Year : 2014 | Volume
: 39 | Issue : 2 | Page : 63--67
World witnesses a tumultuous year while India reports an eventful decade in the long story of polio eradication
Department of Community Medicine, University College of Medical Sciences, Delhi, India
Prof. Sanjay Chaturvedi
Department of Community Medicine, University College of Medical Sciences, Dilshad Garden, Delhi-110 095
With recent outbreaks in Syria and Horn of Africa, silent circulation of wild poliovirus type 1 (WPV1) in Israel, West Bank, and Gaza, and fresh spate of violence against vaccinators and their security personnel in Pakistan, the world is facing a turbulent final ascent to the summit of polio eradication. On the positive side, we may also be witnessing the end of wild poliovirus type 3 (WPV3) and defused programmatic crisis caused by funding gaps, while India registers third consecutive polio-free year. Having a cogent endgame plan 2013-2018, informed by some cardinal lessons learned from an eventful decade in India, is also a very significant development. Now, there is a parallel pursuit against WPV and vaccine-derived poliovirus (VDPV). Endgame would also involve integration of at least one dose of affordable inactivated polio vaccine (IPV) to up-scaled routine immunization (RI), switch from trivalent oral polio vaccine (tOPV) to bivalent oral polio vaccine (bOPV) in 144 countries before 2018, stockpiling of mOPV, and simultaneous global cessation of bOPV before 2020. Role of antivirals in post-eradication era is still unclear. Some specific threats emerging at this stage are as follows: Global buildup of new birth cohorts in non-endemic countries with weak RI and downscaled supplementary immunization activities (SIAs), tremendous pressure on peripheral health workers, and fatigued systems. Cultural resistance to transnational programs is taking a violent shape in some areas. Differential interpretations of «SQ»right to say no«SQ», on both sides of the divide, are damaging a global cause. Amidst all these concerns, let us not forget to underline the sacrifice made by frontline vaccinators working in some of the most challenging circumstances.
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Chaturvedi S. World witnesses a tumultuous year while India reports an eventful decade in the long story of polio eradication.Indian J Community Med 2014;39:63-67
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Chaturvedi S. World witnesses a tumultuous year while India reports an eventful decade in the long story of polio eradication. Indian J Community Med [serial online] 2014 [cited 2020 Nov 29 ];39:63-67
Available from: https://www.ijcm.org.in/text.asp?2014/39/2/63/132714
Chairperson Sir, distinguished guests, fellows, and friends. It is an honor to be asked to deliver this oration named after God's own healer-Dhanvantari. The legend underscores a curious irony that even the God needs a doctor. One who is acknowledged as Mahamritunjay, Mahabhishag, and Vaidyanath may also fall sick and would need a healer. I thank my Association for being in the thick of this irony. I have chosen to speak on polio eradication for two reasons-India reports third consecutive polio-free year on January 13, 2014, and the world witnesses some worrisome developments affecting the polio endgame.
As the Lancet Infectious Disease captured the sentiment of the year that was, its editorial in the January issue of 2014, entitled 'A wake-up call for polio eradication', underscored the gravity of wild poliovirus type 1 (WPV1) outbreak in Syrian Arabic Republic.  A total of 23 cases, most recent being on December 17, 2013, were reported from this country disturbed by civil strife. The geographical distribution of virus indicated to a widespread circulation in the country, ranging from eastern province to Aleppo in the north (one case reported from Damascus was later found to be Sabin-like). The source of infection originated in Pakistan and was detected in Egyptian sewage in January, 2013. It is relevant to mention here that Syria has been polio-free since 1999. The country is facing a war-like situation for a couple of years, resulting into a perilous combination of devastated public health system, poor sanitation, rapid decline in polio immunization rates-from 91% in 2010 to 68% in 2012-, and massive displacement. Nearly 3 million people have crossed international borders to migrate to Lebanon, Jordan, Iraq, Israel, Turkey, and Egypt. The migration is posing threat to other continents, including Europe that has been polio-free for over a decade.
