How India went from 741 cases to zero in just two years

The last case of wild polio virus reported in India was exactly one year ago, on January 13, when stool samples showed that 18-month-old Rukhsar Khatoon in West Bengal had polio. She has since recovered, but it is the progress of whittling down from the largest number of cases in the world to zero that is fascinating to public health experts globally.

Clearly, the nation had to overcome tremendous challenges to get here – not least of them, a huge population, the logistics of covering a vast geographical area, poor sanitation and infrastructure, resistance among some groups of people to taking the vaccine, and children of migrant communities who were difficult to cover.

It was with the Expanded Immunisation Programme in the late 1970s that India started its battle against polio. In 1985, it became a part of the Universal Immunisation Programme launched throughout the country. A significant milestone in the journey was the launch of the National Pulse Polio Initiative (PPI) in 1995-96, targeting coverage of every child under five in the country with the Oral Polio Vaccine (OPV) to be given on two National Immunisation Days, one each in December and January, followed by more focused state-level immunisation campaigns throughout the year. The PPI set for the nation a new target — eradication of polio by 2005.

This involved better social mobilisation through involvement of millions of frontline workers from the private health sector, members of Rotary International, volunteers, anganwadi workers, besides the massive public health workforce. In addition, the PPI created systems – cold chains for storage and transportation of the vaccines, ensuring vaccine vial monitors on each vial, follow up and mop up campaigns to track children left out during immunisation days.

India has spent more than Rs. 12,000 crore on PPI, a Union Ministry of Health release said. One of its major partners, Rotary International says it has spent over $149 million in India over the years, as part of its contributions. In each PPI, 24 lakh vaccinators visit over 20 crore households to ensure that nearly 17.2 crore children, less than five years, are immunised with the OPV. Mobile and transit vaccination teams immunise children at railway stations, bus stands, market areas, and construction sites. Special rounds were held to give the OPV to children of migrants and refugees.

And yet, concerns remained. Pockets of Uttar Pradesh and Bihar were still endemic, responsible for the cases being reported in the country, directly, and through migration. In recent years, the government targeted 107 ‘high risk' blocks in Uttar Pradesh and Bihar, and identified the challenges, which included remote locations, refusal of vaccine in some areas, and migrating populations. ‘Influencers', including religious leaders, were enlisted and tracked for each high risk area, and this helped polio teams reach more families. Positive results were seen as a consequence: UP and Bihar have not reported any case of polio since April 2010, and September 2010, respectively.

While India has clearly stepped into the endgame stage, it is by no means closure, public health specialists warn. Mr. Azad tempered his joy over the achievement with concerns about the future. “We are excited and hopeful, and at the same time, vigilant and alert”. He cautioned that there was no room for complacency, with the nation having to maintain its zero-cases record for the next three years to be able to totally ‘eradicate' poliomyelitis. “It is a great stride forward,” Deepak Kapur, Rotary International's India Polio chair, said. “However, it is just one stride ahead. Only one third of the journey has been completed, we need three clean years for the certification.”

The greatest concern is the possibility of infections carried across borders by migrating populations. GPEI points out that in 2011, Pakistan and Afghanistan both saw alarming increases in polio cases, and poliovirus from Pakistan re-infected China (which had been polio-free since 1999). In Africa, active polio transmission continues in Nigeria, Chad and the Democratic Republic of the Congo, with outbreaks in West and Central Africa in the past 12 months reminding the world that as long as polio exists anywhere, it remains a threat everywhere. Lieven Desomer, Polio Chief, UNICEF India, said, “The key challenge now is to ensure any residual or imported poliovirus in the country is rapidly detected and eliminated. This requires very high levels of vigilance and emergency preparedness to respond to any importation of wild poliovirus.”

In an e-mail response to The Hindu, Nata Menabde, WHO Representative to India, explained, “India must now capitalise on this progress and secure polio eradication. It must continue to protect children in polio campaigns and through improved routine immunisation coverage. Complacency is not a luxury the program can afford; continued high level vigilance for polio, emergency preparedness, and intense immunisation activities will be essential for rapid detection and elimination of any circulating poliovirus.”

(With inputs from Aarti Dhar in New Delhi)