Q. We are grateful to Dr. Jacob John for drawing attention in a recent editorial in Indian
Pediatrics(1) and elsewhere(2) to the goal of polio eradication. The
editorial, however, contains some misunderstandings and references to dated information, which paint an unnecessarily discouraging picture. We are happy to report that earlier theoretical concerns have not materialized, and that the status of polio eradication is not as gloomy as he describes.
The polio eradication program in India was launched by national consensus following careful deliberations by a team of Indian experts, including Dr. Jacob John, in consultation with their colleagues around the world. The program was endorsed by state health ministers at a meeting in Delhi on 19-20 July 1995. The commitment to the people of India is that their children will forever be spared the threat of poliomyelitis through successful eradication of the wild poliovirus.
The strategy for eradication has been defined by the Government of India and endorsed by the World Health Organization (WHO). It is based on a strategy that has proven successful not only in Latin America, but everywhere it has been applied, including neighboring China(3), Indonesia, Sri Lanka(4), Cambodia and Viet Nam(5). As Dr. Jacob John correctly states, much of this strategy is based upon research done by scientists in India. Out- breaks of "provocation polio" resulting from this strategy have never been re- ported, in India or any other country.
The author is correct in emphasizing the importance of surveillance. His bleak assessment of the surveillance system in India, however, is based on grossly out- dated information from 1992. The situation has improved dramatically since then. In October 1997, a national system for surveillance of polio and all other forms of acute flaccid paralysis (AFP) was launched. This system for the first time allows public health officials to pinpoint areas where poliovirus persists, and where supplemental immunization is needed.
The AFP surveillance system functions through the existing government network of District
Immunization Officers (DIOs), with technical assistance from the WHO. Since October 1997, over 3,400 health care institutions have begun reporting weekly to the DIOs whether or not they have seen any children with AFP. This has resulted in an increase in reported polio cases due to improved detection and investigation of AFP dases. A total 4,387 AFP cases were reported through this system in the first 9 months of operation. Eighty per cent of cases were investigated within 48 hours of reporting, and 2 stool specimens for virus culture were collected from 49% of the cases within 14 days of the date of illness onset (the target in each case is at least 80%). The system relies on a network of 9 laboratories. Ninety six per cent of stool specimens have been received by the laboratories in good condition. The sensitivity of polio surveillance will be monitored by the reported rate of non-polio AFP, which is expected to be at least 1 per 1,00,000 children under 15 each year. The currently reported annualized rate of non-polio AFP is 0.55. Rapid reporting
of AFP cases by
everyone who treats children will be necessary to achieve the required level of surveillance sensitivity nationwide. Modifications in the surveillance strategy will be made as necessary and will certainly be tailored to local circumstances.
Surveillance reports confirm the success of the current eradication strategy. Type 2 poliovirus may have already been eradicated, and preliminary results of genetic sequencing suggest a substantial reduction in the genetic biodiversity of remaining strains (personal communication, Dr. J. Deshpande, Enterovirus Research Center, Hafkin Institute, Mumbai).
The surveillance network is entirely within the Government system and application of the network to other public health concerns is anticipated, with the benefit of infrastructure, skills and experience gained through polio surveillance.
The goal of polio eradication by the year 2000 should not be confused with the certification of polio eradication. Eradication will be achieved when the last case of polio is reported from India, Certification will require at least 3 years of observation after eradication is achieved, in the presence of continuing high quality active surveillance.
Whether polio will be eradicated from
India in the year
remains to be seen,
but it will certainly be close. It is clear that the concerns expressed by Dr. Jacob John have not materialized, and the constraints are being rapidly overcome. India's strategy for polio eradication is proving successful. It is not at a crossroads. It has just hit the highway. Now is not the time to stop and look backward, but to unite in our effort, open throttle and speed ahead.
Assistant Commissioner (Immunization),
Ministry of Health and Family Welfare,
402 D Wing, Nirman Bhawan,
New Delhi 110 all, India.
National Professional Officer,
World Health Organization,
534 A Wing, Nirman Bhawan, New Delhi 110 011, India.
W. Gray Hlady,
World Health Organization,
534 A Wing, Nirman Bhawan, New Delhi 110 all, India.
John TJ. India's polio eradication efforts at cross roads. Indian Pediatr 1998; 35: 307-310.
Flawed immunization policies in India led to polio paralysis [news report]. Brit Med J 1998; 316: 1261.
Ke-an W Li-bi Z, Otten, Jr. MW, Xing-Iu Z, Chiba Y, Rong-zhen Z, Tao X, et a/. Status of the eradication of indigenous wild poliomyelitis in the People's Republic of China.
Infect Dis 1997; 175 (Suppl 1): S105-S112.
Andrus JK, Banerjee K, Hull BP, Smith Jc, Mochny 1. Polio eradication in the
World Health Organization South East Asia region by the year 2000:
Midway assessment of progess and future challenges.
Infect Dis 1997; (Sup pI 1): S89-S96.
