Dr. Steve Cochi

Steve Cochi

TORGHELE: It is July 12, 2016. I am Karen Torghele, and I'm at the Centers for Disease Control and Prevention today with Dr. Stephen Cochi, who is the senior advisor to the director in the Global Immunization Division at the Centers for Disease Control in Atlanta. Welcome, Dr. Cochi.

COCHI: Thank you, Karen.

TORGHELE: Thank you for agreeing to be interviewed for the Global Health Chronicles Polio Project. To begin with, would you talk a little bit about your background before you came to CDC [Centers for Disease Control and Prevention] and how you came to work here?

COCHI: Yes. I trained as a pediatrician and spent two years after my pediatric training working in the Indian Health Service, as a pediatrician in the Southwest, in New Mexico, on the Navajo reservation, and that's when I learned about CDC. I had some friends and colleagues who had, after their training, gone 00:01:00to CDC, so I had some inside look into the world of public health. And in my pediatrician role on the Navajo reservation, I really started to think more and more in terms of the importance of public health to the work that I was doing. So I got the opportunity in 1982 to come to CDC to do the two-year Epidemic Intelligence Service, or EIS, training program, and that was my way into a career at CDC working in preventive medicine and public health.

TORGHELE: What was your assignment?

COCHI: Well, I was assigned to the Division of Bacterial Diseases, and we worked on a lot of vaccine-preventable diseases like pertussis and diphtheria and pneumococcal pneumonia. And so that gave me a chance to whet my whistle on 00:02:00vaccine-related matters. I was already very interested in vaccines and immunizations, because that's one of the bread-and-butter areas of work and interest that pediatricians are involved in. So on that basis I spent three years working in the division of bacterial diseases, and then I had the opportunity to do a preventive medicine residency program at CDC, assigned to the immunization program at CDC, and that's where I've been working ever since then.

TORGHELE: Did you know, when you started at CDC, that it would become your career?

COCHI: That's a very good question, Karen. No. As a matter of fact, my plan was to do two years of epidemiology training and service at CDC, and then I was 00:03:00interested in going back to do a fellowship in infectious diseases, pediatric infectious diseases. Well, that never happened, because I grew to love the work at CDC, and I came to terms with the fact that a career at CDC and in public health would still allow me to be a doctor, as it were, even if I weren't a doctor seeing patients. So I was able to learn to love public health, and not feel like my role as a doctor was going to be confined to clinical medicine and seeing patients.

TORGHELE: So you got to see the role, as an epidemic intelligence service officer, of prevention, and you learned how to do surveillance in your EIS course. And how did you use that and some of the other things you used in your EIS course during your two years? Was it two or three years as an EIS officer?

COCHI: Two years as an EIS officer, and then I stayed on for an additional year. In fact, the training and experience that I received in EIS and shortly thereafter on disease surveillance has been just fundamental to the work that has carried me forward, first working in the domestic immunization program at CDC and then, since 1993, in the global immunization program. Disease surveillance for vaccine-preventable diseases is just a bedrock fundamental activity that is the basis for the work that we do in measuring the impact of vaccines. And vaccine-preventable diseases are actually very ideal diseases to 00:05:00do surveillance, because it's easy to diagnose these diseases and follow the temporal trends of the disease and see whether your vaccine intervention is working or not. And if there are problems in certain areas, trying to diagnose what the problem is, is it failure to vaccinate, or are we dealing with vaccine failure? So you can adjust your program accordingly. I guess the bottom line is that disease surveillance for vaccine-preventable diseases is really the hallmark of, and one of the fundamental cornerstones, of global immunization.

TORGHELE: That's a very good summary of how surveillance helps in vaccine-preventable diseases. Talking about the history of polio, a lot of 00:06:00people want to know when polio started affecting human populations.

