Global Polio Eradication: history, achievements

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Global Polio Eradication history, achievements
challenges

• Omar Khan, MD MHS

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Overview

• History Relevance
• Basics of Polio
• Vaccination
• Eradication plan
• Achievements
• Challenges
• Personal experiences
• A polio cartoon

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History Relevance
The more definitions change, the more they stay
the same Polio defined in 1895 and 2005
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History Relevance

• Poliomyelitis
• Acute inflammation of the anterior horns of the
  gray matter of the spinal cord, leading to a
  destruction of the large multipolar cells of
  these horns. It is most common in children,
  coming on during the period of the first
  dentition and producing a paralysis of certain
  muscle groups or of an entire limb.Goulds
  Illustrated Medical Dictionary, 1895

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History Relevance

• Poliomyelitis
• An inflammatory process involving the gray
  matter of the cord. An acute infectious disease
  caused by the poliomyelitis virus and marked by
  fever, pains, and gastro-enteric disturbances,
  followed by a flaccid paralysis of one or more
  muscular groups, and later by atrophy.
• Stedmans, 2005

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History Relevance

• In 1916, New York City experienced the first
  large epidemic of polio, with over 9,000 cases
  and 2,343 deaths. The 1916 toll nationwide was
  27,000 cases and 6,000 deaths. Epidemics worsened
  during the century in 1952, a record 57,628
  cases of polio were reported in the United
  States.
• Polio (also called infantile paralysis) was most
  often associated with children, but it affected
  teens and grown-ups as well. Between 1949 and
  1954, 35 percent of those who contracted polio
  were adults.
• Sign from a home
• in Atlanta where an
• infant contracted
• polio, 1941

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History Relevance

• 1953 Pool in Elmira, New York, with sign
• indicating it is closed due to polio

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History Relevance

• The first known polio outbreak in the United
  States?

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History Relevance

• Vermont, 1894
• Early in the summer just passed, physicians in
  certain parts of Rutland County, Vermont, noticed
  that an acute nervous disease which was almost
  invariably attended with some paralysis, was
  epidemic and a general feeling of uneasiness
  was perceptible among the people in regard to the
  new disease that was affecting the children.
• -- Dr. C. S. Caverly, reporting on the first
  epidemic outbreak of polio in the United States,
  1894

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History Relevance

• Polio affected events, lives, and people

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History Relevance

• Throughout most of the 20th century, hospitals
  operated under strict and orderly patient
  regimens. Epidemic conditions, combined with the
  lack of a cure for polio, heightened everyones
  anxiety.
• During a 1934 epidemic in Los Angeles, 5 percent
  of doctors and 11 percent of nurses who treated
  polio patients contracted the disease.

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History Relevance

• Whats this?

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History Relevance

• Iron lung ward at the Massachusetts General
  Hospital

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History Relevance

• The last cases of wild (naturally occurring)
  polio in the United States were in 1979 in four
  states, among Amish residents who had refused
  vaccination.
• 2006 is the 50th anniversary of the announcement
  that Dr. Jonas Salk had developed a polio
  vaccine Smithsonian exhibit (below)

