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India still on top of the world polio map

By Ranjita Biswas

Despite launching the largest ever mass immunisation campaign against polio in February 2003, targeting 165 million children, the battle against polio has not been won. To understand the causes of the repeated occurrence, we need to understand the profile of the wild polio virus

The recent news that the Global Polio Eradication Initiative has placed India on top of the world polio map, with 82 cases diagnosed till February this year, makes depressing reading. The success of the past years in bringing down the number of polio infections appears to have been reversed. More so since the other endemic countries, Nigeria, Pakistan and Afghanistan, together reported only 23 cases in the same period.

Union Health Minister Anbumani Ramadoss has gone on record to say that his ministry is going to review "the entire polio programme", pointing out that although it spent Rs 1,300 crore last year on the polio eradication programme, and this year's budget allotment for the same is Rs 1,042 crore, the scenario was grim. Bihar, particularly, is showing up as a major worry area and Uttar Pradesh (UP) remains a problem state.

Polio, affecting mostly children between the ages of two and five, is a contagious disease that thrives in fetid conditions and cripples its victims, sometimes even causing death.

The polio immunisation programme worldwide is run by Unicef, the World Health Organisation (WHO) and Rotary International, with technical support from the United States Centres for Disease Control and Prevention. Besides the routine immunisation regimen, India also conducts 'pulse' immunisation campaigns twice a year that are aimed at reaching every vulnerable infant.

When India began its pulse polio programme in 1995, it was projected as being one of the biggest public health programmes in the world. The target year for complete eradication was ambitiously set at 2000. But subsequent spurts of fresh cases pushed the target year forward by another five years, which too could not be met. It was then set at 2007, but that has not happened either. To be declared polio-free, a country must have no new cases for three consecutive years.

As for the statistics, the number of polio cases jumped from 268 in 2001 to 1,600 in 2002. In February 2003, India launched the largest ever mass immunisation campaign against polio, targeting 165 million children. But even in that year there were 225 cases, though in 2004 there was a significant drop to 136 cases. India recorded 864 polio cases in 2007, compared to 676 cases the previous year.

Referring to the current situation, WHO and Unicef officials point out that to understand the reason for the repeated occurrence, and not to lose heart, one has to understand the profile of the wild polio virus. Of the 106 cases diagnosed till March 6 this year, 105 belong to the P3 variety while only one is the most contagious and virulent strain, P1. Among the polio viruses P1, P2 and P3, the last is the weakest. P1 moves fast and one out of every 200 people is affected by paralysis. In the case of P3, the figure is one in 1,000, say experts. P2 has been eradicated worldwide.

Of the 35 states and union territories in India, only Uttar Pradesh and Bihar remain worry areas for P1 polio. Even the widely reported case of young Sandeep Yadav, discovered to be infected with polio in January 2008, in Kolkata (the case caused panic, as West Bengal was declared a polio-free state), apparently caught the infection in Bihar. Unicef officials in Kolkata claim it was the P3 strain.

Since the launch of the Global Polio Eradication Initiative in 1988 there has been a spectacular drop in the number of polio cases every year. According to an expert at the WHO (New Delhi), who did not want to be named, this is a huge improvement considering that figures from the Indian Academy of Paediatrics reveal that during the '70s and '80s, 150,000-200,000 children in India were reported to have contracted polio. In 1994, before the campaign was introduced in 1995, around 50,000 polio cases were diagnosed. "It is perceived as a major victory against the disease and a rare instance in the history of eradication of contagious diseases in the world," says the expert.

The recent outbreak of the P3 variety has something to do with policy change. In December 2004, when the situation was reviewed by the WHO and the India Expert Advisory Group (IEAG) set up by the government in 1999 as a group of national and international experts on polio eradication, it was decided that in order to better tackle the disease the programme should "go sequentially, one by one". A monovalent vaccine for "efficacy" of Type 1 was recommended, the logic being that since this strain was the most virulent one, leading to paralysis, it should be eradicated first. Then one could move on to P3.

The WHO recommends using a monovalent vaccine in countries where there is only one type of virus in circulation (generally, Type 1, but also Type 3). Monovalent OPV1 (oral polio vaccine) provides increased immunity to the Type 1 polio virus. India began introducing the monovalent vaccine in 2005.

One of the biggest areas of change has been in Uttar Pradesh, says Nasir Ateeq of Unicef, Kolkata. Experience has shown that the virus takes hold and spreads quicker in densely populated unhygienic conditions. Ignorance and religious diktats contribute too. To address Uttar Pradesh's "underserved community", in early-2004 Unicef collaborated with government agencies in confidence-building measures when it found that parents lacked confidence in the medication and it became necessary to explain to them that it was a 'preventive' measure rather than a 'curative' one. Unicef took the help of community and religious leaders. Superstition about the polio drops, apprehension about it being a 'birth control' device, even that it was against the religion, have, in the past, bogged down immunisation programmes not only in Uttar Pradesh and Bihar but also in communist-led West Bengal. In the latter, roping in local leaders and religious heads to endorse the programme yielded good results. Considering that in 2003 West Bengal figured in the WHO's 'polio menace list', by 2004 only one case was reported.

The government of Saudi Arabia has also played an indirect role in helping the polio drive, though few health officials like to talk about it. The government announced that, starting January 2006, Haj pilgrims to Mecca would have to comply with the stricture that all children below the age of 15 must carry polio immunisation certificates. Ateeq claims that as a result, in western Uttar Pradesh (recognised worldwide as being a hub of the disease) not a single case of P1 has been reported within the last 13 months. In 2007 there were only four P1 cases, two of them from Muslim families. "This is significant, and the result of focused intervention programmes." This year too, all 15 cases reported from Uttar Pradesh are of the P3 variety. Unicef believes that the greater challenge now is Bihar.

To try and wipe out the Type 3 strain, the government is planning to advance the pulse polio rounds in Uttar Pradesh, Bihar and parts of Haryana from April to March 30.

However, whilst commenting on the fact that the Type 1 virus is on the decline in India, Ramadoss told the news agency IANS: "Polio is polio. A child suffers from one strain or the other."

(Ranjita Biswas is a journalist based in Kolkata. She writes mainly on women and gender issues, HIV/AIDS, and the environment. She is also Editor of Trans World Features)

InfoChange News & Features, March 2008