COCHI: Historically, we don't know too much about the ancient history of polio, but we do know that it was a disease, a virus, that existed in ancient times. We have, for example, Egyptian hieroglyphics that show the long-term effects of polio in the sketches of people. So we know that it existed back in ancient times. Fast-forwarding to the late nineteenth century, that was really the first time in history that there were recognizable polio epidemics, and those epidemics continued into the twentieth century. And it's not entirely clear why 00:07:00polio became an epidemic disease in the late nineteenth century, although the general view is that sanitation began to improve substantially toward the end of the nineteenth century, making it possible for infants and young children to live more and more years without having their first exposure to the poliovirus. So instead of, historically, every young infant either developing paralytic polio or becoming immune to the polio after the exposure to the poliovirus, immune for life, more and more children were living several years into their lives before they had their first exposure. So the accumulation of children 00:08:00susceptible to polio until they were two, three, four years old led to explosive outbreaks of polio. So that's what we started seeing in the late 19th century and on into the twentieth century.

In fact, in 1916 there was a gigantic polio outbreak in New York City, several thousand cases of polio. And that was, at that point in time, the largest polio epidemic ever in the United States. And that really captured a lot of attention and concern, which, later on, not too much later, led to very substantial efforts to develop polio vaccines through the support of the Foundation for Infantile Paralysis, which President Franklin D. Roosevelt began in the 1930s, 00:09:00having been affected himself.

TORGHELE: So when you say that sanitation was a factor, how is polio transmitted?

COCHI: Yes, polio is a disease that is primarily transmitted person-to-person. Either through coughing and sneezing in close contact of that nature, or through contaminated feces. So a parent changing the diapers of a young infant who is infected with poliovirus can then transmit the virus to other children in the household. And so there can be a spread through the fecal-oral content, or through coughing and sneezing, from person to person within households, as well as in communities and schools and so on. It is also possible to contract polio 00:10:00through contaminated water, sewage, through other means, even food, but the primary means is person-to-person spread.

TORGHELE: That explains a lot about how sanitation made a difference. So they had natural immunities if they were exposed through the fecal-oral route before good sanitation was brought in?

COCHI: That's right. And one of the interesting things about poliovirus, first of all, there are three different types of virus. So we're trying to eradicate, in essence, three diseases, three in one, and the vaccine is called a trivalent vaccine. It's three separate vaccines that are combined together, and each person needs to become immune to all three types in order to be fully protected against polio.

TORGHELE: In talking before, you were talking about how the Centers for Disease 00:11:00Control changed when polio became a public health issue and CDC became actively involved. Can you talk a little bit about that? Even though you were too young to be here then, but you were mentioning some of the history of CDC and how it changed CDC and how CDC impacted polio.

COCHI: Yes. If we go back several decades in time, as I had mentioned a few minutes ago, the Foundation for Infantile Paralysis supported the development of polio vaccines, and there were two lines of scientific research. There was work being done on the killed, or inactivated, polio vaccine, and that was Dr. Jonas Salk working out of Pittsburgh. And then Dr. Albert Sabin was working on 00:12:00weakened live attenuated polio virus strains that would go into an oral vaccine rather than an injectable vaccine. So these were the two pioneers in scientific research to develop polio vaccines. Well, there was a footrace during the 1940s and the early '50s to develop and test these two different vaccines. And the Salk vaccine, which was the killed injectable vaccine, won the footrace and was licensed in the United States in 1955. And as part of that licensure, I think, there were six vaccine manufacturers who were licensed by the predecessor to the Food and Drug Administration to sell and deliver the vaccine to the population 00:13:00of the United States. And as it turned out, one of those six manufacturers had a problem in the production of their vaccine.

The basic idea in producing this vaccine is you take live poliovirus and you kill it or inactivate it using formalin. So you put it in the formalin until the viruses all die, and then that killed virus vaccine is injected into each person. But one of the manufacturers had a process that didn't completely inactivate the live poliovirus. And so within about six weeks after the licensure of the vaccine, cases began springing up, in various parts of the country, of paralytic polio following the administration of the killed polio 00:14:00vaccine. And the killed contaminated vaccine, with not properly killed virus, was found to be the origin.

