Mission immunisation and polio eradication

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Today polio stands eliminated from all but two countries in the world. India was declared to have eliminated polio in the year 2014. Ten years later about 65 odd cases are still reported annually from Pakistan and Afghanistan. 24th October is world polio day, and we still await its global eradication.

Origins of poliomyelitis or Polio

Story of polio is indeed strange. We only find scanty mentions of this limb and muscle paralysing illness in ancient and medieval literature. First description of the disease was by Dr Micheal Underwood, an English physician in 1789. He described it as fever, followed by limb-paralysis, mostly affecting infants. Fifty years later, in 1840 German Orthopaedic surgeon Jacob Heine and Swedish paediatrician Karl Oskar Medin suggested that this disease is contagious. Till this time, polio was an infrequent occurrence.

First polio epidemics occurred in US in 1894, followed by 1916 and 1952. Many children died, and others were crippled for life. We could identify survivors by their callipers, crutches or wheelchairs. Amidst these occurrences, in 1921 Franklin D Roosevelt, who was then about 40 years old, developed paralysis of both his legs. Doctors attributed this illness to polio. This was probably first turning-point in history of this disease.

First turn-around

Roosevelt became US president in 1932. He won a second term in 1936. In 1938 he established a charity – National foundation for Infantile paralysis – “march of the dimes”. This charity funded polio research. While Roosevelt died of stroke in 1945, his efforts lived on. In 1949 John Enders, Thomas Weller, and Fredreick Robbins isolated polio virus. This earned them 1954 Nobel Prize in Medicine.

Meanwhile Jonas Salk developed first polio vaccine in 1953. He first tested this vaccine on himself, and his family. In the next two years about 1.6 million children in US, Canada and Finland were “tested”and vaccine was found to be safe and useful. This first vaccine was approved in 1955, and by 1957 the number of cases of polio in a year in US had dropped from 58000 to 5600. It took “March of Dimes”, 20 years for this turn-around.

Cutter incident

US pursued polio immunisation at an aggressive pace. Salk vaccine was a solution of killed polio viruses, that was administered by an injection – known as in-activated polio vaccine (IPV). US government tested this vaccine in school-children in 1954 – in one of the largest public health experiments. Salk did not patent his vaccine. Clinical trials were successful, and in 1955 US government asked twelve companies to produce it in bulk for the entire country.

Public sentiment, a heroic polio affected president, and quest to save children were all forces behind this agressive mission. However, vaccine produced by one of the companies (Cutter Laboratories) contained live virus. About 40,000 children who got Cutter vaccine developed polio, three died, and entire world was skeptical. While, US continued its vaccine program, Europe delayed its launch due to safety concerns. For instance, France launched mass vaccination program only in 1958.

Oral polio vaccine

Albert Sabin, was also engaged in polio virus research in US. In 1956 he developed an oral polio vaccine (OPV). Since US had already rolled out IPV, Sabin tested his oral vaccine in Congo, and then in Soviet Union and Czechoslovakia. Despite cold-war, and ideological differences, US scientists also endorsed this vaccine.

This vaccine was administered in sugar cubes to school children. OPV made Czechoslovakia became first country in the world to eliminate polio in 1960. Sabin also made this vaccine available without any patents. OPV became an important tool in polio elimination crusade, in most part of the world. For instance, Cuba launched its polio vaccine mission in 1962, and has reported negligible polio cases ever since.

Till 1970s, different countries in the world followed their own immunisation policies. Coverage was poor, especially in the developing countries. Before 1970, polio was considered a problem of the rich and developed. Lameness surveys revealed polio to be a much greater problem in the tropics. Polio was added to the vaccination schedule. In 1974 Who launched expanded program of immunisation (EPI) that included vaccination for TB, Polio, Diphteria, Tetanus, Whooping cough, Measles and small-pox. We were already in process of small-pox eradication. (See a blog on small-pox eradication in postage stamps here)

Eradication of small-pox gives a push to immunisation agenda

Success begets success. In 1979 small-pox was eradicated from the globe. WHO made an official announcement on 8th May 1980. Forty years later, we realise that this event was the second-turning point in our journey towards elimination of polio.

