India’s health ministry, celebrating a year of freedom from wild polio, now faces a dilemma that public health experts had predicted years ago: the very vaccine it is using to fight polio is causing more polio paralysis than the wild poliovirus.
India observed last Thursday as a milestone, marking a full year without polio caused by a wild poliovirus.
But surveillance data show that last year, seven children in India developed polio from vaccine-derived poliovirus (VDPV), the medical term for a virus from the oral polio vaccine (OPV) that has regained the ability to cause disease.
Such infections occur when virus from the OPV, after being excreted by vaccinated children, regains neuro-virulence and the ability to circulate in the environment and strikes other vulnerable children.
Public health experts also estimate that between 100 and 180 children in India develop vaccine-associated polio paralysis (VAPP) each year, a rare but serious side effect of the OPV they had received to protect them from the wild poliovirus. As opposed to VDPV infection, VAPP affects the vaccinated children themselves.
“Our war on polio isn’t over,” said T. Jacob John, a former head of virology at the Christian Medical College, Vellore.
“Even if India remains free of wild polio in 2012 and 2013, it will need to pencil a strategy to eradicate all of polio — including VDPV (infections) and VAPP.”
Paediatricians and public health experts emphasise that it is the OPV alone that has helped India achieve the current zero level of wild polio — after thousands of infections each year during the 1980s and 1990s.
“It is the OPV that is even now preventing tens of thousands of children in India from getting polio every year. It is important to appreciate the huge number of cases this vaccine is averting,” said Hamid Jafari, head of the National Polio Surveillance Project, a joint initiative by the health ministry and the World Health Organisation.
“We are not out of the woods yet. India will need to continue using the OPV for several years to secure eradication, to maintain high levels of immunity among children, and to prevent any re-emergence of polio,” Jafari told The Telegraph.
Wild poliovirus circulation persists in Pakistan, Nigeria and Afghanistan. Health officials are wary that the movement of people, which had once carried polio from India into Angola, might now bring polio back into India from these countries.
Both VDPV infections and VAPP are long-recognised problems linked with the OPV, which is made from weakened but live viruses. Many countries, including America and Britain, have switched to an alternative, inactivated and injectible polio vaccine (IPV) made from killed viruses with no risk of vaccine-linked polio.
India’s public immunisation programme relies exclusively on the use of the OPV, and the IPV is used in India only in the private sector. The Indian Academy of Paediatrics recommends three doses of the IPV at six, ten and 14 weeks after birth, to be given along with routine doses of the OPV.
Polio control experts are particularly worried about VDPV. Global surveillance efforts picked up 430 cases of VDPV from several countries between July 2009 and March 2011. As long as OPV is used, virologists, say the world is at risk of VDPV causing polio in unprotected children.
Achieving a polio-free world will require the “cessation of all OPV” and with it the elimination of the risk of VAPP or VDPV infections, two immunisation experts, Stephen Cochi and Robert Linkins, from the Centers for Disease Control in the US said this week in the Journal of Infectious Diseases.
The India Expert Advisory Group, a body of international experts advising India on polio, had last July urged the health ministry to develop a road map for the eradication of all polio: that is, both wild and vaccine-linked polio.
In the six months since then, the health ministry has not articulated how it plans to approach the polio endgame.
“We have been struggling to eradicate the wild virus,” said Ajay Khera, deputy commissioner for immunisation in the health ministry.
“We have no policy yet on what to do after eradication of the wild poliovirus. We are waiting for a global consensus to emerge on the way forward.” Public health experts have long predicted financial and logistical hurdles in future efforts to replace OPV with IPV.
“The solutions aren’t going to be easy,” John said from Vellore.
The IPV is expensive and there are concerns that the industry may not have enough of the vaccine to supply it to India. But an articulation of vaccine policy by the government may stimulate the industry into bolstering capacity, John said.
In a commentary three years ago in the Indian Journal of Medical Research, calling on the government to pencil an endgame eradication strategy, John and a Bijnore-based paediatrician, Vipin Vashishta, had cited a Sanskrit proverb: “Do not wait to dig a well till the house starts burning.”
“The fire is here now,” John said yesterday. “But it appears that India hasn’t even decided to dig the well.”
Cases of non-polio acute flaccid paralysis, better known as AFP, has sharply increased with the increase in the administration of oral polio vaccination (OPV) in the country under the much-acclaimed polio eradication programme.
According to a report by Dr. Neetu Vashisht and Dr. Jacob Puliyel, appearing in the April-June issue of the Indian Journal of Medical Ethics, the incidence of non-polio AFP had gone up by 12 times over and above the normal rates with the onset of the administration OPV 10 years ago. The report appeared at a time when Kerala is getting prepared for another round of OPV on April 15.
