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History & RelevanceHistory & Relevance

Basics of PolioBasics of Polio Vaccination Vaccination Eradication planEradication plan Achievements Achievements

ChallengesChallenges Personal experiencesPersonal experiences A polio cartoon A polio cartoon

OverviewOverview

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Poliomyelitis:Poliomyelitis:

Acute inflammation of the anterior horns of the gray Acute inflammation of the anterior horns of the graymatter of the spinal cord, leading to a destruction of thematter of the spinal cord, leading to a destruction of thelarge multipolar cells of these horns. It is most commonlarge multipolar cells of these horns. It is most commonin children, coming on during the period of the firstin children, coming on during the period of the firstdentition and producing a paralysis of certain muscledentition and producing a paralysis of certain muscle

groups or of an entire limb.groups or of an entire limb.Gould¶s Illustrated Medical Dictionary, 1895 Gould¶s Illustrated Medical Dictionary, 1895

History & Relevance

History & Relevance

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Poliomyelitis:Poliomyelitis:

An inflammatory process involving the gray matter of An inflammatory process involving the gray matter of the cord. An acute infectious disease caused by thethe cord. An acute infectious disease caused by thepoliomyelitis virus and marked by fever, pains, andpoliomyelitis virus and marked by fever, pains, andgastrogastro--enteric disturbances, followed by a flaccidenteric disturbances, followed by a flaccidparalysis of one or more muscular groups, and later byparalysis of one or more muscular groups, and later by

atrophy.atrophy.S tedman¶s, 2005 S tedman¶s, 2005

History & Relevance

History & Relevance

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In 1916, New York City experienced the first large epidemic of In 1916, New York City experienced the first large epidemic of polio, with over 9,000 cases and 2,343 deaths. The 1916 tollpolio, with over 9,000 cases and 2,343 deaths. The 1916 tollnationwide was 27,000 cases and 6,000 deaths. Epidemicsnationwide was 27,000 cases and 6,000 deaths. Epidemicsworsened during the century: in 1952, a record 57,628 cases of worsened during the century: in 1952, a record 57,628 cases of

polio were reported in the United States.polio were reported in the United States.

Polio (also called infantile paralysis) was most often associatedPolio (also called infantile paralysis) was most often associatedwith children, but it affected teens and grownwith children, but it affected teens and grown--ups as well. Betweenups as well. Between1949 and 1954, 35 percent of those who contracted polio were1949 and 1954, 35 percent of those who contracted polio wereadults.adults.

Sign from a homeSign from a home

in Atlanta where anin Atlanta where an

infant contracted infant contracted

polio, 1941 polio, 1941

History & Relevance

History & Relevance

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The first known polio outbreak in the United States?The first known polio outbreak in the United States?

History & Relevance

History & Relevance

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Vermont, 1894:Vermont, 1894:

³Early in the summer just passed, physicians in certain parts of ³Early in the summer just passed, physicians in certain parts of Rutland County, Vermont, noticed that an acute nervous diseaseRutland County, Vermont, noticed that an acute nervous diseasewhich was almost invariably attended with some paralysis, waswhich was almost invariably attended with some paralysis, wasepidemic « and a general feeling of uneasiness « wasepidemic « and a general feeling of uneasiness « wasperceptible among the people in regard to the µnew disease¶ thatperceptible among the people in regard to the µnew disease¶ thatwas affecting the children.´was affecting the children.´

---- Dr. C. S. Caverly, reporting on the first epidemic outbreak of Dr. C. S. Caverly, reporting on the first epidemic outbreak of polio in the United States, 1894polio in the United States, 1894

History & Relevance

History & Relevance

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History & Relevance

History & Relevance

Polio affected events,Polio affected events,

lives, and peoplelives, and people

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History & Relevance

History & Relevance Throughout most of the 20th century, hospitals operated under Throughout most of the 20th century, hospitals operated under

strict and orderly patient regimens. Epidemic conditions, combinedstrict and orderly patient regimens. Epidemic conditions, combinedwith the lack of a cure for polio, heightened everyone¶s anxiety.with the lack of a cure for polio, heightened everyone¶s anxiety.

During a 1934 epidemic in Los Angeles, 5 percent of doctors andDuring a 1934 epidemic in Los Angeles, 5 percent of doctors and

11 percent of nurses who treated polio patients contracted the11 percent of nurses who treated polio patients contracted thedisease.disease.

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What¶s this?What¶s this?

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Iron lung ward at the Massachusetts General HospitalIron lung ward at the Massachusetts General Hospital

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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. JonasSalk had developed a polio vaccine: Smithsonian exhibit (below)

History & Relevance

History & Relevance

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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 thedisease 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 ³iron 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.