And the epidemiological work that was done to identify this single manufacturer out of the group of six manufacturers was done by CDC, and that's when CDC developed a polio surveillance unit to track polio cases, both the naturally occurring polio cases as well as investigations of the rare instances of vaccine-associated polio. So this was a tremendous epidemiological feat that was conducted over a very short period of time by CDC investigators way back in 1955. And one of the enduring results of this was that at that point, at that 00:15:00moment in time, the public health service in Washington was responsible for tracking all of the infectious disease surveillance in the country. Within a few years that responsibility was delegated to the CDC. And so CDC, by the late 1950s, became the central location for infectious disease surveillance in the United States, because of the success and the reputation that CDC developed in dealing with this crisis.

TORGHELE: So there's Centers for Disease Control, and there was also the National Institutes of Health [NIH]. Why was CDC chosen over NIH to do that work with identifying what was causing the paralytic polio?

COCHI: Well, because CDC is the lead organization, the lead public health agency in the U.S. government, the lead prevention agency, the lead agency that was closely connected to the state and local health departments. CDC was the disease detective. CDC has the expertise for detecting, investigating, and responding to outbreaks of infectious diseases. NIH has a very important role, but their role is limited to basic scientific research and vaccine development. So the roles are very clearly demarcated, and the Food and Drug Administration [FDA] is responsible for testing and licensing vaccines, and regulating vaccine 00:17:00manufacturers to make sure that those vaccines continue to be safe and effective. So, very well-demarcated roles, but CDC's role clearly was the lead role in dealing with this crisis and in tracking infectious diseases throughout the country. And that role has continued right up to the present day, and including on the global scene. CDC plays a fundamental role in supporting the World Health Organization [WHO] and its member states in strengthening disease surveillance, and especially surveillance for vaccine-preventable diseases like polio.

TORGHELE: During the '50s, was there an impact that the media had on the way things were handled related to polio and the vaccinations, how the vaccine was 00:18:00received and all of that, at that time?

COCHI: Very good question, Karen. It was almost a different era. It was a different era. Jonas Salk, when his vaccine was licensed, was a tremendous hero. He was almost God-like in the minds of the American public. He had developed a miracle tool that would protect and save their children from the scourge of polio. And there was so much fear. There was so much fear of polio, because every year there were epidemics, in the summertime, of ten thousand to fifteen thousand paralytic polio cases in the United States. So fear was rampant, and I think the vaccine demonstrated the power of vaccines, the value of vaccines.

And that era, in the mid- to late '50s, was followed during the 1960s by the development and introduction of vaccines against measles and rubella. We already had diphtheria-tetanus-pertussis vaccine, in the early '70s mumps vaccine, and then fast-forwarding to the last twenty years, we have had quite a few additional vaccines against meningitis, against human papillomavirus, which causes cervical cancer, and varicella, or chickenpox, vaccine. So we now have an armamentarium of vaccines to provide an umbrella of protection for children and adults that numbers more than twenty vaccines. And it's one of the biggest 00:20:00achievements in public health in history, the impact that vaccines have had in terms of preventing disease, disability, and death, to the point where they're often taken for granted by a public that has had so much benefit from vaccination that they don't see these diseases any longer. So we have to always keep that in mind, be mindful of the importance of sustaining our immunization program to make sure that every child has the benefit of these vaccines and is protected from these completely preventable diseases.

TORGHELE: That's a good point, because when you don't see those diseases, it's hard to realize that you still need to get vaccinated against them.

COCHI: And that's one of the motivations for those of us who work in global health and global immunization. Those diseases still exist, and we see them, and they still are inflicting devastating consequences. For example, measles, until the turn of the century, was still killing nearly a million children, and this for a vaccine that through UNICEF [United Nations Children's Emergency Fund] cost about twenty-five cents a dose and is highly effective. So there are still inequities in the world that are in need of addressing. So the work of CDC and global immunization is designed in a twofold fashion: first, to protect the U.S. population against the importation of these diseases that we no longer see, but 00:22:00represent threats to Americans, and the threat of importation and outbreaks that result from that, but also the humanitarian goal of reducing the morbidity and mortality that these diseases cause worldwide. And that, in turn, is going to protect the American people better because there aren't reservoirs around the world that are reservoirs for importation into the United States.

