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Global Polio Eradication: history, achievements

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Title: Global Polio Eradication: history, achievements


1
Global Polio Eradication history, achievements
challenges
  • Omar Khan, MD MHS

2
Overview
  • History Relevance
  • Basics of Polio
  • Vaccination
  • Eradication plan
  • Achievements
  • Challenges
  • Personal experiences
  • A polio cartoon

3
History Relevance
The more definitions change, the more they stay
the same Polio defined in 1895 and 2005
4
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

5
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

6
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

7
History Relevance
  • 1953 Pool in Elmira, New York, with sign
  • indicating it is closed due to polio

8
History Relevance
  • The first known polio outbreak in the United
    States?

9
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

10
History Relevance
  • Polio affected events, lives, and people

11
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.

12
(No Transcript)
13
History Relevance
  • Whats this?

14
History Relevance
  • Iron lung ward at the Massachusetts General
    Hospital

15
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)

16
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.
17
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.
18
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
19
A bit about polio basics
20
Life cycle of poliovirus
21
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

22
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.

23
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.

24
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).

25
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.

26
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.

27
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

28
Vaccination trend in the US
29
Vaccination trend in the US
IPV-OPV
All-IPV
30
Vaccination schedule in the US
Vaccine IPV IPV IPV IPV
Age 2 months 4 months 6-18 months 4-6 years
31
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

32
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

33
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

34
Eradicating polio the plan
  • Interrupting transmission 2004-5
  • Certifying polio-free regions 2006-8
  • Cessation of OPV 2006-8
  • Mainstreaming the GPEI 2009

35
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

36
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)

37
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.

38
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

39
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

40
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).

41
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

42
Eradicating polio achievements
43
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

44
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.

45
Eradicating polio problems
  • Increasing money being spent on smaller number of
    cases
  • Donor fatigue
  • Health worker fatigue and frustration when will
    it be over?

46
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

47
Map
48
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

49
More on the resentment mass graves near
Pak-Afghan border
50
The polio vaccination team vehicles
51
Getting there isnt half the problem its most
of it
52
Polio reservoirs
  • Sewage

Drinking water
Sewage
53
Polio markings an inexact science
54
Finding a case (1 of 19 in 2005)
55
Vaccination campaigns Village in Pakistan
Refugee camp in Afghanistan
56
Vaccination campaigns
  • Empty canisters of vaccine to tally up
  • List of potential polio cases

57
Vaccinated!
  • Vaccinated childrens 5th fingernail is marked
    with purple indelible marker

58
Polio in comic book form
  • http//www.pbs.org/wgbh/aso/ontheedge/polio/

59
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)
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