cripple EFFECT

Moradabad district in western Uttar Pradesh (UP) holds a dubious distinction: this year it has registered the highest number of polio cases of any district in the country. When this magazine went to press, officials there were gearing up for a special polio vaccination drive slated for December 10. They exuded confidence; quite unimaginable for officials of a district that has recorded 64 polio cases this year. “Everything is under control now,” said Moradabad’s district collector Pandhari Yadav. “More cases are now being reported from other UP districts,” he said. This year, 234,520,826 children in UP had been vaccinated by October 2006. But 471 of the total 571 polio cases in India in 2006 have come from this state (see: Polio vault). District officials in Moradabad claim they have done their best, and their counterparts in the National Polio Surveillance Project (NPSP)—a watchdog appointed by the World Health Organization (WHO)—support their assertions.

Despite the vaccine
Moradabad is not the only problem area. In neighbouring Bijnor, 27 polio cases have been detected this year. Monis of village Daulatabad is one of polio's 2006 victims. Seven doses of vaccination did not protect the two-year old from the disease. Several rounds of vaccination also failed to protect Bikash and Nikhil of Shadipur village in the same district.

When India's mass anti-polio campaign began in 1995, this failure wasn't anticipated. It was a joint effort of the Union government and the Global Polio Eradication Initiative (gpei), a programme of who, Rotary International, unicef, and a few other international organisations. who's role is a major deviation from its typical, advisory role in such matters.

It was believed that two drops of the oral vaccine, administered three times to all children below three years, would be sufficient to stem the disease. 2000 was set as the deadline for polio eradication, and it was believed that by 2005, all traces of polio would be removed. Much store was laid on the theory of herd effect vaccinating a majority of the children within one region would ensure protection of the rest.

Today, the herd effect has been forgotten all children below the age of five have to be vaccinated; that, too, every time a round of vaccination is held. The polio eradication programme has become a long-drawn affair, with 44 rounds of inoculation held since its inception.

But, the partners of the high-profile programme remain optimistic of rooting out polio in even the stubborn areas of western up. "The polio programme has shown that India is capable of eradicating polio--every single district of India has at some point been polio-free," says Jay Wenger, project manager of India's National Polio Surveillance Project (npsp). "There is no question that polio eradication is feasible. The only question is whether all children in the remaining infected areas can be reached with polio vaccine enough number of times to eradicate this disease forever. To succeed in eradicating polio in the few remaining endemic areas, we need political oversight at all levels, and also facilitate community mobilisation," says Bruce Aylward, gpei's international coordinator.

Better said than done.

GPEI began in 1988. The polio eradication programme involved administering multiple doses of the oral polio vaccine to all children in affected areas. The doses were administered in pulses: all children below the age of three in an area were inoculated simultaneously. US $5 billion have been spent under the programme. Consequently, 190 countries are poliofree. The disease remains endemic in four countries: India, Afghanistan, Pakistan and Nigeria. These countries have spread polio to 12 other countries which had freed themselves of polio. This year, these countries accounted for only 8 per cent of all polio cases: a significant drop from the 60 per cent last year.

But the four high-risk countries have a put a spanner in GPEI’S works. In 2003, only 784 polio cases were reported all over the world. But the incidence of the disease has risen to 1,763, this year with more than 1,654 of them in the high-risk countries. Since 2003, around US $50 million has been used to carry out control measures in these countries, says WHO spokesperson Sona Bari. For example, it took US $6.1 million to control the epidemic in Namibia, where even adults were found susceptible (see map: 1,763).

But now funds seemed to be drying out (See graph: Going Dutch). The agencies at the helm of GPEI had estimated that governments in a polio-free world would save around US $1.5 billion in vaccine, treatment and rehabilitation costs each year. That western Europe would save US $200 million a year and the savings for the US would amount to US $230 million a year. This was a major motivation for the developed countries to put in money in the project. Globally, the cost-effectiveness ratio of polio eradication was estimated at an impressive US $ 52.50 per disability-adjusted life year (DALY) saved. It was also estimated that failure to root out polio would result in at least 10.6 million new cases of polio worldwide in the 40 years since 1988, representing the loss of 60 million DALYS—nearly all in poor developing countries. Donor agencies also believed that polio could be rooted out in a manner similar to small pox (see box: Smallpox vs poliovirus).

