Polio eradication strategies on a periodic age basis is discussed with its pitfalls and achievements, Recommendations and Future Challenges.

1. Lessons Learnt From Polio
Eradication in India & Future
Prospects
Dr. Jishnu Sathees Lalu
Dep of Community Medicine
AIMS,Kochi

2. Contents
• Introduction
• History
• Epidemiology of polio virus
• Polio Eradication in India
• Lessons learnt from polio eradication in India
• Future prospects
• conclusion

3. Introduction
• Polio was hyper endemic in India with 2-4
lakhs cases annually.
• One in 200 infections leads to irreversible
paralysis.
• The world is on the verge of achieving WPV
eradication.

4. History
• The oldest and clearly identifiable reference of
polio is an Egyptian stele which is more than
3000 years old
• Till 1952 epidemic outbreaks were being reported
annually.

5. Epidemiology

6. Agent
• Enterovirus subgroup- Picarnoviridae family
• Inhabitants of the GI tract
• 3 serotypes polio virus
• IP-7 to 14 days
• Transmission is possible as long as the virus is
shed. Highly infectious in the absence of
immunization.

7. Reservoir
• Man is the only known reservoir of infection.
• Fecal oral route transmission, oral – oral
transmission is also possible.

8. Clinical features
• Upto 72% of all infections in children are
asymptomatic- sheds virus in stools
• 24% Low grade fever,sore throat with out CNS
invasion- abortive polyomyelitis
• Fewer than 1 % of all polio cases results in
flaccid paralysis.
• Many patients with paralytic poliomyelitis
recover completely. Weakness or paralysis
present for >12 weeks will stay permanent.

9. Types of paralytic polio
• Spinal polio- most common, asymptomatic
paralysis often involving the legs.
• Bulbar polio- leads to weakness of muscles
innervated by cranial nerves.
• Spinobulbar polio- a combination of
both(19%)

10. Lab testing
• Virus isolation: from stools and rarely from
CSF or Blood.
• RT-PCR or Genomic sequencing - for
distinguishing from “wild type” or “vaccine
type”

11. Vaccines
• No treatment
• Can be prevented through effective
vaccination.
• First vaccine Salk vaccine in 1955
• Trivalent Sabin vaccine in 1961

12. IPV OPV
• Consists of formalin
inactivated whole
virions of all 3
serotypes poliovirus
• Contains live attenuated
Polio virus 1,2 and 3.

13. VAPP ,VDPV& cVDPV
• VAPP- Paralytic disease occurring in vaccine
recipients, or contacts of recipients immunized
with OPV
• VDPV-Vaccine virus genitally reversed to
neurovirulent Virus known as VDPV and
transmitting to unvaccinated children causing
polio outbreaks.
• cVDPV- If one genotype of VDPV is detected in
two or more children with polio.

14. WHO South East Asian Region
[SEAR]
1. Bangladesh
2. Bhutan
3. Democratic People's
Republic of Korea
4. India
5. Indonesia
6. Maldives
7. Myanmar
8. Nepal
9. Sri Lanka
10. Thailand
11. Timor-Leste
SEAR
certified on
27 March ‘14

15. Total cases WPV cVDPV
Globally 27 0
in endemic countries 27 0
in non-endemic countries 0 0
Global polio status

16. 24
Total =27
3 Endemic countries
Pakistan
Afghanistan
Nigeria
3

17. Pre eradication Era

18. 1 Hyper endemic India
2 EPI in India
3 GPEI

19. Hyper endemic polio era
• Incidence in India were the highest reported
anywhere (2 – 4 lakhs cases).
• Post independence India targeted diseases like
TB , Malaria, Leprosy and Kala azar but not
poliomyelitis.
• Inspite of the availability of IPV in 1955,OPV
was imported in 1962.

20. EPI era
• EPI was launched to protect from 6 vaccine
preventable disease.
• Achieve a vaccination coverage of >80%
• India began the attempt to control polio by
immunization only in 1978 .
• WHO launched EPI in 1974.

