Polio did not leave India overnight!

What is polio?

Transmitted via the faecal-oral route, poliovirus invades the central nervous system and as it multiplies, destroys the nerve cells that activate muscles, causing irreversible paralysis in hours. Of those paralysed, 5-10% die when their breathing muscles become immobilized. There is no cure for polio, but there are safe, effective vaccines which, given multiple times, protect a child for life. If sufficient numbers are immunized against polio, the virus is unable to find susceptible children to infect, and dies out.

India was removed from the list of polio endemic countries after completing a year without reporting any case of polio In January 2012, a major milestone in the history of polio eradication. 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.

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. 
 

The strategy to make it happen

A number of major interventions and innovations have been made over the years to strengthen the polio eradication initiative in India and overcome the challenges and barriers that the programme faced. These interventions and innovations were reviewed, assessed and improvised to match the intensive efforts which became increasingly focused to address issues in the key vulnerable areas and among the most susceptible populations. The interventions covered all aspects of the programme – surveillance, supplementary immunization activities, vaccines, communication and research – and were strongly evidence-based, with detailed data to support why and where they were being introduced.

Innovations: Surveillance

Polio case identification – Initially, polio cases were classified based on the clinical features of polio or on a laboratory confirmation. In 2001, the case classification scheme was changed to a virological scheme where cases were classified as polio based only on a laboratory confirmation. This is a more accurate and reliable system of case identification.

Reporting network expansion – A large network of health facilities – over 33,700 sites, including public and private health facilities (ISM practitioners and quacks and faith healers included) have been enrolled as reporting sites for acute flaccid paralysis (AFP – suspected polio) cases in India. This has resulted in an increase in the number of AFP cases detected for investigation across the country, thereby increasing sensitivity of the system including amongst migrant populations.

Increase in sensitivity of AFP surveillance – In 2004, the case definition of AFP was broadened

to make the surveillance more sensitive for AFP case detection. There has been a dramatic increase in the number of AFP cases reported and investigated since.

Change in laboratory testing methodology – A new methodology for testing stool specimens was introduced in the laboratories in 2007, reducing the laboratory testing time by half. The new system takes about two weeks, thus ensuring a more speedy action after detection of wild poliovirus. The earlier laboratory methodology for testing stool sample for detection of wild poliovirus cases took up to five weeks for confirmation of a case.

Supplementary surveillance for polio – Wild poliovirus transmits through the faecal-oral route.

Therefore, environmental sewage specimen testing was started in Mumbai in 2001 to detect wild poliovirus to supplement the AFP surveillance. This has been subsequently expanded to Delhi

in 2010 and to Patna in Bihar and Kolkata in West Bengal in 2011.

Genetic sequencing of wild poliovirus – Genetic mapping and matching of every wild poliovirus

is conducted to determine the origin of the virus, track the spread of transmission, and also to determine the number and spread of genetic clusters of the virus. This helped the programme carry out immunisation and follow-up action effectively, not just in the area the wild poliovirus was detected, but also the origin of the virus/area of importation and areas at highest risk of further spread.

Innovations: Polio Immunization

House-to-house vaccination – When the programme started, the Pulse

Polio was a booth-only activity where children were given oral polio drops on the supplementary immunization activity days. To improve immunization coverage, the booth activity was extended to house-to-house immunization to actively search for and vaccinate missed children.

Identification of missed children – To facilitate identification of missed children, finger marking of every vaccinated child was launched in 1999. The little finger on the left hand of the child was marked with indelible ink. In order to ensure completeness of coverage, the vaccinators marked houses as P (all children in the house immunized) or X (children missed) based on whether all eligible children in the household had been vaccinated or not by the polio vaccination team.

Categorization of X houses visited – Categorization of X houses into sub-categories such as locked houses, houses with a sick child, houses that resist vaccination etc was introduced to facilitate appropriate follow up for vaccination. Using this categorization, houses with sick children can then be visited by doctors, refusal families can be visited by influencers, and so on.

Back-up ‘B’ team – The back-up team concept was introduced to ensure immunization of children who had missed being vaccinated despite revisits of the vaccinators to the household during the days

of the campaign. These missed children are usually those who are at school, sleeping in the morning,

with their parents at their places of work, or those whose parents have refused vaccination. After

the vaccination team ‘A’ has completed the morning visit to each and every household as

per the micro-plan, a ‘B’ team visit was started to vaccinate the children missed by team ‘A’.

Integration with NRHM – The polio programme has been integrated  with the National Rural Health

Mission (NRHM). The NRHM is aimed at ensuring effective healthcare through a range

of interventions at individual, household, community, and most critically at the health system levels.

The community worker ASHA – a trusted member of the community- is involved in mobilization and vaccination for polio.

Transit sites vaccination strategy –Children on the move often miss polio immunization. In order to vaccinate them, transit vaccination teams are deployed at train stations, on running trains, bus stands, highways, markets, prominent road crossings to give polio vaccine to children in transit.

Congregation site vaccination – Large gatherings at fairs and festivals provide regular opportunities for the poliovirus to spread and also for the programme to vaccinate the vulnerable population. Polio

immunization is carried out at all fairs and festivals in and around polio-endemic states – both at the

venue of these gatherings, and also all along the routes which people take to reach these venues.

Newborn tracking – With data showing that most polio cases occur in children less than two

years of age, a system was introduced in 2006 to identify, track and immunize every newborn child in the highest risk areas of Uttar Pradesh and Bihar. By ensuring newborns are quickly added to microplans and introduced into the routine immunization system, each child in these vulnerable areas receives up to eight doses of OPV through polio rounds as well as the routine doses before the age of one year.

The complete report: http://www.unicef.org/india/Polio_Booklet-final_(22-02-2012)V3.pdf

References:

1. http://www.unicef.org/india/health_3729.htm
2. http://www.polioeradication.org/Infectedcountries/India.aspx
3. http://world.time.com/2013/01/13/how-india-fought-polio-and-won