Strained money bags

Once a country is declared polio free, GPEI discontinues its aid to vaccination campaigns. Most times, the countries lack internal funds to continue with the programme. So people there become vulnerable. The disease’s resurgence has dampened donor enthusiasm. Compare this with the donation in December of US $476 million into the global fight against bird flu, as pledged at the global bird flu summit in Africa. Polio no longer gets the investment required to deal with the disease: efforts to control the epidemic in Namibia this year took a total of US $6.1 million, of which US $5.4 (90 per cent) came out of the poor country’s kitty. The financial requirements for 2006 are estimated at US $705 million, but there is a funding gap of US $50 million. This money is urgently needed by December 2006 for expenditure in the first half of 2007. The funding gap for 2007-2008 is pegged at US $390 million. GPEI requires US $130 million for emergency response to importations in 2006-2008. The funding gap would have the worst effect on India, which requires US $180 million for the year 2006-07. In donor circles, it is felt that governments of the affected countries should put in more money. Countries like Nigeria and India are seen as self sufficient in meeting part of the money needed for the cammpaign.

“The Indian government has had to pay money for the programme for the first time in 2006. The funding agencies today don’t believe the claims of WHO and other orgnaisations that the disease can be eradicated,” says Onkar Mittal of Swasthya Neeti Samvad, a health discussion forum. For the year 2006-2007, the Indian government has commited US $210 million for the programme. Aylward asserts that the funding gap is only a matter of perception: “The funding gap is almost entirely due to the delay in polio eradication in the four remaining endemic countries.” Deepak Kapur, chairperson of Rotary International’s India National PolioPlus Committee, is steadfast about his organisation’s support to the campaign. “Donor fatigue will always be there, since the programme is huge and has taken longer than expected. Rotary shall continue to raise funds across the world for this initiative,” he says.

If only paucity of funds was the only problem. But it is not. Amar Singh, Moradabad’s immunisation officer, has a simple explanation for the recent spurt: “This is the epidemic year.” He might be right; the disease has been seen to follow a cyclic pattern. Every fourth year sees a rise in the number of cases. Down To Earth asked Singh why the district did not take special steps when it was known that 2006 was going to be an epidemic year. He declined to comment, stating merely that the disease is now under control.

This assertion notwithstanding, the failure in UP’S polio eradication programme is apparent. The administration has decided to change the strategy this year. Instead of using the trivalent vaccine, which targeted all the three strains of the poliovirus, the programme has been administering the monovalent oral polio vaccine (mOPV1), which is effective only against the P1 virus. After finding incidence of the P3 viral strain, December 2006 saw a special round of mOPV3.

It is now believed that that three strains of the poliovirus in the trivalent vaccine compete with each other, reducing the vaccine’s overall efficacy. Children under five in Moradabad, Badaun, Bareilly, Ramnagar and JP Nagar were slated to receive MOVP3 on December 10.

Earlier this year, mOPV1 targeted the most common of the three poliovirus strains. But many areas in Moradabad continue to be ravaged by polio virus’s two common strains. For example, in village Naherther in the Sambhal block, two-year old Mohammad Kaif is afflicted by the P3 virus, while threeyear old Akansha is struck by the P1 variety. This year, 52 cases of P1 and 12 cases of P3 have been reported from Moradabad.

Viral preferences

The poor have borne the brunt of the failure to eradicate polio. Bikash and Nikhil’s father, Subhash, for example, is a daily-wage labourer, who has not been able to work since his children contracted the disease. His wife and he have been camping since November in Meerut, where the children are being treated by a local vaidya. They have spent Rs 25,000 on treatment. Subhash’s mother Rajo says that they have heard that treatment can cost as much as Rs 1 lakh per child, but the family does not have any long-term plans.

Monis's parents are also getting him treated by a private doctor. The government doctors at the Kotwali block dispensary have told them there is no treatment for the disease. One of the teams that came after the child fell sick promised them Rs 10,000 for treatment. But they heard nothing further about it.

Besides being a cause of personal tragedy for families of victims like Mehreen and Nikhil, the disease also affects the country productivity. According to the Union ministry of health and family welfare’s multiyear strategic plan, annual losses to India’s GDP due to polio-related disability is around Rs 2,700 crore. This is a conservative estimate. It excludes the cost incurred on treatment of polio cases. The document also points out that, at the current rate, operational costs are around Rs 4 per round per child. The cost of oral polio vaccine per round per child is around Rs 5.

