What Is Wrong With The Vaccine World?

Polio has been with us for thousands of years, but large epidemics seem to have become common only in the last 150 years or so. You may know already that Wild Type (or the natural virus) polio is still found in only two countries in the world, Pakistan and Afghanistan. In fact of the 3 natural strains of Polio, strains 2 and 3 are felt to be extinct, and only strain 1 remains in circulation. Total world cases of natural paralytic polio today are very few. Here is a nice graph showing the effect of the introduction of the Polio vaccine on United States cases.

Live attenuated polio vaccine (OPV) replicates in the human gut and is shed in the stool of vaccinated people, and in occasional persons can revert to a neuropathogenic form which then can infect unvaccinated people, potentially causing paralysis. The original Salk polio vaccine is an inactivated vaccine (IPV) which cannot replicate and is extremely effective in preventing symptomatic disease, but it does not prevent a person from getting infected (with either wild type or oral vaccine derived virus) and then excreting it in the stool. In 2012, 400 cases of circulating vaccine derived polio (cVDPV) occurred world wide, approximately twice the number of natural polio cases that year. By 2022, the WHO reported 320 vaccine related cases, compared to 6 cases of Wild Type polio in 2021. Currently there is an outbreak of vaccine derived polio ongoing in the Democratic Republic of Congo and Burundi. When these outbreaks occur, the standard WHO response is to rush into the area and administer as much OPV as possible. The rational is that, while both vaccines are effective in preventing paralytic disease, people who receive the IPV have little intestinal immunity and will become infected with the circulating oral vaccine strain and continue the chain of excretion transmission—whereas the OPV gives better immunity at the gut level, so fewer people will be excreting virus. The only folks at risk for paralytic disease are the unvaccinated and immune compromised. If it seems perhaps a bit questionable to respond to an oral vaccine generated outbreak by administering more oral vaccine, then perhaps your brain is wired like mine. In all fairness, it is a complicated question with lots of variables and practical limitations. Of course vaccinologists have tried for years to develop an oral attenuated vaccine which would be even safer. Type 2 strain was most frequently implicated in vaccine outbreaks, and several years ago a novel type 2 vaccine was developed— it seems to be an improvement but a current outbreak now in Peru is due to this vaccine. The safety hurdle is that polio is fundamentally a gut virus, and only occasionally (1:200 - 1:500) finds its way into the nervous system. The oral vaccine strains like to persist in the human intestine for quite a while in many people, and when viruses replicate, they mutate, and when they pass from person to person they recombine. The power of enormous numbers is always on their side, just like artificial intelligence. Some of us will be old enough to remember the magnitude of the problem, and the terror prior to Salk’s vaccine roll out in 1954.

Polio ward in 1952 with Iron Lungs

Let’s move to the Americas, where the last case of Wild Type polio in the US was in 1979, and both hemispheres were declared free of natural polio in 1997. A total of four out of the 35 countries in the Americas have abandoned use of the oral vaccine and exclusively use the IPV: the US, Canada, Costa Rica and Uruguay. So every case of paralytic polio in North and South America over the last quarter century has been due to the oral polio vaccine. The US case in Rockland county, New York this year was an example. It is true that the WHO has stated it is a goal to eventually abandon use of the oral vaccine in favor of the IPV. All the countries in the Americas still using the OPV have different regimens which include at least one dose of IPV, but let’s not make this overly complicated. So if the WHO says it’s a goal to stop using a vaccine that is the sole source of paralytic polio in this hemisphere, what is the problem?

Whenever there is a glaring contradiction in Public Health, and a no-brainer solution which is not being implemented, you can bet money is the answer. It turns out that IPV supply is the main impediment to progressing to a world where we don’t give a vaccine which leads to neuropathic polio virus circulation, and causes paralysis of several hundred children every year. Over the last three years of the Pandemic in both North and South America, there has been a dramatic decline in the percentage of children fully vaccinated against polio. That means that the population of young people susceptible to outbreaks of vaccine derived disease has significantly increased, and as catch up programs of mass administration of OPV are undertaken we can expect the numbers of paralytic cases to rise. As I mentioned above, there is currently a case of vaccine derived paralysis in Peru. In the district where the child was infected the rates of full (3 dose) polio vaccination have declined from 96% in 2019, to 33.8% in 2021, and 43.6% in 2022. The emergency response will be pumping out more of the oral vaccine, but now into a huge population of infants susceptible to infection and possible vaccine induced paral`ysis.

In the grand scheme of the vaccine world, polio vaccine is a bit player, relatively cheap when sold to UNICEF and third world governments. While OPV costs much less than a dollar (in bulk to UNICEF or governments), IVP is a bit more expensive, and the current supply would not be sufficient to suddenly switch over, world wide. There are also the other costs to be incurred with an injectable like syringes and needles. Trained medical personnel to administer doses is cited as an impediment, but ALL countries currently using the new oral vaccine since 2016 (which only contains polio types 1 and 3) give one dose of the IVP as part of the series. The polio endgame around the world is uncertain. Total eradication, like smallpox, with the result that vaccinations could be stopped is nowhere in sight. In the Americas though, it seems possible we could switch over to use of the safer IPV. With all hemispheric cases of paralytic disease for the last 25 years being due to the vaccine, the course seems clear. This week we listened to Stephan Bancel, CEO of Moderna, tell Congress that his company will be raising the price of their COVID vaccine to $130 a dose. (That is a 4-5x multiple of what Warp Speed paid). Moderna made 20 billion in profit during the 2 years the vaccine was distributed; forget about Pfizer which sold the bulk of vaccine—they at least didn’t take taxpayer dollars to develop their product. Of course Bancel says, “Don’t worry, you won’t be paying that much for it—insurance, or Medicare or Medicaid will pay”, but any sentient tax and premium payer knows the truth. Let’s not pick on the Pharmaceutical industry—we don’t want to stifle innovation, and I wouldn’t want any of my friends to cancel me. Last week we saw unveiled a 7 trillion dollar budget. I’ll remind everyone of the obvious, that’s 7,000 billions. How much utter nonsense is contained in ANY US national budget? Your answer of, “A whole lot” is correct. If we are spending approximately 1.5 trillion dollars a year which we don’t have, and have to conjure by printing money, couldn’t we take an infinitesimal amount of that for something that should matter to all of US?