India’s success story against polio

It is heartening to note that India, despite initial bungling managed to come up a winner in the drive for eradication of polio, even as World Health Organisation (WHO) warned recently that the crippling disease has reemerged as public health emergency, after new cases of the scourge began surfacing and spreading across borders from countries like Afghanistan and Pakistan.

Polio, a crippling and potentially fatal viral disease that mainly affects children under the age of five, has come close to being beaten as the result of a 25 year effort. In 1988, the disease was endemic in 125 countries – with the highest concentration in South Asian countries and Africa. Today, the virus is considered endemic in only three countries: Afghanistan, Pakistan and Nigeria, according to WHO data. 

Earlier, last year, the WHO had officially certified India along with 10 other Asian countries free of polio, after a panel of experts verified that the countries went three years without reporting a single new case of the dreaded disease. The certification has confirmed one of India’s biggest public health success stories, accomplishing something once thought impossible, thanks to the massive and sustained immunization programme involving thousands of health workers who have worked with government, non-government organizations, civil society backed by WHO, UNICEF, Rotary International and Global Polio Eradication initiative. 

The certification is particularly significant in India, home to 1.2 billion people, and which until 2009 accounted for a very high number of the estimated 3,50,000 cases globally. Before the polio eradication drive was launched, practically 2,00,000 children would be crippled every year, and India was looked upon as the epicenter of polio. In fact, between 1988 and 2009, India accounted for half of the world’s new polio cases.

Let us take a brief look at the history of India’s polio eradication programme, which has been a subject of controversy, with local health activists constantly pointing to certain major flaws in the implementation of the programme.

From 1979, the expanded programme on immunization (EPI) began giving three doses of oral polio vaccine (OPV) to infants on national immunization days (NIDs). Polio continued unabated during 1980s, primarily because of lopsided concentration and focus on combating the disease solely through NIDs, without giving equal importance to routine immunization. So busy was the government machinery in achieving cent per cent coverage on NIDs, that they overlooked the importance of routine immunization, as was required to be done. According to the ministry of Health (MoH), there were 2,00,000-3,50,000 cases of polio a year. Research pointed to reason for the failure, namely, low vaccine efficiency against type-I and type-3 polio viruses.

In 1988, the Immunization Mission assessed OPV and injectable polio vaccine (IPV), Indian research pointed to high efficacy of IPV (even with only two doses) and dismal performance with three doses of OPV. It was pointed out that with IPV no child had ever developed polio after three doses – even two doses immunize nearly 100 per cent if given eight weeks apart. On the other hand, it was pointed out that OPV was incompatible with eradication. Self-sufficiency of IPV was recommended, to which end, the Ministry of Science and Technology established a public sector company at Gurgaon, with France transferring the required technology for operation of the plant. But the Ministry of Health scuttled the project by refusing to licence IPV. In the same year (1988), a private industry successfully manufactured IPV combined with DPT, which is an ideal vaccine for polio, but that too was scuttled by the Ministry of Health. During the early 1990s, the number of cases declined, but the proportion of polio cases occurring among vaccinated children increased.

Eradication efforts began on a war footing in 1996. From 1996, national pulse polio campaigns added many more rounds of immunization, going up to six and even ten doses of OPV. In 2005, only 66 cases occurred in Uttar Pradesh and Bihar (which witnessed polio outbreaks in the 1980s and 90s), a 99.90 per cent reduction. Disappointingly, 2006 witnessed an outbreak with over 700 cases.

The global polio eradication strategy demands sustaining high routine polio vaccination. However, in India, campaigns achieved skewed coverage – walking children were brought to pulse polio immunization (PPI) booths on NIDs even as babies were kept at home, even hidden away, because of lack of knowledge and information about the importance of immunizing them.

What was sadly missing was the effort to hammer in the fact that NIDs are part of a mass programme, and, in the absence of routine immunization, fail to effectively combat polio. 

Health activists have been highlighting that as per WHO recommendations, there are four major strategies for polio eradication, namely, high routine immunization (HRI) coverage, mass immunization on NDs, regular surveillance and mopping up operation. While HRI should aim at vaccinating 90 per cent of the infants against polio before they are one year old, it is recommended that particular attention be paid to the underprivileged sections of society, because they are more prone to infection.

Health experts emphasized that NIDs would be effective only in the presence of good surveillance system and mechanisms that are well equipped to identify polio cases. Mopping-up in turn comprises intensive house-to-house immunization to ensure that all eligible children are covered. All children in a specified age group (usually 0 to 59 months) are immunized during the mopping-up operation, regardless of their occasional immunization status.

In fact, there have been suggestions that awareness along with publicity should not be a one-time exercise scheduled on the eve of NIDS, but must be conducted all through the year. It also necessitates creating proper awareness among parents, who should not construe NIDs as constituting total protection against polio. 

There is no room for complacency. The WHO has advised India to maintain sensitive surveillance and ensure high childhood immunity against the wild polio virus, as this is vital to ensure that no strain of polio is imported to the country until eradication is attained worldwide. 

On forthcoming World Polio day, let us all pledge ourselves to work collectively and help wipe out polio from the face of the earth.

(The writer is a freelance journalist)