Tangermann RH, Bilous
Maher C, Aylward RB, Schnur A, Sato Y, et a/. Poliomyelitis eradication in the Western
Infect Dis 1997; 175
I am grateful for the opportunity to clarify the various issues raised by Drs. Sarkar, Banerjee and Hlady.
They thank me for drawing attention to polio eradication in India.
India's policy, strategy and tactics of polio eradication are not yet
widely known. For example, in the public announcement of India's achievements in health in our golden jubilee year of independence, the progress of guinea worm eradication and leprosy elimination are highlighted but polio eradication effort is totally
missing(1). In the Report of the Indpendent Commission on Health in India, the concept or target for polio eradication finds no mention at all(2). That polio eradication has got no recognition or importance even in current and impact- making publications, both governmental and nongovernmental, speaks volumes on the failure of my colleagues in their advocacy role. Being aware of the slackness on the part of our health bureaucracy on the polio front, I have been trying my utmost to remedy this anomalous situation. For over one decade, until my superannuation in December 1995, I have been sending every month of every year, to the Ministry of Health and the South East Asia Regional Office of the WHO, tokens of reminder of the urgency for and a design of disease surveillance and of polio control(3). A detailed review of tactics to achieve polio eradiation in India was published in 1993, incorporating
ideas from many earlier publications desperately trying to wake up our
health ministry from its slumber(4). Yet another review was published in
1996(5). In all these, I was acting as the advocate for the best
interests of both the ministry officials and the nation. My editorial in
Indian Pediatrics was meant to strengthen the hands of Dr. Sarkar to accelerate the polio eradication efforts and to enable him to seek more support(6). The tone of the rejoinder in which my friends have attempted to picture me to have some reservations about polio eradication points to their inability to distinguish friend from foe and facts from fiction. To accept therapy, one must first accept the presence of disease; if problems are denied, solutions will not be applied. A word of caution from an honest friend is more valuable than a thousand words of flattery from "yes-men".
In order to give due respect and seriousness to the specific points in their letter, I shall identify areas of agreement between our views, present items of obvious misperception or misrepresentation by them and point out issues over which there is genuine disagreement.
The authors agree that a surveillance system began only very late and currently it is not detecting the expected number of cases of non-polio AFP (0.55 instead of 1 per 100,000 under 15). They realize that rapid reporting of AFP by everyone who treats children (and not by the public sector only) will be necessary and that modifications
in the surveillance system are needed. Thus they agree with me that
currently our surveillance is qualitatively poor. We are now at a
decision junction or cross roads at which point a choice must be made
from among different options that are available for qualitative and
quantitative improvement of surveillance in order to make it suitable to satisfy the stringent
requirement for documenting the exact state of polio-myelitis in all of India. According to them, only about 3400 health care institutions have begun weekly reporting of AFP. If the estimate of India's requirement as 70,000 reporting stations is taken seriously, the present coverage is only 5%(5).
The second item on which the authors
agree with me is about the likelihood of India not succeeding in eradicating polio by the year 2000. "Whether polio will be eradicated from India by the target date remains to be seen" is what they admit. Having agreed with two of my major concerns, they have ignored many others, presumably for want of answers. My point is simply that even at this late hour we may be able to accelerate the process of eradication if we can analyze each issue and face deficiencies one by .one, so that we give our best to catch up to the deadline of 2000.
It is obvious that my friends had not paid attention to details of the
two references they attribute to me before writing the letter in response(6,7). The
author of the second reference is in fact Ganapati Mudur, a journalist(7). He was concerned mainly with the flaws of immunization policies of the 1970's and 1980's and with the consequent occurrence of provocation polio. That Dr. Sarkar and colleagues have not understood Mudur becomes more obvious when they declare that the liberal doses of OPV under the strategy of eradication have not resulted in provocation polio. Mudur
was clear that it was injections that provoked polio, not OPV. The theme
presented by Mudur, quoting some of my earlier writing, was that provocation polio could have been avoided in the 1980's jf sufficient numbers of doses of OPV had been administered to reduce the circulation of wild polioviruses(7,8). It is elementary knowledge that pulse immunization achieves this and virtually eliminates provocation polio. When OPVinduces polio it is called 'vaccine associated polio' and not provocation polio. These two have been confused with each other because both are adverse reactions to immunization, one in- directly to OPT and the other directly to OPV.
Another source of their misinterpretation is the semantics of 'strategy' and 'tactics'. There is only one global strategy for the global eradication of polio and that en- tails adequate surveillance, adequate virological examination and adequate immunization: This is universally accepted. The editorial has been erroneously accused to suggest that the strategy is at crossroads but in reality it was clearly stated that "there are alternate tactics possible for disease surveillance, virological investigations and polio immunization". All three parameters require qualitative and quantitative improvements if we must eradicate polio on schedule. It is worth checking the dictionary
meaning of the words strategy and tactics, borrowed from th-e'1ingo of
war. In the popular comic series Asterix and Obelix, the Roman soldiers with their rigid tactics of fight are defeated every time by the Gauls
who alter their tactics as the situation demands. If the epidemiological tactics of polioviruses vary geographically, we must also allow flexibility to choose the right tactics of fight against them. Blowing one's own trumpet may mislead the soldiers to think the war has already been won, when the need of the hour is a clarion call to the soldiers to fight, since the war has only just begun.
