Thursday, 11 December 2014 03:50



On 13 January 2014, India achieved a major landmark in its fight against Polio. The day marked three years since the last case of wild polio was reported in India.

Polio, a crippling disease, had held the world to ransom in the 1950’s and 1960’s. It has been almost eliminated today with the help of the oral polio vaccine, a planned strategy, availability of sufficient funds and the commitment of devoted volunteers and international health agencies.

The introduction of bivalent oral polio vaccine in 2010 also helped India to battle the disease. Previously, India had been using a monovalent vaccine that protected only against type 1 poliovirus transmission, not type 3, which was causing repeated disease outbreaks.

In 2009, India reported 741 polio cases, more than any other country in the world, according to the Global Polio Eradication Initiative. The last case was reported from West Bengal in 2011, when an 18-month-old girl was found to have contracted the disease.

India faced unique challenges in eradicating polio. Among them were the high population density and birth rate, poor sanitation, widespread diarrhoea, inaccessible terrain and reluctance of a section of the population to accept the polio vaccine.

Role of Rotary International in Polio Eradication

Rotary International is the volunteer arm of a global partnership dedicated to eradicating polio. In 1985, Rotary International volunteers around the world embraced the fight against polio in 1985, under the ‘POLIOPLUS’ programme — the most ambitious programme in Rotary’s history — a public-private partnership to assist International Health Agencies and governments in eradicating polio from the world.

The PolioPlus programme was introduced in India in 1986, with the Rotary International providing a grant of US $ 2.6 million to Tamil Nadu for the purchase of Polio vaccine. A year later the nation-wide focus on PolioPlus began. US $ 20 million were made available for the purchase of Oral Polio Vaccine, surveillance activities, social mobilization and cold chain support.

Between 1991 and 1994, immunization drives in the form of Shishu Suraksha Diwas (Child Protection Days) were organized all over India by Rotary Clubs and Rotarians. Rotary International also started vigorous and consistent advocacy efforts and eventually succeeded in convincing the government of India about the need for launching Pulse Polio immunisation all over the country.

In 1994, the New Delhi government became the first State government to launch the PulsePolio Immunization drive. The central government followed suit in 1995-96. It designated two National Immunization Days (NIDs) and since then a series of NIDs have been successfully conducted. In 1999, the programme was intensified in order to meet the global deadline.

In 1988, a separate committee, named the India National PolioPlus Society (INPPS), was established by Rotary International to exclusively steer its polio eradication programme in India.

Rotary volunteers committed finances and, with the cooperation of National Health ministry, WHO and UNICEF, assisted in vaccine delivery, social mobilization and logistic management.

-Source: Rotary International Website

NPAFP increase a concern

India’s dramatic turnout in polio eradication, though, has seen a consistent sidelining of the increasing incidence of non-polio acute flaccid paralysis (NPAFP) cases. Many health activists say the government, in its rush to get the polio-free certification for the country, ignored the increasing incidence of NPAFP.

Acute flaccid paralysis (AFP) is a condition in which a patient suffers from paralysis that results in floppy limbs due to reduced muscle tone. While AFP is symptomatic of polio, it can be caused by other diseases such as the Guillain Barre Syndrome and nerve lesions as well.

Government surveillance data shows that India has the world’s highest rate of NPAFP incidence. In 2011, the year India reported its last polio case, nearly 61,000 children were detected to be suffering from NPAFP.

According to some researchers, there is a link between the increase in dosage of polio vaccination and the increasing cases of NPAFP. However, as per global benchmarks, as polio incidence comes down, the rate of NPAFP should also reduce.

Majority of NPAFP cases are reported from Bihar and Uttar Pradesh, where several immunization rounds were held to reach universal coverage.

The health ministry has denied NPAFP is rising, stating that the increasing numbers are indicative of good government surveillance.

Threat of Global Resurgence

The polio-free certificate that India will receive is just a piece of paper. While India appears to have stopped indigenous transmission of wild poliovirus, the risk of importation is real and has increased since 2013 with outbreaks in the Horn of Africa region and the Middle East, in addition to the continuing poliovirus transmission in Afghanistan, Pakistan and Nigeria. India, thus, needs to stay extremely vigilant and continue with its efforts. Supplementary immunization has to be kept up until routine immunization is up to the mark.

The India expert advisory group on polio has recommended that the country’s immunization programme switch from trivalent oral polio vaccine and only rely on the oral bivalent variant, reducing chances of vaccine derived polio virus infection. The switch will be accompanied with a booster shot of injectable polio vaccine. The WHO strategic advisory group of experts (SAGE) on immunization has called for a global, coordinated withdrawal of type 2-containing OPV by the end of 2016, and switch to bivalent OPV.

Polio Eradication and Endgame Strategic Plan 2013–2018

The Polio Eradication and Endgame Strategic Plan 2013–2018 has been developed by the Global Polio Eradication Initiative (GPEI), in consultation with experts, donors, health authorities and other stakeholders, to deliver a polio-free world by 2018. The plan was made following a directive of the World Health Assembly.

The Plan has four objectives:

1. Poliovirus detection and interruption: The aim is to stop all WPV transmission by the end of 2014 and any new outbreaks due to a cVDPV within 120 days of confirmation of the case. The three endemic countries, the countries at highest risk of importation in Africa and countries with persistent cVDPV or a history of cVDPV emergence will be the center of focus. Efforts will concentrate on enhancing global poliovirus surveillance and ensuring rapid outbreak response. The tailored Emergency Action Plans being implemented in each endemic country is complemented by this objective.

