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How India went form 741 cases to Zero in just two years_An article from THE HINDU
How India
went from 741 cases to zero in just two years
RAMYA KANNAN
“Only one third of the journey has been
completed”
The last case of wild polio virus reported in India
was exactly one year ago, on January 13, when stool samples showed that
18-month-old Rukhsar Khatoon in West Bengal had polio. She has since recovered,
but it is the progress of whittling down from the largest number of cases in
the world to zero that is fascinating to public health experts globally.
Clearly, the nation had to overcome tremendous
challenges to get here – not least of them, a huge population, the logistics of
covering a vast geographical area, poor sanitation and infrastructure,
resistance among some groups of people to taking the vaccine, and children of
migrant communities who were difficult to cover.
It was with the Expanded Immunisation Programme in
the late 1970s that India started its battle against polio. In 1985, it became
a part of the Universal Immunisation Programme launched throughout the country.
A significant milestone in the journey was the launch of the National Pulse
Polio Initiative (PPI) in 1995-96, targeting coverage of every child under five
in the country with the Oral Polio Vaccine (OPV) to be given on two National
Immunisation Days, one each in December and January, followed by more focused
state-level immunisation campaigns throughout the year. The PPI set for the
nation a new target — eradication of polio by 2005.
This involved better social mobilisation through
involvement of millions of frontline workers from the private health sector,
members of Rotary International, volunteers, anganwadi workers, besides the
massive public health workforce. In addition, the PPI created systems – cold
chains for storage and transportation of the vaccines, ensuring vaccine vial
monitors on each vial, follow up and mop up campaigns to track children left
out during immunisation days.
India has spent more than Rs. 12,000 crore on PPI,
a Union Ministry of Health release said. One of its major partners, Rotary
International says it has spent over $149 million in India over the years, as
part of its contributions. In each PPI, 24 lakh vaccinators visit over 20 crore
households to ensure that nearly 17.2 crore children, less than five years, are
immunised with the OPV. Mobile and transit vaccination teams immunise children
at railway stations, bus stands, market areas, and construction sites. Special
rounds were held to give the OPV to children of migrants and refugees.
And yet, concerns remained. Pockets of Uttar
Pradesh and Bihar were still endemic, responsible for the cases being reported
in the country, directly, and through migration. In recent years, the
government targeted 107 ‘high risk' blocks in Uttar Pradesh and Bihar, and
identified the challenges, which included remote locations, refusal of vaccine
in some areas, and migrating populations. ‘Influencers', including religious
leaders, were enlisted and tracked for each high risk area, and this helped
polio teams reach more families. Positive results were seen as a consequence:
UP and Bihar have not reported any case of polio since April 2010, and
September 2010, respectively.
While India has clearly stepped into the endgame
stage, it is by no means closure, public health specialists warn. Mr. Azad
tempered his joy over the achievement with concerns about the future. “We are
excited and hopeful, and at the same time, vigilant and alert”. He cautioned
that there was no room for complacency, with the nation having to maintain its
zero-cases record for the next three years to be able to totally ‘eradicate'
poliomyelitis. “It is a great stride forward,” Deepak Kapur, Rotary
International's India Polio chair, said. “However, it is just one stride ahead.
Only one third of the journey has been completed, we need three clean years for
the certification.”
The greatest concern is the possibility of
infections carried across borders by migrating populations. GPEI points out
that in 2011, Pakistan and Afghanistan both saw alarming increases in polio
cases, and poliovirus from Pakistan re-infected China (which had been
polio-free since 1999). In Africa, active polio transmission continues in
Nigeria, Chad and the Democratic Republic of the Congo, with outbreaks in West
and Central Africa in the past 12 months reminding the world that as long as
polio exists anywhere, it remains a threat everywhere. Lieven Desomer, Polio
Chief, UNICEF India, said, “The key challenge now is to ensure any residual or
imported poliovirus in the country is rapidly detected and eliminated. This
requires very high levels of vigilance and emergency preparedness to respond to
any importation of wild poliovirus.”
