India three years polio-free
Wild poliovirus has not been found in India since 13 January 2011 meaning that, from that date, India is no longer a country where polio is endemic. Three years of being polio free is a notable milestone for the country as a whole, but the success of the immunization and awareness campaign has had a wider impact. With this achievement, it is hoped that soon the entire WHO South-East Asia Region can be certified polio free. A commission of experts will meet on 26-27 March 2014 to analyze the data and determine the polio status for the Region.
Historically, India has been the largest endemic reservoir of polio in the world with between 50 000 to 100 000 paralytic polio cases occurring each year between 1978 and 1995. It has also been one of the main sources of polio importation for other countries. This achievement has been driven by the partnership between the Government of India, international organizations, local NGOs and other institutions. An extraordinary mobilization of health workers was necessary to reach this point, particularly in the Uttar Pradesh and Bihar states. The outcome of this has been an improved vaccine delivery system, better trained health staff and high quality surveillance, monitoring and research mechanisms.
This does not mean that the virus cannot reemerge within any of the countries or the Region. There is no room for complacency with ongoing polio vaccination work. High immunity levels must continue in order to protect those in the Region and as newer, more comprehensive interventions are developed, these too need to be rolled out. Furthermore, whilst no new cases of wild polio have been recorded recently, the disease in different forms can be brought in to the Region via those who have contracted it in other parts of the world and then travel to South-East Asia.
Facts about Polio Certification
In 1988, the forty-first World Health Assembly adopted a resolution for the worldwide eradication of polio. Here are some polio certification facts:
- No single country can be certified as polio free. WHO Regions as a whole are certified as polio free
- For certification, all countries in the WHO Region need to not register a case of wild polio for 3 years in the presence of high quality surveillance
- The formal process for certification of polio eradication was established in 1995 at the first meeting of the Global Certification Commission (GCC)
- There are National Certification Committees (NCCs) who focus on analysis at the country level. In WHO's South-East Asia Region, each of the 11 member states has a NCC
- All Regions have a certification commission. WHO SEAR has the South-East Asia Regional Certification Commission which comprises eleven global and regional experts. It is this commission that can certify the South-East Asia Region as polio free
- Three Regions (Americas, 1994; Western Pacific, 2000; Europe, 2002) have already been certified as polio free
About poliomyelitis (polio)
Poliovirus is transmitted mainly from person-to-person through the fecal-oral route and on average, depending on the serotype (poliovirus type 1, 2 or 3), a single case of paralytic polio represents 200 to 1000 silent infections surrounding the case.
WHO fact sheet on polio
10 facts on polio eradication
About Vaccine derived polio
The work to date on the eradication of polio from the South-East Asia Region is the culmination of a long standing partnership between WHO and donors such as Rotary International, Centers for Disease Control and Prevention (CDC), UNICEF, the Bill and Melinda Gates Foundation and USAID.
For more information on WHO South-East Asia Regional Office’s work on Polio, visit the immunization section.
WHO India Country Office article on "Keeping the polio virus at bay".
A few days ago, Ramesh Ferris took his first ride on a motorbike. Born in India and raised in Canada, Ferris made the journey into rural India to meet Ruksa Khatun, the 3-year-old girl who is the last child in India known to have contracted polio. This weekend, as the nation quietly marked two years without a single infection by the wild poliovirus, that child’s parents wondered how they were going to manage the surgery her doctors say she needs on a foot crippled by the disease.
Ferris would understand the gravity of their situation better than most. After he was paralyzed by polio as an infant, his birth mother was unable to provide him with the care he needed and placed him in an international orphanage. He was adopted by a family in Canada’s Yukon territory, where he grew up, eventually becoming an advocate in the global drive to end polio. India was once considered the center of the crippling disease — and was expected to be the last place it would be eradicated. But last year, the World Health Organization (WHO) confirmed that polio was no longer endemic in India. Next year, if no new cases arise, the country will be declared polio-free, perhaps the greatest public-health feat it has ever achieved, saving hundreds of thousands of children from paralysis and death.
India’s accomplishment was a triumph of consistent and strong political will as well as international coordination and has given a huge lift to the global fight against polio, a disease that as recently as 1988 claimed 350,000 people each year. In 2012, the global caseload was just 222. When India came off the WHO list last year, the number of countries where the virus is still endemic came down to three: Nigeria, Pakistan and Afghanistan. “Given India’s complex circumstances in terms of where people live and its topography, it’s astounding it came off the list before other countries,” says Ferris.
(Read TIME’s cover story on how geopolitics may threaten the global effort to fight polio.)