I do not want our country to be one of the last in the world to eliminate polio for two reasons. Let me quote from the history of smallpox eradication. "The Final Victim. The last person to catch smallpox (Variola major) by ordinary transmission was a three-year-old malnourished Indian girl called Rahima Banu who fell victim to the deadly virus on 16 October 1975. A massive effort by WHO workers succeeded in saving Rahima's life and ensuring that the outbreak did not spread."(9). So the first reason is not to be caught in the same situation a second time in history. How would Drs. Sarkar and Banerjee feel if the final
victim of polio was to be identified as another malnourished Indian child? If it happens, then we will all feel shame, disappointment and gloom; that is exactly what I would like to tell them to avoid at all costs. Obviously my friends do not show any sign of such anxiety. The second reason
is that the problems and solutions of the control and elimination of
polio in developing countries have been learned and taught in our country ahead of all others, starting from even before the establishment of the Expanded Programme of Immunization and that process continues even today. Advice is given by WHO in good faith based on the experience and expertise gained
elsewhere by the experts of the WHO. It is for our national leaders to apply some independent thinking and to accept what is sound and modify what is not. Blind acceptance of foreign policies have misled us in the past in many fields such as nutrition and the control of other diseases. In the case of polio, I had shown the errors of WHO's and Government's policies as far as India is concerned, on four issues. They were the inadequacy of 3 doses of OPV, the inappropriateness of 85% immunization coverage target, the need for pulse immunization to rapidly break poliovirus transmission and the critical importance of de-centralized and efficient surveillance for achieving and documenting polio eradication. On all counts my stand based on science and Indian experience has been vindicated and the credibility of the opposing agencies has been eroded. Why were these lessons not acted upon by our country health officials? India could have eliminated polio in the middle of or late 1980's and led the world on this front if our policy makers had self confidence and objectivity.
Since pulse immunization started in December of 1995 and surveillance in October 1997, the effect of pulse on polio epidemiology
in India can never be measured. There is suspicion that this sequence
might have been intentional in order to inflate the requirement of poliovaccine which to date is totally imported. If unintentional it has been irrational. It is heartening to know that recently one manufacturer in India has been supplied with Sabin seed viruses to begin in-country manufacture even though we do know that OPV's
days are numbered. Some time in the not-too-far future the world will have to discontinue using OPV.
The year 2000 is round the corner and we have no more time for any more
errors as the throttle is being opened to speed away on the polio
eradication highway. We have been taken previously on wrong high- ways
and at least this time let us be sure of our road map which are the
tools of measurement and of prevention of poliovirus circulation.
I must concede that the interpretation of the eradication target of 2000
may be open to differing views. If the reported last case of
poliomyelitis occurs at the end of the year 2000, we will not know if
poliovirus circulation would have ceased unless we wait for 3 more
years. Since polio has continued to occur even in 1998, on December 31,2000 we will not know if eradication has been achieved no matter when the last case is going to be, be it in 1999 or in 2000. If Dr. Sarkar
had been confident that the present trend shows that the last case will
be before the end of 2000, I am willing not to debate this point.
However, as mentioned earlier, whether we will reach the target even according to their interpretation remains to be seen. In other words they are still not confident that the present tacties will see the end of polio by the end of 2000. If Dr. Sarkar is willing to examine the need for midcourse corrections of our tactics then I pledge all help as president elect of the Indian Academy of Pediatrics
and in my personal capacity. The prestige of the nation in the timely achievement of polio eradication rests in the hands of Dr. Sarkar and not in those of the WHO, which is not the executing but only the advisory agency. If India failed, no one will blame the WHO because many countries have already eliminated polio with their advice.
Committee on Immunization
Indian Academy of Pediatrics,
Tamil Nadu - 632 002,
Ministry of Health and Family Welfare. Fifty Years of Achievements in Health. In- dian Express, New Delhi; 30-8-1997, p10.
Mukhopadhyaya A. Report of the Indepenent Commission on Health. Voluntary Health Association of India, New Delhi, 1997; pp 125-126.
3. John TJ, Samuel R, Balraj V, John R. Dis- ease surveillance at district level. A model for developing countries. Lancet 1998; 352: 58-61.
John TJ. Immunization against polio-viruses in developing countries. Rev Med Viro11993; 3: 149-160.
John TJ. Can we eradicate poliomyelitis? In: Frontiers in Pediatrics. Eds. Sachdev HPS, Choudhury P. New Delhi, Jaypee Brothers, 1996; pp 76-90.
John TJ. India's polio eradication efforts at crossroads. Indian Pediatr 1998; 35: 307-310.
Mudur G. Flawed immunization policies led to polio paralysis (News). Brit Med J 1998; 316: 1261.
John TJ. DPT and poliomyelitis in developing countries. Curr Sci 1998; 74: 185- 187.
Duin N, Sutcliffe J. A History of Medicine from Pre History to the Year 2020. Lon- don, Simon and Schuster, 1992;