Poliovirus: finish the job

Indian child receiving one of the four necessary poliovirus vaccine doses. Photo credit: Global Polio Eradication Initiative.

After a year without a polio outbreak, India was crossed off the World Health Organization’s (WHO) list of polio epidemic countries last month, leaving only Pakistan, Nigeria, and Afghanistan.

However, experts warn that mitigation and containment are not enough. Using strategies proven successful in India, final efforts in the world’s vulnerable regions are being implemented to ensure that the poliovirus cannot regain a stronghold.

“India is now in the same situation as all other polio-free countries in the world, in that they are at risk of re-infection from the remaining endemic countries until the disease has been eradicated everywhere,” Dr. Bruce Aylward, WHO’s Assistant Director-General for Polio, Emergencies and Country Collaboration, tells MediaGlobal. “We have seen time and again that poliovirus from endemic areas can spread to re-infect polio-free countries.”

Previously viewed as the most formidable stronghold of the poliovirus due to sanitation issues, remote rural villages, and an extensive migration population, India was not a prime candidate for poliovirus eradication. When the Global Polio Eradication Initiative (GPEI) launched in 1988, in partnership with WHO, Rotary International, and UNICEF, India reported 24,000 cases per year.  By 2009 though this number had dropped to 741, then to 42 in 2010, and finally zero cases in 2011.

“India is proof of concept that polio can be eradicated. It is one of the most densely populated countries in the world, and yet with their political will, their financial commitment, and their drive towards excellence, they finished the job,” Carol Pandak, Manager of Rotary International’s PolioPlus Program, tells MediaGlobal.

Due to the proven commitment of the Indian government, a variety of strategies were implemented to ensure complete immunization coverage of children under the age of five. Specifically, education and communication were key tools. “You cannot just go house to house,” Pandak tells MediaGlobal. “You have to figure out where these people come from, who do they trust to get those people to do the immunization?”

Consequently, strategies that engaged and educated local religious and traditional leaders on the benefits of polio immunization were vital in reaching rural communities. Extensive mapping of the migrant population, found to be an originator for the emergence of the poliovirus, was also conducted to ensure every child was immunized. Finally, India ensured the completion of its strategies though a strict accountability system.

“Ultimately, these efforts ensured that virtually all children were reached with the right vaccine, enough times, across all areas of the country, to actually stop the individual transmission chains,” Aylward tells MediaGlobal. “From a technical and operational perspective, it is an unparalleled success, and it clearly underscores the technical feasibility of polio eradication worldwide.”

In the remaining epidemic classified countries, the current local strategies to prevent a polio outbreak are lacking.

“In Nigeria, Pakistan, and Afghanistan, there is strong support from the national governments, and innovative activities are being implemented in all of these countries,” Aylward tells MediaGlobal. “However, this commitment has not yet fully translated into consistent improvements at the district-level, which is where the program is implemented.”

During the recent PolioPlus Summit 2012 in Delhi, these countries evaluated India’s strategy towards ensuring complete immunization of children.

“India did it by mapping out their entire migrant population, by going into the slum areas, by conduction immunization over and over, but really understanding where those missed children were and figuring out how to get them. Pandak tells MediaGlobal. “I think if you can replicate that in Afghanistan, Pakistan and Nigeria, the job will be finished.”

While finishing the fight will save the world $40-50 billion in poliovirus containment costs over the next 25 years, and prevent over 10 million cases of paralysis, the current strategy is hampered by a $1.09 billion funding gap. With sufficient funding experts believe the disease could be eliminated within the next 18 months.

There is a realistic plan to achieve a polio-free world in the near-term.  But we are currently lacking the financing, and this dangerously augments the risk of failure,” Aylward tells MediaGlobal. “And frankly, the consequences of failure are unthinkable: as many as 200,000 children again paralyzed by this disease each and every year, within the next ten years.  Given how close we are, failure should not be an option.”

If the effective local strategies of India can be implemented in Afghanistan, Pakistan, and Nigeria, the poliovirus will soon be the third infectious disease, after smallpox in 1980 and rinderpest in 2010, which has been successfully eradicated.