For the first time in the history of mankind, we could demonstrate that diseases can be eradicated. Polio was the next target. In 1979, Rotary international announced its polio eradication efforts. It chose Philippines, and initiated a mass polio immunisation. Five years later, in 1985 Rotary International launched it “Polio-plus” initiative, and pledged 120million USD. Oral polio vaccine (OPV) was the tool used across developing world. This was a time when HIV pandemic had already hit the headlines. Oral was more acceptable, and OPV became a way to go.

Global polio eradication initiative

In 1988, WHO resolved to eradicate polio. This was named GPEI – Global polio eradication initiative. All countries of the world resolved to strengthen their immunisation programs. For instance, India embarked on a Universal immunisation goal in 1985. In addition to polio, it seemed possible to eliminate other vaccine preventable diseases as well. As a part of this immunisation push, many countries launched immunisation awareness drives. Postage stamps, across developing world were an integral part of this campaign.

Success at last

First success for polio was in 1991, when Luis Fermin Tenoro in Peru was its last victim in the Americas. Three years later, in 1994 WHO declared North and South America to be Polio free. This event had a profound impact on mass immunisations across the world.

In 1997, Mum Chanty was the last polio victim in Cambodia, and entire West pacific region. Three years later, in the year 2000 WHO declared elimination of polio from the West Pacific region. Two years later, in 2002 Europe was also declared as polio free (last case was Malik mines, in Turkey).

In 2003, only six countries had new polio cases – India, Indonesia, Yemen, Pakistan, Afghanistan and Nigeria. Immunisation efforts were bearing fruit.

Countries in Africa and Asia coordinated and strengthened their Polio immunisation campaigns. We had monthly oral polio drop campaigns. In India a popular slogan was “two drops of life”.

In 2008, new outbreaks were reported in Nigeria, Congo and Tajikistan. We could contain all of these quickly. In 2011, we had last reported wild polio victim from India. In 2014 WHO declared entire south-east asian region (that includes India) as polio free.

A success that endangered polio vaccination

In 2011, when we were at the verge of global polio eradication, US army, CIA and other agencies were close on heels of dreaded terrorist Osama-bin-Laden. CIA used vaccination program as a cover for surveillence. Health-workers engaged in administering polio drops in the locality were approached to run a fake vaccination program, and also asked to collect blood samples. Their spy-work helped identify Osama-bin-Laden’s hideout. CIA could confirm his identity, and Osama was killed in a raid. Shakil Afridi, a physician involved in this operation in 2011 is still in a Pakistani prison.

This clandestine operation had a fallout on mass polio immunisations in the region. Health teams were attacked, threatened and even killed. Immunisations were suspended. Vaccine hesitancy soared in the region. Polio persisted. Fake vaccination had undermined genuine efforts. While WHO declared Africa as polio free in 2020, Pakistan and Afghanistan remain only two countries in the world that still report cases. While in 2021, one case each was reported from both these countries, there were 22 reported cases the next year.

Awaiting eradication

Today, we still await global polio eradication. As polio cases fell, risk of vaccine polio cases was a concern. Therefore, we have phased out oral polio vaccine (which had three strains of live polio virus. We started this switch in 2016. Of three strains of wild polio virus, only one remains. We have declared strains 2 and 3 as eradicated in 2015 and 2019 respectively.

There are some twists in this tale. Roosevelt probably did not suffer from polio. His illness was probably a nerve inflammation – Gullian Barre Syndrome. Salk’s polio vaccine was not the first. It was William Hammon, but protection of his vaccine lasted only for five weeks. We celebrate Salk, but it was Sabin’s oral vaccine that has helped in polio eradication efforts. Today we have phased out OPV, and are back with IPV. Last, CIA claims that health team disguised as hepatitis vaccine workers and not as polio. None-the-less breach of neutrality in health care delivery have pushed back global eradication efforts by at least a decade. Despite these twists, we are on verge of a global eradication.