2. Immunization systems strengthening and OPV withdrawal: The eventual withdrawal of all OPV, beginning with the withdrawal of the type 2 component of trivalent oral polio vaccine (tOPV) is important to eliminate cVDPVs. The goal is a 10 percent improvement in coverage rates in worst-effected areas. The interruption of all poliovirus transmission will also help to build a stronger system for the delivery of other lifesaving vaccines. All 145 countries that currently use OPV in their routine immunization programmes will be invloved. The GPEI will give particular attention to 10 countries that closely align with GAVI’s focus countries, consisting of the three polio-endemic countries plus seven other countries at high risk of WPV outbreaks and recurrent cVDPV emergence: Angola, Chad, the Democratic Republic of the Congo, Ethiopia, India, Somalia and South Sudan.

3. Containment and certification: All Member-States of the World Health Organization will be engaged by work under this objective, to eradicate polio from the face of the earth, as also ensure that all poliovirus stocks are safely contained by 2018. International consensus on long-term bio-containment requirements for polioviruses will be needed for this. All six WHO regions will also need to have Regional Certification Commissions in place to review documentation from all countries and verify the absence of WPV.

4. Legacy planning: According to GPEI, “this objective aims to ensure that the world remains permanently polio-free and that the investment in polio eradication provides public health dividends for years to come.” GPEI further says that “careful planning is essential to ensure that lessons learnt during polio eradication, as well as the assets and infrastructure built in support of the effort, are transitioned responsibly to benefit other development goals and global health priorities.”

- Source: Global Polio Eradication Initiative Website

Insecurity in Pakistan and Nigeria

The insecurity in Pakistan and Nigeria poses a new and real threat to the polio eradication effort. However, because the leaders of Afghanistan, Nigeria and Pakistan remain fully committed to stop the transmission of polio in their respective countries, the efforts are continuing and the GPEI has developed an overarching framework that is tailored to each area. According to the framework, the programme must be institutionalized within the broader health agenda and must maintain neutrality.

International, national and local Islamic leaders have been romped in to build ownership and solidarity for polio eradication across the Islamic world.

Polio – Key facts

  • Poliomyelitis or Polio was first recognized as a distinct condition by Jakob Heine in 1840. Its causative agent, poliovirus, was identified in 1908 by Karl Landsteiner.
  • Polio mainly affects children under five years of age.
  • One in 200 infections leads to irreversible paralysis. Among those paralysed, 5% to 10% die when their breathing muscles become immobilized.
  • In 2013, only three countries (Afghanistan, Nigeria and Pakistan) remain polio-endemic, down from more than 125 in 1988.
  • As long as a single child remains infected, children in all countries are at risk of contracting polio. Failure to eradicate polio from these last remaining strongholds could result in as many as 200 000 new cases every year, within 10 years, all over the world.
  • In most countries, the global effort has expanded capacities to tackle other infectious diseases by building effective surveillance and immunization systems.

Polio and its symptoms

Polio is a highly infectious disease caused by a virus. It invades the nervous system, and can cause total paralysis in a matter of hours. The virus enters the body through the mouth and multiplies in the intestine. Initial symptoms are fever, fatigue, headache, vomiting, stiffness in the neck and pain in the limbs. One in 200 infections leads to irreversible paralysis (usually in the legs). Among those paralyzed, 5% to 10% die when their breathing muscles become immobilized.

Poliovirus enters the body through the mouth, infecting the first cells with which it comes in contact—the pharynx and intestinal mucosa. There is no cure for polio; it can only be prevented. Polio vaccine, given multiple times, can protect a child for life.

Factors that increase the risk of polio infection or affect the severity of the disease include immune deficiency, malnutrition, physical activity immediately following the onset of paralysis, skeletal muscle injury due to injection of vaccines or therapeutic agents, and pregnancy.

- Source: Wikipedia and WHO Websites

Polio Vaccine

There are two type of vaccine that are used to combat polio. Virologist Hilary Koprowski developed the candidate polio vaccine in 1950. It is based on one serotype of a live but attenuated (weakened) virus. In 1952, inactivated virus vaccine was developed by Jonas Salk. The Salk vaccine, or inactivated poliovirus vaccine (IPV) develops protective antibody to all three serotypes of poliovirus, making at least 99% people immune to poliovirus following three doses.

The live, oral polio vaccine (OPV)was developed by Albert Sabin. The Sabin vaccine replicates very efficiently in the gut, the primary site of wild poliovirus infection and replication. However, the vaccine strain is unable to replicate efficiently within nervous system tissue and there is a remote chance of the vaccine reverting (becoming a cause of a polio attack).

OPV has been the vaccine of choice for controlling poliomyelitis in many countries, because it is inexpensive, easy to administer, and produces excellent immunity in the intestine (which helps prevent infection with wild virus in areas where it is endemic). Most industrialized countries, though, have switched to IPV, which cannot revert, either as the sole vaccine against poliomyelitis or in combination with oral polio vaccine.

OPV vs IPV: Unlike OPV, IPV confers very little immunity in the intestinal tract. When a person immunized with IPV is infected with wild poliovirus or a cVDPV, virus can still multiply inside the intestines and be shed in the stool, risking continued circulation. For this reason, OPV is the vaccine of choice wherever a polio outbreak needs to be stopped.

However, the OPV use in routine immunization has to eventually cease. There is a huge threat of vaccine-associated paralytic polio (VAPP), into a polio-free world, if the administration of OPV is not eventually stopped. The threat of Polio outbreaks due to circulating vaccine-derived polioviruses (cVDPVs) will also remain, thus negating the achievement of eradication.