Two years without polioT. JACOB JOHN The large sums of moneyspent in the eradication of the disease is an investment in theeconomic development of the countryIn the 1980s, only three decades ago, 200,000 to 400,000 children, allunder 5 years, were afflicted with polio paralysis annually in India. Thatwas a daily average of 500 to 1000 cases. By the age of six, eight among1,000 children already had polio paralysis; two would have died. In otherwords, one per cent of infants born were destined to develop polio.Global movementIn 1988, India joined the global movement for polio eradication — at a timewhen we had not even succeeded in bringing polio under control. Control
status required at least 95 per cent reduction. In 1978, India launched theExpanded Programme on Immunisation (EPI) with BCG and DPT vaccines.The oral polio vaccine (OPV) was introduced the next year. Naturalpolioviruses are called ‘wild’ to distinguish them from vaccine poliovirusesthat constitute OPV. Vaccine viruses are ‘attenuated’ from wild viruses —which means they have lost most of their ‘virulence,’ the ability to causeparalysis and the ability to spread fast among children. These two are thedreaded qualities of wild polioviruses.By 1988, diphtheria, whooping cough and neonatal tetanus had declined tocontrol levels as a result of EPI’s efforts. But polio did not come undercontrol — showing that OPV was not as effective in India as in the West orin China. There, just three or four doses protected all children. In India, wehad to give many more doses for equal effect. From 1994, India begannationwide OPV campaigns (called pulse immunisation) — two per year —to give additional doses to all under-five children irrespective of thenumber of doses already given. That resulted in effectively controlling polioby 2000. One of the three types of polioviruses, wild type 2, was eveneradicated by October 1999 when the average number of OPV doses hadreached six per child. The type 2 component of OPV was not only moreeffective against that type, but it also inhibited the effect of types 1 and 3.That left India with the struggle to eradicate wild types 1 and 3 using ablunt weapon, the trivalent OPV (tOPV), containing types 1, 2 and 3, whichis necessary to attack all three viruses simultaneously. In the Gangetic plainStates, particularly Uttar Pradesh and Bihar, 9-10 pulse immunisationcampaigns were conducted annually from 2004 to 2010. We thendeveloped OPV containing just type 1 to make the tool sharper against thetype 1 wild virus. That is called ‘monovalent OPV’ (mOPV-1). Eventually,India made ‘bivalent OPV’ (bOPV) with types 1 and 3. Remember, we didnot have wild type 2 virus since 1999. With new tools and coveringalmost100 per cent children in their homes, while travelling, in brick-kilnand sugarcane fields where temporary migrant labour set up homes, wildpolioviruses had no place to hide. We succeeded in stopping thetransmission of type 3 in 2010 and type 1 in 2011. The last child with wildvirus polio was detected in Howrah, West Bengal, with the onset ofparalysis on January 13, 2011. Since then, only bOPV has been used forimmunisation campaigns in U.P. and Bihar, while tOPV is used in routineEPI and national pulse immunisation campaigns twice each year.
How sure are we that wild polioviruses have been totally banished? There isa solid body of evidence to show this. All hospitals and clinics that attend tosick children have been networked to report any illness that even remotelyresembles polio. Such illness is called ‘acute flaccid paralysis’ (AFP). Stoolsamples from every child with AFP are collected and tested for the presenceof polioviruses. Every poliovirus so detected is further tested to distinguishwild poliovirus from vaccine poliovirus. When a lot of OPV is given tochildren, many with AFP would have vaccine polioviruses. That is to beexpected. Sewage samples are collected every week from several wards ofMumbai, Delhi, Kolkata and Patna. During 2011 and 2012, all sewagesamples were consistently negative for wild polioviruses (but with plenty ofvaccine viruses). In northern India, the last footholds of wild polioviruses,the second half of each year was the season of high wild virus transmission.We passed two ‘high seasons’ in 2011 and 2012 without a single case. Indiahas truly succeeded, silencing the many prophets of failure.Highly contagiousWild polioviruses are highly contagious — illustrated by some 50 episodesof international importations to countries that had once eliminated themusing OPV. We had exported wild viruses to Nepal and Bangladesh in ourneighbourhood, and to Bulgaria, Angola, China and Tajikistan, to namesome distant ones. Now India is polio-free and vulnerable to importationfrom Pakistan, Afghanistan and Nigeria — the three countries that have notyet eliminated wild polioviruses. We cannot lower our guard and mustcontinue pulse immunisations as though importation is imminent. Indiahas five points of border-crossing with Pakistan: two in Jammu-Kashmir,two in Punjab, and one in Rajasthan. At every point, individuals are givenone dose of tOPV when they enter India.What was very remarkable was that India’s money went into the lion’sshare of expenditure for polio eradication in the country, thus easing upglobal funds for use in other countries that needed them more than we do.India spent about Rs 1000 crore every year since 2000.The rationaleMany have questioned the wisdom of spending such large amounts on onechildhood disease. Was polio worth eradicating? From a humanitarianviewpoint as well as human rights angle no child deserved to be paralysedby a preventable disease. We know the struggle we had to go through
merely to keep polio under control. Eradication is the best form of control.Once affected with polio, many children are neglected, do not completehigh school, take up simple jobs like bicycle repair, managing telephonebooths, etc.The disability-determined productivity loss may be taken as about half ofthe gross domestic product per capita. That amounts to approximately Rs50,000 per year; cumulated over 30 years of productive life, India waslosing Rs. 15 lakhs per person — for a staggering Rs 45,000 crore perannum loss to the domestic economy from just one disease, polio, thataffected 300,000 children each year. Controlling diseases that affectproductivity is indeed a development activity. Eradicating polio is aninvestment. The absence of polio is both a measure of, and a means to,development.The National Polio Eradication Certification Committee will confirmeradication of wild viruses and review the secure containment of laboratorystorage of wild poliovirus strains or specimens likely to contain them beforecertifying India free of wild viruses. The Committee will wait for three yearsfrom the last virus detection before certification procedures, expected afterJanuary 2014. Thereafter, India will use only bOPV; later that will also bewithdrawn, globally, synchronously. These rules of polio eradication ‘endgame’ have been drawn up by the World Health Organisation and wereendorsed by the World Health Assembly in 2012. In order not to create anypolio immunity vacuum, the inactivated poliovirus vaccine will beintroduced and sustained for at least five years. Polio eradication will thenmean ‘no infection with any poliovirus, wild or vaccine.’(The author was on the teaching faculty of Christian Medical College,Vellore, until retirement)Keywords: wild polio virus, pulse polio drive, polioimmunisation, UNICEF, polio epidemic, polio eradication, WHOHeartiest congratulations to the entire Polio eradication team!from: AbhinavPosted on: Jan 14, 2013 at 14:22 IST
This just confirms the improvement in living standards we have acheived inIndia socially & as a country in whole, for the past few years. keep up thegood work!from: Venu Gopal Reddy MuvvaPosted on: Jan 14, 2013 at 12:25 ISTKudos to Polio eradication team !! Polio is eradicated from our country onlybecoz of relentless effort of the vaccination team and the planners indeed.But at the same time we have to be very careful and make every possibleeffort to disinfect any immigrant before they enter Indian territory.from: Abhishek SinghPosted on: Jan 14, 2013 at 11:25 ISTI commend and salute the efforts of all the individuals involved ineradicating polio in the country. Keep Going STRONG!from: AnkushPosted on: Jan 14, 2013 at 01:09 IST