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Evidence of sporadic epidemics of polio predate
recorded history. 1789, British physician
Michael Underwood provides first clinical
description of the disease.
1840, Jacob Heine describes the clinical features
of the disease as well as its involvement of the
spinal cord. 1894, first outbreak of polio in
epidemic form in the U.S. occurs in Vermont, with
132 cases.
1908, Karl Landsteiner and Erwin Popper identify
a virus as the cause of polio by transmitting the
disease to a monkey. 1916, large epidemic of
polio within the United States. 1921, FDR
contracts polio at age 39. Although he is open
about having had polio, he conceals the extent of
his disability. 1929, Philip Drinker and Louis
Shaw develop the iron lung to aid
respiration. 1930s, two strains of the poliovirus
are discovered (later it was determined that
there were three). 1931, scientists create the
first filter able to trap viruses. 1933, FDR
inaugurated president of the United States. 1935,
Maurice Brodie and John Kolmer test polio
vaccines, with disastrous results. 1938, FDR
founds the National Foundation for Infantile
Paralysis, known today as the March of Dimes.
1940s, Sister Kenny, an Australian nurse, comes
to the U.S. to promote her new treatment for
polio, using warm compresses to relax painful,
contracting muscles and massage for
rehabilitation. 1947 - 50, Dr. Jonas Salk is
recruited by the University of Pittsburgh to
develop a virus research program.
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1953, Salk and his associates develop a
potentially safe, inactivated (killed), injected
polio vaccine. 1954, nearly two million children
participate in the field trials. 1955, news of
the success of the trials is announced by Dr.
Thomas Francis in a formal press conference at
Ann Arbor, Michigan, on April 12, the tenth
anniversary of FDR's death. The news was
broadcast both on television and radio, and
church bells rang in cities around the United
States. 1955 - 57, incidence of polio in the U.S.
falls by 85 - 90. 1957 - 59, mass clinical
trials of Albert Sabin's live, attenuated vaccine
in Russia. 1962, the Salk vaccine replaced by the
Sabin vaccine for most purposes because it is
easier to administer and less expensive. 1968,
passage of the Architectural Barriers Act,
requiring that all federally financed buildings
be accessible to people with disabilities. 1979,
last case of polio caused by wild virus in
U.S. last case of smallpox in the world. 1980s,
post-polio syndrome identified by physicians and
people who had polio. 1980, the first National
Immunization Day for polio held in Brazil. 1981,
poliovirus genome sequence published. 1985,
Rotary International launches PolioPlus
program. 1988, Rotary International, PanAmerican
Health Organization, World Health Organization,
Centers for Disease Control, UNICEF begin
international campaign to stop transmission of
polio everywhere in the world. 1990, Passage of
the Americans with Disabilitites Act (ADA),
providing broad legal protections for people with
disabilities. 1999, inactivated polio vaccine
replaces oral polio vaccince as recommended
method of polio immunization in the United
States.
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A bit about polio basics

• If the ability to replicate is one of lifes
  attributes, then polio is a chemical with a life
  cycle. Viruses are living chemicals. They have
  structural uniformity, like crystals, but can
  only self-replicate inside living cells.
  Poliovirus is made up of carbon, hydrogen,
  nitrogen, oxygen, phosphorus and sulphur from
  these elements, the virus forms its RNA
  (ribonucleic acid) genes, and its protective
  protein coat.
• -- Jeronimo Cello, Aniko V. Paul, Eckard Wimmer,
  creators of the synthesized poliovirus, 2002

Poliovirus EMs
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A bit about polio basics
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Life cycle of poliovirus
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A bit about polio

• Affects mostly children under 3 (50 of all
  cases)
• Majority asymptomatic
• About 10 will get minor illness fever,
  nausea, vomiting
• 0.5 -1 infections leads to irreversible
  paralysis (AFP), with maximum effect taking place
  in 3-4 days
• Legs affected more than arms paralysis of
  respiratory muscles is life-threatening
• Humans are the only reservoir for the poliovirus.
  The virus does not naturally reproduce in any
  other species.
• Transmission is usually fecal-oral (oral-oral is
  possible)
• Virus sheds from stool for 4-6 weeks
• No treatment deformity and handicap can be
  minimized with early PT

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A bit about (post) polio

• Post-polio syndrome (PPS) a disorder of the
  nervous system that appears in people who
  experienced paralytic poliomyelitis, usually 15
  40 years after the original illness.
• The main symptoms are new progressive muscle
  weakness, severe fatigue and pain in muscles and
  joints. Less common symptoms include muscle
  atrophy, breathing and swallowing difficulties,
  sleep disorders, and cold intolerance.
• Exact mechanism by which PPS causes fatigue,
  pain, and new weakness is not completely
  understood.

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A bit about (post) polio

• Possibly related to the gradual loss of
  individual nerve cells, and subsequent loss of
  nerve transmission to these fibers.
• After the original polio infection, surviving
  nerve cells sprout extra branches that re-attach
  to muscle fibers.
• Although the the muscle fibers occasionally work
  as well as before, some suggest that PPS develops
  because these extra axonal sprouts cannot hold
  forever, but instead get weaker over time due to
  overexertion.

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Eradicating polio?

• In 1988, the World Health Assembly (WHA) the
  annual meeting of the ministers of health of all
  Member States of the World Health Organization,
  voted to launch a global goal to eradicate polio.
• As a result, the largest public health effort to
  date was put together The Global Polio
  Eradication Initiative (GPEI).