Dr. Jacob, also a member of the national technical advisory group on immunisation and of the working group on food and drug regulation in the 12th Five Year Plan, told DC on Friday that there was a definite co-relation between the increase in the number AFP and the irrational administration of OPV.
Normally, he said, the chances of children under the age of 15 getting affected by non-polio AFP are 1-2 per 100,000. But, the rate of non-polio AFP nationally “is now 12 times higher than expected.” In 2011, an additional 47,500 children were newly paralyzed, over and above the standard rate of 2 children per 100,000 non-polio AFP cases, says the paper in the journal.
Dr. Jacob said the increase in the occurrence of non-polio AFP could be directly linked to the massive increase in the dosage of OPV in the name of eradication. Although, the increase in the non-polio AFP was known for quite some time, it was for the first time that a co-relation was established by collating the data of the national polio surveillance, he said.
“It is sad that, even after meticulous surveillance, this large excess in the incidence of paralysis was not investigated as a possible signal.”
, nor was any effort made to try and study the mechanism for this spurt in non-polio AFP.”
According to Dr Jacob, the dream of eradicating polio will remain a mirage due to the existence of “residual samples of samples virus stored in laboratories, by vaccine-derived polioviruses or by poliovirus that is chemically synthesized with malignant intent”.
The increase in non-polio AFP might have been caused by the increase in OPV, leading to virus strains other than that of causing polio getting active, he said.
The Polio Global Eradication Initiative (PGEI), founded in 1988 by the World Health Organization, Rotary International, UNICEF, and the U.S. Centers for Disease Control and Prevention, holds up India as a prime example of its success at eradicating polio, stating on its website (Jan. 11 2012) that “India has made unprecedented progress against polio in the last two years and on 13 January, 2012, India will reach a major milestone — a 12-month period without any case of polio being recorded.”
This report, however, is highly misleading, as an estimated 100-180 Indian children are diagnosed with vaccine-associated polio paralysis (VAPP) each year. In fact, the clinical presentation of the disease, including paralysis, caused by VAPP is indistinguishable from that caused by wild polioviruses, making the PGEI’s pronouncements all the more suspect.1
According to the Polio Global Eradication Initiative’s own statistics2 there were 42 cases of wild-type polio (WPV) reported in India in 2010, indicating that vaccine-induced cases of polio paralysis (100-180 annually) outnumber wild-type cases by a factor of 3-4. Even if we put aside the important question of whether or not the PGEI is accurately differentiating between wild and vaccine-associated polio cases in their statistics, we still must ask ourselves: should not the real-world effects of immunization, both good and bad, be included in PGEI’s measurement of success? For the dozens of Indian children who develop vaccine-induced paralysis every year, the PGEI’s recent declaration of India as nearing “polio free” status, is not only disingenuous, but could be considered an attempt to minimize their obvious liability in having transformed polio from a natural disease vector into a man-made (iatrogenic) one.
VAPP is, in fact, the predominant form of the disease in developed countries like the US since 1973.3 The problem of vaccine-induced polio paralysis was so severe that the The United States moved to the inactivated poliovirus vaccine (IPV) in 2000, after the Advisory Committee on Immunization Practices (ACIP) recommended altogether eliminating the live-virus oral polio vaccine (OPV), which is still used throughout the third world, despite the known risks.
Polio underscores the need for a change in the way we look at so-called “vaccine preventable” diseases as a whole. In most people with a healthy immune system, a poliovirus infection does not even generate symptoms. Only rarely does the infection produce minor symptoms, e.g. sore throat, fever, gastrointestinal disturbances, and influenza-like illness. In only 3% of infections does virus gain entry to the central nervous system, and then, in only 1-5 in 1000 cases does the infection progress to paralytic disease.
Due to the fact that polio spreads through the fecal-oral route (i.e. the virus is transmitted from the stool of an infected person to the mouth of another person through a contaminated object, e.g. utensil) focusing on hygiene, sanitation and proper nutrition (to support innate immunity) is a logical way to prevent transmission in the first place, as well as reducing morbidity associated with an infection when it does occur.
Instead, a large portion of the world’s vaccines are given to the Third World as “charity,” when the underlying conditions of economic impoverishment, poor nutrition, chemical exposures, and socio-political unrest are never addressed. You simply can’t vaccinate people out of these conditions, and as India’s new epidemic of vaccine-induced polio cases clearly demonstrates, the “cure” may be far worse than the disease itself.