January 13 marks what is arguably one of history’s greatest public health wins: India, long considered the most technically challenging place on earth to end polio, has gone three years without registering a case. It has earned itself official victory over polio, and in the process provided lessons now being used to eradicate the disease around the world.
Ten years ago, prospects for ending polio in India were shrouded in pessimism. As recently as 2007, the country was home to two-thirds of the world’s polio cases, leaving hundreds of children disabled. With a population of more than one billion, areas of conflict and poor health infrastructure, few imagined that India could turn the tables against polio so quickly.
But India did it. Driven by strong political commitment and accountability at all levels, the country brought cases down from 741 in 2009 to zero in 2012. It rallied 2.3 million vaccinators, who in 2011 alone delivered 900 million doses of the oral vaccine to even the hardest-to-reach communities. It set up a robust surveillance system, comprised of 33,000 reporting sites, to quickly track and tackle the virus. Since the last case in January 2011, not a single child has been deprived of the ability to walk, run or jump because of polio. Official certification that polio has been eliminated from India — and WHO’s entire South-East Asia Region — is expected in March.
Three years later, the polio infrastructure continues to protect children not just from poliovirus but from a myriad of other vaccine-preventable diseases. The polio program created a network of health workers that now delivers other vaccines and health interventions across the country, and polio training and monitoring programs have supported the introduction of hepatitis B and Japanese encephalitis vaccines. The polio surveillance system has been expanded to help track outbreaks of measles and other diseases.
Inspiration for the world
India’s accomplishment resonates beyond its borders. It proves that polio can be defeated in even the most complex circumstances and offers tangible lessons for success in those few other countries where polio is still endemic: Afghanistan, Pakistan and Nigeria.
In fact, many of India’s lessons learned now form the backbone for polio programs around the world, and have informed the global Strategic Plan guiding the final stages of eradication. These innovations range from new technical strategies, including using different variations of the polio vaccine to maximize immunity, to programmatic tactics such as finger-marking to better track children that receive the vaccines.
For example, Afghanistan reworked its monitoring system based on India’s, so that new data are now presented at regular meetings and corrective actions determined on the spot. Also taking cues from India, Nigeria adopted a house-based micro-planning approach for its vaccination campaigns, which maps children and vaccinator responsibilities at the household rather than district level to improve planning and accountability. These are relatively simple changes, but ones that make a big difference in the quality of campaigns.
Thanks in many ways to these lessons from India, the endemic countries have made progress, cornering the virus to just a few geographical areas and giving us confidence that the global Strategic Plan is working. Nigeria reduced case counts by more than 55 percent in 2013, with five previously polio-ridden states reporting zero cases. Afghanistan’s traditionally endemic south has shown dramatic progress, with just one case since November 2012, down from 80 in 2011. In Pakistan, 80 percent of its polio cases are in just two areas in the northwest: the Federally Administered Tribal Areas and Khyber Pakhtunkhwa.
Getting to zero
Despite all this progress, challenges remain, and this year’s outbreaks in the Horn of Africa and Syria are proof that no country is safe until polio is eliminated from its last reservoirs.
The remaining pockets of polio present unique obstacles, often embedded in complex local political issues. In northern Pakistan, for example, insecurity and inaccessibility seriously compromise effort, and have fueled an outbreak in the country that is also infecting children in eastern Afghanistan.
In the face of these challenges, perhaps the greatest lesson from India is that ending polio requires a comprehensive toolbox. No single strategy or technical breakthrough is a silver bullet. Eradication efforts must be pursued from every angle, continually revised to match local contexts and challenges, and be supported at every level.
We know, programmatically, what is needed to eradicate the polio, and recent progress gives us an opportunity like never before. Now, we need to break down the remaining political barriers and see the effort through so that no child suffers from this disease ever again.
India’s incredible accomplishment proved skeptics wrong. Now we must take the success one step further: Let’s eradicate the disease, and prove what’s possible when the world rallies to protect children’s health.
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