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Vaccination the key intervention in the GPEI

• 2 ways to get immunity infection or immunization
• The live attenuated oral polio vaccine (OPV) was
  developed by Dr. Albert Sabin in 1961. The
  inactivated (killed) polio vaccine (IPV), was
  developed in 1955 by Dr. Jonas Salk and is an
  injected vaccine.

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Vaccination Salk vs Sabin

• OPV (Sabin) provides immunity to all 3 strains
  of polio. Induces humoral immunity systemically
  as well as local GI mucosal immunity (which
  limits transmission during outbreaks).
• IPV (Salk) Also induces humoral immunity via
  antibodies. However, it induces very low levels
  of immunity to poliovirus locally, inside the
  gut. As a result, it provides individual
  protection against polio paralysis but, unlike
  OPV, cannot prevent the spread of wild polio
  virus.

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Vaccination Salk vs Sabin

• IPV cannot cause vaccine-associated paralytic
  polio (VAPP).
• OPV can, but at a rate of 1/2.5 million doses
• US started OPV in 1961, switched to IPV in 1999
• OPV benefits for public health programs are
• easy to give (drops)
• cheap (8 cents a dose) vs IPV (almost 1/dose
  with syringe, not including cost of health
  worker)
• short term shedding of live virus from immunized
  kids will likely immunize others via contact
• Interrupts transmission during outbreaks due to
  mucosal GI immunity

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Vaccination trend in the US
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Vaccination trend in the US
IPV-OPV
All-IPV
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Vaccination schedule in the US
Vaccine IPV IPV IPV IPV
Age 2 months 4 months 6-18 months 4-6 years
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Eradicating polio?

• When GPEI was launched, wild poliovirus was
  endemic in more than 125 countries on five
  continents, paralyzing more than 1000 children
  every day
• Since 1988, some two billion children around the
  world have been immunized against polio

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Eradicating polio funds

• Funding 3 billion to date
• The major players in the GPEI are the World
  Health Organization (WHO), Rotary International,
  the US Centers for Disease Control and Prevention
  (CDC) and UNICEF.
• In 1987, Rotary international launched a 120M
  campaign for polio
• The campaign raised 247M in 1 year

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Eradicating polio who does what

• WHO overall coordination of NIDs, SNIDs, mop-up
  campaigns as well as technical assistance and
  strategy
• Rotary advocacy and funding at the global and
  local country levels
• CDC technical expertise, polio surveillance, epi
  investgations
• UNICEF field-based support for polio vaccination
  as part of its own EPI (Expanded Programme on
  Imunizations) initiative

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Eradicating polio the plan

• Interrupting transmission 2004-5
• Certifying polio-free regions 2006-8
• Cessation of OPV 2006-8
• Mainstreaming the GPEI 2009

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Eradicating polio the reality

• Interrupting transmission 2004-5
• High infant immunization coverage with four doses
  of oral polio vaccine (OPV) in the first year of
  life - routine immunization with OPV
• National immunization days (NIDs) to provide
  supplementary doses of oral polio vaccine to all
  children under five years of age
• Surveillance for wild poliovirus through
  reporting and laboratory testing of all cases of
  acute flaccid paralysis (floppy) among children
  under fifteen years of age
• Targeted "mop-up" campaigns once wild poliovirus
  transmission is limited to a specific focal area

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Eradicating polio the reality

• Certifying polio-free regions 2006-8
• Achieving certification-standard surveillance
• Ensuring access to a WHO-accredited laboratory
• Ensuring containment of wild polioviruses and
  Vaccine Derived Poliovirus (VDPVs)
• Completing the certification process (regulatory
  in nature)

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Eradicating polio the reality

• Cessation of OPV 2006-8
• Polio outbreaks caused by vaccine-derived
  polioviruses (VDPVs) have shown that continuing
  the use of oral polio vaccine (OPV) for routine
  immunization could compromise the goal of
  eradicating all paralytic disease due to
  circulating polioviruses.
• Therefore to minimize the risks associated with
  the use of oral polio vaccine it has been
  recognized that the world must stop the routine
  use of this vaccine as soon as possible after
  global certification, while surveillance
  sensitivity and population immunity are high.