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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 topeople with disabilities.

1979, last case of polio caused by ³wild´ 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.

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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 structuraluniformity, like crystals, but can only self-replicateinside living cells. Poliovirus is made up of carbon,hydrogen, nitrogen, oxygen, phosphorus andsulphur; from these elements, the virus forms itsRNA (ribonucleic acid) genes, and its protectiveprotein coat.

-- Jeronimo Cello, Aniko V. Paul, Eckard Wimmer,creators of the synthesized poliovirus, 2002

A bit about polio: basics A bit about polio: basics

PoliovirusPoliovirusEMsEMs

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A bit about polio: basics A bit about polio: basics

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Affects mostly children under 3 (50% of all cases)

Majority asymptomatic

About 10% will get µminor illness¶: fever, nausea, vomiting

0.5 -1% infections leads to irreversible paralysis (AFP), withmaximum effect taking place in 3-4 days

Legs affected more than arms; paralysis of respiratory muscles islife-threatening

Humans are the only reservoir for the poliovirus. The virus doesnot 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 earlyPT

A bit about polio A bit about polio

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A bit about (post) polio A bit about (post) polio

� Post-polio syndrome (PPS): a disorder of the nervous systemthat appears in people who experienced paralytic poliomyelitis,usually 15 40 years after the original illness.

The main symptoms are new progressive muscle weakness, severefatigue and pain in muscles and joints. Less common symptomsinclude muscle atrophy, breathing and swallowing difficulties, sleepdisorders, and cold intolerance.

Exact mechanism by which PPS causes fatigue, pain, and newweakness is not completely understood.

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A bit about (post) polio A bit about (post) polio

� Possibly related to the gradual loss of individual nerve cells, andsubsequent loss of nerve transmission to these fibers.

After the original polio infection, surviving nerve cells sprout extrabranches 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.

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In 1988, the World Health Assembly (WH A) theIn 1988, the World Health Assembly (WH A) theannual meeting of the ministers of health of allannual meeting of the ministers of health of all

Member States of the World HealthMember States of the World HealthOrganization, voted to launch a global goal toOrganization, voted to launch a global goal toeradicate polio.eradicate polio.

As a result, the largest public health effort to As a result, the largest public health effort todate was put together: The Global Poliodate was put together: The Global PolioEradication Initiative (GPEI).Eradication Initiative (GPEI).

Eradicating polio?Eradicating polio?

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2 ways to get immunity: infection or2 ways to get immunity: infection orimmunizationimmunization

The live attenuated oral polio vaccine (OPV)The live attenuated oral polio vaccine (OPV)was developed by Dr. Albert Sabin in 1961. Thewas developed by Dr. Albert Sabin in 1961. Theinactivated (killed) polio vaccine (IPV), wasinactivated (killed) polio vaccine (IPV), wasdeveloped in 1955 by Dr. Jonas Salk and is andeveloped in 1955 by Dr. Jonas Salk and is aninjected vaccine.injected vaccine.

Vaccination: the key intervention in the GPEI

Vaccination: the key intervention in the GPEI

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OPV (Sabin): provides immunity to all 3 strains of polio.Induces humoral immunity systemically as well as localGI mucosal immunity (which limits transmission during

outbreaks).

IPV (Salk): Also induces humoral immunity viaantibodies. However, it induces very low levels of immunity to poliovirus locally, inside the gut. As aresult, it provides individual protection against polioparalysis but, unlike OPV, cannot prevent the spread of wild polio virus.

Vaccination: Salk vs Sabin Vaccination: Salk vs Sabin

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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 likelyimmunize others via contact

Interrupts transmission during outbreaks due to mucosal GI immunity

Vaccination: Salk vs Sabin Vaccination: Salk vs Sabin

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Vaccination trend in the US Vaccination trend in the US

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VA Cases VA O V ses s

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Vaccination schedule in the US Vaccination schedule in the US

VaccineIPV

IPV

IPV

IPV

Age2 months

4 months

6-18 months

4-6 years

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When GPEI was launched, wild poliovirus wasendemic in more than 125 countries on five

continents, paralyzing more than 1000 childrenevery day

Since 1988, some two billion children aroundthe world have been immunized against polio

Eradicating polio?Eradicating polio?

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Funding: $3 billion to date

The major players in the GPEI are the World

Health Organization (WHO), RotaryInternational, the US Centers for DiseaseControl and Prevention (CDC) and UNICEF.