So that's how we got into the polio eradication business, because it both protects the U.S. as well as for humanitarian reasons, eradicating a virus that has been a scourge of mankind since the beginning of time. So it's great to be 00:23:00sitting here and talking with you here. It's July 12, 2016, and there are less than twenty polio cases detected in the world this year, and in only two countries, Pakistan and Afghanistan, in only parts of those two countries. So we are on the verge of completing the eradication of polio, but it's been a very long journey.

TORGHELE: How long has polio been absent from the United States?

COCHI: We documented the last outbreak of what we call indigenous polio, that arising from the U.S. population, rather than solely being imported, in 1979, 00:24:00and it was among an Amish population. But even that virus had been originally imported from religious groups in the Netherlands. So we probably stopped polio transmission in the United States sometime during the 1970s, but we've been totally free of polio in the United States since 1979. Only the exception of a very small number of importations of poliovirus from the developing world that have not resulted in polio outbreaks. So we've had the benefits for, what is it, three and a half decades now that the vaccine has provided the umbrella of protection. And now we're just trying to ensure that that umbrella of protection that the polio vaccines provide is enjoyed by every child in the world. And 00:25:00we're very close to reaching that.

TORGHELE: Exciting news. Now, as far as the budget allocated by Congress, can you talk a little bit about that and how that works?

COCHI: Yes. This has a lot to do with, this really helps me to describe the evolving role that CDC has played in global polio eradication. We were involved very heavily in polio eradication in the Americas, which was the first region of the world to create a target of eradicating polio from the Western Hemisphere by 1990. And particularly on the laboratory side we were quite involved in that achievement, which took place in 1991. We had very limited resources at CDC to 00:26:00do so, because we did not have a separate budget to deal with polio or any other global health issue in the CDC budget at that time. But fortunately there was recognition by the U.S. Congress of the need for investing in global health, and so in 1991 CDC got its first earmarked budget for global health, and it was specifically for polio eradication. It was $3.1 million in 1991. Our current budget for polio is $159 million. So you can see how much things have changed from 1991 to the present time, but it was very much welcomed in 1991.

We had about a three-million-dollar budget and about six people, epidemiologists and program officers together with the polio laboratory. So we started very small, but the role of CDC has increased tremendously since that time. In fact, CDC is one of the, what are called the four spearheading partners that lead the polio eradication initiative. They consist of WHO, UNICEF, Rotary International, which is by far the largest private sector partner involved in the polio eradication initiative, and CDC. And in recent years they've been joined by the Bill & Melinda Gates Foundation. Bill Gates has, in the last several years, provided lots of advocacy and resources to help us get across the finish line. 00:28:00So the CDC role has evolved to the point where we are involved deeply in supporting WHO, in polio-infected countries, in stopping polio. We have a global special reference laboratory for poliovirus that is the number-one poliovirus reference laboratory in the world, and the polio surveillance and laboratory network globally relies heavily on the work that they do. So we've come a long way, and our role has increased over time, and we have also increased our role in other global immunization and vaccine areas accordingly. So CDC has stepped 00:29:00into a tremendous need for technical, program, and laboratory support, for global health issues in general, and particularly global vaccines and immunization issues.

TORGHELE: You mentioned the organizations that are working together to end polio. Can you talk a little bit more about how you collaborate and how you agreed which role each organization is going to have?