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Eradicating polio the reality

• Mainstreaming the GPEI 2009
• Minimize the perception of this being a vertical
  program
• GPEI has supported the delivery of other health
  services, such as the distribution of vitamin A
  supplementation, integrated disease surveillance,
  supporting routine immunization services, and
  supporting the implementation of activities of
  the Global Alliance for Vaccines and Immunization
  (GAVI)
• Transition polio human resources and
  infrastructure for the use for other disease
  control programs

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Eradicating polio achievements

• By end-2003 (I.e., in 15 years), the no. of
  countries with endemic polio had shrunk to 6
  Afghanistan, Egypt, India, Pakistan, Niger,
  Nigeria.
• The early leader was Latin America PAHO (the
  regional WHO office) committed in 1985 to
  eradicate polio from the Americas
• The last case in the Americas was in 1991 a
  3-year old boy (Luis Tenorio) in Peru

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Eradicating polio achievements

• In 1995, a Global Commission for Polio
  Eradication was formed, and prepared regional
  plans which gave rise to GPEIs current structure
• In 1995, Afghanistan allowed its 3rd national
  1-day ceasefire for immunizations to happen
• Also in 1995, India conducted its first National
  Immunization Day (NID), vaccinating a historic
  87M kids
• The last case in China was in 1996 the last case
  in the Western Pacific region (the 2nd to be
  polio-free) was 1997 (Cambodia).

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Eradicating polio achievements

• 1999 more African countries, e.g. Angola and
  Congo, agree to cease-fires for polio campaigns.
• 2000 low of 719 cases
• 2001 low of 483 cases
• 2002 blip of 1919 cases, in only 7 countries
  98 of these were in India, Pakistan and Niger
• 2002 EURO becomes the 3rd region to be
  polio-free
• 2006 296 cases so far

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Eradicating polio achievements
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Eradicating polio problems

• In Nigeria, some states suspended polio
  immunization in August 2003, following concerns
  regarding the safety of the polio vaccine
• A new outbreak occurred, originating in one of
  those states, re-infecting previously polio-free
  areas within Nigeria
• Eight previously polio-free countries across
  Africa were re-infected as well

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Eradicating polio problems

• Somalia is the only country in the world with a
  geographically expanding polio outbreak. Plagued
  by ongoing conflict, insecurity, lack of a health
  infrastructure and low rates of population
  immunity, it is at the top of the Global Polio
  Eradication Initiative's list of acute
  challenges.

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Eradicating polio problems

• Increasing money being spent on smaller number of
  cases
• Donor fatigue
• Health worker fatigue and frustration when will
  it be over?

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Polio figures today (if today is May 2, 06)

• Nigeria (endemic) 236
• India (endemic) 22
• Somalia (importation) 20
• Afghanistan (endemic) 6
• Niger (importation) 3
• Pakistan (endemic) 2
• Indonesia (importation) 2
• Ethiopia (importation) 2
• Yemen (importation) 1
• Bangladesh (importation) 1
• Nepal (importation) 1

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Map
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Notes from the field

• Joined Pakistan and
• Afghanistan team in Nov. 05
• for NIDs
• Rapidly learned why 80 of cases in these 2
  countries are in about 3 provinces
• Social determinants of health demonstrated
  daily cultural barriers mistrust resentment
  from Afghan/Soviet war inequity between these
  impoverished areas and the rich cities
• Unpredictable barriers the largest natural
  disaster to his South Asia (earthquake killing
  80,000) had just hit

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More on the resentment mass graves near
Pak-Afghan border
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The polio vaccination team vehicles
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Getting there isnt half the problem its most
of it
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Polio reservoirs

• Sewage

Drinking water
Sewage
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Polio markings an inexact science
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Finding a case (1 of 19 in 2005)
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Vaccination campaigns Village in Pakistan
Refugee camp in Afghanistan
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Vaccination campaigns

• Empty canisters of vaccine to tally up

• List of potential polio cases

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Vaccinated!

• Vaccinated childrens 5th fingernail is marked
  with purple indelible marker

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Polio in comic book form

• http//www.pbs.org/wgbh/aso/ontheedge/polio/

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Links References

• WHO site /GPEI
• www.polioeradication.org
• Polio Case Count http//www.polioeradication.org/
  casecount.asp
• CDC www.cdc.gov/nip

Acknowledgement With thanks to David Heymann,
Tim Brookes, and the American Public Health
Association (APHA)