21. Introduction of OPV didn’t cause
any decline in cases.

22. Factors lead to EPI failure
1. Coverage of 80% vaccination was achieved
slowly
2. Low vaccine efficacy
3. Provocation poliomyelitis

23. Recommendations to improve
Vaccine Efficacy
• At least 5 dose polio immunization
• Giving the doses in pulse fashion
• IPV given intra dermaly in fractionated doses
• Later ,> 80 % 3 dose OPV coverage-result in
improved vaccine efficacy and indirect herd
effect.

24. GPEI Phase
• 1988, WHA – target polio for global eradication
by 2000.(125 countries endemic)
1. maintaining high coverage of vaccination with at
least three doses of live oral polio vaccine
(OPV),
2. providing supplemental rounds of vaccination
3. establishing an effective mechanism for the
surveillance of acute flaccid paralysis (AFP)
4. house-to-house OPV “mop-up” campaigns
carried out at the final stage in a limited
geographical region.

25. • Polio burden had not reached control status in
India
• Polio cases were estimated to be > 22 lakhs
from 1980 through 1990.
• To certify as polio free in 2000,India should
report zero case by 1997.

26. Factors lead to the burden
• Serious under reporting of cases continued.
• EPI could only deliver vaccine ,not measure or
monitor the disease burden.
• GOI relayed on EPI to achieve the target even
after data showed the national policy was
faulty.

27. Era of Eradication
1 1995- 2000
2 2000-2005
3 2005 to Rukhsar

28. 1995- 2000

29. • India’s effort to implement polio eradication
started only in 1995 targeting eradication by
2000.
• PPI of children under 5 years at fixed booths on 2
National Immunization days, separated by six
weeks during the winter months.
• WHO,UNICEF,CDC and Rotary International
designed a modus operandi for India
• Launches the NPSP in 1997,a collaboration of
WHO and GOI.

30. Lessons from EPI failure
1. Failure to vaccinate
2. Failure of vaccination
3. Lack of nation wide surveillance

31. Failure to vaccinate
• Nation wide PPI campaigns 1995-1999, WPV2 stopped
circulating by 1999 October.
• In 1999,India was divided into high, medium and low risk
states.
• Sub-national vaccination rounds were conducted in high
and middle risk states.
• In order to improve the coverage of vaccination House to
house immunization was started in 1999 to actively search
and vaccinate missed children.

32. NPSP
• Founded in 1997- the heart of India’s polio
eradication
• Active surveillance of AFP cases in the entire
country.
• IEAG revised quality of AFP surveillance to at
least 2/100,000.
• Unfortunately, even as >10/100,000 were
reported.

33. Did we miss the target?

34. Achievements
• Nation wide PPI campaigns stopped the
transmission of WPV2 by October 1999. last
case was in Aligarh, Uttar pradesh.
• WPV circulation was limited essentially to the
two Northern states of Bihar and UP.
• India declared 2005 as the target year for polio
eradication in the National Health policy.

35. New tactics for 2005

36. NPSP
• Adopted a ‘Virological scheme’ in place of clinical
classification of AFP cases.
• Environmental sewage specimen testing started in
2001.
• Expanded its network with more than 200 SMO.
• Increased sensitivity- the program soon became
able to detect any poliovirus transmission anywhere
in the country.

37. Virologic Classification Scheme
AFP
Wild Poliovirus Confirm
Inadequate Stool
Specimens
No Wild Poliovirus
2 Adequate Stool
Specimens
No Residual
Weakness
Residual Weakness,
Died or Lost to f/u
Expert
Review Discard
(Non-Polio AFP)
Compatible
Discard
(Non-Polio AFP)
Discard
(Non-Polio AFP)

38. Immunization
• House to house vaccination strategies were
strengthened
• Identification of missed children- the little
finger of the left hand was marked with
indelible ink.
• Transit vaccination- teams stationed at bus
stands, railways stations, highways etc.

39. Social mobilization
• Social mobilization network was launched in
UP and Bihar- to generate community support
for polio immunization.
• Convergence-to generate acceptance among
the community
• Under served strategy- targeting poor
Muslim communities.

40. Social mobilizing Network
• Launched in 2001 to generate community support.
• Community mobilizers work with local medical
practitioners, religious leaders, school teachers
and others to influence local people in support of
vaccination.
• Mobilized communities house by house to accept
OPV and other health interventions.

