It was once thought impossible, but two million footsoldiers and a 35-year-fight have won India its biggest public health success story. Pritha Chatterjee & Santosh Singh on how the battle was won and the biggest challenges ahead.
It’s one of the busiest spots along the porous India-Nepal border. At about 1.30 pm in Raxaul, in Bihar’s East Champaran district, there is a huge flux of Indians and Nepalis at the bus stand and the railway station. As people get off bikes, cars, rickshaws and tongas, many of them headed to the other side of the border, a group of eight men stands out. They flag down, sometimes even run behind, any vehicle carrying a child who looks below the age of five. They then introduce themselves to the parents as government-authorised polio vaccinators, and convince them to get their child immunised. Split into four teams of two member each, the eight have been at the job everyday at this transit point since 2011, even though the last polio case reported from Bihar was in September 2010.
Surjit Singh, 35, and Dinesh Kumar Singh, 40, two of the vaccinators deployed at the Shankar-acharya gate at Birganj, manage to convince Babita, an Indian with a relative in Nepal, to allow them to administer polio drops to her one-year-old son. “I am used to seeing vaccination at the border as I frequently travel to Nepal,” she says.
An average of 130-200 children are given polio drops each day at this gate alone, from 7 am to 7 pm. “We give polio doses to children coming from Nepal too,” says Surjit. For this, they take the help of Sashastra Seema Bal personnel. They are deployed at 17 checkpoints on the India-Nepal border in East Champaran, and their presence ensures that “all children below five years crossing the border are immunised”, says Surjit. “Even if a child coming from Nepal has taken the polio dose recently but his/her nail mark is faded, we give the dose.”
Surjit and Dinesh are among the two million-plus footsoldiers in India’s biggest public health success story. On January 13, 2014, India crossed an important milestone — three years have passed without any new reported case of polio, making it eligible to be declared polio-free. Surjit and Dinesh manned an important frontier along with many others in that battle, ensuring the disease didn’t sneak in across the international borders with Pakistan, Nepal, Bangladesh, Myanmar and Bhutan, by running continuous polio immunisation posts. Of the three remaining countries in the world that are still battling polio, Pakistan is one, the others being Nigeria and Afghanistan.
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It was just four years ago, in 2009, that India reported the highest number of polio cases in the world — 741. Raxaul, where the danger lies both within and outside, is among the high-risk blocks in the country. Bihar has 41 such blocks, of the 107 in India, classified thus because of the present or suspected prevalence of the P1 strain of the virus, as well as the poor drainage system and sanitation that help spread the disease.
Bihar is also believed to have exported the polio virus to other parts of country. It reported the first P1 case in the late 1990s; the number rose to 61 in 2006, fell to 45 in 2007, and further dropped to three in 2008. It, however, resurfaced in a big way in 2009 with 38 cases.
Raxaul reported one P1 case in 2005 and three in 2006. Dhaka, another high-risk block, 70 km away and also on the Nepal border, reported 10 P1 cases between 2002 and 2010. Of the three polio cases reported from Dhaka in 2010, one was of a two-and-a-half-year-old girl called Khushbu Kumari from Bisrahiya village — now the last known case of Bihar.
Daughter of a daily-wage labourer, Khushbu can’t walk and doesn’t go to school. She uses a tricycle given by the state government to move about. According to Dr Madhup Vajpayee, the WHO Regional Team Leader in Bihar, Khushbu contracted an “imported virus”. “Her stool culture and genetic sequencing suggest it’s a case of virus imported from Nepal. People here have relations by marriage with the neighbouring country,” Dr Vajpayee says.
As India celebrates its success, cross-border entry of the polio virus is one of the major remaining threats. The biggest risk is posed by Pakistan, where polio workers are high on the target list of militants, with several killed even in the past week.
As part of the risk-mitigation strategy, India has made it mandatory for all travellers from polio-endemic and re-infected countries to receive oral polio vaccine four to six weeks before coming to India. Polio immunisation posts like the one at Raxaul have been set up at other places along the border with Nepal, Pakistan, Bangladesh, Myanmar and Bhutan.
“The cross-border import of the virus is a huge concern. After remaining polio-free for more than nine years, China was infected due to a virus from Pakistan in 2011. India has, in the past, exported the virus to African countries,” points out Deepak Kapur of Rotary International, who is also chairperson of the India National PolioPlus Committee.