Polio in monetary terms

A lot of money has been spent to eradicate polio in India. In 1996, Rs 400 crore came from international agencies including the Rotary International. But the government also had to take loans from agencies like the World Bank. The Union government spent Rs 1,000 crore of its own money on the programme in 2006 so far—expenditure on all other essential immunisation (diphtheria, whooping cough, tetanus, measles, tuberculosis and polio) is Rs 300 crore in 2006. The costs do not include expenditure on the government machinery used. All this hasn’t done much to end the suffering of victims such as Monis.

One walk through the locality where he lives makes the reasons for his afflictions apparent. The cobbled path is flanked by open drains; dredged out sludge lies spattered at several places. A recent paper in the journal Science says unsanitary conditions and high levels of malnutrition are main reasons for UP’S failure to eradicate polio. And, according to a document by the Nutrition Foundation of India, 52 per cent of the children in UP are malnutrioned.

This not all. Unsanitary conditions fester in Moradabad’s most affected block: Sambhal. The block has reported 14 cases of the disease, eight of them in urban areas. Sneha of Manglapura is an urban victim of the virus. She developed high fever in June, and though medicines were given to her, she got paralysed below her shoulder. Her father Sharafat has other worries, too. His elder daughter Sumaila had contracted polio five years ago, and he is yet to get a report from the government certifying that she has the disease. Sneha’s samples have also been taken, but her test report has not been delivered also. Sharafat has decided against getting his children vaccinated anymore till he gets the reports. So, he has nothing to prove that his children have polio. If he gets them, he wants to question the basis of the polio eradication campaign.

Money doesn't kill a disease 

The vaccinators have even promised to give Sharafat money for constructing a latrine. But he is adamant. Sharafat represent that 63 per cent of UP’s population that, in the statistics of the Planning Commission, lacks access to sanitation. The chances of contracting polio are obviously rife under such conditions.

The situation is worse in villages. Of the total 474 cases of polio in UP in 2006, 347 cases are from rural areas. The UP government does have the Total Sanitation Campaign for rural areas under which money is given to families below poverty line. Even if the money was offered, it is too little to construct a latrine, says Mittal. The government gives about Rs 1,200, though a toilet actually costs about Rs 4,000-5,000.

Anatomy of financial burden 

Now the government has decided that if people in villagers do not make toilets, it would take the draconian measure of lodging a police complaint against them.

INITIALLY, it was said polio was not getting eradicated due to Muslims resisting vaccination. Nobody buys this anymore of 474 cases in up this year, 190 are Hindus. Regardless of religion, a majority of the victims are poor. "Many do not vaccinate because of deep frustration with the programme, and rumours that the vaccine is not safe, or simply because they want other services (health, financial) that they need, not just polio drops for their children," says Kapur.

What is evident this time is that in many cases, several rounds of vaccinations haven't been enough to prevent the disease. The variables are too many to control. One pertains to the method of administration. It is a live vaccine that can lose potecy in less than 30 minutes; it is imperative to store it at low temperatures at all times. Such conditions are often not met. This could explain why many vaccinated children contract polio.npsp was put in place in 1997 just to ensure that this kind of problems did not harm the campaign.

Operational gaps are many--such as vacant medical officer positions, poorly supervised vaccinator teams, poor booth placements and poorly selected and trained teams. In July 2006, ieag expressed concern at the large number of medical officers' posts lying vacant in the high-risk districts. In western up, such vacancies are a whopping 30 per cent.

On the other hand, people recruited to implement the vaccination drive often lack the requisite skills. According to Chandra Pal Singh Azad, president of Bharat Gyan Vigyan Samiti (an ngo working on science and literacy), Moradabad, the programme suffered when it was decided to pay the vaccinators and mobilisers. He explains the programme was initially manned by volunteers, motivated by the desire to help the people and repected by the people. It was their mobilisation that led to a sharp fall in polio in 2003 in fact just one child contracted the disease that year. But then paid volunteers were roped in for Rs 25 per day. Many of the new vaccinators were outsiders; local mobilisation was ineffective.

Guidelines say only people from government departments can be recruited for the drive, with priority on women workers. Such people cannot match the drive of social activists. "There is a need to adapt these guidelines to the area," says Said Fatma, incharge of the urban area polio program in Sambhal. She also feels a door-to-door campaign makes people suspicious of an ulterior motive.