In 1987, Rotary international launched a $120Mcampaign for polio

The campaign raised $247M in 1 year

Eradicating polio: fundsEradicating polio: funds

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WHO: overall coordination of NIDs, SNIDs, mop-upcampaigns as well as technical assistance and strategy

Rotary: advocacy and funding at the global and localcountry levels

CDC: technical expertise, polio surveillance, epiinvestgations

UNICEF: field-based support for polio vaccination aspart of its own EPI (Expanded Programme onImunizations) initiative

Eradicating polio: who does what Eradicating polio: who does what

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Eradicating polio: the planEradicating polio: the plan

Interrupting transmission: 2004-5

Certifying polio-free regions 2006-8

Cessation of OPV 2006-8

Mainstreaming the GPEI 2009+

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Eradicating polio: the realityEradicating polio: the reality Interrupting transmission: 2004-5

High infant immunization coverage with four doses of oral poliovaccine (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 poliovirustransmission is limited to a specific focal area

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Eradicating polio: the realityEradicating 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 DerivedPoliovirus (VDPVs)

Completing the certification process (regulatory in nature)

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Eradicating polio: the realityEradicating 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 stopthe routine use of this vaccine as soon as possible after globalcertification, while surveillance sensitivity and populationimmunity are high.

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Eradicating polio: the realityEradicating 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, suchas the distribution of vitamin A supplementation, integrateddisease 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 usefor other disease control programs

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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 (theregional WHO office) committed in 1985 toeradicate polio from the Americas

The last case in the Americas was in 1991: a 3-yearold boy (Luis Tenorio) in Peru

Eradicating polio: achievementsEradicating polio: achievements

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In 1995, a Global Commission for Polio Eradication wasformed, and prepared regional plans which gave rise toGPEIs current structure

In 1995, Afghanistan allowed its 3rd national 1-dayceasefire for immunizations to happen

Also in 1995, India conducted its first NationalImmunization Day (NID), vaccinating a historic 87Mkids

The last case in China was in 1996; the last case in theWestern Pacific region (the 2nd to be polio-free) was1997 (Cambodia).


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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 3

rd

region to be polio-free 2006: 296 cases so far


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Eradicating polio:Eradicating polio:achievementsachievements

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Eradicating polio:Eradicating polio:

problemsproblems In Nigeria, some states

suspended polio immunizationin August 2003, following

concerns regarding the safetyof the polio vaccine

A new outbreak occurred,originating in one of those

states, re-infecting previouslypolio-free areas within Nigeria

Eight previously polio-freecountries across Africa were re-infected as well

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Somalia is the only country in the world with a

geographically expanding polio outbreak.Plagued by ongoing conflict, insecurity, lack of ahealth infrastructure and low rates of populationimmunity, it is at the top of the Global PolioEradication Initiative's list of acute challenges.

Eradicating polio: problemsEradicating polio: problems

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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

Polio figures today (if today is May 2, 06)Polio figures today (if today is May 2, 06)

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MapMap

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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 theseimpoverished areas and the rich cities

Unpredictable barriers: the largest natural disasterto his South Asia (earthquake killing 80,000) had

just hit

Notes from the fieldNotes from the field

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More on the resentment: mass graves nearMore on the resentment: mass graves nearPakPak--Afghan border Afghan border

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Getting there isnt half the problem;Getting there isnt half the problem;its most of it its most of it

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Polio reservoirsPolio reservoirs

SewageSewage Drinking water Drinking water SewageSewage

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Polio markings: an inexact sciencePolio markings: an inexact science

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Finding a case (1 of 19 in 2005)Finding a case (1 of 19 in 2005)

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Vaccination campaigns: Vaccination campaigns: Village in Pakistan Village in Pakistan Refugee camp in AfghanistanRefugee camp in Afghanistan

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Vaccination campaigns Vaccination campaigns

Empty canisters of Empty canisters of

vaccine to tally upvaccine to tally up

List of potential polioList of potential polio

casescases

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Vaccinated! Vaccinated!

Vaccinated children¶s 5Vaccinated children¶s 5thth fingernail is markedfingernail is marked

with purple indelible marker with purple indelible marker

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http://www.pbs.org/wgbh/aso/ontheedge/polio/http://www.pbs.org/wgbh/aso/ontheedge/polio/

Polio in comic book form:Polio in comic book form:

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WHO site /GPEI:WHO site /GPEI:www.polioeradication.orgwww.polioeradication.org

Polio Case Count:Polio Case Count:http://www.polioeradication.org/casecount.asphttp://www.polioeradication.org/casecount.asp

CDC:CDC: www.cdc.gov/nipwww.cdc.gov/nip

LinksLinks & References& References

AcknowledgementAcknowledgement

With thanks to David Heymann, Tim Brookes, and the AmericanWith thanks to David Heymann, Tim Brookes, and the American

( )( )

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