Polio Free India: A Perspective

 

During the 65^th Republic Day parade while recounting on the notable achievements of the past one year, apart from the successful launch of Mangalyaan, GSLV, rescuing the pilgrims from the Uttarakhand floods, evacuation of people during the cyclones in Andhra Pradesh and Odisha, eradication of polio has found a special mention. India has come a long way towards the total eradication of Polio and WHO is going to make an official announcement on the same.

The Pulse Polio programme has been initiated in the year 1995 by the  Ministry of health and family welfare of Government of India and state governments with the support of several multilateral partners like WHO (World Health Organisation), UNICEF and the Rotary International. India has began its tryst with the oral polio vaccine immunisation programme by adopting the WHO’s expanded programme on immunisation in 1978. Prior to it nearly 500 children were paralyzed by the wild polio every day. With coordinated and intense mass immunisation programme the numbers have come down to 2000 cases annually till 2009 and in 2010 there were just 42 cases of polio.  While in 2011 a single case was detected from West Bengal on January 13^th 2011. With three consecutive years of zero incidence of the disease, India is now all set to be declared Polio free by the South East Asia Regional Certification Commission for Polio Eradication (RCCPE) scheduled to meet in Delhi in the last week of March 2014 to review documents of 11 countries of the region.

The battle of polio eradication was taken up by 2.4 million vaccinators, social mobilisers and community health workers for 35 years. Nearly 170 million children under the age of five were immunised during every round. The fight couldn’t have been won but for the dedication and relentless work of the frontline workers whose services were backed by an investment of nearly 3 billion dollars by the government of India and other donors. Reaching out to the vast population of diverse social-cultural back grounds and overcoming several physical and social barriers and achieving higher rates of immunisation covering the most vulnerable and migrant population in spite of poor health infrastructure in India has been the most challenging task.

As India is set to celebrate its splendid success cross border entry of polio seems to be a major threat especially from Pakistan where a large number of Polio vaccinators are still targeted by the militant groups as western ploy. Earlier, China which was Polio free reported incidence of polio following the import of virus from Pakistan in 2011. Hence heightened monitoring of International borders across Nepal, Bangladesh, Myanmar, Bhutan and Pakistan by running continuous Polio immunisation check posts is essential to prevent the virus from being imported back into the country through the immigrants. Three countries in the world are still battling with polio which includes Pakistan, Nigeria and Afghanistan. 

Surveillance of Polio was initiated in 1997 with WHO setting up the National Polio Surveillance Project to help early detection and prompt investigation of children with incidence of paralysis. Polio is highly infectious disease and caused by polio virus and passed through person to person (faecal-oral) contact. Hence the investigation includes testing of stool samples from various locations to confirm the presence of the virus. This surveillance has been useful in identifying the gaps and strategic planning of the immunisation scheme for better coverage of population in the polio prone areas. Oral Polio Vaccine (OPV) developed by Sabin containing mixture of live attenuated polio strains of all three types of polio virus types was initially used for immunisation. Despite the best of efforts India failed to achieve the target of polio eradication by 2000. Then efficacious monovalent oral polio vaccine (mOPV) was introduced in 2005 to more rapidly interrupt the virus. Based on further investigations, The India Expert Advisory Group on Polio (IEAG) has advised that type 1 and 3 seems to be more prevalent following which bivalent vaccines were administered from 2010.

Under the Polio Eradication and Endgame Strategic Plan a body which receives inputs from WHO, UNICEF, Centres of Disease Control Atlanta, strategy is to shift to bivalents with attenuates of type 1 and 3. From 2015 onwards to achieve comprehensive complete eradication along with regular oral vaccines a round of Injectible Polio vaccine (IPV) containing silent instead of live attenuates of vaccines shall be administered.

While the country is tipped towards the status of being declared as polio free nation, another similar paralytic condition in children is on rise. Nearly 53,000 cases of non polio acute flaccid paralysis (NPAFP) were reported in the past 13 months in the states of Bihar and Uttar Pradesh alone. Acute flaccid paralysis (AFP) is the term used to describe the symptoms of Polio which are characterised by weakness or paralysis and reduced muscle tone. The cause of AFP is mostly polio virus but in some cases it is can be caused by non-polio virus. The WHO’s Weekly Epidemological Weekly annualised the non-polio AFP to the tune of 15.06 cases for one lakh children below the age of 15 while the global rate is 5.48. One of the reasons for the high rate of AFP in the two states is both the states are subjected to highest level of surveillance by the WHO as they were traditionally known to be regions endemic to incidence of Polio.

Though the exact reasons for higher incidence of the NPAFP are still not clear, a paper published in the Indian Journal of Medical Ethics proposed that increased proportion of the polio doses might have resulted in increased NPAFP rate. But the WHO office in India countered it and now ICMR has taken up the investigation of NPAFP. Some experts view that increased surveillance coupled with the expanded definition of AFP, along with more intense training of health workers on what constituted AFP might perhaps be the reason for increase in reporting of cases rather than the real increase in incidence of the disease that might caused these symptoms.

India has several short comings- its weak health care system, poor sanitation, contamination of water supply, endemic belts of polio where resistance for virus started building up from 1990’s, resistance to vaccination due to misconceptions and inaccessibility to various regions. Though celebrations are justified several health workers and doctors believe that India owes a dedicated national programme for the existing patients already diagnosed with polio. Polio is a preventable neuronal disease through natural means like providing clean water and sanitation. But India has opted for a tedious technical route of vaccination for eradication due to the low standards of sanitation and hygiene. It is for the same reason that experts from all over the world thought it would be near impossible for India to achieve massive target of polio eradication.

Polio eradication is a model of excellence and this model should be effectively utilised for other public health initiatives in the country. Using the polio infrastructure, expertise and operational experience it should strengthen routine immunisation and protect its children from the vaccine preventable diseases. These dedicated efforts shouldn’t rest in laurels but should continue to deliver till the global polio-free certification is achieved. The existing channels can be used for eradication of other vaccine preventable diseases like measles and rotavirus infections.  After eradication of small pox in 1978, polio is the second disease that has been eliminated through immunisation in India.

 

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