There are other constraints. B K Dutt, a paediatrician in Moradabad, says the programme is being run against the very logic of pulse polio vaccination inoculating all children under five at one go. Operational limitations mean that one vaccination round usually extends to 12 or 13 days.

Critics also question the basis of India's anti-virus programme before the current resurgence npsp data. A huge surveillance network has been set to monitor the anti-polio programme and generate data in 2005, around 9,500 reporting units and 12,300 informer units were part of the network. These include private practitioners and even quacks or polio doctors and religious heads. Everything is done with great speed, the district immunisation officer or the surveillance medical officer initiate investigations within 24 hours.

npsp data shows that the number of cases fell down from 3,047 in 1997 to just 54 in 2005. A paper in the International Journal of Health Services (Vol 35, No 2), points out a major misrepresentation. Before 1997, all paralytic cases diagnosed as polio were on the basis of clinical diagnosis. After 1997, the diagnosis was based on microbiological tests, and only those cases for which wild poliovirus was isolated from faeces were classified as polio. This led to a fall in the number of cases. "Number of cases before and after the change in the definition cannot be compared," says C Sathyamala, one of the authors.

While the cases of polio went down, data from 2001 to 2003 showed a disturbing trend the number of non-polio cases of paralysis increased. Most of these were in up and Bihar, which saw multiple rounds of vaccinations. It is suggested that there is a direct link between an increase in the number of polio vaccinations and the increase in the number of paralysis cases.

"Vaccine manufacturers are misleading the funding agencies about the seriousness of the diseases and that it could be eradicated. The earlier the funding agencies realise the disease cannot be eradicated, more money is going to be saved," says Anant Phadke of cehat, an ngo in Mumbai. Several countries have given up the oral polio vaccine in light of the vaccine associated polio paralysis.

CONTROVERSIES dog the viability of 'eradication', the nature of the vaccine, and the ways to implement the programme. But India is moving on with the oral polio vaccination (opv).

gpei experts maintain that if the virus could be rooted out in Congo (with routine immunisation at 0 per cent), in Bangladesh (with sanitary conditions similar or worse that those in India) and in over 95 per cent of India itself, it can be eradicated from up and Bihar as well. "Experience, tells us that the current outbreak will not hang on in other areas but retreat to the toughest spots in up and Bihar. That is where we must hit. There is a need for area-specific strategies. What works in West Bengal might not work in up," Wenger says.

The Indian Academy of Pediatrics (iap) too believes that the disease can be eradicated, but suggests a slight change in the strategy of administering the vaccine. It cites data to show that the disease mostly afflicts children below two years. The data also shows that around 10 doses are needed to prevent polio. But children between 6 and 9 months cannot be administered these many doses. So, iap recommends the more expensive inactivated polio vaccine (ipv) along with opv.

But ipv use strikes a raw chord (see box Oral the cheaper route). It was the vaccine of choice when the programme began. But difficulty in administering it and high costs militated against its use. ipv use is slated to come up for ieag's approval at its next meeting. In fact, Moradabad and JP Nagar had also been identified for a pilot project to introduce ipv during the January 2007 round of vaccination. But this decision has been put on hold because of the resurgence of polio this year (see 'Prickly issue', Down To Earth, June 15, 2004).

There are others, like the Jan Swasthya Abhiyan, a network of groups working on community health, that feel that the goal of eradication is not feasible. They suggest a phasing out of the anti-polio programme and making polio vaccine a part of routine universal immunisation programme. They call for more investment in sanitation and argue for making drinking water safe. This, they feel, would protect children from more than just polio. They have evidence to back their suggestion the polio control programme was working well as a part of the routine immunisation, before the anti-polio campaign was stepped up. The incidence of polio fell from 24,000 in 1988 to 4,800 in 1994.

"who should admit its programme has failed. This is not the Indian government's failure. An uninfluenced group of experts should show the way forward," says Sathyamala. The Jan Swasthya Abhiyan also doubts ieag's neutrality, since it comprises experts from organisations promoting the vaccination programme. Vipin M Vashishtha, pediatrician in Bijnor, says "The programme has been started, it cannot be stopped. Have a deadline and ensure that the disease is eradicated within that. If this fails, have alternative strategies in place." He also suggests research into new vaccines. For making sense of this confusion, the government needs to show a better understanding. Political commitment is essential.