One Per Cent To Go: Can We End Polio?
By Julie UlbrichtJuly 3, 2012
Celebrities, Rotary clubs, Bill Gates — a massive group effort has seen the world get very, very close to wiping out a crippling, life-threatening disease. So, why has the World Health Organisation now declared polio a global health emergency?
“I’m doing it right now! It's amazing!” buzzed the message to my phone. “I’m here with a four-year-old kid named Aditya in rural Patna. He was just vaccinated and he has a big smile on his face!”
Longtime anti-poverty campaigner Hugh Evans was texting from the Indian state of Bihar. He was there with UNICEF to see how, for the second time in human history, the world is working together to eradicate a disease.
The first disease vanquished by such a concerted effort was smallpox. For more than two decades now the target has been polio, one of the oldest, most dreaded and contagious conditions known to humanity.
I then spoke to Evans on the last of three scheduled National Immunisation Days, funded by the Indian government, to ensure every child is vaccinated against this crippling, potentially lethal virus.
"Yesterday we were in one of the most full-on urban slums I've ever been to. Absolutely no sanitation. Rubbish everywhere. As soon as it rains, the place is literally turned into a giant sewage dump." Despite these conditions, and in sweltering heat, Evans had observed hundreds of children receiving two drops of pink liquid — he even administered some himself — and watched as officials recorded the number and location of each child. Within days, this data would be sent to an independent monitoring board in Geneva, Switzerland.
"It's so awesome!" Evans's voice breaks into laughter, suggesting wonder at how such efficiency and organisation could have infiltrated this remote part of the world. That morning, people from the World Health Organisation (WHO) and UNICEF, along with Indian health workers and volunteers from the community, had assembled to talk strategy, pick up coolers filled with vaccines, and head off for a day of immunising children.
Days like these have occurred over and over, and all over the world, since the establishment of the Global Polio Eradication Initiative (GPEI), which formalised polio eradication as a global goal in 1988. And the campaign has been hugely successful. In fact Bahir, where Evans and his companions were that day, was the last Indian state to record a case of polio, and that was back in January 2011. Anti-polio workers are determined to ensure that India stays on top of its vaccination schedule to be officially certified polio free in January 2014.
But even as Evans described the happiness of little Aditya, his sister Aniket, and their father Anil Chaudhary, in Bahir, a family in another ancient city, Peshawar, in the Federally Administered Tribal Areas (FATA) of Pakistan, was not so fortunate.
Back in March this year, a doctor in Peshawar's government-run hospital told a tribesman who had brought his sick son from Bara Tehsil, in the Khyber Agency of FATA, that the six-month-old infant, named Farman, had polio. Farman is one of 84 people worldwide who have so far been diagnosed with polio in 2012. He is now crippled for life.
Polio is a virus that invades the nervous system. It can cause total paralysis within hours, which sometimes leads to death by asphyxiation. The disease was previously unknown to Farman's parents, even though the area where they live had seen another case that month.
Farman's father, Syed Faqir said "I also took him to the spiritual healers who have blown Islamic verses on him. I have been told [by Muslim physicians] that he would be fine after three months treatment." However, unfortunately for Farman, there is no cure for polio. Prevention is the only effective policy.
PREVENTING POLIO has been the aim of the Global Polio Eradication Initiative (GPEI), an organisation that brings together the WHO, UNICEF, the United States Centres for Disease Control and Prevention (CDC) and Rotary International, and partners with governments as well as the Bill and Melinda Gates Foundation. Yet areas like the FATA remain a breeding ground for polio.
Polio vaccinators — health workers from government agencies and volunteers — strive to reach every child of every people group in every pocket on the planet. Why did the enclave of Bara Tehsil miss out? Farman's home is in the FATA, which are occupied by two fundamentalist Islamic militia, Lashkar-e-Islam and Ansarul Islam. Rocket and mortar attacks are an earth-shattering accompaniment to daily life, and visitors to the area must be accompanied by an armed escort at all times. In 2009 it simply became too dangerous for vaccinators to continue their work. And so the FATA has flared as a breeding ground for polio. And while polio raises its spectre anywhere, it remains a threat everywhere.
