide a snapshot of virus infection within populations where mild disease is present or where small ruminants are regularly vaccinated.     

Working ‘off the record’: polio eradication and state immunity in Chad

The reappearance of polio in Chad generates anxieties about governance as well as public health. Since Chad was declared polio-free in 2003, at least 180 cases of paralytic polio have been linked to importations of wild poliovirus from Nigeria. In efforts to eradicate polio through house-to-house vaccination campaigns, international agencies have aggressively implicated political leaders, placing those authorities in a bind. On the one hand, governments are required to demonstrate compliance in the form of universal vaccination. On the other hand, the legitimacy of political leaders and of local authorities in particular depends upon their ability to show compassion for their populations and to be responsive to individual circumstances and concerns about the drops. This article looks at how the obligation of the African state to adopt global public health policy as its own becomes problematic when the goals and protocols of international agencies rely on the assumption that the state controls its population. Under pressure to render account to international agencies, state officials deploy high-level politicians to enforce vaccination mandates at critical moments, create administrative forms to record campaign progress that conceal difficulties in vaccinating children, and use statistics to portray the campaigns as success stories. Local authorities, who feel the bind most acutely, grant exceptions to the mandate of universal vaccination to certain subjects and work with local vaccinators and supervisors to keep cases of unvaccinated children ‘off the record’. These efforts allow the vaccination campaigns to be carried out without incident even as they work against the goal of polio eradication.     

Quadruple therapy with ecabet sodium,omeprazole, amoxicillin and metronidazole is effective for eradication of Helicobacter pylori after failure of first‐line therapy (KDOG0201 Study)

Background and object: An antiulcer agent, ecabet sodium, is active against Helicobacter pylori. The aim of the present study was to clinically examine whether eradication therapy, which includes ecabet sodium, is effective in eradication of H. pylori after failure of first‐line therapy. Methods: Patients with peptic ulcer who failed with first‐line triple eradication therapy containing clarithromycin received quadruple therapy with omeprazole (20 mg, twice daily), amoxicillin (750 mg, twice daily), metronidazole (500 mg, twice daily) and ecabet sodium (1000 mg, twice daily) for 14 days. Eradication of H. pylori was judged by ¹³C‐urea breath test 8 weeks later. Results: Fifty‐two patients (36 men and 16 women) were included. Their mean age was 51·4 years (range 28–73). One patient dropped out because of diarrhoea. The eradication rate was 98·0% (50/51) according to the per‐protocol analysis and 96·2% (50/52) according to the intention‐to‐treat analysis. Side effects occurred in seven patients, but none were serious. Conclusions: Quadruple therapy including ecabet sodium is useful as second‐line eradication treatment for H. pylori.     

Development and introduction of inactivated poliovirus vaccines derived from Sabin strains in Japan

During the endgame of global polio eradication, the universal introduction of inactivated poliovirus vaccines is urgently required to reduce the risk of vaccine-associated paralytic poliomyelitis and polio outbreaks due to wild and vaccine-derived polioviruses. In particular, the development of inactivated poliovirus vaccines (IPVs) derived from the attenuated Sabin strains is considered to be a highly favorable option for the production of novel IPV that reduce the risk of facility-acquired transmission of poliovirus to the communities. In Japan, Sabin-derived IPVs (sIPVs) have been developed and introduced for routine immunization in November 2012. They are the first licensed sIPVs in the world. Consequently, trivalent oral poliovirus vaccine was used for polio control in Japan for more than half a century but has now been removed from the list of vaccines licensed for routine immunization. This paper reviews the development, introduction, characterization, and global status of IPV derived from attenuated Sabin strains.