NEW DELHI (Thomson Reuters Foundation) - India is marking three years since its last reported case of the crippling polio virus, paving the way for it to be officially declared polio-free.
The efforts made by India to eradicate the disease by massive oral immunisation campaigns have been lauded by health experts who say this is a milestone in the fight to stamp out polio in the three countries where it remains – Nigeria, Afghanistan and Pakistan.
The Thomson Reuters Foundation spoke to Nata Menabde, the head of the World Health Organisation in India on how the country managed to free itself of the wild polio virus.
What do you think lies behind India's success in eradicating the virus?
I think the biggest and most significant factor is really the commitment of the Government of India. The second factor is the unfailing and seamless partnership between the government and the WHO, Rotary and Unicef.
But most of all it is the commitment of millions of frontline workers who have been rigorously, tirelessly chasing and vaccinating all those kids.
What were the challenges involved?
One of the big challenges was reaching the most vulnerable areas and the most susceptible populations. It has been very big challenge – for surveillance, reaching with vaccines and vaccinating the kids. Then there was the large migratory population.
What innovative approaches were used?
House-to-house vaccination has been a very important innovation to detect and vaccinate children. This was done by marking every house where vaccinators had been with a painted “P” to show immunisation had been covered.
On train stations, highways, trains, markets, bus stations and even at cultural and social gatherings such as festivals, we have been targeting vulnerable populations.
We have introduced a newborn tracking system in Uttar Pradesh and Bihar for every child so they get the vaccine before they reach one year of age.
We have also looked at construction sites, peri-urban and slum areas.
We enlisted the help of clerics and imams when we were dealing with some resistance in Muslim communities who had an impression that the vaccination was a hidden sterilisation effort and that it would lead to impotency.
There has been a major collaborative effort by Unicef who led the social mobilisation campaign and those leaders have played a critical role in convincing the population and mobilising families to bring their children for immunisation.
What role has the WHO played in supporting India?
The surveillance system that WHO has been running to track any suspected case actually involved almost 39,000 health facilities across the country. Annually, there are some 60,000 cases that are investigated and a range of 120,000 specimens – there are two - which are tested annually.
We have eight laboratories accredited by WHO in India. So there has been a major effort in the environmental sampling such as the collection of sewage samples which would be regularly tested for any possible circulation of the polio virus.
So laboratory quality assurance is a very important part of having reliable surveillance which we have been doing for years now. And then of course, we have supported government in planning immunisation campaigns, implementing and evaluating.
Can India now sit back and relax?
The biggest risk at the moment is the risk of complacency, which unfortunately comes in when we don't see cases of wild polio.
We have to be very well aware that there have been many occasions when polio has travelled out of India to countries, for example, like Tajikistan. So it can easily travel back into India, just as it has travelled out. We have to constantly be ready to respond to any emergencies.
So having India polio-free does not mean that it cannot be infected by the imported virus. You have to be constantly ready to respond to any emergencies. This is a very important focus area on which we are working with all the states to have all the emergency response plans defined so that within a couple of days we can have a full mop-up campaign if there any case of importation.
How strong is India's surveillance of the virus?
In the global context, we are just reaching one milestone with the eradication of polio from India.
Sensitive surveillance systems are one of the most important pre-conditions for eradicating polio. In India, there have been a lot of changes to the surveillance system over the years. For example, there has a huge expansion of the institutions which report on any suspected case and this has led to large number of cases being detected and so increases the sensitivity of the system.
In fact today India's surveillance system surpasses the global standard for sensitivity so we are catching many more cases that we are required to catch. That is a very important guarantee that we won't miss any cases anywhere.
There have also been changes in the laboratory techniques for stool tests. The time required to come up with results of any test used to be four to five weeks. But since 2007, we have changed this technology and now it only takes two weeks to get a result.
This gives us the possibility to intervene much earlier in any emergency.
Supplementary surveillance has also been introduced in terms of sewage specimen collection. It is now done in five cities to get information about the polio virus even before it is affecting any child.
Are lessons learned in India being shared with polio-endemic nations Pakistan, Afghanistan and Nigeria?
The India experience is already being shared with other countries so that they can apply the lessons and best practices of India in these countries.
The WHO sent two missions of 16 medical officers each for a duration of three months to Nigeria in 2012. The WHO has also shared the guidelines and other standard operating procedures with delegates from Afghanistan and Pakistan who visited India in 2012.
How big is the threat that India could see a resurgence of the virus?
Well, of course, the threat is there and to reduce the risk of polio virus importation, polio immunisation posts have been set up along the international borders – not only with Pakistan, but with Nepal, Bangladesh, Bhutan and Myanmar – and children of under five years that are crossing the border are being rigorously vaccinated. Eight million children are vaccinated every year along these borders.
Recently, India has introduced a requirement that travellers from polio endemic countries have to take oral polio vaccine before their departure to India. So India is looking at it very seriously.
But since 2000, almost 49 countries which have been polio free for a long time have suffered from one or more importations of the wild polio virus. That is to say between eight and ten countries annually face a situation where someone brings a polio case into the country.
How do you personally feel having been part of this effort?
It makes us extremely proud and highly responsible for having helped the government to reach this incredible achievement.
But very importantly it has shown to the world that polio eradication is possible even in the toughest situations. Nobody has bigger issues than India and now others will feel they are under-performing. So it is extremely important for the global eradication of polio.
While the whole global eradication process was stagnating, India has been the rescuer of this belief that it is possible.
Polio eradication is a very costly operation and so donors and partners were losing hope and patience. Now they are all actively mobilised into channeling their efforts to stopping the virus.
It has given confidence to donors, it has given confidence to and pressured governments of other endemic countries and it has demonstrated that persistent efforts can make a difference.