41. • Celebrities like Amitabh Bachan as brand
ambassador of UNICEF motivated leaders and
community for greater progress.
• The mass following of the celebrity and his
endorsement of the polio programme is widely
recognized as being a key generator of
community support for polio vaccination.

42. CONVERGENCE
• In addition to providing information about
OPV, the Social mobilizing network shares
information on
1. EPI
2. exclusive breast feeding
3. the use of ORS and Zinc to tackle diarrhea
etc.
4. Sanitation and hygiene

43. Under served strategy
• A special strategy to reach the under served
Muslim communities.
• To tackle the disproportionately high
percentage of polio cases.
• Developed partnership with key muslim
leaders and institutions- for polio acceptance

44. Why Bihar and UP were high risk
states?
• Even after several PPI and Subnational rounds
WPV transmission couldn’t be interrupted .>85%
of the cases were reported from these two states.
• 60% of WPV cases from the Muslim community.
• 32% cases of Non-Polio AFP had received 3 or
less tOPV doses

45. How did we target them?
• Social mobilization was first launched in UP and later
in Bihar in 2003.
• Underserved strategy
• Ulemas committee- engaged key religious leaders to
get community support for polio eradication.
• Local level microplaning
• Expanded the no. of AFP reporting units

46. Did we miss 2005 target too?
• 66 cases were reported in 2005.
• The virus strayed into other states as far south
as Karnataka, kerala and Tamil nadu.

47. Achievements
1. A sensitive surveillance system to identify any
case of poliovirus transmission across the
country.
2. The under-served strategy improved the vaccine
acceptance in the marginalized sections of the
society.
3. Transit vaccination and house to house
immunization improved the coverage >95%

48. What was lacking ?
• Failure to vaccinate both under EPI schedule and
in Pulse campaigns.(Bihar-27%,Western UP-38%
and Eastern UP- 45%)
• ‘Failure of vaccine’- the extremely poor efficacy
of OPV permitted WPV transmission in western
UP and in Bihar.
• Persistent transmission attributed to failure of
vaccine and very high FOT of WPV due to the
very high density of infant population.

49. 2005 to Rukhsar

50. Vaccine and vaccination changes
• Monovalent vaccine against WPV 1 and WPV
3 were introduced.
• To counter vaccine failure and failure to
vaccinate, the number of PPI campaigns was
increased to 10 each year from 2005 and the
under-served and transit vaccination strategies
were sustained.

52. • In 2006 outbreak-638 cases of WPV1 and
28cases of WPV3
• Population immunity gap was found <2 yrs
children, due to poor UIP coverage with tOPV
and less opportunities to receive mOPV1 in
Pulse campaigns.
• Migrant strategy: reach out to the most
vulnerable migrant population in brick kilns,
construction sites and nomadic sites

53. New born tracking
• introduced in 2006- to identify, track and
immunize every new born child in the highest
risk area of UP and Bihar.
• Each child in this vulnerable area will receive
at least 8 rounds of OPV before the age of 1
year through UIP and PPI campaigns.

54. Targeting WPV1 WPV3
• India in 2006 prioritized elimination of WPV1
– >90 % of polio cases in the country and the
agent of re infection of a few polio free
countries and states were WPV1.
• SIA campaigns used mOPV1 and mOPV3.
• IEAG planned sequential elimination of
WPV1 first and WPV3 later.

55. Kosi river area intensification.
• Difficult to access area
• Satellite offices and over night stay points
were set up to reach areas were children were
being missed.

56. Strategy against 107 blocks
• Conducted additonal mOPV3 SIA rounds while
continuing to use m OPV1 for most SIA.
• Multi pronged strategy to address polio associated
risk factors with rapid improvement in sanitation
and hygiene,availablity of clean water, exclusive
breast feeding and the prevention and control of
diarrhea.

57. • By 2009 WPV1 had virtually disappeared but
due to less use of mOPV3 and poor UIP
coverage of tOPV, WPV3 outbreaks continued
to report.
• bOPV was recommended instead of mOPV3 to
address both WPV1 and WPV3.