In an e-mail response to The Hindu,
Nata Menabde, WHO Representative to India, explained, “India must now
capitalise on this progress and secure polio eradication. It must continue to
protect children in polio campaigns and through improved routine immunisation
coverage. Complacency is not a luxury the program can afford; continued high
level vigilance for polio, emergency preparedness, and intense immunisation activities
will be essential for rapid detection and elimination of any circulating
poliovirus.”
(With inputs from Aarti Dhar in New Delhi
Polio free does not mean paralysis free_An article form THE HINDU
January 3, 2013
Polio free does not mean paralysis free
N. GOPAL RAJ
There
is no room for complacency that India has eliminated this crippling disease as
Uttar Pradesh and Bihar have recorded a high incidence of a condition
symptomatic of it
Identifying
children who suddenly display muscle weakness, often not moving one or more of
their limbs as a result, forms the cornerstone of polio surveillance. Such
children could have “acute flaccid paralysis” (AFP) that is symptomatic of
polio, a disease caused by a virus. But AFP can also arise for other reasons,
including infection by non-polio pathogens.
No child in India
has been diagnosed with polio for nearly two years now and all the indications
are that the virus responsible for it is no longer circulating here. However,
the country’s polio surveillance system has indicated a sharp increase during
recent years in the number of non-polio AFP cases.
Alarming
data
Data published by
the World Health Organisation show that close to 8,000 non-polio AFP cases were
identified in India during 2003. They went up to over 12,000 the following
year, more than 26,000 in 2005 and crossed 40,000 by 2007. In 2011, there were
more than 60,000 non-polio AFP cases.
A good polio
surveillance system ought to pick up all AFP cases among children so that they
can be screened for poliovirus infection. On average, only about one child out
of every 200 children carrying the poliovirus develops AFP. Such cases must be
identified so that appropriate immunisation measures can be undertaken.
India’s polio
surveillance shows that the country is polio-free. But it also indicates that
the country now has the world’s highest rate of non-polio AFP cases. According
to data published in WHO’s Weekly Epidemiological Record, India’s annualised non-polio AFP rate for 2011
stood at 15.06 per one lakh children below 15 years of age, compared to a
global rate that year of 5.48.
Moreover, most of
the country’s non-polio AFP cases occur in just two States — Bihar and Uttar
Pradesh. They accounted for about 61 per cent of the 53,000-odd non-polio AFP
cases identified in the country in 2012, according to data from WHO’s National
Polio Surveillance Project. As a result, the two States have far higher
annualised non-polio AFP rates than other States — around 34 for Bihar and
about 23 for Uttar Pradesh. The rate for the country as a whole is slightly
over 12.
“The increased
non-polio AFP rate is due to increased reporting of AFP cases due to deliberate
efforts of the programme to increase the sensitivity of the surveillance system
since 2004,” according to the WHO Country Office for India. In a written
response provided to this correspondent, the health body said these efforts
were more intense and closely monitored in the traditionally polio-endemic
states of Bihar and U.P., resulting in even higher rates of reporting of AFP
cases in those States.
In 2004, a number
of steps were initiated to strengthen surveillance in order to accurately and
more rapidly detect all polio cases in the country, it said. Those measures
included expanding the definition of AFP; increasing the number of AFP
reporting sites; increasing the number of active surveillance visits; and more
training for health professionals on what constituted an AFP case.
Since then, the
number of AFP cases that were reported and investigated continued to increase,
it noted. This was not due to an increase in the incidence of a specific
disease that might cause these symptoms. Rather, it was the direct result of
surveillance activities for AFP cases being strengthened.
The programme in
India had taken a much broader interpretation of what would qualify as an AFP
case than other countries have. Although facial paralysis would not be part of
a standard definition of AFP, it was included in that definition for India.
Other similar examples were diseases like meningo-encephalitis, Bells palsy,
post-diphtheria polyneuritis and spinal muscular atrophy. Data had shown that
broadening the case definition led to the detection of some polio cases that
would have otherwise been missed, the WHO Country Office noted.
