Polio free India: Challenges Ahead

Sir,

India, which once had the highest number of polio cases in the world, has achieved 3 years without any case of wild polio virus.The last poliovirus was detected in Howrah district of West Bengal with date of onset 13th January 2011. Environmental sampling reaffirms progress, as no wild poliovirus has been detected in sewage samples after week 45 of 2010. Data from the entire country for the period 2008-2012 has been reviewed by the South-East Asia Regional certification commission for polio eradication (SEA-RCCPE). The RCCPE has concluded that there is no circulating poliovirus in India, and the AFP Surveillance system is capable of rapidly detecting any importation. India along with 10 other countries of South east Asian region will be declared as the 4th Polio free WHO region at the end of March 2014 (3 out of 6 WHO Regions have already been certified “Polio Free”-American region in September 1994, Western Pacific region in October 2000 and European region in June 2002).

The achievement by India is an outcome of strong political commitment, assured financial resources, introduction of more efficacious vaccines (bOPV), underserved strategy, reaching out to the most vulnerable groups like mobile & migrant population, and newborn tracking.

However despite unprecedented progress we are not risk free and there is no room for complacency. Polio continued to lurk in several countries around the world in 2013.

The endemic zones of Pakistan(92 cases) ,Afganistan(14 cases) and Nigeria (53 cases)continued to constitute a risk. There have been importations from endemic countries into central Africa, Horn of Africa and the Middle East, resulting in huge outbreaks. The virus is now concentrated in areas with poor access. In 2013 globally there were 399 polio cases of which 240 cases were found from non- endemic countries like Somalia(190),Kenya(14), Syrian Arab Republic(23) ,Ethiopia(9)and Cameroon(4). WPV1-positive samples have been detected by environmental surveillance in Israel and West Bank and Gaza since February 2013 and continue to be detected in 2014.Genetic testing determined that the virus originated in Pakistan and travelled to Israel via Egypt. Already six new WPV1 cases reported in this month from Pakistan¹

Along with possible risk of international importation of WPV we also need to keep a close vigil on other challenges like any complacency or lack of focus, any gap in AFP surveillance at micro-level, areas with low population immunity and emergence of vaccine derived polio viruses.

The priority issues² to mitigate risk for polio reintroduction in India are-

1. to maintain population immunity by strengthening routine immunization ,high quality supplementary immunization ensuring 0% missed children in pulse polio and special effort for high risk and hard to reach areas,

2. 365 day cross border vaccination at international border to interrupt entry of virus,

3. Certification standard AFP surveillance system(at least 2 non-polio AFP case/100000 under 15 children and 80% adequate stool sample)³; and

4. Updated emergency preparedness and response plan (EPRP) to tackle any importation.

As a part of the risk mitigation strategy the Government of India has decided that all travelers from the polio endemic and re-infected countries should receive OPV at least four to six weeks before their departure to India⁵.

The lessons learned from India’s case are now part of the global strategic plan to secure a polio-free world by 2018. At the Global Vaccine Summit in April last year, the Global Polio Eradication Initiative(GPEI) announced the new polio eradication and endgame strategic plan 2013-2018.⁴The end game strategy^2,4 will revolve around-

1. Strengthening of health systems to improve routine immunization coverage ,

2. sequential removal of oral poliovirus vaccines from routine use to minimize the risks associated with use of OPV in the post eradication phase,

3. Switch from tOPV to bOPV for RI and SIAs ( around 2016), and

4. Building type 2 immunity prior to switch to minimize risk of VDPV emergence post switch by introducing IPV before switch (~ 2015) and ultimately withdrawal of all OPV from programme (~2019)

Actions are already being taken to mitigate the risks and overcome the remaining challenges in India.Lessons learnt from polio eradication initiative are being used for strengthening routine immunization. It is not over until it is over everywhere in the world.”

Proress of polio eradication in India

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1. Polio this week. available from www.polioeradication.org/dataandmonitoring/poliothisweek.aspx

2. 25th Meeting of the India Expert Advisory Group for Polio Eradication(IEAG). Delhi,India,3^rdMay2013.Conclusions and Recommendations.

3. Field Guide:Surveillanceof Acute Flaccid Paralysis. Child Health Division. MIHFW. Govt. of India.2005;3-38

4. Global Polio Eradicationinitiative. Polio eradication and Endgame strategic plan 2013- 18.Available from www.polioeradication.org/Resourcelibrary/strategyandwork.aspx

5. Keeping the polio virus at bay.available from www.searo.who.int/india/en