Correspondence
Poliopolis
Despite global withdrawal of mono­
valent oral live-attenuated type-2
polio vaccines (OPV2) in May, 2016,
recent circulating vaccine-derived
type-2 poliovirus (cVDPV2) outbreaks
in Africa highlight the danger of polio
re-emerging in high-risk populations
with low levels of immunity because
of poor vaccine coverage.1 The only
appro­p riate countermeasure to
control and minimise spread of such
outbreaks is deployment of stockpiled
monovalent OPV2 vaccine, but this
approach could seed further cVDPV2
outbreaks. An international effort
through a scientific consortium
of vaccine devel­o pers and global
agencies, supported by the Bill
& Melinda Gates Foundation,
has sought to make more stable
attenuated vaccine polioviruses for
use in outbreaks with minimal risk of
generating new cVDPVs.2,3
In pre-clinical models the resulting
two novel OPV2 candidates have
been shown to be genetically more
stable than the Sabin OPV, and so are
less likely to revert to neurovirulent
strains shed by vaccinees. Going
on to demonstrate the safety and
immunogenicity of these candidates
in humans in the era following
global withdrawal of OPV2 and WHO’s
containment recom­m endations 4
has posed unique challenges for the
conduct of a phase 1 study that starts
clinical develop­ment. To overcome
this, a unique purpose-built contained
environment, Poliopolis, was created
in the grounds of Antwerp University
Hospital in which to perform phase 1
testing of both novel OPV2 candidates
in healthy adult volunteers (figure).5
Two groups of adults spent 4 weeks
of foreseen confinement from the
outside world, with all biological
waste, clothing, food, and water
captured for decontamination, to
allow monitoring of shedding of the
orally administered vaccines without
risking environmental release of these
genetically engineered polioviruses.
www.thelancet.com Vol 394 July 13, 2019 115
Fire exits
Kitchen
and dining
room
Consulting
Individual bedrooms
rooms
Corridor
Goods
entrance Recreation room
and library
Staff
entrance
Staff
exit
Goods Decon
exit room
Figure: Diagrammatic representation of the modular design of Poliopolis
Rectangles represent the prefabricated modules that were assembled on site to create the facility.
The creation of this self-contained
unit was achieved in less than
6 months as a successful outcome of
a major collaborative effort involving
scientists, staff at the University of
Antwerp and the university hospital,
building contractors, munici­ p ality
including local police and fire service,
the Belgian Government, and global
partners. Safety of the volunteers
and the local community were the
paramount considerations, with all
medical and psychological aspects
considered for the former, and all
practical physical barriers in place for
the latter. As voluntary confinement
of 15 candidates was anticipated to
last 28 days, psychological assessment
at screening was an important factor
in the selection process. Without
connections to water or sewage
infrastructure, the local population
was protected from accidental release
of the novel viruses.
The accomplishment of this innova­
tive clinical trial will lead to further
and larger planned assessments of
both vaccine candidates in other age
cohorts and hopefully eventually
ensure their suitability for deployment
as the first line of defence against
cVDPV2 outbreaks. The successful
clinical development process of these
vaccines is expected to be instrumental
in ensuring long-term success of
completing poliovirus eradication.
We declare no competing interests.
Staff
Corridor
toilet
Toilets
Fitness
room
Toilets
Corridor
Internal garden Showers
Showers
Individual bedrooms
Laboratory
facilities
Corridor
Waste water
management
Waste water
management
Tank Tank
*Pierre Van Damme, Ilse De Coster,
Hilde Revets, Ananda S Bandyopadhyay
pierre.vandamme@uantwerpen.be
Centre for the Evaluation of Vaccination, Vaccine and
Infectious Disease Institute, University of Antwerp,
2610 Antwerp, Belgium (PVD, IDC, HR); and Bill &
Melinda Gates Foundation, Seattle, WA, USA (ASB)
1 Mbaeyi C, Alleman MM, Ehrhardt D, et al.
Update on vaccine-derived poliovirus outbreaks
- Democratic Republic of the Congo and Horn of
Africa, 2017–2018. MMWR Morb Mortal Wkly Rep
2019; 68: 225–30.
2 Bandyopadhyay AS, Garon J, Seib K,
Orenstein WA. Polio vaccination: past, present
and future. Future Microbiol 2015; 10: 791–808.
3 Bandyopadhyay AS, Modlin JF, Wenger J,
Gast C. Immunogenicity of new primary
immunization schedules with inactivated
poliovirus vaccine and bivalent oral polio
vaccine for the polio endgame: a review.
Clin Infect Dis 2018; 67 (suppl 1): S35–41.
4 The Global Polio Eradication Initiative.
Polio endgame strategy 2019–2023: eradication,
integration, certification and containment.
April 30, 2019. http://polioeradication.org/wp-
content/uploads/2019/03/polio-endgame-
strategy-2019-2023.pdf (accessed
April 25, 2019).
5 Van Damme P, De Coster I,
Bandyopadhyay AS, et al. The safety and
immunogenicity of two novel live attenuated
monovalent (serotype 2) oral poliovirus vaccines
in healthy adults: a double-blind, single-centre
phase 1 study. Lancet 2019; 394: 148–58.
