ndia celebrated its victory over polio on 11th
February 2014 after an extraordinary fight against the disease for
almost two decades since the introduction of the Global Polio
Eradication Initiative (GPEI) in India. The South-East Asia Region of
the World Health Organisation (WHO) was certified polio free, on March
27, 2014 by the WHO’s Regional Certification Commission for polio
eradication certification.
From the billions of ordinary civilians and grassroot
workers to the top Government and international agencies, the story
speaks about the stupendous success of unified and sustained relentless
efforts of all to reach this great milestone, unmatched by any herculean
task post India’s independence. India could overcome both biological and
sociocultural barriers in polio control and Indian Academy of
Pediatrics (IAP) played its role by supporting and promoting the
government initiatives all along.
Margaret Chan, Director General of WHO – while
congratulating the country on this achievement – went on record to say,
"India has shown the world that there is no such thing as impossible.
This is likely the greatest lesson and the greatest inspiration for the
rest of the world." We have been fortunate to have Dr. Jacob John whose
long standing recommendation to the GPEI – of introducing injectable
polio vaccine (IPV) by all oral polio vaccine (OPV)-using countries to
complete and conclude polio eradication – was finally reflected in the
2013 end game strategy by the GPEI. The WHO, in its Polio End Game
Strategic Plan (2013-2018), has chalked out definite plans for
management of risks of poliovirus in the post-eradication era [1]. The
first step is to address the risks of circulating vaccine-derived
polioviruses (cVDPV) which can be equally catastrophic. This will
require stopping all routine immunization with type-2 OPV, and switch
from trivalent to bivalent OPV in a globally synchronised manner. This
strategy involves the mighty challenges of withdrawing and safely
destroying all the trivalent OPV stocks in the field, simultaneously
maintaining the population immunity at the highest possible level, lest
the cVDPV may occupy the place of the wild virus after stopping OPV.
It is now inevitable for India to introduce IPV in
the Universal Immunization Program (UIP), achieve its very high
coverage, and thereafter withdraw OPV synchronously [2]. Polio control
was achieved by a dedicated structure, but the responsibility of
sustaining high polio immunization in the post-elimination phase is a
challenging task. The country also needs to gear up for local
manufacture of these vaccines to minimize the financial burden. WHO may
not allow use of the wild polio virus for manufacturing the IPV by the
local manufactures. Apart from the problem of insufficient availability
of the vaccine, there are issues of cold chain capacity and health
infrastructure for administering an injectable vaccine .
Change in the Recommendation on Polio Vaccines by the IAP
Previously, the IAP recommended a combined schedule
wherein both OPV and IPV were administered simultaneously to maximize
the immune response in an individual. It was in accordance with the
government policy of using OPV when the wild polio virus circulation was
ongoing. However, after controlling the wild virus circulation in 2011,
it was felt necessary to focus more on the safety issues of the OPV like
vaccine associated paralytic polio (VAPP) and cVDPV. Accordingly, in
2012, the Academy advocated the use of IPV in the primary schedule at 6,
10 and 14 weeks, and use of OPV at birth, 6 months and 9 months [3]. The
recommendation of the IAP to adopt sequential IPV-OPV schedule is very
much in line with the decision taken by the GPEI of phased withdrawal of
the Sabin viruses, beginning with the highest risk Type-2. The IAP has
retained the birth dose of oral polio; the high levels of maternally
transmitted antibodies should mitigate the risk of VAPP in those
receiving OPV at birth. This birth dose, though not highly immunogenic,
improves seroconversion of subsequent doses of polio vaccines. OPV with
IPV in this sequential schedule provides the benefit of superior gut
immunity as compared to only IPV schedule. IAP is committed to support
GPEI activities in the country, and its members are advised to encourage
administration of OPV doses during the National Immunization Days (NIDs)
and supplementary immunization days (SNIDS) of the Government of India.
At the same time, there is a serious threat of
importation of wild viruses from three polio-endemic countries:
Afghanistan, Pakistan and Nigeria. This necessitates a continuous
vigilance for polio, atleast till the entire world is declared free of
polio. With the enemy no more in sight, it will be a more challenging
task to remain non-complacent and prevent any resurgence of polio. The
Academy lauds the National Polio Surveillance Project for its
outstanding services in providing technical and logistic support in the
polio eradication drive, and believes that its continued hawk eye
vigilance will be able to tackle this threat. It also cautions its
members to remain vigilant and continue to report every case of
paralysis to the authorities.
Dr Jacob John rightly points out in his article [2]
on India’s journey to polio free status that "we are not yet out of the
woods but at its edge." The polio story is not over until both the wild
and vaccine-derived polio get eradicated from the world. IAP is
signatory to scientific declaration on polio eradication and support
Global Polio Eradication End Game Strategy Plan launched by the GPEI in
April 2013. The Academy is deeply committed to polio eradication
initiative in the country and pledges its continued support in the
post-eradication era. With sustained efforts of both vigilance and
tactful post-eradication strategies, this story is bound to have a happy
ending.
References
1. WHO. Polio endgame Strategic Plan and Legacy
Planning Draft-Polio Eradication End Game (2013-2018). Available from:
URL:
http://www.who.int/immunization/sage/meetings/2012/november/1_DRAFTGPEI_Endgame
StrategicPlan23Oct12.pdf. Accessed April 18, 2014.
2. John J, Vashishtha VM. Eradicating poliomyelitis:
India’s journey from hyperendemic to polio-free status. Indian J Med
Res. 2013;137:881-94.
3. Indian Academy of Pediatrics Committee on
Immunization (IAPCOI): Consensus Recommendations on Immunization and IAP
Immunization Timetable 2012. Indian Pediatr. 2012;49:549-64.