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The detailed story of how India won the battle against poliovirus

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On World Polio Day, excerpts from book, ‘Polio: The Odyssey of Eradication’ by Thomas Abraham.

The polio eradication campaign’s most anguished and difficult years in India were from 2005 to 2011. This was a period when polio exploded in large, periodic outbreaks in Uttar Pradesh and Bihar, even though the WHO and its partners had thrown the equivalent of the kitchen sink at the virus, with some of the most intensive polio vaccination campaigns the world had seen. Children in parts of western Uttar Pradesh and Bihar were being fed polio drops once a month as opposed to the two times a year that was supposed to be the norm. A new monovalent OPV had been introduced in these states in the hope that at least one of the two poliovirus serotypes could be stamped out. But it was not at all clear that any of this was working. In 2005, after an intensive vaccination campaign with the new monovalent Type 1 vaccine, the number of cases of polio in India had been brought down to a low of fifty-four. This led to optimistic predictions that the disease could be wiped out the following year. But between 2006 and 2008, the numbers had shot up again to nearly 900 cases.

Vaccinators and their supervisors in Uttar Pradesh and Bihar were being stretched to their limits by these repeated campaigns. Some went on strike demanding better pay. Parents were becoming increasingly irritated and suspicious about these repeated knocks on their doors by health workers forcing polio drops on their children.

Could polio actually be wiped out from India? Should the government continue to spend money on eradicating polio, or should it use the money to focus on other diseases, officials asked. Was OPV as effective as the WHO claimed it was? All the questions and doubts that had been raised since the 1960s about the right strategy to eradicate polio surfaced again. Should the polio campaign use IPV instead of OPV? Should a combination of the two be tried? Should the polio campaign get involved in strengthening routine childhood immunisation instead of concentrating solely on delivering polio vaccine through house-to-house campaigns? Should improving sanitation and hygiene be seen as part of the polio eradication mission?

It was not just the government that was sceptical. A group of Indian doctors and epidemiologists also felt that the strategies the WHO was pursuing would lead nowhere. The Indian Academy of Paediatrics, an umbrella organisation for the country’s paediatricians, felt that WHO’s reliance on OPV alone was unwise, given that efficacy of the vaccine was low in the environmental and social conditions that existed in the heavily populated states of northern India. Some decades earlier in the 1990s, there had been a proposal to start manufacturing IPV in India, but that never got off the ground. However, there remained a strong body of professional opinion that favoured using IPV as well as OPV.

It was in India that the debates over the dangers of the Sabin vaccine and its propensity to provoke paralysis in some recipients, or VAPP, was brought back under the spotlight. The polio programme and the Indian government never publicly talked about OPV’s known propensity to cause paralysis, at the rate of roughly one child being paralysed per million doses of vaccine distributed. This rate of paralysis was small, but given the scale of India, where around 150 to 160 million doses were administered at each national immunisation day, as well as the additional doses that children were given during subnational immunisation rounds, several hundred children were developing polio from the vaccine.

The WHO and the polio programme justified use of the vaccine on the grounds that the risk of the virus reverting to a disease state needed to be balanced with the benefit of a polio-free world. The Indian government had no interest in publicising these risks because it could lead to claims of compensation from children who were affected by the vaccine (as had happened in the United States). IPV did not have these side effects, and the Indian Academy of Paediatrics urged the Indian government to introduce IPV in addition to the OPV in order to reduce risks.

It was also in India that a question that ticks like a bomb beneath every global health initiative surfaced again: who was polio eradication a priority for? Was it a priority for India where so many other diseases demanded greater attention? Or was it a greater priority for the wealthy developing countries that had eliminated the disease, but did not want to face the threat of it being reimported from countries where it still circulated? This was a question that public health experts in the West critical of the concept of eradication had raised decades earlier. This argument had more or less disappeared from the discourse in the West, but it re-emerged with new vigour from Indian academics, who found the emphasis on polio questionable. A ‘Memorandum on Pulse Polio’ submitted to the WHO and UNICEF in New Delhi by a group of academics from Jawaharlal Nehru University in New Delhi claimed that the polio eradication initiative had been thrust on India by the WHO, UNICEF, the US Centers for Disease Control and Rotary International. It contended that a ‘disease of lower public health importance in the country has been justified on the grounds of some small saving for developed nations’.

A group of Indian doctors and academics, dubbed the ‘dissenters’ by the historian William Muraskin, subjected the polio campaign to the kind of critical scrutiny that it was not accustomed to anywhere else in the world. The polio campaign blamed the health authorities in the problem states of UP and Bihar for not implementing immunisation campaigns with sufficient care and rigour. Yet Indian critics wrote ‘the failure of the eradication campaign is not because of a lack of proper implementation (as they so often claim) but because of a flawed strategy itself.’6 Many of these objections were valid, and others less so. But it is to the credit of the polio programme that it persisted, and mobilised the political support it needed from the central and state governments to bulldoze ahead until polio disappeared from India.

Despite often valid criticism of the campaign, the eradication of the poliovirus from India will go down as a magnificent chapter in the history of public health. It was achieved by meticulous implementation of a vaccination programme that reached children in some of the most physically and epidemiologically challenging environments that the polio programme had ever encountered. These ranged from the squalid slums where sewage and drinking water ran together, to remote huts on the floodplains of the Kosi river in Bihar where no health care worker had ever gone before. As we shall see in the following section, nowhere else had the poliovirus been successfully hunted down in conditions that were so challenging.

 This excerpt is from ‘Polio: The Odyssey of Eradication’ by Thomas Abraham, published by Westland

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