Polio: Reaching Every Child

Ann Lee Hussey administers polio drops to a child at a railway station in Moradabad, Uttar Pradesh. Photograph courtesy Anne Lee Hussey

Arshi and Bilal are sweet 2-year-olds living in the Dhaulana block of Ghaziabad, Uttar Pradesh. They smile, coo their first words and cuddle. But neither can stand without aid.

A year ago, their families noticed something unusual in their leg movements. Laboratory tests confirmed their worst fears—both children had contracted the crippling disease of polio. High population density, open sewers, polluted drinking water and malnutrition have made such places in Uttar Pradesh and Bihar perfect targets for the poliomyelitis virus, which attacks the nervous system of young children and can cripple them for life.

Last year, 42 Indian children became victims of the virus. Many will require multiple surgeries to be able to walk. That number, tragic as it is, represents a 90 percent drop in Indian polio cases from 2009 to 2010.

“This year we have seen an unprecedented progress never seen in the program before,” says Hamid Jafari, project manager of the National Polio Surveillance Project. “Strong and well coordinated partnership between the Government of India, WHO, UNICEF and Rotary International has ensured this success,” says Jafari, who has also worked as chief of the polio eradication branch at the U.S. Centers for Disease Control and Prevention, in Atlanta, Georgia.

Rotary International is a service organization established in Chicago, Illinois, 106 years ago, now with branches around the world, including 106,000 members in India. Rotary is committed to stopping the spread of polio from the remaining endemic countries—India, Nigeria, Afghanistan and Pakistan. Rotarians not only raise money to pay for polio immunization, but members travel long distances to help out.

One of these is Ann Lee Hussey, a veterinary technician and survivor of polio from Maine, the northeastern-most U.S. state. She has been coming to India for the past 10 years. She was in Moradabad, Uttar Pradesh, in November 2010 for an immunization campaign, then led a team of volunteers to help the anti-polio campaign in Nigeria.

Hussey remembers her first visit to a clinic in India, in January 2001, where she met with several polio survivors: “One particular girl caught my eye. She was 9 years of age. As I returned her smile I looked down and saw the same, thin right leg, the same heavy metal brace…. As I looked back at her face, tears streaming down my cheeks, she smiled again, seeming to understand my personal pain. I cried for her, I cried for me, I cried for all the senseless waste polio has brought to so many for so long.”

India is among the four countries that have failed to eradicate the polio virus, largely because it has found escape routes in the two most populous states, Uttar Pradesh and Bihar. In 2009, India had 741 cases of polio: 602 in Bihar and 117 in Uttar Pradesh.

Jafari explains why these two states have been among the most difficult places on Earth to fight against polio. “U.P. and Bihar, especially western U.P. and central Bihar, have posed a number of challenges because of high population density, poverty, low routine immunization, low sanitation and low hygiene. Widespread diarrheal diseases in these areas make the polio vaccine less effective.” Extensive movement of population from these areas poses another challenge. “They are more likely to miss the immunization campaigns. So, when they move, the virus moves with them,” he says.

Parents’ superstitious refusal to get their children vaccinated has been a major problem in certain parts of these states but Jafari says community participation has improved. “There are, of course, still some pockets of refusal associated with rumors or concerns about the safety of the vaccine. But we have actually found a higher level of acceptance in all communities and cases of reluctance and refusal have gone down.”

Tajikistan is an example of why it is so important to eradicate the polio virus completely. The Central Asian country had been free from polio since 1996, but in 2010 the virus spread from Uttar Pradesh, and has afflicted 458 children in Tajikistan, says Jafari.

As long as the polio virus is active in any part of the world, there may be an outbreak in other parts of the world. “India is really very, very important for global eradication of polio,” says Jafari. “Given the scope of challenges, the size, population and risk factors for polio, if eradication succeeds in India, then the global fight against polio is won.”

This requires repeated immunization drives in the polio endemic regions, which is a task of gigantic proportions. Last year, Uttar Pradesh and Bihar received “intense mobilization and up to 10 rounds of polio vaccination,” says Jafari. “Every house was visited eight to 10 times a year; 60 million children were given polio drops.” In a polio-free country, generally three doses of the routine vaccine are considered enough. But polio hotspots like Uttar Pradesh and Bihar require much more.

In January 2010, a bivalent vaccine was introduced which has the capacity to fight against type 3 polio and the more virulent type 1. This vaccine was developed and tested in India by WHO and is now being used globally. “We have seen significant decline in both type 1 and type 3 polio cases because of the use of the bivalent vaccine,” says Jafari. In routine immunization programs, the standard trivalent vaccine is generally used. It provides immunity against all three types of polio virus, although type 2 has already been eliminated. The last case was in 1999 in Aligarh, Uttar Pradesh.