Moreover, in the
remaining polio-endemic countries of Nigeria, Pakistan and Afghanistan too,
efforts to strengthen polio surveillance were resulting in increased non-polio
AFP cases being reported, it added.
The high non-polio
AFP rates in the country ought to be a “red flag”, remarked T. Jacob John, a
leading virologist who was with Christian Medical College, Vellore, and is
known for his work on polio eradication.
With heightened
polio surveillance, sick children with suspected paralysis or possible
neurological maladies were being identified and tested by the polio
surveillance system, he remarked. However, the neurological disorders given by
the WHO Country Office as examples of the expanded definition of AFP were
likely to account for only a small part of the increase in non-polio AFP cases
being seen in India.
No
clear picture
Unfortunately, the
cases of children with non-polio AFP were not being monitored by either the
polio eradication programme or the larger state health care system. As a
result, there was no clear picture of what was causing the AFP, the kind of
diseases these children displayed, or how many of them were seriously affected,
he pointed out.
A range of
non-polio pathogens could produce AFP, said Dr. John. With many such pathogens,
the paralysis they caused would often disappear in a short period of time.
However, others were capable of causing quite serious diseases, disability and
even death.
Two teams of Indian
scientists recently studied the sorts of enteroviruses found in children with
non-polio AFP. Enteroviruses are a diverse group, most of which replicate in
the alimentary tract. The poliovirus is part of this group. Several non-polio
enteroviruses have been associated with a range of acute and chronic human
diseases, including polio-like paralysis.
In a study
published in 2009, a team at the Sanjay Gandhi Postgraduate Institute of
Medical Sciences in Lucknow tested over 46,000 stool samples from children with
AFP in U.P., Bihar and other northern States between 2004 and 2007. In the
other study, C. Durga Rao of the Indian Institute of Science, Bangalore, and
his colleagues looked for enteroviruses in stool samples collected from more
than 2,700 children with non-polio AFP in Kerala, Karnataka and Uttar Pradesh
between 2007 and 2009.
Enteroviruses
Both groups found
that only about 30 per cent of the non-polio AFP cases were associated with
enteroviruses. These viruses could therefore only partially explain the
non-polio AFP cases being detected.
In a paper
published early last year in the Indian
Journal of Medical Ethics, Neetu Vashisht
and Jacob Puliyel of the St. Stephens Hospital, Delhi, gave another perspective
on the issue. Children in Bihar and U.P. have received more doses of oral polio
vaccine than elsewhere in the country. The oral vaccine, it was found, became
less efficacious in the face of gut infections and diarrhoea that were widely
prevalent in those States.
In their paper, Dr.
Vashisht and Dr. Puliyel analysed the non-polio AFP rates across all States
over 10 years up to 2010, and found that the rate “increased in proportion to
the number of polio vaccine doses received in each area.” In 2012, the number
of doses of oral vaccine given to children in Bihar and U.P. had come down and,
for the first time, there was a decrease in the non-polio AFP cases in those
States, Dr. Puliyel told this correspondent.
There was need for
“a critical appraisal to find the factors contributing to the increase in
non-polio AFP with increase in OPV [oral polio vaccine] doses — perhaps looking
at the influence of strain shifts of entero-pathogens induced by the vaccine,”
said Dr. Vashisht and Dr. Puliyel in the paper.
The non-polio AFP
rate was not correlated with the number of oral vaccine doses that were
administered, countered the WHO Country Office in its response. The largest
number of oral vaccine doses given in India was in 2004, which had the lowest
non-polio AFP rate in the last eight years. Moreover, although the number of
oral vaccine doses given in the country had shown a continuous decline since
2007, the non-polio AFP rate had increased during the same period. In Bihar and
U.P. too, there were similar trends of reduced oral vaccine doses and rising
AFP rates during 2007-2011.
“The ICMR [Indian
Council of Medical Research] is leading the investigations into non-polio
causes of AFP,” the WHO Country Office stated.
