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Polio virus: A lurking danger

As news of the onset of another outbreak of the polio virus lurks, it is our operational efficiency, capacity building of the healthcare system, monitoring systems and infrastructure of our robust polio programme that will hold us in good stead. As we stand with our chin up, India is optimistic that every loophole has been addressed to mitigate risks of import and transmission of the virus.Sonali Patranabish takes a peep

There’s indeed something to be jubilant about, a milestone achieved, a landmark reached of being a polio-free country in the last 13 years. This feat to completely eradicate the polio virus seemed like a formidable task at some point in time but was achieved through painstaking efforts and unwavering commitment towards a common cause. At the global level, it seemed that eradicating polio from India would be like a tough nut to crack given the poor sanitation and hygiene levels and the densely populated situation. However, through mass vaccination programmes and thoughtful strategies, India was able to rise above the water and completely eradicate the Polio virus through their undying resolve.

In the backdrop of this celebratory moment, an ominous voice rings on the return of the polio virus. This crippling disease has made a comeback in the US in 2022, a country with a robust healthcare system that had eradicated the polio virus almost three decades ago has fallen prey to this deadly disease. The virus was detected in wastewater samples as well as tested in a traveller. While one thought that the polio virus was wiped out, the resurgence has rung an alarm. What has been even more unnerving has been the fact that the re-emergence has occurred in relatively high-income countries like the US and the UK. The case in the US was however traced back to its origin in Pakistan, through London and finally to an orthodox undervaccinated community in New York.

While the US had cornered the wild variant of the Polio virus, under the aegis of the Global Polio Eradication Initiative (GPEI), the strain that made headlines was the vaccine-derived polio virus (VDPV). The outbreak in the West was directed towards communities going unvaccinated and remaining under-vaccinated. The unvaccinated are at a higher risk of contracting the VDPV, a variant of the original weakened virus from the OPV. Such cases of VDPV are not very recent, in fact, there have been quite a few cases reported in 2020 in low-income countries like Afghanistan, Pakistan and the Democratic Republic of Congo.

Dr Gloria Rey, an expert at the deadly and crippling disease polio and regional advisor with PAHO( Pan American Health Organisation), states that the weakened form of the live virus from the OPV vaccine, once shed into the environment and communities with low-immunisation coverage, revert and mutate to a deadly strain causing irreversible damage in the form of paralysis. Are these sorts of outbreaks globally going to crash our hopes and joy and dampen our spirits over our Polio-free certification from the WHO which we have earned over the last two decades? Industry insiders and epidemiologists have however shared a word of caution for our frontline polio warriors.

Dr Monica Gulati, Executive Dean, Faculty of Applied Medical Sciences, LPU states that we as a country need to have our guard on given that we are pitted against a wall of surmounting challenges. Gulati adds, “The challenges that we face are multi-fold including the complexity of viral strains (wild as well as vaccine-derived), neighbourhood of two polio-infected countries, a huge number of travellers from polio-infected countries, much lower immunisation rates than the desirable 95 per cent and periodic emergence of vaccine-derived poliovirus in the sewage samples.”

Nevertheless, India’s intensive polio eradication programme is quite comprehensive. Our blueprint to tackle the virus face-up is all-inclusive, backed by a dynamic government and Polio partners from across the globe, WHO, UNICEF, Rotary International and the CORE group. Fortified by dedicated frontline workers, India is upbeat about the ‘model of excellence’ that will hold us together even through a storm.

Upper Hand with OPV. There has been a misconception that the polio virus would only be a threat to low-income countries which vaccinated with the Sabin vaccine which is more prone to mutations, unlike wealthy Western countries which vaccinated with the Salk vaccine/ inactivated Polio vaccine ( IPV) which is resistant to mutations.

Despite the ambivalent opinion on OPV and IPV, OPV has risen to be the golden arm of the polio eradication programme due to its cost-effectiveness and ability to confer immunity. IPV while being effective in managing paralysis, is not very effective in curtailing the spread of the virus or simple terms an outbreak, unlike OPV.

“Polio vaccines are an integral part of the Universal Immunization Programme and Bharat Biotech has been the largest supplier of oral polio vaccines to Govt of India for more than 15 years,” opines Suchitra Ella, MD Bharat Biotech.

India uses the OPV as part of their immunisation programmes and has ensured to maintain a rolling stock of OPV in response to the detection or emergence of the wild-type strain or VDPV.

The National Technical Advisory Group on Immunization ( NTAGI) has suggested the addition of even an IPV as part of their concerted efforts to nab the virus.