Dr Bruce Aylward is the Assistant Director-General for Polio, Emergencies and Country Collaboration at the WHO, and he has been working towards eradication since 1992. He says, "The nature of this disease means you've got to get to every single quarter, every single community, and you've got to get them repeatedly and keep them under surveillance. It's not a hit-and-run operation, it is about establishing some kind of sustainable access to children, to achieve eradication."
The global effort to end the spread of polio boasts impressive numbers. As recently as 1988, polio paralysed more than 1,000 children worldwide every day. Since then, according to the GPEI, 2.5 billion children have been immunised against polio, with the cooperation of more than 200 countries, 20 million volunteers, and a campaign backed by international financing of more than USD8 billion. Last year, 650 cases were reported and this year, there had been only 84 at the time of writing. What's more, India has just been removed from the list of endemic countries as it hasn't had a reported case since January 2011. The number of polio cases worldwide has decreased by more than 99 per cent. There is less than one per cent to go.
But transmission of the disease has never ceased in Pakistan, Afghanistan and Nigeria, and since 2009 has actually resumed in Angola, Chad and the Democratic Republic of the Congo — countries that were previously polio free. Other cases have been imported into a further eight African countries, and over twenty cases were reported in China in 2011.
While Farman is one of just 22 cases reported in Pakistan in 2012, even a single confirmed instance of polio is considered by the WHO to be evidence of an epidemic because, chillingly, only 10 per cent of people carrying the virus show any visible symptoms; the unknowing carry the disease on foot, and by train, and among passenger lists, across borders.
Despite enormous progress, final eradication efforts are proving so difficult that the World Health Assembly, at a meeting in the last week of May this year, passed a resolution declaring polio to be a "programmatic emergency in global health" and the GPEI tabled an Emergency Action Plan. This reaction is unique; typically emergency declarations are made in response to pandemics, however in this case emergency status was about taking action now to eliminate a future epidemic.
SMALLPOX WAS THE FIRST human disease to be eradicated from the planet. That campaign took a 14-year, country-by-country strategy, at a fraction of the USD9 billion spent so far on eradicating polio. Protection against smallpox requires just one injection. Rendering a child immune to polio can require repeated vaccination; children in some areas need to receive polio drops up to 10 times before they're fully immune.
While polio today is typically associated with the remote, impoverished or war-ravaged communities, it was once rife in the middle classes. At the beginning of the 20th century, fear gripped parents throughout much of the developed world as polio struck thousands of children. In A World Without Polio, an historical account of the fight against polio commissioned by pharmaceutical company and producer of polio vaccines, Aventis Pasteur, authors Bernard Seytre and Mary Shaffer write: "No one had any idea where this unpredictable infection came from. Epidemiologists were at a loss to explain how it was transmitted."
Epidemics of the virus closed schools and filled hospitals. Summer became known as "polio season", and pools and parks were abandoned because people feared the spread of this horrendous disease. In October 1916, in New York City alone there were 2,448 deaths, and the summer of 1952 saw 60,000 cases in the US resulting in 3,000 deaths.
Polio is contracted orally, by eating food or drinking water contaminated with the virus, or by coming into contact with an infected person's faeces or saliva. Once inside the body, the virus multiplies in the intestine. When the virus has passed into the bloodstream, it can damage nerve cells in the spinal cord and brain, causing paralysis within hours. According to the WHO, one in 200 infections leads to irreversible paralysis, generally in the legs, and there is a 5 to 10 per cent chance that those who are paralysed will die as the paralysis spreads and eventually restricts their breathing.
While polio generally affects children under three, adults also can contract it.
Polio's most famous victim was US President Franklin Delano Roosevelt, who was paralysed as an adult in 1921. Although Dr. Armond Goldman wrote a piece for the Journal of Medical Biography in 2003 saying it was more likely that Roosevelt had suffered a different, related disease called Guillain-Barré syndrome, there's no doubt Roosevelt played an important role in the movement to eradicate polio.
