Polio puzzle

THE apprehensions of May that there could be a polio outbreak this year (see Frontline, May 19, 2006), are turning out to be true. Given the higher number of cases in the pre-peak transmission period this year as compared to last year, such a prediction did not require a soothsayer; it was so obvious that officials in the Health Ministry did not hesitate to vent it openly.

It is still the peak transmission period and the number of confirmed polio cases has already touched the figure of 155 (in 29 districts), as compared to the total of 66 (in 35 districts) in 2005 and 134 (in 43 districts) in 2004 . The year 2005 had the lowest transmission ever but that declining trend has clearly buckled, though perhaps not as dramatically as in 2002 with 1,600 cases (see Frontline, January 2, 2004). But it could still rise to overtake the 2003 figure of 225 (in 87 districts) by the season's end in October. In any case, the hope of eradication by 2007 - two years behind the revised deadline and seven years behind the original deadline - has taken a severe beating.

What is a matter of both hope and despair is that the cases are confined to clusters in Uttar Pradesh (134) and Bihar (14), the former in particular. (The remaining seven seem to be spill-over into neighbouring States.) There is hope because it shows that the immunisation strategies adopted - National Immunisation Days (NIDs) and Sub-National Immunisation Days (SNIDs) - are satisfactory, as they seem to have worked well in the rest of the country despite the inherent limitations of the oral polio vaccine (OPV). There is despair because, despite enormous effort and mounting resources, these States have become stubborn barriers to polio eradication. The most worrisome aspect of polio infection in U.P. is that it has spread from the western parts to the central districts. "The virus has been granted the opportunity to survive in the country and chances of eradication by next year are the lowest at this point of time," points out Sobhan Sarkar, Former Deputy Director of Child Health in the Ministry of Health, and Family Welfare now a consultant to the Ministry's immunisation programme. "Implementation has improved in Bihar but something has to be done about Uttar Pradesh," he said.

The performance in Bihar has, bettered the expectations of the India Expert Advisory Group (IEAG) of the joint WHO-Indian government National Polio Surveillance Project (NPSP). Today, it is mainly confined to the region around Patna. As suggested earlier (see Frontline, May 19), this is the result of effective administration and supervision of the programme in the State. As regards U.P., the Centre has attributed the failure to the inefficient and ineffective administrative machinery behind the immunisation drives, both routine and pulse.

In spite of the introduction of the more efficacious monovalent OPV (which is more effective against the widely prevalent Type 1 of the virus) instead of the trivalent OPV (which works against all three types but has lower efficacy against Type 1) in all the endemic districts last April, the decrease in virus activity achieved last year could not be consolidated upon this year because of administrative failure, Health Ministry officials asserted. As against only 5 per cent of `missed houses' last year, the fraction this year has shot up to more than 24 per cent in some blocks of the highly endemic districts of Moradabad, JP Nagar, Bareilly, Rampur, Badyun and Bijnor in western U.P. Of the 13 endemic districts in U.P., these had accounted for as many as 107 cases this year, with Moradabad accounting for the most at 43 cases.

One of the main causes of this, say Ministry sources, is the fact that U.P. Chief Minister Mulayam Singh Yadav is also Health Minister. Pre-occupation with other matters prevents him from devoting adequate time to health issues. This has not only affected the polio programme but also prevention of other diseases, notably Japanese encephalitis. For example an order suspending the Chief Medical Officer (CMO) in charge of the polio programme was issued by the State government nine months after the decision. As a result of this delay, the CMO remained in office ineffectively and did not do anything, according to the Health Ministry.

Ministry officials are, in fact, concerned about the international move within the WHO to declare polio as a notifiable disease. If this happens, it could have serious economic implications, particularly in terms of visa issue for travel to developed countries and polio-free developing countries.

R. RAMACHANDRAN