With a collective resolve, the world can turn this crisis-like situation into an opportunity to address the funding gaps to avoid a 2012-like programmatic emergency, to minimize the immunity gaps by carrying forward the supplementary immunization activities (SIA) in endemic countries and raising the alarm to strengthen routine immunization (RI) everywhere, and to rigorously maintain the sensitivity of acute flaccid paralysis (AFP) surveillance. But the cardinal question is as follows: Do we need a Syria-like experience for a wake-up call, when 2013 was punctuated with several worrisome events, arguably much bigger in significance and gravity? Let us take a rundown through the events of a turbulent 2013. On December 31, 2012, the world missed the deadline to stop WPV transmission once again. Set in 1988, Global Polio Eradication Initiative's (GPEI) original deadline of 2000 had already been extended several times.  The new year started with fatal attacks on vaccinators by Islamic extremists, mainly in Khyber Pakhtunkhwa and Waziristan provinces of northwest and Sindh in south. On January 1, 2013, six female health workers and a male doctor were shot dead, and this tragic event had a history. Since mid 2012, over 30 health workers have been killed in Pakistan. Several security personnel on polio duty have also been shot dead or bombed. , Similar threats have been reported from Nigeria as well.
What offset the case count in 2013 was the WPV1 outbreak in Horn of Africa, mainly involving Somalia (190 cases), Kenya (14 cases), and Ethiopia (9 cases), from May through December. This resulted in a situation where annual number of WPV cases from non-endemic countries outnumbered the cases from the endemic countries (240 versus 159).  This has happened only once before, in 2010, when outbreaks in Tajikistan and Congo did offset the calculus (1120 versus 332). Although this phenomenon is expected as we approach the peri-eradication period, it is unsettling nonetheless. Equally worrisome was the silent circulation of WPV1 in Israel, West Bank, and Gaza. Starting from February, 2013, this continues in 2014. Although no case was reported because of high inactivated polio vaccine (IPV) coverage, Israel had to reintroduce oral polio vaccine (OPV) in the national immunization schedule besides deploying it through several SIAs to interrupt this circulation. 
The year 2013 would also be documented as a year of some great positives. With 'zero case', the world might be witnessing the end of second wild poliovirus-WPV3. Affected countries, with global partners, could generate and sustain a rapid and effective response against outbreaks and could also stem the silent circulation. They have also evolved customized microplans and security protocols to address cultural and social resistance to polio campaigns, under extremely difficult circumstances. With assured commitment of support from partners, funding gaps are being plugged rapidly. And at the global level, there was a series of cardinal events that marked 2013. In January, the World Health Organization (WHO) supported 'Scientific Declaration on Polio Eradication',  and in April, the GPEI launched 'Endgame Strategy 2013-2018' at the World Health Assembly. 
Lessons Learned from India
One of the highlights of the endgame strategy is the emphasis on 'all polio disease (wild and vaccine-related)', which guides a parallel pursuit of WPV eradication by 2014 and elimination of circulating vaccine-derived poliovirus (cVDPV) within 120 days of new outbreak. This strategy also underlines several lessons learned from India, 'the most technically challenging place'. Some of the simple programmatic interventions like finger marking, house-based microplans, and mapping missed children are now being used in the remaining endemic countries. Other more complex lessons learned at the 'ground zero' of western Uttar Pradesh and Kosi belt of Bihar, during a very eventful decade relate to the following: Different complexions of social resistance against SIAs, type of vaccine to be used during SIAs, probable game changers, and the big picture of such an unprecedented eradication program. The speaker, in his individual capacity and as part of the polio group at International Clinical Epidemiology Network (INCLEN), has been engaged in polio-related enquiry, advisory and program activities since the first pulse polio campaign in Delhi in 1994. As academic group, we have also been engaged in the debates and evidence generation from the polio hotspots, and many of the present risks to the program were foretold and documented in the polio- and pandemic influenza-related discourse. ,,,,,,, In fact, it would be wrong to place undue importance at one particular arm of interventions. There may be serious breakthroughs during the course of India story, but identifying a single game changer may not be correct. This was realized that such an unprecedented community-based program could never be managed as a 'technical mission'. Vaccines, immunology, and microbiological issues were of cardinal importance but addressing social and cultural resistance to repetitive vaccination was critical to the success of the program.  