Hathiakheda, Uttar Pradesh: Arjun Tejpal stands outside his hut in his grandmother’s arms, unmindful of the swarming flies. As she lets go of him, he takes baby steps and walks around the verandah like any other toddler. A closer look reveals a slight limp: the ominous signature of polio, a viral disease that destroys motor neurons, weakens muscles and often paralyses and deforms legs.
Click here to view a slideshow on poor personal hygiene in India’s polio zone.
The three-year-old’s case history is curious. Not just because he was the first polio victim of 2009, but more because it demonstrates the limits of medicine in India, one of the only four countries still battling the disease. According to his family, Arjun succumbed despite being given 11 doses of polio drops. His illness marked the beginning of a fresh resurgence of polio in India—largely in Uttar Pradesh and Bihar. The number of cases rose to 703 in 2009, from 559 in 2008, a 26% jump. Of the total number of cases, 625 were the more common poliovirus type 3 (PV3) and 79, poliovirus type 1 (PV1), brought about by a rapidly spreading, more severe strain of the virus.
Testing the limits
Cases such as Arjun’s define the limits of the oral polio vaccine (OPV), its effectiveness curtailed by low immunity, malnutrition and complete lack of sanitation and personal hygiene.
“No vaccine in the world provides 100% protection. The polio vaccine has very high efficacy, but there is little it can do when the child’s immune system is so weak that the antibodies don’t remain in the gut. The children are under-nourished and live in dirty conditions with faecal matter disposed in the open,” says Mohammad Arif Khan, programme co-ordinator for western Uttar Pradesh with Rotary International’s PolioPlus.
The polio virus is carried in faecal matter and enters the body through contaminated food or water.
“It is fortunate that Arjun received so many doses of the OPV, else his deformity and paralysis would have been far worse,” adds Dr Khan.
In Hathiakheda—and in many parts of Uttar Pradesh and Bihar—faecal matter flows through open drains that line both sides of garbage-laden roads. Private toilets are a luxury. In Hathiakheda, only five of the 335 houses have toilets, the rest use the open toilet located in the forest just behind the village. Water for drinking, bathing and washing clothes comes from the same hand pump that pumps water from 20ft below. The government mandates that drinking water must be pumped from 70ft or below to ensure that there is no risk of contamination.
Hathiakheda has two of these government hand pumps, yet villagers prefer other pumps for their drinking water. They know which is safer and cleaner but shallow water “tastes better” they say.
Six out of every 10 children in Hathiakheda also weren’t vaccinated for any other illness apart from polio.
“The first year of the life of the child is the most precious. During this year if the child is given all the injections, against all the six diseases, then he develops immunity that cannot be developed later,” says Sudhir Gupta, member of Rotary’s National PolioPlus Committee in Moradabad. He cites lack of routine immunization as a major cause for the spread of polio. The six diseases he refers to are measles, diphtheria, tuberculosis, pertussis, tetanus and polio.
Like Arjun, the routine immunization Rehan Ashraf has received is polio drops. In fact, he is one of the seven children in his family who has received immunization only against polio. Rehan’s right leg hangs limply. Now two years old, he can’t stand or walk, despite having received the complete rounds of polio drops throughout 2008 and 2009. Rehan is one of the 625 victims of PV3; he received close to 14 rounds of immunization against PV1, but only three rounds against PV3. His house is the last in the many lanes in the Pakbada village near Moradabad. He is the victim of a strategy put in place by the government that emphasized eradicating PV1 first and then PV3.
“The concentration has been (on eradicating) PV1 and we have been able to bring down those cases. So, all the vaccination rounds have been focusing on the OPV1. We all understand that for a child PV1 or PV3 doesn’t make a difference, but to eradicate PV1, experts felt this should be our strategy,” says Manjit Sawhney, of Rotary International and part of the National Polio Surveillance Project (NPSP) team.
It is for this reason that PV3 cases have been increasing in the country, though experts insist that though the number of cases may have increased, but the spread of the virus has declined.
“Although the total number of cases in 2009 may be more, India is making steady gains towards polio eradication. The geographic scope of both poliovirus type 1 and type 3 has been reduced further in 2009,” says Hamid Jafari, project manager, World Health Organization (WHO)-NPSP. He adds that in 2008, PV1 cases were reported from eight states and PV3 from 10 states. In contrast, in 2009, poliovirus type 1 and type 3 have been reported from six states.
Most of the cases of PV3 occurred in western UP (571) and some in Bihar (114) in districts where predominantly monovalent OPV1 (mOPV1), which is meant to prevent polio virus type 1, was used to halt the remaining chains of type 1 poliovirus transmission. Bihar’s Kosi belt is another affected area—largely because health workers can’t easily access villages there.
Although cases of polio have increased, or maybe because of it, these parts of the country exhibit a sharp improvement in awareness about other health problems. In Hathiakheda and Pakbada, the discovery of polio cases led the government to appoint community-level healthcare workers for the block. Sabina Sheikh is one such worker; she works in Pakbada village and creates awareness about polio and other illnesses, urging villagers to get their children immunized.
“Rehan’s parents have been refusing to get any of their children immunized against other diseases because they insist the vaccine gives their children fever,” she explains. Sabina has told the family that the fever helps create immunity against many other diseases, and claims that the family is rethinking its decision.
Many families, though, used to refuse to get their children immunized against polio.
“They ask us why we focused on polio and what we were doing about the numerous other health problems their children suffered from,” says Syed Masoom Ali Azad, the imam in Moradabad.
To address this, Rotary International has helped organize, since 2007, health camps where families can get their children’s medical problems checked. “To win some you have to lose some,” says Khan. “We feel bad that so many children have been infected by PV3, but the truth is that we are also protecting many from PV1 and PV3, and from many other health problems.”
Personal habits and poor sanitation is not something a vaccine will prevent, but polio has helped create awareness even for that.
A new strategy
Almost three years ago the government announced plans to introduce the injectable polio vaccine. That initiative, however, has been put on the backburner. Instead, in November the government announced its plan to introduce the bi-valent polio vaccine (bOPV; it attacks strains of polio virus type1 and type3) in January in a fresh attempt to eradicate polio from the country. On 10 January, with the launch of the first Pulse Polio campaign in the country, the Centre also launched the bOPV in Bihar.
“With the introduction of the bOPV, we hope to eradicate, if not both types, then at least poliovirus type1 by the end of the year,” says Sawhney. “Once we eradicate PV1, most of our battle is won and then it won’t take long to eradicate PV3.”
While an independent review of India’s polio project by WHO conducted in 2009 recommends focusing on eradicating PV3 as well, India Expert Advisory Group, the highest advisory body for polio in India, is of the opinion that the use of the bivalent OPV will help achieve interruption of transmission of polio type 1 while maintaining more effective control of polio type 3.