India’s polio progress and the global eradication effort

India marked a historic moment last week: It has been a year without a confirmed polio case. For a country that had for several years the highest number of cases in the world, the achievement was remarkable. The global effort to eradicate polio, launched in 1988, has brought the disease down to the last hundreds of cases every year. The effort has cost $9 billion so far, including $2 billion from the US government.

Ellyn Ogden, USAID’s worldwide polio eradication coordinator since 1997, spoke to GlobalPost from Delhi this week about how India did it and what the overall eradication fight looks like. In 2011, the global number of polio cases will approach between 630 and 640.

Q: What happened in India?

A: It’s a phenomenal achievement with the amount of work going into vaccinating India’s 172 million children.

Q: What were the key strategies to stop transmission?

A: What impresses me about India was they were willing to confront the obstacles. If there were a lot of children in one area, they put in more teams. If teams were not performing, they were held accountable. If families were not accepting vaccination, they found ways to convince them. They pulled together to answer people’s questions. They worked through floods. They realized there weren’t enough health posts along the Kosi River, for instance, and then there was flooding there. So they set up these satellite immunization posts all along the river to make it easier for families to get vaccinated.

They also dealt with migrants and nomads, really marginalized people, and they set up a whole strategy to identify them and make sure vaccinators went to those places. They were constantly looking at the data, looking at what they were missing, finding the gaps, and changing their plans to address them.

Q: Did you think it was possible five years ago?

A: I always thought it was possible. I’m an optimist. We cut down the time frame with a bivalent vaccine. In many countries, they stopped it with a trivalent vaccine. And we tried monovalent vaccines as well.

Q: Explain a bivalent vaccine.

A: OK. The normal vaccine you get is trivalent; it provides protection against all three types of polio, 1, 2, and 3. But there’s been no number 2 wild type in the world since 1999. The trivalent vaccine is very strong against number 2, but not against 1 and 3. So we weren’t getting as big an immunity boost as we needed. We changed to a vaccine that combined the type 1 and type 3 together. It built the population immunity in those types very quickly. The quality of the rounds (of vaccinations) was so good, it was pretty much reaching every child. They listed households where kids were absent during the vaccinations so they would go back, and they actually did go back. Someone is always checking on others’ work. This meticulous attention to detail has built population immunity where it looks like we have stopped transmission.

Q: What can other countries learn from India?

A: One is admitting where you have gaps. This is not meant to criticize countries. It’s really meant to expose the problems, and then solve them. It means digging into the data, looking at the subpopulation, looking at volunteers to see who is performing and who isn’t. It’s very hard for governments to do all this, but letting things go means the virus keeps circulating.

Q: What trouble spots in the world worry you?

A: The data is showing Pakistan has numbers of cases that are significantly higher than in the past (approaching 200 cases in 2011). Nigeria’s cases are up substantially from last year. Afghanistan has an increase. Chad and the Democratic Republic of Congo still have a substantial number of cases; their campaigns are sub-quality. Angola has a few gaps, mostly in Luanda. We now have only type 3 viruses in West Africa. The next big event may be to interrupt type 3 virus around the world.

Q: Are you worried about cases from Pakistan affecting India?

A: There’s never been a documented case of polio coming from Pakistan to India or vice versa. There is no evidence of spread. But that said, there are certainly cases from Pakistan that have been detected in China – 20 cases in fact. The Indian virus also went to Angola and started spreading there, and that spread to the DR Congo. There’s a risk from re-importation from Africa into India as well.

Q: What is the mood now in India with those in charge of polio eradication? Are they celebrating?

A: Everybody is cautious. They are happy, but they understand how fragile the success is. I met with government officials in West Bengal and nobody was really celebrating. They marked the anniversary, people acknowledged it, but people were getting ready for the next immunization campaign. Door-to-door activities are starting this week. They are really focused to reach the kids they didn’t reach last time. Although they’ve had a lot of success, they still had 43,000 households who refused vaccinations. That poses a risk. Nobody is resting on their laurels on this.

Q: How does it look for eradication of polio now?

A: I think we can really do it. We pretty much owe it to India to give this effort some time. They worked so hard to get 172 million kids vaccinated. There are always skeptics. But it doesn’t get much more difficult than in India. If they can do it here, we should be able to do it anyplace with the tools and strategies we have.

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