India moves closer to polio end-game
On 25 February 2012, WHO removed India from the global list of polio endemic countries. This milestone was celebrated not only in India and WHO’s South-East Asia Region, but around the world. The achievement was lauded by many health experts and development partners as living proof that polio eradication is technically and programmatically feasible if the proven strategies are fully implemented.
As 13 January 2013 passes, India and the South-East Asia Region celebrate the second year in history when there have been no new cases of wild poliovirus reported in the region. We are encouraged by the continued commitment of not only the government of India, but by all Member States of the region and the partners supporting the Global Polio Eradication Initiative, mainly US Centers for Disease Control, the Gates Foundation, Rotary International, UNICEF and WHO.
India’s polio strategy
Each nation-wide polio vaccination campaign in India involves vaccinating nearly 172 million children in more than 225 million households by 2.3 million vaccinators. Reaching the vast population with diverse sociocultural practices, overcoming the geographical barriers, achieving high vaccination coverage in all urban and rural areas despite weaknesses in health systems and ensuring coverage of the most vulnerable newborns and migrant populations have been the major challenges that were overcome by the polio programme in India. Perseverance and resilience of all stakeholders continue to be key factors in progress to date.
The programme involved the local religious leaders and institutions to solicit support and engagement of all sections of the society and implemented a special plan for 107 high-risk blocks of UP and Bihar to provide a complete package of health and sanitation services in addition to improving polio vaccination coverage in these blocks. Special vaccination teams were deployed during each campaign to vaccinate children in transit – at bus stands and railway platforms, inside running trains, on national highways and in market places. Appropriate communication strategies were designed by deploying more than 5000 community mobilization coordinators in UP and Bihar to mobilize families refusing vaccine to influence them to accept the programme. Indian celebrities were engaged to endorse the programme to enhance the visibility and improve acceptance of the polio vaccine. As a risk mitigation strategy, 81 posts along the Indo-Nepal border and five along the Indo-Pakistan border were set up to ensure continuous vaccination of all children crossing these borders.
New vaccines were introduced to address the challenges related to vaccine failures in areas with high force of poliovirus transmission and compromised vaccine efficacy due to environmental factors. The more efficacious monovalent oral polio vaccine (mOPV) was introduced in 2005 and the bivalent OPV in 2010 to break the last chains of poliovirus.
An intensive monitoring system was put in place to identify gaps in the preparedness and implementation of the polio vaccination campaigns. More than 3000 independent monitors were deployed to provide feedback so that programmatic actions could be taken based on real time information generated through this system.
Surveillance for polio continued to operate at very high levels of sensitivity and speed. The surveillance system, including the laboratory performance, consistently surpassed the WHO recommended standards and global indicators of sensitivity. Sewage sample testing was conducted in Mumbai, Delhi, Patna and Kolkata to detect any wild polioviruses in the environment. Surveillance data were consistently used to prioritize and guide immunization activities and strategies.
The polio eradication initiative in India was backed by appropriate research studies to generate evidence to guide strategies and formulate policies. Studies to assess the population immunity and to explore the best vaccines for boosting population immunity were behind major programmatic decisions.
India’s progress and efforts have been lauded by both, national and international health experts and groups. The Independent Monitoring Board, convened at the request of the World Health Assembly to monitor and guide the progress of the Global Polio Eradication Initiative’s Strategic Plan, has in its various reports appreciated the Indian Government and its polio partners for their coordinated efforts to reach zero status. A recent report of the Board states “The very best news comes from India. For years, many believed that the challenge of stopping polio transmission in India would be the downfall of the programme; that, quite simply, it could not be done. They have been proven wrong. What many thought unachievable has been achieved.”
Time for sustained surveillance
While tremendous progress has been made over the past many years and sustained over the past two years, India remains at a risk of polio resurgence through a distant or cross border importation of the wild poliovirus from countries where the virus continues to circulate. India, therefore, needs to ensure that high immunity is maintained against poliovirus, the surveillance remains sensitive to pick up any importation and all states are in a state of emergency preparedness to respond urgently to any importation, if it were to occur.
India’s programme is now supporting the polio eradication initiative in the remaining polio endemic countries – Afghanistan, Nigeria, and Pakistan. Multiple missions comprising WHO, UNICEF and other agency staff have gone to these countries during the past year to share and apply the information and knowledge acquired by the India programme over the past 16 years.
The polio infrastructure, expertise and operational experience is now being used to strengthen routine immunization in India and to protect its children from various vaccine preventable diseases, as well as for overall strengthening of existing health systems, by applying the lessons learnt during the course of polio eradication.
WHO South-East Asia Region
Completing two years without the detection of any wild poliovirus in India brings the South-East Asia Region of WHO closer to being certified as polio-free. The Region, comprising 11 countries (including India), is on track to be certified polio-free upon completion of three years of not reporting any wild poliovirus – in early 2014. The South-East Asia Region will be the fourth WHO region in the world to be certified as polio-free.
As it completes two years, India is also looking forward to playing a role in the development of the polio end-game strategy, with support from WHO and other partners. The strategy involves a carefully planned phased withdrawal of the oral polio vaccines from the programme while phasing in the use of inactivated polio vaccine (IPV). India is a front runner in conducting research to support policy decisions as a part of the polio end-game strategy.
The momentum of this accomplishment by India must continue. India cannot pause as long as wild poliovirus continues to circulate anywhere in the world. Sustained efforts must continue until global polio-free certification is achieved.