Circumventing cross border transmission

Cross-border travel leads to a situation where we encounter people from other countries who have been administered other forms of the polio vaccine, it becomes easy for the virus to be transmitted especially in regions low on immunisation. India has been vigilant about the transmission of the virus from the cross border and hence. The GoI has a ruling that mandatory vaccination is to be provided to international travellers to and from eight other affected countries with the help of continuous vaccination teams (CVT). Rigorous vaccination is even carried out at international borders and boundaries of India to minimise the risk of transmission if the virus through special booths set up at all borders.

Awareness 

From the universal immunization programme to the Pulse Polio programme, India has always been driven to put an end to this fatal illness. Ella states, “Government of India’s Universal Immunization Program (UIP), is a great success in the number of doses delivered and lives saved across a wide spectrum of infectious diseases and vaccines. One special case is its success in polio eradication efforts, which has resulted in a polio-free India for the past several years.”

The GoI has rolled out a host of programmes like the Pulse Polio immunisation programme which operates twice a year. Sub National Immunisation Day which is conducted in high-risk states. AFP( acute flaccid paralysis) surveillance is conducted to keep a tab on the virus through laboratory analysis. Such mass immunisation programmes that have delivered close to a billion doses have helped confer population immunity.

Steadfast surveillance and response systems

Authorities have been extremely vigilant about the circulation and importation of the wild-type poliovirus and even VDPV. Continuous environmental surveillance of sewage samples is conducted to have a close watch on the virus especially in regions with large migratory populations like Mumbai, Delhi and Kolkata. Our country also has in place a Rapid Response Team (RRT) in the wake of an outbreak and emergency preparedness and response plans (EPRP) with steps to be taken in the event of detection of the polio virus.

Dealing with Vaccine hesitancy – Innovative strategies

As a nation, we have been constantly innovating and devising strategies in the wake of a new challenge be it accessibility to vaccination in remote areas and hard-to-reach populations and communities amidst conflicts and emergencies. However, while authorities and personnel committed towards complete eradication may sound like a broken record as they insist on pushing for mass vaccination, it is an irrefutable fact that low-immunisation rates, anti-vaccination sentiments and under-vaccination can impede the incredible progress we have made over the years to combat this deadly virus.

Ella mentioned, “While routine immunisation rates in India face challenges due to our large population, cultural and geographic diversity, oral polio vaccines are provided free of charge, at birth, during routine immunisation and through pulse polio campaigns. This ensures a very high coverage rate and establishes eradication of polio disease.”

However, India already has a clear roadmap etched out for dealing with such challenges. The 107 block plan was implemented in 2009 to deal with issues like vaccine acceptance and deployment, dealing with vaccine hesitancy groups, vulnerable populations that consist of migrant workers and religious minorities who lack faith in the government’s initiatives. Similarly, in 2002 the Social Mobilization Network was formed (SMNet) with GOI and Rotary International as partners to improve their outreach of hard-to-reach groups. Community mobilisation coordinators were given the onus of educating and bridging communication gaps across target groups specifically on the polio vaccine.

Ella goes on to add “The immunisation in India is one of the best in the world, due to its wide coverage of infectious diseases through life-saving vaccines. What is important is that India has excellent capabilities for innovation, novel product development and large scale vaccine manufacturing, to meet domestic and global demands.”

Reflective practices

The polio eradication programme has been constantly reviewed by the Indian expert advisory group for polio eradication which boasts of a panel of national and international expertise who continually review the programme and make necessary iterations in the wake of day-to-day challenges. India is cognizant of the risk of outbreaks globally and has even made amends in their strategies, like switching from trivalent OPV to bivalent OPV. The GoI along with WHO and other partners have also decided upon phasing out OPV and introducing the IPV as part of the immunisation regimen.

Unique interventions

The success of the polio eradication programme as part of a massive public health initiative was hinged on collaboration, unique interventions like getting celebrities on board to promote the programme and using mass -media like radio to encourage everyone to get themselves vaccinated.

India has emerged as a thorough winner, our breakthrough in successfully being able to nab the wild-type variant in the last 13 years is indeed laudable. We as a nation have addressed every concern and tackled every roadblock head-on, which has resulted in helping us flatten the curve. The polio endgame strategy has been one that has been emulated by even our neighbouring countries which have been endemic to the polio virus. The monumental success has been attributed to the steadfast approach by the government, proactiveness at the administrative level, seamless technical assistance as well as logistical efficiency.

 

 

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