Health officials seem to be in a self-congratulatory mode, since no case of paralytic polio has been reported during 2011. But that doesn't mean that polio has been eradicated. As has happened in some other countries, polio cases can reappear.
Secondly, different public health experts have pointed out that polio cannot be eradicated through vaccination alone. Poliomyelitis, like many other infectious diseases, is primarily a disease of poverty, leading to insanitation and malnourishment. In developed countries, polio declined along with improvement in living standards, including sanitation. Vaccination played only a supplementary role in the disappearance of polio cases.
However, now an illusion has been created that we can overcome polio through vaccination alone. Polio incidence can be substantially brought down through immunisation. But there are technical reasons why, unlike small pox, polio cannot be eradicated through vaccination.
HIGHER LIMB PARALYSIS
Under the Indian eradication programme, three doses of oral polio vaccine were introduced from 1978–79 into the National Immunisation programme. This reduced paralytic polio cases by 80 per cent — from 24,257 in 1988 to 4,793 in 1994. But in 1995, under the influence of international agencies, the polio eradication strategy was launched, with a manifold increase in expense and human power deployment in polio vaccination.
The Central Government spent Rs 1,747 crore on pulse polio in 2009-10, and a total of more than Rs 12,000 crore during the last 12 years. When, in 2006-07, it spent Rs 1004 crore on Pulse polio, routine immunisation with some other vaccines received only Rs 327 crore, and tuberculosis control Rs 184 crore. And the context is — we have approximately 1.5 crore in tuberculosis cases and four lakh annual tuberculosis deaths compared with the estimated 20,000 cases, and less than 500 deaths annually, when the polio eradication programme was launched.
The justification for the polio eradication programme is that it would substantially reduce the incidence of lameness in children, because polio constitutes the most important cause of preventable lameness in children. But in reality, the incidence of limb-paralysis in children has increased after the Polio Eradication Initiative!
The Web site of the National Polio Surveillance Project (NPSP) reveals that the number of cases of Acute Flaccid Paralysis (AFP) in children increased from 3,047 to 60,466 (20 times) during 1997 to 2011! Officials argue that this rise in figures is because of thorough documentation and increased sensitivity of the surveillance system for recording AFPs, and that most of these children are later found to be normal. However, if the sensitivity of the surveillance system is increased in, say, the year 2000, we would see a steep rise in AFP cases in only 2001, and may be 2002. The continuous steep rise in AFP cases from 1998 till today belies this ‘explanation'.
Dr Jacob Puliyel, invoking the Right to Information, accessed Uttar Pradesh data which revealed that in 2005, of the 10,055 AFP cases, 2,553 cases were followed up for two months, 898 (39 per cent) continued to have paralysis. These were thus not ‘false positive cases' but were cases of paralysis as such. Dr Satyamala confirmed this for 2006, by again invoking the RTI. That most of these cases of ‘residual paralysis' don't have a polio virus in their stools is no consolation for the paralysed children and their parents.
It is possible that massive use of Oral Polio Vaccine (which contains attenuated but live polio virus) has mutated into a new virus which doesn't have identical morphological properties of the polio virus, but which causes paralysis. A rational and humane response to this rise in paralysed children should have been to suspend the additional dosages of the Oral Polio Vaccine and to investigate the matter. If any other scientific explanation is found, this programme can be exonerated. But till then, to continue with these additional dosages of Oral Polio Vaccine is unethical.
It is necessary that all these children who have lost their limbs be fully rehabilitated, and their parents adequately compensated. Criminal liability should be ascertained for those officials who have suppressed this information of breakup of follow-up of AFP cases, and those officials and policymakers who are responsible for continuing this policy of PEI.
It is well-known that Oral Polio Vaccine inevitably causes Vaccine Associated Paralytic Polio (VAPP) in a miniscule proportion of Oral Polio Vaccine receivers — an average 1 case of VAPP per 4 million doses of polio. In India, due to Pulse Polio, it is expected that annually there would be approximately 200 cases of VAPP till Pulse Polio continues. These children have to sacrifice their limbs involuntarily on the altar of ‘Public Good', that too, without getting rehabilitated, and without their parents getting compensated! The Jan Swasthya Abhiyan made the demand for rehabilitation and compensation for VAPP cases. The National Human Rights Commission recommended it. But the government ignored it.
Till polio isn't eradicated globally, developed countries will have to continue polio-vaccination even if there have been no cases of polio in these countries. Hence, it is in their interest that Polio Eradication is continued, even if it may not be the priority of the developing countries. One way of doing this is to exaggerate the problem of polio. In 1988, 32,419 cases of paralytic poliomyelitis were reported globally. While estimating the paralytic cases, WHO increased this figure 10-fold, to 3,50,000, with the argument that the actual cases were ten times the reported cases. By a sleight of hand, in subsequent literature, the word “reported” was deleted and it was claimed that annually polio paralyses ‘more than 3,50,000 children'!
It should also be pointed out that polio is only one cause of lameness in children, and the overwhelming majority of AFP cases are due to non-polio viruses. Hence, even if polio is eradicated, it will reduce lameness in children by only approximately 20 per cent. We should certainly try to control polio through vaccination and sanitation. But to create an impression that we are eliminating lameness in children through polio-vaccination is misleading.
(The author is associated with Jan Swasthya Abhiyan and Medico Friend Circle.)