It was highlighted in some of the Indian hotspots that the district level SIA coverage might have looked good in spite of harboring clusters of perpetually unimmunized children. When located in dense population with poor sanitary conditions, such clusters may sustain low level of WPV circulation. This has happened in Netherlands where several outbreaks of poliomyelitis occurred in the last 3 decades of 20 th century, among clustered unvaccinated persons despite around 97% vaccine coverage rates.  Many shades of social and cultural resistance were also identified and systematically deconstructed in India. The phenomenon had a strong share of religious and geopolitical contents. On another plane, communities on the other side of class divide, across religions and social groups, remained sceptic clients of this repetitive population-based intervention. Several filibusters also played their roles in stalling the progress of the social acceptance, and in the midst of this noise, children were held hostage between parents and the state for different types of barter and bargain. ,
The type of vaccines used in SIAs was also a contested territory generating several ethical as well as technical concerns. In 2005, a calculated epidemiologically guided decision was taken to selectively target WPV1. This was done in consideration of higher paralytic rate of WPV1 and its tendency to spread to polio-free areas. Arguments that trivalent oral polio vaccine (tOPV) was a weaker vaccine in comparison with monovalent oral polio vaccine type 1 (mOPV1) gradually gained momentum and support. But, from the ethics point of view, the risk involved in targeting a single virus in SIAs was significantly high in the backdrop of dismal RI with tOPV. From the client's side, the severity of paralysis caused by WPV3 was no lesser that that caused by WPV1. When a large proportion of children did not receive tOPV for nearly a year in some areas, many thought that this paved the way for unleashing of WPV3. mOPV1 was deployed at a massive level in Uttar Pradesh and Bihar from April, 2005, and we witnessed explosive outbreaks of WPV3 in 2007-2009. mOPV3 was also used from December, 2005 in some selective SIAs, but the damage might have been done. While taking a very strong position on this issue, the Indian Academy of Pediatrics (IAP) termed the surge of WPV3 in 2007-2009 as an 'Iatrogenic Outbreak'. The academy, through its presidential note, also expressed concerns that the indigenous expert advice was ignored in some critical decisions.  The best way would have been to target both the viruses concurrently. This was ultimately done in 2009 with bivalent oral polio vaccine (bOPV), which proved to be a major breakthrough. There are some unanswered technical questions also in this narrative. mOPV1 and mOPV3 were licensed in India in early 2005. This major step was based on a 3-decade old Indian study.  Although their protective efficacy was assessed, through a case-control study in Uttar Pradesh and Bihar, in 2006, they were already being used in several SIAs starting from as early as April, 2005.  Was this placing cart before the horse? A newer high-potency vaccine that was already deployed on a massive scale should have been supported by a robust prerelease evidence base. Moreover, the higher potency of mOPV used in the study was not considered a putative factor of difference between mOPV versus tOPV, and the stark difference in the efficacy was seen only in Uttar Pradesh when Bihar was comparable in diarrhea, sanitation, and overcrowding.
Threats to the Endgame
Coming back to endgame post-eradication interface, we have to stop WPV transmission globally by the end of 2014, assure delivery of at least one dose of affordable IPV through RI, and boost RI coverage drastically. Once this is achieved, a switch from tOPV to bOPV in RI and SIAs is to be planned between 2016-2018 in approximately 144 countries. These two steps would finally pave the way for simultaneous global cessation of bOPV in 2019-2020. Meanwhile, some stockpiling of mOPVs would also be required for post-eradication phase. Potential role of antiviral drugs in this era is also being explored by GPEI, as the IPV protects the recipient but does not stop poliovirus shedding. Established in 2006, poliovirus antivirals initiative is trying to develop two categories of antivirals: Capsid inhibitors and protease inhibitors, to take care of resistance-related issues in future. They are presently being tested to prevent, reduce, or stop poliovirus shedding in subjects given OPV. If found successful, their anticipated use may be among immunodeficient people who are chronically shedding poliovirus and for unintentional laboratory exposures. Antivirals may also be deployed, along with IPV, in the communities exposed to cVDPV outbreaks. 