COCHI: Yes, that's a very interesting part of the initiative, Karen, and a very important part. Focusing on the four spearheading partners, I think there is a good symphony of effort, because the roles that each of these partners plays are largely complementary. WHO is the lead organization in the polio eradication 00:30:00initiative, because they are the world's health department, and they also answer to all of the 194 member states of the World Health Organization. And they have, through their regional committees and their global world health assembly, which meets every year in Geneva, they have a mechanism for responding to the needs of the member countries. They're also the lead organization for the disease surveillance. And so CDC plays a fundamental role in supporting WHO's work in polio surveillance and the surveillance of other diseases, other vaccine-preventable diseases like measles, for example. (By the way, WHO has country offices in virtually every one of its member states).

The same is true for UNICEF, which is a child advocacy-focused organization, but 00:31:00which historically has played a very important, a very critical role in the implementation of immunization programs at the country level, supporting the country ministries of health. They have a big forte in terms of procuring and distributing vaccines at inexpensive prices through their procurement mechanisms and in negotiating with manufacturers. They are very involved in the communications side, the messaging, why it's important for children to receive vaccines, and in social mobilization, the preparation for mass campaigns and the like.

And finally, Rotary is sort of the heart and soul of the polio eradication 00:32:00initiative. It's a service organization of 1.2 million members throughout the world. They have played a tremendous role in advocacy and fundraising, and have provided nearly two billion dollars over time from their membership to support polio eradication. So it is their single largest global priority and activity. So with those four organizations and their complementary roles, I think we've been very successful in moving ahead and making progress, and in taking advantage of each organization's institutional strengths.

TORGHELE: Within each of those organizations, there have been a number of people 00:33:00who have lost their lives in the polio eradication effort. Can you talk a little bit about that?

COCHI: Yes. And this is primarily frontline workers who are out there doing polio mass campaigns who can be in the wrong place at the wrong time, whether it's in Pakistan or Afghanistan stepping on a landmine, or driving a vehicle over a mine, or even being kidnapped and killed by the Taliban. This has happened, unfortunately, and it's a real tragedy, and it's really an irrational 00:34:00situation that occurs in our world. These are largely volunteers or frontline workers, many of them women, who are serving their communities, working for virtually nothing, but committed to protecting the children of their communities against polio. Then we have other instances where frontline workers have died because of auto accidents, drownings, and eaten by a crocodile trying to cross a river in South Sudan. I mean, these things happen.

To try to celebrate the tremendous role that they've played, CDC and its core 00:35:00partners, especially Rotary, established a Polio Heroes Fund at the CDC Foundation, which tries to recognize those frontline workers who have either been killed or severely injured in the course of their work. And where these recognitions have taken place in each country, the ministry of health and the partners in country have brought the family together to honor the worker and provide at least a small remuneration to try to help the family to deal with the aftereffects of, you know, a caretaker who's lost their life or has been 00:36:00severely injured. So this is one of the main ways that we have tried to recognize the tremendous role that the upwards of twenty million frontline polio workers and vaccinators have played in the course of this global initiative.

TORGHELE: An incredible number of people that are involved.

COCHI: It's a social movement. This has become a social movement, and I believe it's the largest global public health movement initiative ever. And I think it's an illustration in the twenty-first century: the way we have success in public health, and perhaps in any other sphere, is by coming together in partnerships to get the job done.

TORGHELE: We have talked a little bit about how surveillance methods have been 00:37:00used. Are there specific surveillance methods that you need to use to adapt to a difficult setting or set of circumstances when you've done your polio surveillance?

COCHI: The hallmark of polio surveillance is that we search for the children, it's almost always children, but occasionally, rarely, adults can develop the syndrome, children who develop an acute floppy paralysis. We call it acute flaccid paralysis or AFP, and that is sort of a signal that that person, that child, may have just contracted polio. But we don't know for sure, because there are other conditions that can cause a similar floppy or flaccid paralysis. So we 00:38:00have to confirm that by taking a stool specimen, actually two stool specimens, and testing in the laboratory to see if the poliovirus is present. And that is a way that we confirm that that acute flaccid paralysis is due to polio rather than some other condition. So this form of surveillance has been used widespread, all over the world, as the way that we detect and track polio in the world. And more recently we have supplemented this surveillance with sewage sampling in high-risk countries, either in countries that either have, like Pakistan or Afghanistan, still circulating poliovirus, or in the recent past where polio is endemic in countries. So we take a sewage sample every month from 00:39:00several sites in urban areas, in particular looking for the poliovirus as a sign of silent spread of the poliovirus, even in the absence of the acute flaccid paralysis cases. So these are the two main ways in which we detect and track polio in the world.