Despite his handicap, Roosevelt became President in 1932, and in 1938 he established the National Foundation for Infantile Paralysis (NFIP), to treat polio victims and to fund research into finding a cure for polio, if possible, or even preventing it. The NFIP-funded research eventually led to the creation of a vaccine.
"To dance so that others may walk" was the slogan of Roosevelt's famous Birthday Balls, which were held annually from 1934, to raise funds for polio victims.
In 1938 comedian Eddie Cantor dreamed up a campaign called the March of Dimes, which implored Americans to send a dime to the President. Fifty extra postal clerks were required to handle the overwhelming number of mailed coins, write Seytre and Shaffer in A World Without Polio. The book describes how workers in the White House mailroom complained that the US Government had nearly stopped functioning because they couldn't find official mail amid all the dimes they received.
Celebrities such as Judy Garland also fronted March of Dimes, and it became one of the most popular fundraising drives in US history, yielding USD622 million between 1938 and 1959, despite the deprivations suffered by the people there during World War II.
Developing a vaccine, however, was a tough task. Seytre and Shaffer write that several vaccines were prematurely trialed, causing allergic reactions, polio itself and, in some instances, death. By 1935, researchers were jaded. However, the scientific community asked whether there might be more than one strain of the virus. And the answer came from Australia.
Earlier, in 1931, two Australian researchers, Dr Frank M. Burnet — after whom Melbourne's Burnet Institute is named —and Dr Jean Macnamara identified that the virus had at least two strains, and that exposure to and immunity to one strain did not confer immunity to the other. It was finally established that there were three strains of the virus — a finding essential to the development of a vaccine.
Two virologists in America then divided opinion within research-and-development circles, by presenting very different approaches to developing a vaccine against polio. Jonas Salk from the University of Pittsburgh developed an inactivated, or dead, vaccine, which could be administered via an injection and became known as the Inactivated Poliovirus Vaccine (IPV). Albert Sabin at the University of Cincinnati believed that only a live but weakened virus vaccine could offer long-term immunity; so he developed the Oral Poliovirus Vaccine (OPV). Salk believed inactivated vaccines were safer, but Sabin argued that the OPV was stronger and more effective.
In fact both vaccines and their subsequently reformulated versions have been essential to eradication efforts. The OPV can be administered by anyone, whereas the IPV injection must be administered by a certified health worker. There is simply no way the huge numbers of children who have been immunised could have been reached without the simplicity of the orally administered vaccine. World-renowned photographer Sebastião Salgado has captured images of children being vaccinated through train windows in India, in war-ravaged areas of the Sudan and in the Somalian desert where the people lead a nomadic life.
Yet because OPV contains a live virus, the risk of actually infecting children with polio remains. T. Jacob John is a professor of virology and paediatrics at the Christian Medical College in Vellore, India. He emphasised to The Global Mail the importance of switching to a dead vaccine to keep polio eradicated. "The point is that use of OPV is incompatible with eradication [because it can cause vaccine-derived polio viruses] … When OPV is stopped, VDPVs [Vaccine Derived Polio Viruses] will expand and replace wild polio viruses."
Therefore, once transmission of the wild poliovirus has ceased — which will only occur through OPVs — the transition to an inactivated vaccine will be essential.
Dr Bruce Aylward and the WHO concur that the development of a new IPV will be paramount to countering vaccine-related outbreaks. But, Aylward says, not only will switching from the OPV to IPV incur up to 10 times the cost, but IPV in its current state is only suitable for use in industrialised countries.
The post-eradication era is still a way off, with an estimated USD945 million still needed to rollout current immunisation programs in 2012/2013. While USD344 million has been pledged, there is a risk the commitments won't be fulfilled. Because of the shortfall in funds, the GPEI has had to cut or reduce immunisation programs in 24 countries. What's more, Aylward says that in the second half of 2012, programs in the infecting countries — Pakistan, Afghanistan and Nigeria — will cease for lack of funds.