Understanding how a country so huge, so diverse and so poor managed to stop polio transmission offers important lessons both for the complicated international effort to eradicate the disease for good and for India’s own health care system. The oral polio vaccine was introduced in India in 1978, a year before the U.S. was declared polio-free. In 1985, Rotary International launched its global effort to end polio everywhere. India was a signatory to the 1988 WHO treaty committing participating nations to be part of that effort. But on the ground in India, “there was not much happening,” says Dr. Naveen Thacker, a past president of the Indian Academy of Pediatrics and a member of the expert advisory group to the Indian government for polio eradication.
It wasn’t until 1994, when the local government of the New Delhi capital region conducted a hugely successful mass immunization campaign targeting children, that the idea began to gain momentum that India might actually be able to tackle this disease. Though other Indian states like Kerala and Tamil Nadu had conducted similar campaigns before, it wasn’t until the national government saw tangible progress that officials were sufficiently convinced they could make a difference.“That’s when India decided to go after polio in a big way,” says Thacker. Routine immunization — in which patients sought out the vaccine themselves — had reduced polio but couldn’t stop it from spreading. Reported immunization coverage across India was officially as high as 90%, but the disease was still being transmitted.
In 1995 and ’96, the government started to organize annual national immunization days, and in 1997, India established the National Polio Surveillance Project. In 1999, it set up an expert advisory group that monitored the program and provided continuous evaluation of how the disease was behaving around the country. Eventually, that group, which Thacker was a part of, decided the best way to fight the disease was to focus on the states of Uttar Pradesh and Bihar, two of the poorest areas in the country where polio transmission was uninterrupted. Crucially, the group also decided to target migrant workers moving in and out of those states and started vaccinating along the trail that migrants followed.
(PHOTOS:Pakistan’s Fight Against Polio)
It worked. By 2009, 741 cases of polio were reported in India, says Thacker. By 2010, that number dropped to 42, and by 2011, only one case — as of today, India’s last — was reported in the entire country. Today, officially 71% of children in India are immunized against polio, with 98% of children in the highest-risk areas having been immunized. In the process, the National Polio Surveillance Project became India’s most extensive public-health surveillance system. There are currently 27,000 reporting units across the country, run through a combination of funding from the government, WHO, UNICEF, the Bill & Melinda Gates Foundation and the CDC, among other groups. India has become one of the world’s largest donors to global polio eradication, putting billions of dollars into fighting the disease at home and also lending its hard-won expertise to Pakistan, Afghanistan and Nigeria, where the virus is still being actively transmitted. (Here’s a graphic of how the global polio program is funded.)
Members of the national surveillance team have gone to Nigeria and Pakistan in particular to help those countries set up similar systems. It’s an especially complicated task in Pakistan, where the effort to immunize children has become highly politicized, as anti-Western hard-liners have scared parents in high-risk areas into refusing the vaccine by spreading rumors about its safety and, worse, by attacking the vaccinators themselves. In December, the murder of nine health care workers during a polio-vaccine drive was linked to the Pakistani Taliban. It’s part of what makes this stage of the fight against polio — so tantalizingly close to being over — such a crucial one. As TIME’s Jeffrey Kluger wrote in a recent story on polio and politics: “All viruses fight back against their eradication. Polio is the only one with a propaganda wing and an armed militia on its side.”
The wisdom gained during the long years of hard work in India will not go to waste there. Infectious diseases like tuberculosis could benefit hugely from the kind of political will and national coordination that the government has shown in fighting polio. The infrastructure of the national surveillance project is already being used to deliver other health services to people living in hard-to-reach parts of the country.
(MORE:What’s Blocking the Final Stand Against Polio?)
Whatever the disease, it’s people like Ramesh Ferris who can do the most to persuade the public to take action. Last July, he went to Karachi to help educate parents about polio immunization. He climbed six flights of stairs on his crutches to reach a family on the top floor and show them firsthand the risk to which they are exposing their kids by refusing to let them get the vaccine. After a long, tense moment, the family opened the door and let him in, and Ferris personally administered the vaccine. “We have invested so much time and money into this fight. We can’t let hostility and misconceptions veer off our journey,” he says.
In India, too, Ferris cautions that the fight isn’t over just because the country has gone two years without new transmissions. “There is something called the polio endgame,” says Thacker. “You have a war, and once you declare the war is over, you take your weapons back and just survey.” India isn’t there yet. Children need to keep getting vaccines, and surveillance can’t stop, especially with a neighboring country in which the disease is still on the move. Says Ferris: “We’re not out of the woods yet.”