Indian Pediatrics 2008; 45:388-390
Polio Eradication and Environment
Environment: The Missing Link in Polio Eradication Program
"Improved sanitation explains the virtual eradication of Polio from the USA in the early 1960s, when only about two-thirds of the population was immunized with the Salk vaccine, and the subsequent absence of circulating wild–type polio viruses in the United States and Europe. Poor sanitation and crowding have permitted the continued transmission of poliovirus in certain poor countries in Africa and Asia, despite massive global efforts to eradicate polio, in some areas with an average of 12-13 doses of polio vaccine administered to children in the first 5 years of age"(1).
"The science, applied in repeated vaccination campaigns, had also begun to perplex the public .…….. why repeated doses? Hasn’t my child been protected enough? Why must we do it round after round year after year? And why is my child still infected by polio when he has been vaccinated many times"………... In industrialized countries children were sufficiently protected after receiving three doses of OPV, usually through routine immunization. For developing countries, epidemiologists had yet to determine exactly how many doses were enough due to the presence of a host of other viruses in unhygienic environments. The practice of open defecation and fecal contamination of drinking water easily precipitated viruses’ transmissions. Children’s vulnerability to infections and diarrhea somehow reduced the efficiency of each dose of OPV in fighting the poliovirus. More than three doses were thus required for developing countries, delivered through the NID, a supplementary immunization activity to bring additional dosage to children, including newborns. For India, where 80% of its rural population had no toilet at home, the Ministry of Health and Family Welfare recommended eight to ten doses for each child"……... "There was also a difference between protecting the child from the virus and eradicating the disease………….. A child adequately protected from the virus would not lead to disappearance of the disease in the environs. As long as there were other children unvaccinated or inadequately protected with enough dosage, the virus would continue to thrive. As the virus was discharged from the guts of infected children or adults by means of feces, the untreated human waste often ending up in open sewers, lanes and rivers– would become the source of transmission for others. Once out in the open, the virus looked for human bodies to host it. Children in the surroundings who were either inadequately immune or worse still, unvaccinated at all, would succumb to its lethal, crippling effect. The eradication of polio thus called for rounds after rounds of campaign to vaccinate every targeted child, including the annual cohort of 25 million newborns in India"(2).
On the Scenario of Sanitation in India
"Half of the Indians, let’s say over 500 million people, have no access to toilets……. One out of every five people worldwide with no access to basic sanitation facility is an Indian." [Jon Lane, Head of the Water Supply and Sanitation Collaborative Council of Geneva, Switzerland](3).
On the Economic Aspects
1. "By 2005, we had spent more than 25 billion rupees in the polio eradication campaign. We had further borrowed a loan of 180 million US$ from the World Bank"(4-6).
2. "The Cabinet Committee on Economic Affairs (CCEA) on Friday decided to implement the Polio Eradication Strategy recommended by experts for the period 2007-09, with an expenditure of Rs. 2344.56 crores"(7).
3. "The Union Budget for the year 2007-2008 allocates Rs. 1290 crores for polio eradication(8). Rest of the money needed for the program to be accessed from external funds"(7) and the "Union budget this year has increased the allocation for sanitation to Rs. 1200 crores"(8).
4. "If the government spends $ 1 on sanitation, it actually gains $ 9, (quoting WHO statistics)" [Jon Lane](3).
5. "Due to poor sanitation, people in India face many health hazards and in monetary terms the cost to the country of treatment of such ailments is Rs. 2 billion and the lost of working days due to it is worth Rs. 3 billion. An improved toilet system would help India save Rs. 5 billion every year which can be utilized for the benefit of economically weaker sections of society." [APJ Abdul Kalam, former President of India](3).
It is clear from above that we need to have a relook at our priorities and reallocate our finances accordingly. A good environmental sanitation is going to be, by far, the biggest help in eradication of poliomyelitis. In the absence of this we will continue to debate on the number of doses of the vaccine or the number of rounds of vaccination needed for eradication. Even, whether at all we will be able to do so or which vaccine is superior.
Much of the resistance seen in the program is not against the program per se but to the chronic apathy to providing the basic amenities: "Meerut residents use pulse polio campaign to voice their concerns….. during a pulse polio drive on Sunday, officials had to face the opposition from the locals who furnished a list of their demands…….the government is spending hefty amount of money on the pulse drive, which is useless unless our living conditions are improved, charged the local residents." Hindustan Times (page 3, August 4, 2006 New Delhi).
The United Nations has quite appropriately declared 2008 as year of sanitation. The Indian Academy of Pediatrics (IAP) needs to grasp this opportunity and take it as a mission and a crusade to focus on intensive efforts in the field of improving environmental sanitation and public health system. Every occasion, every opportunity should be taken to press this point.
"Changes are brought about not by those with credentials but by those with concern" (anonymous).
Competing interests: None stated.
th Edition. New Delhi: Saunders Elsevier; 2008. p. 1344.
2. The OPV condundrum. A critical leap to polio eradication in India. Unicef regional office for South Asia. Working paper June 2003, page 13. Minutes of the informal meeting of Experts for Polio Eradication, India. www.unicef.org/rosa/critical.pdf. Accessed on 16.03.2008.
3. Improving sanitation in India will cut down the disease treatment cost. www.indiaenews.com/india/2007/105/79035.html. Accessed on 16.03.2008.
4. Sathyamala C, Mittal O, Dasgupta R, Priya R. Polio eradication initiative in India: Deconstructing the GPEI. Int J Health Services 2005; 35: 367-383.
5. World Bank. Project Appraisal document: on a proposed IDA credit in the amount of sdr 106.5 million (US 142.6 million equivalent) to India for an immunization strengthening project, 32. Health and Nutrition and Population sector unit, South Asia Region 2000.
6. World Bank. Supplemental credit document. International development association, proposed supplemental credit of SDR 59.5 million (US $ 83.4 million equivalent) to India for the Immunization Strengthening Project, Human Development Unit, South Asia Region, 2003.
7. Rs. 2344 cr polio eradication program cleared. www.in.news.yahoo.com/20080308/r_t_ie_nl_politics/tnl-rs2344cr polio eradication program 0058794.html. Accessed on 16.03.2008.
8. Budget 2007, Budget 07-08, India budget 2007-08. The strategy for polio eradication is revised. www.exim.indiamart.com/budget2007-08. Accessed on 16.03.2008.