TORGHELE: What are some of the more difficult countries that you all have had to work with?

COCHI: Difficult countries, yes. This gives me a chance to say that the polio eradication initiative started in 1988 through a World Health Assembly resolution. This is the annual meeting of all of the ministers of health of every one of the 194-member countries in Geneva at WHO headquarters. And there 00:40:00was a resolution resolving to eradicate polio by the year 2000, but it got a slow start. There were very, very few resources, and although there was an active regional eradication effort going on in the Americas led by the Pan American Health Organization, almost nowhere else in the world did anything else really get started until about the mid-1990s, with the exception of the western Pacific region of WHO, one of the six WHO regions. So there were very few resources, but the program started to take hold and accelerate toward the late 1990s. And we started with 125 countries that were endemic for polio in 1988, and about three hundred fifty thousand cases of polio. By 2001 we were down to 00:41:00ten endemic countries, and we were down to a couple of thousand polio cases in the world. So there was a tremendous acceleration but then we got down to a very small number, just a handful of countries in the first decade of this century that had weak immunization and health systems, low vaccination coverage, poor management, not very good quality polio mass campaigns. And so we were kind of stuck, and things stagnated for the first decade of this century.

And to answer your question, there were four countries that were particular challenges. They were Pakistan, Afghanistan, India and Nigeria. And somebody coined, you take those four letters: P-A-I-N, pain. Those are the PAIN 00:42:00countries, and we had endemic polio in those countries throughout the first decade of this century. But a major way forward, a major milestone, was that India in 2011 had its last polio case. The second-largest country in the world, the country that historically had by far the most polio cases, a country where many experts, at least some experts, felt that it was impossible to eradicate polio. So once we did it in India, I think we were assured that this is possible to do everywhere. Also we had, obviously, problems with the situations in Afghanistan and Pakistan with insecurity and civil conflict. And in Nigeria we had major difficulties in 2003 with suspicion by a few political and religious 00:43:00leaders, Muslim religious leaders, claiming that the vaccine was tainted with HIV virus or was tainted with hormones, that we're trying to sterilize their children, and so there was a suspension, in several states of northern Nigeria for one year beginning in 2003, of the use of the oral polio vaccine, which led to tremendous resurgence of polio in Nigeria and spread of the Nigerian polio virus to about twenty-five countries throughout sub-Saharan Africa and in the Middle East and even as far as Indonesia.

So that was a big setback, but with all of these setbacks and with all of the pain of the first decade of this century, we turned it around and are now 00:44:00working with an endgame strategic plan through the end of this decade to finish off the last vestiges of poliovirus by, hopefully, the next year, and then certification process to take place within three years after that to globally certify the world as polio-free, in the same way smallpox was certified as having been eradicated back in 1980.

TORGHELE: I wonder if you could describe being in those areas that still had polio, and what's that like. And what you can see happening as far as eliminating polio from those last remaining countries?

COCHI: Being in these areas, you can see what a challenge it is. I've gone to northern Nigeria, and northern Nigeria suffered tremendously under a series of military dictatorships until the year 1999, when a democratic government was restored. There was pilfering of government resources in every way, shape, and form. There was destruction of the primary care clinics throughout the north, leading to pretty much a nonfunctioning public health system. Added to that the challenges of poverty and poor sanitation and low educational attainment, tremendous challenges to overcome. We have finally, working with the government 00:46:00and partners together, overcome those challenges. And the last case of polio in Nigeria occurred nearly two years ago now, in July of 2014 [NOTE: since this interview, three polio cases have occurred in Nigeria in July-August 2016].