I wish very happy new year to all of readers. We
have won a crusade like polio. But there is another enemy have appeared like
AFP. We should also aware of this challenging disease. And government should
take a serious step to eradicate it. As we surmount polio, we also surmount
AFP.
from: AMIT KUMAR SHUKLA
Posted
on: Jan 3, 2013 at 15:43 IST
This is an
eye-opener. Though India has been declare polio-free, we do
want any other epidemic out there to hurt out children. Non-Polio AFP
seems to be the next epidemic, if left unchecked. There is an urgent
need to find the root causes behind AFP and eliminate them. We should
not let AFP become the next Polio type disease.
want any other epidemic out there to hurt out children. Non-Polio AFP
seems to be the next epidemic, if left unchecked. There is an urgent
need to find the root causes behind AFP and eliminate them. We should
not let AFP become the next Polio type disease.
from: Manas
Posted
on: Jan 3, 2013 at 14:38 IST
Frequently Asked Questions on Pulse Polio Activity
FREQUENTLY
ASKED QUESTIONS AND ANSWERS
Q1. Why so
many repeated rounds of OPV campaigns?
Ans. For
individual protection, every child during the first year of life should receive
at least three doses of OPV (routine doses). Like any other vaccine, OPV is not
100%effective. Even children who have received all routine doses and pulse
polio doses can get the disease. The only way to completely eliminate the risk
of getting children paralysed by polio is to completely interrupt the
circulation of wild poliovirus by administration of OPV to all under-five
children over a few days and repeated a few times each year as happens during
NID/SNID. It is essential that all children receive OPV during such NID/SNID
rounds otherwise children in the area will continue to be affected by polio
paralysis. Once polio is eradicated all children will be freed of the risk of
getting polio throughout their life. Even areas that are currently
polio
free, have to continue with NIDs/SNIDs to prevent the risk of importation of
wild poliovirus into such areas.
Q.2 How
long will Pulse Polio rounds continue? Will immunization activities stop soon?
Ans. National Immunization Days, Sub-National Immunization Days and Mop-Up
campaigns need to continue to get rid of the virus from the country. SIAs will
continue in India, for at least the next few years even after the last case is
seen to ensure that polio is really gone from India and till it is certified
that polio has been eradicated from the whole world.
Q3. How soon can we achieve polio eradication in India?
Ans. After
the programme suffered a setback in 2002 when 1600 cases were confirmed in the
country, satisfactory progress has been made due to concerted efforts to
improve the quality of SIAs coupled with increasing the number of rounds to 6-8
each year. This resulted in only 225 cases being confirmed in 2003, with
further decline to 134 cases in 2004 and an all time low of only 66 cases in
2005. With the use of mOPV1 since April 2005 in high risk areas, which is
continuing in the low season (when the effect of OPV is maximum) of 2006, India
is poised to attain eradication in 2006. With the last case being recorded in Jan 13 2011, we are hopeful to
eradicate by 2014.
Q4. Why we
need to give OPV to children who have received routine OPV doses?
Ans. Routine OPV drops are given for individual protection of the children
against polio.
However,
like most vaccines OPV is not 100% effective. Some children do not develop
complete immunity in spite of receiving all OPV doses. The only way to protect
all children from polio is by stopping the circulation of wild polio virus from
the environment. This is possible only if all children less than 5 years of age
receive additional OPV doses simultaneously as is done during the NIDs/SNIDs.
This helps to interrupt circulation of wild poliovirus and thus attain
eradication. This is the only way to ensure that all children are safe and will
not get polio.
Q5. Does
administration of OPV lead to impotence or sterility?
Ans. No, OPV does not lead to any impotence or sterility. It is just a
rumour which has been spread by some unscrupulous persons. OPV, in fact is one
of the safest vaccines which has been in use for more than 30 years. Repeated
doses of OPV minimize the risk of getting polio and are safe. Same OPV is being
used for all communities in India and in several other countries including our
neighbours Bangladesh and Pakistan. Even in Americas OPV was used successfully
during the eradication phase. As with many successful programs, pulse polio
programme also attracts the attention of a few people who try to spread rumours
about the vaccine. None of these rumours have any basis and the people
spreading such rumours are actually working against the interest of the
children of this country.