“Unprecedented social mobilization” in Uttar Pradesh and Bihar is another factor behind the recent success in these two states, says Deepak Kapoor, chairman of Rotary International’s India National Polioplus Committee. He says the committee “has garnered public support for the program by involving the politicians, bureaucrats, local leaders, Bollywood actors and famous sportspeople.” The committee also approached religious leaders to allay fears about the safety of the vaccines, Kapoor says.

The Global Polio Eradication Initiative is led by national governments in partnership with the four spearheading partners: WHO, Rotary International, the U.S. Centers for Disease Control and Prevention and the United Nations Children’s Fund (UNICEF). The Bill and Melinda Gates Foundation is another important partner. What the program has done since its inception in 1988 is unique. More than 2.5 billion children have been immunized with the help of 200 countries and 20 million volunteers, backed by an international investment of over $8 billion. India is an important partner and beneficiary of this initiative.

The United States—through its international development agency, USAID, the Department of Human and Health Services and the U.S. Centers for Disease Control and Prevention—is a major partner and donor in the global fight to eradicate polio. The Centers for Disease Control also provides technical assistance, technologies and methodologies to Indian laboratories to do polio related tests and analysis.

In India, USAID provides about $6 million annually for polio eradication. It supports surveillance and social mobilization activities through the WHO, UNICEF and the CORE group, a network organization of many non-governmental organizations. UNICEF and CORE have extensive engagement with community leaders in thousands of identified high risk areas, with a particular focus on religious leaders and institutions in western Uttar Pradesh and eastern Bihar to ensure that all children below 5 receive their immunization doses. USAID also supports WHO’s implementation of the National Polio Surveillance Project, funding approximately 300 surveillance medical officers and additional full-time staff. These personnel are distributed across India to conduct high quality surveillance for acute flaccid paralysis to detect the transmission of polio in suspected cases, lend laboratory support, and provide technical advice and leadership for supplementary immunization activities. The Government of India provides the vast majority of funding for its national polio eradication program, while the United States and others primarily provide technical support, says Ellyn Ogden, USAID’s polio eradication coordinator. “India has overcome obstacles for reaching every child…with dedication, hard work, innovation and coordination,” she says. It “encourages the remaining infected countries to take all needed measures to stop polio transmission and sets the stage for global certification three years after the last case in the world.”

Without consistent and comprehensive immunization, a gap in immunity could lead to a terrible resurgence of cases, says Erin Soto, mission director for USAID in India. Last year’s “reduced number of cases provides real hope. But we cannot flag in our global efforts or in our efforts to achieve the last mile in India. …Outbreaks this past year in Tajikistan and elsewhere illustrate how crucial our ongoing vigilance and efforts will be,” says Soto.

USAID is supporting three interlinked projects on polio in India to support the national program: CORE Group Project (World Vision U.S.), Polio Eradication (UNICEF India) and National Polio Surveillance Project (WHO). These projects aim to help interrupt the transmission of polio by increasing the numbers of immunization centers (called polio booths) and by reducing the percentage of missed and resistant households during immunization campaigns. There are 4,300 high risk communities in 44 districts in Uttar Pradesh, 300 poorly accessed villages in the Kosi River area of Bihar, and urban areas of Patna and Khagaria that receive special attention through established Social Mobilization Networks. These projects also work to ensure that the migrant and mobile population receives the polio vaccine both through routine and supplementary immunization. The CORE Group Polio project also supports families with crippled children. It helps to improve the timeliness of polio case detection, leading to early reporting of cases.

Devastation by polio in the 1950s and ’60s is still fresh in the memory of many Americans and they continue to extend help in polio eradication efforts. “More than 300 U.S. Rotarians visit India every year to participate in polio immunization campaigns,” says Kapoor of Rotary International. “They keep the enthusiasm up. They raise funds, contribute from their pockets and live in uncomfortable places to help eradicate polio.”

Rotarian Anil Garg, an Indian American financial adviser from Simi Valley, California, comes to India every year. He recalls one incident: “It was in my first trip, in 2000. I saw a young mother bring her infant child to get the polio drops. After the child was immunized, I saw the eyes of the mother and they were filled with gratitude…. It has reinforced my resolve to keep going back until we eliminate polio forever.”

Brad Howard, a Rotarian and owner of an international tour company in San Francisco, California, participated in Indian immunization campaigns in March 2009 and last November in Moradabad. “I worked in a central immunization station where we would immunize hundreds of children, 5 years and younger. The next day we walked door to door to ensure that every single child had been immunized,” he says.

“Until polio is eradicated in India, and throughout the world, children are at risk,” Howard says. “Indian children are at risk, American children are at risk, children in all countries will be at risk.”

Originally published in Jan/Feb 2011

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