Eradicating Polio: Making a Short Story Long

COMMENTARY

Till the week-ending 28 March 2009, I ndia reported 21 cases of WPV, 20 of them from the endemic states of Bihar and Uttar Pradesh and one from Delhi. Nine of these were WPV1 cases signalling that the gains in terms of reduction of WPV1 in 2008 were perhaps short-lived. The number of compatible cases, a critical but underplayed indicator, is yet to be released for the first quarter. Three hundred and fortyseven compatible cases were reported in 2008. The progress in terms of reduction in the number of infected districts has been quite slow from 114 districts in 2006, to 99 in 2007, and 90 in 2008.3

Theory and Practice

Beyond WPV1 and WPV3: The Indian Academy of Paediatrics (IAP) has taken the position that the current surge of WPV3 cases is an “iatrogenic outbreak”. It has argued that despite the epidemiological rationale of prioritising WPV1, it is unethical to underplay the impact of WPV3 since at the host level, the end results are the same. Thus, yet another variant, the Bivalent Oral Polio Vaccine (boPV) is on the anvil. Despite the intricate strategisation by the India Expert Advisory Group (IEAG), balancing monovalent Oral Polio Vaccines (OPVs) and trivalent OPVs, nearly oneeighth of WPV cases in India were WPV1 during 2008 (globally, WPV1 accounted for about 60% cases). Noting the wild virus like characteristics of vaccine derived polio viruses (VDPV) in Egypt (Kew O M et al 2004), John argued for “true eradication”; defined as, “zero incidence of infection with wild and vaccine viruses” (John 2004). The epidemiological rationale of the programme, particularly the notion of “eradication” interpreted by GPEI, has been questioned by other scholars (Sathyamala et al 2005). The 2009-13 Strategic Plan acknowledges that vaccine associated p aralytic polio (VAPP) and VDPV are “inconsistent with global eradication of paralytic poliomyelitis”.

The goal of the present campaign should thus be restated as “elimination” and e fforts made to achieve that (Dowdle 1998).

Injectable Polio Vaccine: Expert bodies such as the IEAG and the Advisory Committee on Polio Eradication (ACPE) have

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signalled the introduction of the Injectable Polio Vaccine (IPV) in western Uttar Pradesh. OPV cessation has been on the cards for some time; the incidence of significant numbers of WPV cases has led to its continuation. At least 1.5 to 4.5 million doses of IPV are expected to be procured once the government of India gives the g o-ahead.

Meanwhile, the global experience is varied; Japan and Cuba achieved interruption with two doses of OPV, while many countries in Latin America, Africa and Asia have used OPV for prolonged periods. Introducing IPV in western Uttar Pradesh could turn out to be a technological gamble. Dasgupta et al (2008) in Moradabad and J P Nagar districts mapped stake holder perspectives regarding introduction of IPV. Issues of logistics difficulties including trained vaccinators (in an already weak health service system) and injection safety were raised strongly both by providers and community stakeholders. IPV was unlikely to have any great demand given the lukewarm response to preventive injections (vaccines) borne out by routine immunisation (RI) coverage rates. Any move to introduce IPV should take these issues into account.

Routine Immunisation

The increased emphasis in routine RI seems to be paying off in Bihar, Chhattisgarh, Jharkhand and Uttar Pradesh. The increase is most dramatic in Bihar and Jharkhand

– a doubling of the rate from 20.7% to 41.4%, and 25.7% to 54.1 %, respectively. Significantly, the proportion of children who have not received any vaccination is also high; as many as 24% in U ttar Pradesh (Dasgupta 2009). In Moradabad, less than a third of the children received three doses of OPV. The corresponding figures for J P Nagar, Baghpat, Badaun, Mainpuri and Aligarh are 36%, 35%, 22%, 37% and 39%, respectively. Accor ding to district-level household survey of the government (DLHS-3), poor RI coverage in the most vulnerable districts shows that things have clearly not worked where they were required the most. The RI programme can deliver only if the primary healthcare services become more effective and responsive. The National Rural Health Mission (NRHM) has brought in some improvements and promises. RI has a long way to

go in these districts if it has to make a difference to the polio eradication campaign.

Patience Is Running Out

Immunisation campaigns are a lot more beyond “technology missions”. They have deeply rooted social and political dimensions, in addition to health benefits. T echnical strategies, specifically, vaccinerelated innovations have hogged the l imelight. Social determinants of the p rogramme have not received the attention that they deserved (Arora et al 2007). S ocial resistance to immunisation programmes (particularly pulse campaigns) by parents of under-five children has been reported from Uttar Pradesh and Bihar (and other parts of the world) along with “fatigue” and “burnout” of the service providers. The two have acted in tandem.

The GPEI has adopted a range of social mobilisation strategies and in the high risk states of Bihar and Uttar Pradesh, there is a platform of the social mobilisation network (SMNet). Vertical programmes like the GPEI leave little space for community involvement in decision-making pro cesses. Though innovations are frequently being made in information, education and communication and social mobilisation strategies, marginalised communities (across religions and social groups) in areas of poor development remain sceptic clients. The feeling of “otherness” needs to be minimised before optimal acceptance for this repetitive state programme is expected. The primary health centre doctor is uniquely positioned to facilitate a process of trust. However, s/he can claim legiti macy only when effective public health services are delivered on the ground. Health services should not be used as a tool but need to be visualised as one of the core components of development.