Adds Dr Nata Menabde, the WHO Representative to India, “We have, in fact, redoubled our efforts to maintain the highest level of vigil as the risk of polio virus importation persists.”
Khushbu, as well as India’s last reported case of polio — from West Bengal in January 2011 — apart, the story of polio-endemic areas is heartening. Surveillance for polio was launched in 1997, with the WHO setting up the National Polio Surveillance Project to help early detection and prompt investigation of children with recent paralysis. The investigation included testing of stool samples in WHO-accredited laboratories to identify polio cases. “The setting up of a surveillance system proved to be the most important milestone in the journey of polio eradication in India by helping identify populations that were at risk and the type of virus circulating among them, besides measuring progress. This information, in turn, led to the development of strategies that helped cover these populations better,” says Dr Menabde.
In November 2009, a consortium of agencies such as the WHO, UNICEF and Rotary International, together with the government of India, called The India Expert Advisory Group on Polio, shortlisted the 107 high-risk blocks in the country — including 66 in western UP.
The next step was differentiated vaccination. Under India’s routine immunisation programme, the oral polio vaccine was given to tackle viruses of types 1, 2 and 3. According to Dr Naveen Thacker, the president of the Asia Pacific Paediatric Association, “After 1995, when major work towards eradication of the virus started, a lot of research was conducted under the aegis of institutes like the Indian Council of Medical Research to establish why despite over 95 per cent immunisation coverage, polio cases were still continuing. In 2005, against one trivalent vaccine for three types of virus, more targeted, monovalent vaccines were recommended for types 1 and 3, the most common strains. But sporadic outbreaks of type 2 continued to be seen.”
In 2010, the IEAG recommended that only a bivalent vaccine be used in the high-risk areas, against types 1 and 3. This finally achieved the seeming impossible — a drop in diagnosed cases from here.
Explains Dr Menabde, “Even though the number of cases kept going up and down after 1998, India continuously overcame the challenges that came. The type 2 virus was interrupted in October 1999, and by 2002, India had stopped circulation of all types of polio virus in all states and UTs except western Uttar Pradesh and Bihar. The programme continued to innovate. This led to a shrinking in the number of genetic families of the polio virus and an increase in the population immunity, until circulation of type 3 virus was interrupted in October 2010 and that of type 1 in January 2011.”
The vaccination was shored up by other measures. Says Kapur, “Rotary provided support in the form of satellite huts (for staying) and to government medical doctors stationed in the Kosi belt. Extensive social mobilisation activities were implemented.”
Rotary also set up a Muslim Ulema Committee to fight misconceptions in the minority community over the polio vaccine, with many of them led to believe that it led to impotency and was part of a conspiracy against them. The government also reached out to Muslim leaders.
A Health Ministry official associated with the National Polio Surveillance Project says none of this would have been possible without the help of a force of health workers trained by agencies such as the UNICEF and WHO. Apart from carrying out vaccinations, they go house to house after every immunisation round to cover those left out. Their goal is to ensure that every child under five is covered.
Dr Menabde sees the success as a heartening example of public-private partnership in health. “This landmark is a great credit to the strong commitment and leadership of the government of India. Credit also goes to the government’s partnership with WHO, Rotary and UNICEF as also the millions of frontline workers —vaccinators, social mobilisers and community and health workers.”
The ministry official says they hope to replicate the success. “The polio workers fought resistant households, religious misgivings, and their dedication empowered us. Now we are working out how to use these workers for other public health programmes.”
There is also consensus that the guard can’t be let down. “There is a continuing risk, and that means, all children up to five years of age need to be protected against polio until it is eradicated globally,” says Dr Menabde, adding that the polio immunisation campaigns and increased routine immunisation coverage would continue.
Between January 19 and 25, joint teams of the state government, WHO and UNICEF held a special six-day immunisation drive at Raxaul. Around 190 villages of Raxaul and Dhaka were shortlisted. Preparations included listing the names of influential people, mukhiyas and sarpanchs in these villages, as well as roping in officials from Nepal.
With the constant movement of people across the border a “tough challenge”, regular meetings are held here of Indo-Nepal officials, while banners and posters are strung across the region, in both Nepali and Hindi, urging parents to go in for vaccination. For the special national drive held last week, approach roads from the border were barricaded.
UNICEF and government officials also track nomadic tribes passing through Raxaul and Dhaka and other parts of the state, with the help of locals, and send teams to immunise them. Their itinerary is established so that other districts where they are headed can be alerted.