Schizophrenia:
a neglected problem in
Pakistan
Schizophrenia is a chronic brain disor­ Submissions should be
made via our electronic
der with symptoms of delusions, hallu­ submission system at
cinations, trouble with thinking or http://ees.elsevier.com/
concentration, and a lack of moti­vation.1 thelancet/
 Correspondence
The disorder affects about 21 million
people worldwide,2 most of whom do
not receive appropriate care. Many
patients live in developing countries,
including Pakistan.
The exact prevalence of schizo­phrenia
in Pakistan is not known, which makes
the incapacitating illness difficult to
combat. 1–2% of the population is
estimated to have the disorder.3
Schizophrenia affects the individual
and their family, both socially and
economi­c ally. 4 Most people with
schizophrenia in developing countries
probably re­ceive little or no formal
care, and some are abandoned by their
families and spend the rest of their
lives homeless without ever getting
evaluated. These scenarios result in
first-episode psychosis not being
treated,5 which poses a major public
health problem.
Most of Pakistan’s population lives
in rural areas, has low literacy rates,
and no knowledge of the disorder, and
therefore people with schizophrenia
Published Online are thought of as being possessed
June 18, 2019
http://dx.doi.org/10.1016/
by a spirit. Instead of consulting a
S0140-6736(19)31102-X psychiatrist they seek treatment from
This online publication has been faith-based healers. Sometimes patients
corrected. The corrected version are beaten by a so-called therapist with
first appeared at thelancet.com the notion that they are inflicting pain
on July 11, 2019
to an evil spirit and not to the patient.
See Online for appendix
Such practices have to be abolished
from society by organising awareness
programmes and offering health-care
services to people with schizophrenia,
with a specific focus on rural areas.
The country already has some non-
governmental organisations that are
addressing the needs of these patients.
For example, the Fountain House
Network offers not only treatment
services but also rehabilitation services,
so that after recovery patients can
integrate back in to society. Also the
internet has helped raise awareness,
but schizophrenia is still perceived
with some apprehension and effective
participation at government level is
necessary.
The government of Pakistan should
take notice of the rising numbers
of people with schizophrenia, and
116 www.thelancet.com Vol 394 July 13, 2019
intervene by raising national aware­ rise reflects an increase in population
ness, by funding resources for effective prevalence is unclear. The apparent
diagnosis, care, and treatment, and by increase could indicate a greater
promoting their social inclusion. willingness to discuss such issues, and
We declare no competing interests. a better recognition of mental health
difficulties by referring clinicians, rather
*Shahzain Hasan, Munsif Adil
dr.shahzainhasan@outlook.com
than increases in morbidity.
One way to assess this question
Neuromind Hospital, Sir Syed University,
Karachi 74800, Pakistan (SH); and Medicare Cardiac is to investigate rates of death by
and General Hospital, Karachi, Pakistan (MA) suicide. If the apparent rise in rates
1 American Psychiatric Association. Diagnostic of emotional problems is due to
and statistical manual of mental disorders, increased recognition and referral of
5th edn. Washington, DC: American Psychiatry
Association, 2013. such difficulties, concurrent changes
2 WHO. Schizophrenia. http://www.who.int/ in suicide rate would not be expected.
news-room/fact-sheets/detail/schizophrenia Using data from the Office for National
(accessed Dec 10, 2018).
3 Ansari I. Mental Health Pakistan: optimizing Statistics, we did a Joinpoint regression
brains. Int J Emerg Ment Health 2015; 17: 288. analysis3 to investigate changes in the
4 Health care reform for Americans with severe rate of suicide among adolescents
mental illnesses: report of the National
Advisory Mental Health Council. Am J Psychiatry aged 15–19 years between 1981 and
1993; 150: 1447–65. 2017 in England and Wales. The best-
5 Taj R, Khan S. A study of reasons of
non-compliance to psychiatric treatment.
fitting model showed that between
J Ayub Med Coll Abbottabad 2005; 17: 26–28. 2010 (95% CI 2006, 2015) and 2017,
suicide rates per 100 000 adolescents
increased by 7·9% per year (95% CI
Rising suicide rates 4·8 to 11·2; figure). Trends differed by
sex, although rates increased for both
among adolescents in sexes. In men, suicides rates increased
England and Wales by 5·9% per year (2·9 to 9·0) between
2009 and 2017 (appendix). The
There are concerns that the incidence absolute number of deaths by suicide
of affective disorders1 and self-harm2 is is lower for women than for men
rising among adolescents. Whether this between 1981 and 2017; however,
7·0
6·5
6·0
5·5
Suicide rate per 100 000 adolescents (%)
5·0
4·5
4·0
3·5
3·0
2·5
2·0 Observed
1981–83 APC = –10·8
1·5 1983–88 APC = 12·1*
1·0
1988–95 APC = –3·5*
1995–98 APC = 6·9
1998–2010 APC = –4·8*
0·5
2010–17 APC = 7·9*
0
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018
Year
Figure: Suicide rate among adolescents aged 15–19 years between 1981 and 2017 (in England and Wales)
Asterisks indicate statistically significant (p<0·05) differences in APC. APC=annual percentage change.