Concluding Comments

The disappointments of 2008 with regard to the pulse polio programme are well known. A “stand alone” success seems elusive, while the public health system in the country continues to be weak. The NRHM has brought some cheer in terms of r esources, infrastructure and models of governance. There has been an intellectual revival of the concept of primary healthcare. The World Health Organisation has recently published the report of the

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Commission on Social Determinants of Health- 2005-2008. Programmes can overrely on technology without due atten tion to social determinants, only at their own peril.

Much action has been witnessed over the last several years, based on recommendations of national and global policymaking bodies. Serious biological and programme management debates have turned into hackneyed clichés about vaccines and doses, driven by bursts of enthusiasm and panic. There have been multiple learnings at local levels and a remarkable commitment by health workers and managers; many are disappointed if not c ynical. The saga of the campaign has taken its toll. Deadlines and milestones have ceased to be relevant. Fatigue, both among com munity members and healthcare workers, is likely to feed upon itself further w eakening the campaign. Migrant workers and religious minorities, clearly among the most marginalised communities, have become targets in a high-risk approach. Given the definitional boundaries, this is at best an elimination campaign; eradication is a distant dream. But even that would not be possible without sound policies, determined social implementation (certainly transcending technical implementation) and refocusing political attention and social control towards building a responsive and effective primary health care system.

A Postscript

The AFP Surveillance Bulletin released on 6 June 2009 put the number of confirmed WPV cases at 63, and in a first in India, two VDPVs one each of Types 1 and 2. VDPVs are defined as live, attenuated strains of the virus contained in the OPV which have changed and reverted to a form that can cause paralysis in humans with the capacity for sustained circulation. P rogramme managers assure us that “they have been seen in many countries. Many VDPVs are isolate that do not progress any further. Those that do circulate respond readily to high quality immunisation response.”4

There are three caveats. First, the emergence of VDPVs signifies continuing low levels of immunity at the population level. Media reports suggest that a two-year-old boy from East Champaran, Bihar, who was confirmed with VDPV, did not receive any dose of RI and was thus vulnerable despite several doses of pulse polio – so much for the myth of the programme machinery. Despite impressive aggregates, less visible clusters of unimmunised children with low RI may sustain the infection; that such clustering is not random is another complex story. Evidence from across the globe (Hispaniola, Philippines, Egypt and Nigeria) is a pointer that VDPVs can circulate silently for prolonged periods. Second, the media report states that “investigations to determine the immunological and clinical status of both have been initiated”. Rare immune deficiency disorders of hosts lead to excretion of immune-deficiency-related vaccine-derived polioviruses (iVDPVs) for prolonged periods. The scientific consensus is that iVDPVs are less dangerous than circulating VDPVs (cVDPVs) at the current phase of the eradication campaign. Whether the cases in India are cVDPVs or iVDPVs are under investigation. But the search for individual-level “risk factors” should not obfuscate population-level d eterminants of low RI coverage; that would be missing the wood for the trees. Third, lower sero-conversion attributed to recurrent infections and malnutrition r equires urgent attention. “Flagship programmes” of the new central government are expected to address these unfinished agenda and have the potential to make a difference; but then, global deadlines have minds of their own.

Notes

1 The World Health Organisation, Forty First World Health Assembly, Geneva, 2-13 May 1988, WHA resolution No 41.28, Global Eradication of Poliomyelitis by the Year 2000, http://www.who.int/ csr/ihr/polioresolution4128en.pdf. Accessed 20 December 2007.

2 Global Polio Update.

3 The National Polio Surveillance Project (NPSP). Infected districts 2008. http://www.npspindia. org/infecteddistricts08.asp

4 Polio from vaccine: India confirms two cases. Posted: Friday, 12 Jun 2009 at 0157 hrs IST. http:// www.indianexpress.com/news/Polio-from-vaccine--India-confirms-two-cases/475202 accessed on 12June 2009.

References

Arora, N K, R Dasgupta and L Sushant (2007): “The Polio Eradication Initiative: Need to Focus on S ocial Determinants”, Indian Journal of Medical Research, 126: 500-01.

Dasgupta, R (2009): “Universal Immunisation Programme (UIP): The Journey and the Tensions” in Chhikara (ed.), Governance: Problems, Prospects and Perspectives (Gurgaon: Hope India Publications).

Dasgupta, R, S Chaturvedi, V Adhish, K K Ganguly, S Rai and L Sushant (2008): “Social Determinants and Polio ‘Endgame’: A Qualitative Study in High Risk Districts of India”, Indian Pediatrics , Vol 45, 17 May, pp 356-65.

Dowdle, W R (1998): “The Principles of Disease Elimi nation and Eradication” in Global Disease Elimination and Eradication as Public Health Strategies, WHO Bulletin, 76(2): 22-25.

John, T J (1996): “Can We Eradicate Poliomyelitis?” in H P S Sachdev and P Choudhury (ed.), Frontiers in Pediatrics (New Delhi: Jaypee Brothers Medical Publishers), pp 76-90.

– (2004): “Who Benefits from Global Certification of Polio Eradication?”, Indian Journal of Medical Research 120, November, pp 431-33.

Kew, O M, P F Wright, V I Agol, F Delpeyroux, H Shimizu and N Nathanson (2004): “Circulating Vaccine-derived Polioviruses: Current State of Knowledge”, Bull World Health Organ (Bulletin of World Health Organisation), 82: 16-23.

Sathyamala, C, Onkar Mittal, Rajib Dasgupta and Ritu Priya (2005): “Polio Eradication Initiative in I ndia: Deconstructing the GPEI”, International Journal of Health Services, Vol 35, No 2, pp 361-83.