Though there were earlier cases of resistance from Muslim families here, this has died down, as community leaders, imams and muezzins have been taken into confidence, say officials. “Some leading Muslim institutes, including a deemed university in Dhaka, even provide us student volunteers during our special drives,” says a UNICEF team member.
Still, the teams of vaccinators, consisting of two volunteers each, now have a Hindu and a Muslim. This was done after complaints of all-Muslim vaccinating teams marking nails of Muslim children from families resisting vaccination as well, without administering them polio drops.
Ramesh, a vaccinator from Raxaul, says: “Now with a team having a Hindu as well as a Muslim, there are few cases of community resistance.”
What may hurt the vaccination drive though are the low wages. Vaccinators are paid Rs 75 per day, and supervisors Rs 175 per day. Vaccinators such as Dinesh Singh hope this money is raised, “to keep their motivation going”. At Raxual border, they have an even smaller demand —masks to protect them from dust.
To be officially certified polio-free, India needs to meet another criterion: destruction or meeting of the international standards concerning safe storage of all lab wild polio virus samples. A National Task Force for Containment of Wild Poliovirus, set up under the chairmanship of the director general, ICMR, last year, is putting together all laboratories that can be used in the country for such safe storage.
In all the 145 countries using oral polio vaccines, the danger of vaccine-derived polio also still remains. “Since these vaccines contain live attenuates of the virus, in some rare cases, these may cause polio,” a Health Ministry official explained. In India, between 2000-2013, of 718 such cases, 628 were of type 2. Therefore, under the Polio Eradication and Endgame Strategic Plan put together by bodies like the WHO, UNICEF and the Centers for Disease Control, Atlanta, the strategy is to shift to only bivalent vaccines containing attenuates of types 1 and 3.
This will be accompanied by at least one round in 2015 and a few rounds later of comprehensive immunisation with the injectible vaccine, which contains silent instead of live attenuates of the virus. This will help strengthen immunisation systems and ensure complete eradication, the ministry official explained.
Whatever the remaining hurdles though, this is one journey with few parallels in India — and recognised as such. Polio teams are now being pressured to “get the government to implement other welfare schemes”, chuckles a UNICEF team member.
In Dhaka, says the member, the polio team was held hostage as they were seen as a means to better roads.
What makes India special
The battle against polio in India officially began in 1978, when it adopted the WHO’s Expanded Programme on Immunisation, an international initiative for global eradication of polio. India’s problems were manifold — a crumbling healthcare system, poor sanitation, contamination of water supply, along with endemic belts such as Bihar’s Kosi region and western UP, which were often difficult to access and in the 1990s, started showing resistance to vaccination because of misconceptions about it. In western countries, sanitation measures and water purification efforts had a huge role to play in the eradication of the virus. To achieve eradication with only immunisation, given India’s sanitation and water conditions, was considered near impossible. An article in The Indian Journal of Medical Research in May 2013 said, “India’s success has silenced critics who predicted that polio itself was non-eradicable; or that polio was not eradicable in India with its low standards of sanitation and hygiene; or that wild polio viruses cannot be eradicated using live OPV; or that polio was not worth eradicating.”
Reserved for polio
The polio ward at St Stephen’s Hospital in Delhi is one of the few such facilities in the country where beds are reserved for polio patients. The nine-bed ward was started in 1987 by orthopaedic surgeon Dr Mathew Varghese, and unlike other hospitals, here not just children but patients in their 30s and 40s paralysed with polio since childhood get admitted for corrective surgeries.
“In general hospitals, most beds and operation theatres in the orthopaedics department are taken up by road traffic accident cases, which are generally emergency ones. Having a dedicated ward means we can accommodate polio patients always, and they come to us from across the country — from Srinagar to Chennai,” says Dr Varghese.
Doctors say that delay in corrective surgery after the onset of paralysis reduces the chances of operation’s success. “In older patients, surgery is more difficult as the joints are stiffer and complications increase. Most of our patients are poor, daily wage labourers with limited education. It is no wonder they come to us so late,” he says.
From 3,000 patients who would get admitted every year in the 1990s to no case of wild polio virus being reported in the last three years is a huge achievement, Dr Varghese says. “While the celebrations are justified, we do need a dedicated national programme for existing patients already diagnosed with polio. We as a country have failed to curtail a preventable disease through natural means like providing clean water and sanitation. We opted for technological solution — vaccination. Having done that, we owe proper rehabilitation, medical and social, to patients,” he says.