Professor Mike Toole, the Burnet Institute's deputy director and head of the Centre for International Health, and a member of the Independent Monitoring Board of the GPEI, identifies the problems in these areas: "Polio this year is in certain minority groups. In Northern Nigeria, nomads are underserved and under reached. In Pakistan, it is the Pashtun speakers. In Afghanistan it is the areas controlled by anti-government elements."
Yet Professor Toole says despite the challenges in accessing children, there is great innovation in several local areas.In Chad two years ago outbreaks spilled over from Northern Nigeria, but the Ministry of Livestock in Chad now tracks the cattle of the nomads to find the children who need immunising. In Pakistan and Afghanistan, male vaccinators had been unable to access the courtyards where women gather, so UNICEF says it trained women, who now visit the courtyards and they have "ensured that all mothers and child care-givers are well informed about National Immunisation Days. These parents and carers are then encouraged to bring their children under five years of age to receive polio drops." Muslim leaders in mosques promote the importance of vaccination in Nigeria, Afghanistan and Pakistan.
Yet there are impediments apart from cost. The UK's Guardian newspaper reported that a fake Hepatitis B vaccination program set up by the CIA in order to obtain DNA from Osama bin Laden's family had hampered polio eradication in Pakistan.
Gulrez Khan, an anti-polio worker from Peshawar where Farman was diagnosed with polio, told news website OnIslam.net: "They (tribesmen) consider us CIA agents, who under the guise of an anti-polio campaign, are there to look for other Al-Qaeda and Taliban leaders."
More recently, the Associated Press reported that a militant commander in Pakistan's northwest warned vaccination teams to stay away from the area until US drone attacks cease.
Despite this, Aylward, who has worked on polio eradication for 20 years, doesn't consider suspicion from locals, mobile populations or even ongoing regional conflict as the biggest hindrances to eradication efforts. Rather, he is discouraged by the international public-health community that says we should accept merely controlling polio as an alternative to eradication. Aylward says if the world chooses to live with the burden of polio, cases will escalate up to 200,000 per year. He is also concerned that leaders of donor nations may not be able to maintain the support and advocacy needed to finish the job.
Aylward lauds the ongoing commitment of Rotary International, a key driver of the creation of the GPEI, which formalised eradication into a global goal in 1988. With 1.2 million volunteers in 200 countries and geographical locations, and 33,000 local clubs, Rotary has used its infrastructure to garner the funds and technical support needed to access populations all over the world. Having raised more than USD900 million, Rotary is more reliable than donor governments, says Aylward. "Rotary's president changes every single year but they maintain their commitment, and increase their stake in it, but I can't count on that same commitment from key donor governments."
Another fan of Rotary International is Bill Gates, who has also made polio eradication the top priority of the Bill and Melinda Gates Foundation and given USD1.3 billion to the cause since 2005.
If polio eradication is achieved, it will serve as a rare, positive testament to the role that an alliance of philanthropists, celebrities and the private sector can play in global development.
The goal to eradicate polio has also resulted in the human and physical infrastructure that can serve other global health goals, including surveillance of and immunisation against diseases such as malaria and measles. The WHO has shifted from being a "technical specialised agency" to an organisation involved in major field operations, deploying 3,500 workers in key polio-infected areas.
But for now, Aylward says, if the world retreats from its commitment, the disease will come back stronger and hit harder when reintroduced into populations that have had no vaccination and no natural immunisation through exposure to the disease during childhood. His claim is supported by a case study from the Netherlands. In 1992 polio travelled from India and infected an Orthodox Reformed Church that opposed all vaccination. The Netherlands hadn't seen a case of polio for 14 years. Out of 71 infected people, 59 were paralysed and two died. The Dutch government had to spend USD10 million to contain the epidemic.
Aylward says polio eradication is an exercise in social justice and equity and a matter of the utmost urgency. "A disease like this is a marker that we are failing to access populations. As long as there is something like polio, you are not gaining universal access, because if you do, this disease melts away quite quickly."
Only political will, USD945 million and time will tell if he's right.