Q6. Does
administration of OPV have any side effects? Does it lead to illness in any
child?
Ans. No, OPV does not have any side effects and it does not lead to any
illness. Many children get sick every day due to different diseases and if
these diseases occur during mass OPV campaigns, it is a mere coincidence.
Q7. Should
OPV drops be given to newborn children?
Yes, OPV
drops must be given to newborn children also, even if they were born
only a few
hours ago.
Q8. Why do
children get polio even after getting OPV?
Ans. As is true of any other
vaccine or medicine, OPV also is not 100% effective. While adequate immunity
will develop in most children receiving the vaccine, a few will still remain
unprotected after receiving repeated doses. This small group of children who have
received vaccine but have not developed adequate immunity can get polio if the
wild poliovirus is circulating in the area. The fact that some children may get
polio even after receiving polio drops, emphasizes the need to eradicate the
poliovirus quickly. It is essential that for complete protection of all
children wild poliovirus should be eradicated and this is only possible through
repeated mass campaigns with OPV as during NIDs/SNIDs. If a few children do not
receive OPV during NIDs/SNIDs, they maintain the circulation of wild poliovirus
and this virus can then attack any child and produce paralysis in children that
are not fully protected.
Unless we reach high coverage uniformly without pockets of children
being left
out, there will always be a risk that some children who have been
vaccinated could be affected by polio since they can still come into contact
with virus.
Thus the only way to assure 100% protection from polio is to
eliminate the poliovirus and thus stop it from circulating from child to child.
It is therefore important that every child under 5 years of age receives polio
drops during every pulse polio immunization round, in addition to their routine
immunizations.
Q9. Should
a child having diarrhoea or other sickness be given OPV drops?
Ans. OPV drops must be given to all children even those who have diarrhoea
or other sickness.
Q10. Does
administration of OPV interfere with administration of drugs or antibiotics
being given to a sick child?
No,
administration of OPV does not interfere with administration of other drugs or
antibiotics.
Q11. Is
there any difference in the vaccine if the colour of the liquid is different?
Ans.
Usually the colour of the OPV is pink. However,
the colour could be yellow or white also and there is no difference in the
quality or type of vaccine.
Q12. Can
an overdose be given accidentally and what would be the consequences?
Ans. There is no danger of overdose. Multiple doses do not cause adverse
reactions.
Q13. Could
it be that the Polio drops are not working properly? Are there problems with
the vaccine in India?
Ans. Oral Polio vaccine, given
multiple times has eliminated polio in the vast majority of countries in the
world. It is the recommended vaccine to eradicate polio, and goes through
rigorous testing arranged by WHO and the Government of India. The polio drops
are working and there is no problem with the vaccine. A drop in the efficacy,
or effectiveness, of vaccine can occur if it has not been maintained at the
recommended temperatures as per the national protocol. However such a drop is
unlikely because of the strict discipline and rigorous monitoring system built
for cold chain maintenance. For example if the vaccine has lost efficacy due to
faulty storage or long power cuts, the colour of the Vaccine Vial Monitor will
change and clearly indicate that vaccine is no longer potent. The vaccine will
then be discarded.
Q14. What
is the cold chain?
Ans. The cold chain is a network of electrical and non-electrical equipment
and human handlers who facilitate safe keeping and transportation of the
vaccine from manufacturers’ level to the point of administration to children.
During all this time the vaccine needs to be kept within a safe temperature
range. Normally, below freezing while
being stored at state and district stores and between 2-8 degrees celsius in
the period immediately prior to distribution and use.
Extract
from IPPI guide published by MoHFW in 2006
Wednesday 2 January 2013
2013 Pulse Polio dates
Pulse Polio dates for the Year 2013 are
January 20 2013 _ Sunday
February 24 2013 _ Sunday
Pulse Polio is conducted on Sundays to ensure
January 20 2013 _ Sunday
February 24 2013 _ Sunday
Pulse Polio is conducted on Sundays to ensure
- Wider Inter Sectoral Convergence
- Larger Community involvement
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