In the context of this interface, we need to take account of some peculiar threats the world is facing today. The biggest of them is the global build up of 'never exposed' young adults, swelling with every new birth cohort. It would have devastating consequences if WPV keeps getting access to polio-eliminated areas with weak RI and downscaled SIAs. Besides causing reversals against polio eradication efforts, such reintroductions in non-endemic countries causing widespread outbreaks are huge setbacks for public health programs in general. Mass fatigue associated with this repetitive exercise, confounded with cynicism in certain sections, and motivated hostility in some regional pockets, is going to put peripheral health workers under tremendous pressure. As we are closing to the new deadline of 2014, some of us will have to reexamine and question the ethics of 'Right To Say No' and will have to apply the principles universally. Let us take the case of a developed country-USA. Two states, Mississippi and West Virginia offer exemption from childhood vaccination on health grounds. This is okay, but when another 15 states add religious reasons to grounds for exemption, they obviously go overboard. Barring some esoteric and freakish interpretations, no living religion or 'way of life' resists disease prevention, and many in USA say that the biggest opposition to vaccines comes from Hollywood celebrities instead of religion. The situation takes a curious turn when another 15 states, including Washington, add philosophical reasons to these grounds. This translates to any reason you want. Just say "I don't want my child vaccinated" and that is it.  Now compare this scenario with that of violent attacks on vaccinators in Karachi or Khyber Pakhtunkhwa by some heavily armed militants who want to exercise their 'Right To Say No' for a whole community, and you get the point. The big question is how fair or how selective we are in applying a so-called 'universal approach'. We cannot offer some of the finest forms of 'right to choose' to the people of high-income countries and continue to deny that elsewhere. Equity is integral to the concept of ethics, so what is right for the privileged cannot be wrong for underprivileged, on both the issues such as 'access to vaccines' or 'freedom of self-determination'. On another plane, any universal coverage, regardless of the soundness of intervention, will go against the very grain of the founding principles of 'Primary Health Care'. This will also move against the ethics of fundamental human rights, right of self determination, autonomy, and right to abstain. Nonetheless, many health interventions would demand best attainable universal coverage before they succeed. In such a scenario, leaving the debate of self-determination to esoteric thinkers or fringe militant groups may be disastrous. Freedom is a wonderful thing, but exercising a fundamental right to kill or deprive someone else is not. Let us make exemptions a bit more difficult and apply that universally! Differential interpretations of 'right to say no', on both sides of the divide, is damaging a global cause.
Civil unrest and war-like situation in many of the remaining polio hotspots have always been serious impeding factors for the program. In some of these areas, social mobilization, managing SIAs, and mapping missed children are extremely difficult and risky for health workers. Sensitivity of AFP surveillance and quality of information on RI and SIA coverage would also remain suspect in these last frontiers. Although surface movement of migrating people may be the major concern for poliovirus spread in pre-eradication scenario, civil aviation will also need to be factored during the post-eradication phase. Magnitude of civil aviation that we have today may also pose some problems.
The Way Ahead
This is also the time to prepare for the next eradicable disease, measles. After the eradication of variola, GPEI was the second worldwide effort of comparable nature. How measles lost out to polio at this stage remains an 'unknown'. Going by scientific rationale, measles should have stayed at the center of the agenda, even if it was crowded. The disease burden of measles was, and continues to be, comparable with any major pediatric health problem. The phenomenal social mobilization and energized health machinery for polio campaigns must also be optimally utilized for this newer challenge. However, measles is going to be a tough ask. With basic reproduction number (R0 ) ranging from 12-18 and herd immunity threshold from 92-94%, the degree of difficulty in eradicating rubeola is going to be much higher. Although measles has a commonality with smallpox in not having subclinical infection, polio is closer to variola in terms of R0 (5-7 versus 6-7) and herd immunity threshold (80-86% versus 83-85%). The best strategy against rubeola would be going big and going fast. Critical question is how to do it without looking like another top-down program of mammoth magnitude, with a dedicated surveillance system. Throwing a vertical program on people by giving it a community-based facade is something that we have witnessed through later half of 20 th century, the new age programs will have to learn to make it community-owned as well. ,
There is another aspect of violence faced by health workers that needs a constant reminder. While we acknowledge the remarkable contribution made by some well-known personalities, we must also remember the phenomenal work done by thousands of vaccinators and volunteers world over who have championed the cause at ground level. Please also spare a thought for the health workers killed on duty, including Akbari Begum, Anita Zafar, and Fahad Khalil who were shot dead on January 21, 2014 in Karachi. Akbari Begum was the mother of a differently abled child. These ordinary people, with extraordinary courage, did not die for polio. They died for modern sensibility and civilized living, in some of the most difficult areas of the world. The cause of polio eradication is just a part of this big picture.
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