Another challenge that was brought home to me in Pakistan, this was in the early 2000s. I got an opportunity to go to the border between Pakistan and Afghanistan, right at a major border crossing point. It's a town called Torkham, and it's right on the Khyber Pass, which is a pass that's steeped in history. The situation that you probably are aware of is such that there's a lot of movement of people, mostly Afghans, across the border between Pakistan and 00:47:00Afghanistan, seasonal movement, and I got a chance to witness just hordes of people crossing the border from Afghanistan into Pakistan. And even as early as then, the Pakistan government had set up a vaccination station on the Pakistan side of the border. So every family that had children that looked like they were under five years of age was diverted to the vaccination station so that they could receive a supplementary dose of polio vaccine. That brought home to me how difficult it is to stop polio, because there's so much silent spread of polio. And the virus moves with the people, and when there is so much mass movement 00:48:00across borders, the virus does not respect borders, and it just shows what a challenge we have had to overcome. But we've been able to do that in virtually every country in the world, save Afghanistan and Pakistan. But we're close.

TORGHELE: Sounds like one of the things you all decided to do was to go where the virus was, not have the people with the virus come to you, but to go to them. So you put up your vaccination stations where they were, for instance, where they were migrating.

COCHI: That's exactly right. And not only vaccination stations at key points of movement of migration at border crossings, but we had the advantage that this is an oral vaccine. So we could take the vaccine house-to-house, and volunteers could be easily trained to drip two drops of this oral vaccine into the mouths 00:49:00of every child less than five years of age, so we could reach inaccessible populations much more easily than if we had to use an injectable vaccine like measles vaccine, because you have to have well-trained and skilled health workers, who were limited in numbers. So this is another aspect of how polio eradication became a social movement, because every polio mass campaign involves mobilization of communities. The community leaders get involved, the teachers get involved, and then the house-to-house distribution and delivery of the vaccine to children in need of it.

TORGHELE: An amazing feat. So, Dr. Cochi, we're sort of winding down. I wondered 00:50:00if there are people who stand out in your mind as having played a significant, or maybe sort of a not-so-significant, role that was important in the work that you all are doing to eradicate polio.

COCHI: Yes, Karen. There are several people that really stick out in my mind in answering that question. First of all, if we look outside of the CDC family, a person by the name of Ciro de Quadros, a Brazilian who worked in smallpox eradication and then in 1978 became the director of the Pan American Health Organization's immunization program, and really was the force behind the creation of a regional polio eradication initiative in the Americas, which was 00:51:00achieved in 1991. He was a tremendous force in every way in polio eradication, and after the achievement in the Americas he continued to play a strong role globally.

Now if we look at people within the CDC community, I think of Bill Foege, former CDC director in the late '70s until 1983, and then went over to the Carter Center to start the Task Force for Child Survival, which was a partnership among a small number of global organizations, including WHO, UNICEF, United Nations Development Program, and the World Bank to improve childhood immunization through an initiative in the late 1980s. But on the side, he was a big advocate 00:52:00for polio eradication and was a major force behind the successful resolution by the World Health Assembly that occurred in 1988. And he has continued to play a role, more recently, as a senior advisor to Bill Gates himself in the creation of the Bill & Melinda Gates Foundation and its central priority on global immunizations. And, of course, Bill has been and continues to be an advocate for polio eradication, which I think infected Bill Gates himself. I think of Walt Dowdle, former deputy director of CDC, who retired in the early 1990s and went over to the Task Force for Global Health at Emory, and he has been a tremendous behind-the-scenes player, particularly in developing and strengthening the 00:53:00global polio laboratory network.