58. Results
• WPV1 recorded lowest numbers in subsequent
years and finally its transmission ceased in
January 2011.

59. Rukhsaar khatoon ,Jan 13 2011

60. Certification of polio eradication
• The national certification committee
• Regional Certification committee
• Global certification committee

61. Lessons learnt

62. 1. Political will and technical leadership
2. Vaccination with a high efficacy vaccine
3. Disease surveillance and immunization progress
monitoring
4. Mobilizing social and community support for
vaccination.

63. Political will and technical
leadership
• India could have achieved eradication decades
ago even before the launch of EPI in 1974.
• Application of the scientific knowledge about
the vaccine and vaccination was neglected by
the government.
• Lack of a public health department with
technical leadership only caused financial
burden.

64. Vaccination with a high efficacy
vaccine
• tOPV had less type 1 and 3 efficacy.
• IPV was proven to highly efficacious and
many countries eradicated polio using nation
wide vaccination with IPV.
• SIA rounds with monovalent OPV against type
1 and 3 drastically reduced the transmission of
WPV1 and WPV3.
• Later SIA included bOPV and curtailed all
WPV 1 and 3 cases.

65. Tactics for Immunization coverage
• House to house vaccination
• Identification of missed children
• Transit site vaccination
• Congregation site vaccination
• New born tracking
• Immunization along the international borders
• Responding to polio as a public health emergency

66. Disease Surveillance for
immunization progress monitoring
• Polio case identification- using virological scheme
• Reporting network expansion- a large network of health
facilities over 33,700sites, including public and private health
facilities.
• Increase in sensitivity of AFP surveillance- by broadening the
definition of AFP cases to make surveillance more sensitive for AFP
cases.
• Sewage sample testing
• Change in laboratory test surveillance- a new methodology of
testing the stools was introduced which takes only 2 weeks of time
compared to 5 weeks earlier.

67. Social mobilization as a key to
eradication
• Social mobilization network
• Migrant strategy
• Under served strategy
• Brand ambassadors and celebrities

68. Delay in achievement
• Lack of technical leadership at central and
state level
• Use of less efficient OPV
• Absence of disease surveillance and laboratory
support services

69. • Any eradication program should be started
with sufficient funds and financial backup
from donors.
• eradication should always be targeted to a
shorter and stipulated time frame, as a long
duration leads to fatigue and decreases the
performance of the people involved

70. Future prospects

71. • Immunization across the international borders and
OPV vaccine certification to travel to endemic
countries.
• True polio eradication = zero transmission of WPV +
Vaccine polioviruses.
• Ethically unacceptable to use OPV after eradication-
vaccine virus-genetic reversal to neurovirulence
• cVDPV – interrupted using IPV.
• Elimination of VDPV using IPV- phase 2 polio
eradication

72. Risk factors of emergence of VDPV-
1. Gaps in population immunity
2. continued use of OPV.
• Introduce IPV in UIP- withdraw OPV after
achieving high coverage for IPV.
• AFP surveillance and virological investigation of
every child with AFP -continued for three
consecutive years following withdrawal of OPV.

73. POLIO ERADICATION END
GAME STRATEGY
• WHO announced the steps to complete and
conclude polio eradication in 2012.
1. Universal introduction of IPV
2. tOPV to bOPV switch

75. Cost and feasibility
• OPV: Rs:4 per dose
• IPV: Rs:80 – 250 per dose
• To reduce overall cost of Imported IPV
1. 2+1 schedule can be used
2. Intradermal injections in fractionated doses

76. Future concerns
• Re emergence of Polio in the post eradication
phase is anticipated.
• Cessation of OPV
• IPV manufacturing using WPV post eradication
pose some risk of inadvertent leak.
• Importation of WPV /VDPV

77. CONCLUSION

79. References
• Eradicating poliomyelitis:India’s journey from
hyperendemic to polio free status-T jacob john
• Polio programme: let us declare victory and move
on- Neetu Vasisht
• Global polio eradication initiative: lessons
learned and legacy- Stephan L Cochi
• The journey to a polio free India:UNICEF
• Polio eradication and end game strategic
plan:GPEI
• Polio eradication in India:Getting to the verge
and beyond:Centre for strategic and International
studies