And then in my closer circle, the polio eradication activity was created at CDC in 1993. We had a very small budget, three million dollars, which rapidly grew as I indicated earlier. But we started with six people, and I was the director, and my deputy was Bob Keegan, a senior public health advisor. And Bob, until several years ago, when he unfortunately passed away due to cancer, was a force of nature in moving forward and advocating for polio eradication, and he helped me tremendously in managing and leading our growing activities at CDC, both in numbers and in budget. In those early years, in the 1990s until 1996, CDC 00:54:00actually hosted the annual global polio eradication meetings here in Atlanta, because WHO had almost no budget, had only a handful of people worldwide that were even working on polio eradication, and did not have the capacity to host and organize a global annual meeting. Finally, largely through CDC's support, as well as other partners like Rotary, by 1996 WHO was able to take over that role and responsibility to host annual meetings beginning in 1996. But I think of Bob Keegan as my friend and colleague who played such an important behind-the-scenes role in those early days.

TORGHELE: Wasn't there a bike ride that Bob Keegan did to raise awareness of polio?

COCHI: Yes. Bob retired from CDC in 2007, I think it is, and he was a person with many hobbies, many interests, beyond work. And bicycling was one of his tremendous loves. So he decided to combine his interest in bicycling with his interest in advocating for polio eradication by organizing a coast-to-coast bike ride from the Pacific all the way to the Atlantic Ocean, and enlisted many people along with way, but raised funds for polio and got a lot of matching 00:56:00funds and had a close collaboration with Rotary International. So he raised more than fifty thousand dollars with this bike trip he organized. And this is remembered now for many years since, and his surviving spouse, Gloria, is planning to organize the tenth anniversary coast-to-coast bicycling trip next year.

TORGHELE: Oh, wonderful.

COCHI: Yeah.

TORGHELE: So to finish up, why don't we talk about the [polio] endgame plan, if you could, and just tell us more about what you think is going to happen over the next couple of years, and how it can be documented that there is no more polio.

COCHI: Yes. We're very close to the finish line, tantalizingly close. As I 00:57:00indicated earlier, we've less than twenty cases of polio, and we're in the high season for polio this year. We have just a few last vestiges of the virus in Pakistan and Afghanistan, mostly along the border. Because we're in the high season, we're not sure whether we're going to see the last case of polio this year. You know, this virus is very tricky, and it finds ways to survive that really challenge us greatly. But we are still hopeful that we'll see the last case this year. But we may have to go into another low season, which is in the wintertime, when it's easier to knock out the last chains of transmission of the 00:58:00virus from person-to-person.

After that, we're in the endgame phase. We're already beginning to get into the endgame phase, where we need to go a three-year period after the last case before global certification takes place. So that's likely to be in 2019. And then the ultimate end of poliovirus is the withdrawal of the use of the oral polio vaccine, which in very rare instances can cause vaccine-associated paralytic polio. So we have to stop using the oral poliovirus vaccine and rely only on the killed or the inactivated injectable vaccine after certification of eradication of polio, so that there's no polio anywhere in the world, due either 00:59:00to the naturally occurring virus or the vaccine, the rare instances caused by the vaccine. So we are beginning now to plan the transition from polio eradication.

There's so many polio assets. The human assets, the surveillance system, the other systems that have been put in place that have been very helpful to developing countries that have worked hard to eradicate polio and have enjoyed the side benefits of these polio assets for other health programs, particularly other activities in the immunization program. And so we're entering a transition period where each country, each organization, and at the global level, we need to have a careful thinking about how we preserve those assets that are so 01:00:00valuable that they need to continue and need to be sustained, so that there's a soft landing after the certification of polio eradication. So we have a few more years of endgame work to go, but by the end of this decade we are all looking forward to having a celebration and a very large party to celebrate the death of poliovirus and the enduring fact that for all future generations to come, no child, no parent will have to live with the fear of polio.

TORGHELE: Wonderful day to anticipate.

COCHI: Looking forward to it.

TORGHELE: I want to thank you so much for all of the additional information you 01:01:00gave us and the description and stories. It's a good addition to what we're doing with the Global Health Chronicles.

COCHI: Delighted to be able to participate, Karen. Thanks for inviting me.

TORGHELE: Thanks very much.