Life after Polio: Towards Improving the Situation of Polio Survivors

~Written by Hussain Zandam (Contact: huzandam@gmail.com, twitter: @zandamatique)

A woman paralyzed by polio, Rotary International (2010)

here is a surge of excitement among international development communities and global health partners as the World Health Organization announced that the battle against polio is gradually coming to an end (WHO, 2013). The Global Polio Eradication Initiative (GPEI) has set out a new strategy (Eradication and Endgame Strategic Plan), which hopefully will be the final onslaught that will result in a global certificate eradication of the disease by 2018 (GPEI, 2013). The eradication will be a significant victory for the global population, as future generations will also be saved from polio's devastating toll of death, morbidity, and disability.

Map of the world comparing countries with polio cases in 1988 and 2014. Centers for Disease Control and Prevention, CDC (2014).

While a vast amount of resources has been disbursed to prevent polio since 1952, inadequate attention has been devoted to understanding the devastations left behind in the lives and households of polio survivors. The damage is more severe in those permanently disabled by the disease and those recently identified with post-polio syndrome (PPS). Post-polio syndrome is characterized by a renewal or new experience of polio symptoms including disability and functional deterioration after years of recovery and functional stability. PPS usually occurs 30-40 years after original infection and affects about 40% of polio survivors including those who developed permanent disability and those who recover from initial affectation with no or few symptoms (Lin and Lim, 2005). 

Although the situation of polio survivors in high-income countries is relatively well documented, there is a dearth of information in low and middle-income countries. This has profound political, economic and social implications for local, national and international policy-making. While the number of individuals disabled by polio will begin to disappear in the next few decades in the developed world, those in the developing world will continue to be a major concern for at least another generation (Gonzalez et al., 2010). And as the population of younger polio survivors reaches middle and old age, a new wave of individuals with PPS will begin to make additional demands on developing countries’ health systems.

Generally, individuals disabled through polio confront not only a range of physical disabilities but also significant social, financial and human rights barriers hindering integration and participation in families and communities. These barriers in turn, lead to chronic ill-health, social marginalization, limited access to education and employment, and high rates of poverty (Groce et al, 2011). Women are impacted disproportionately, as are individuals from poorer households, minority communities and from rural and urban slum areas (WHO/World Bank, 2011). 

To design effective programs and policies that improve life course outcomes for polio survivors, more research is essential. To begin, more accurate estimates of regional prevalence of polio survivors and the degree of residual disability sustained will be useful for efficient planning and appropriate resource allocation. In particular, addressing the stigma and prejudice encountered by persons disabled by polio must be part of long-term strategies to address the needs of people living with PPS and must be linked to broader efforts to confront disability and stigma faced by all people with disabilities. Ratification by countries of the Convention on the Rights of Persons with Disabilities (CRPD) and progressive national legislation are not enough - inclusion of polio survivors in community awareness campaigns and increased support by DPOs is also needed. And given the disproportionate impact of polio on women, DPOs must pay particular attention to gender sensitive research.

References:

Global Polio Eradication Initiative, 2013. Polio Eradication and Endgame Strategic Plan: 2013e2018.

Groce, N., Kett, M., Lang, R., Trani, J.F., 2011. Disability and poverty: the need for a more nuanced understanding of implications for development policy and practice. Third World Quarterly 32 (8), 1493e1513.

Gonzalez, H., Olsson, T., Borg, K., 2010. Management of postpolio syndrome. The Lancet Neurology 9 (6), 634e642.

Lin, K.H., Lim, Y.W., 2005. Post-poliomyelitis syndrome: case report and review of the literature. Annals-academy of MEDICINE SINGAPORE 34 (7), 447

WHO, 2013. Poliomyelitis. Fact Sheet No. 114. WHO, Geneva. http://www.who.int/ mediacentre/factsheets/fs114/en/index.html (accessed 11.08.15.).

WHO/World Bank, 2011. World Report on Disability. WHO, Geneva. http://www. who.int/disabilities/world_report/2011/en/index.html (accessed 12.08.15.).

Polio Eradication: How Close are We?

~Written by Theresa Majeski (Contact: theresa.majeski@gmail.com, twitter: @theresamajeski)

Polio may become the second viral human disease (following smallpox) ever eradicated from this planet. Like smallpox, polio can be prevented with vaccination and, perhaps most importantly, polio relies solely on person-to-person transmission for survival. This means that polio does not require any vectors like mosquitos or snails for its life cycle, so humans are the only ones infected by poliovirus. Polio is usually spread through a fecal-oral route, meaning that the virus is in the stool of an infected person and could come in contact with the mouth of an uninfected person through contaminated foods, hands, utensils, etc. If we can interrupt transmission through vaccination, poliovirus will be unable to find someone unimmunized to infect and will be eradicated.

Polio has a long history within the human population. Only sixty years ago, polio was a feared disease in the United States. Summer time brought with it polio season and public facilities such as swimming pools were shut down. This reaction was not unwarranted. In 1952 almost 600,000 children were infected with the virus. More than 3,000 died and thousands were paralyzed. Iron lungs were used to keep children alive as the paralysis left them unable to breathe on their own.

Photo of children in iron lungs. Photo courtesy of the National Museum of Health and Medicine. 

President Franklin D. Roosevelt contracted polio as an adult, years before taking office. He made fighting polio a national priority and established the March of Dimes to encourage everyday citizens to fund polio research. Jonas Salk created the first polio vaccine, approved in 1955; Alfred Sabin created a second polio vaccine, approved in 1963. Through the use of these two vaccines, the United States was able to eradicate polio by 1979.

Despite this, it wasn’t until the 1970’s that polio was recognized as a serious problem in developing countries. Once polio was identified as being prevalent in developing countries, routine immunization campaigns were implemented worldwide which helped bring polio under control in many countries. In 1988, when the Global Polio Eradication Initiative began, more than 1000 children worldwide were paralyzed by polio every day. Since then, the global incidence of polio has decreased by 99 percent.

Countries that have achieved elimination have not done so without challenges. The two polio vaccines have benefits and drawbacks. The Salk vaccine, also called the inactivated polio vaccine (IPV), contains chemically inactivated polio virus. It stimulates a strong systemic immune response but because it is an injection, it does not cause a strong mucosal immunity. Without a strong mucosal immune response poliovirus can replicate in the intestines of immunized people without causing symptoms and can then be contagious. On the other hand, the Sabin vaccine, also called the oral polio vaccine (OPV), is a live-attenuated vaccine. This means that the vaccine contains live, weakened poliovirus. The Sabin vaccine is given orally so it stimulates mucosal immunity and systemic immunity. However, because it is a live vaccine, it can revert to a virulent form and cause vaccine-derived polio infection. The Sabin vaccine is easier to administer because it doesn’t require syringes, and it provides longer immunity than the Salk vaccine, however, it requires strict transport conditions because it is live. The World Health Organization is advocating for countries to move towards the IPV and phase out use of the OPV, to help prevent vaccine-derived polio cases. The Global Alliance for Vaccines (GAVI) recently announced that they will be helping Pakistan introduce the IPV as part of the Polio Eradication and Endgame Strategic Plan 2013-2018.

Currently, polio is endemic in only three countries: Nigeria, Pakistan and Afghanistan. In order for a country to be declared free of polio, three years must pass without a case of endemic (wild type) polio. Nigeria achieved one year without an endemic polio case on 24 July 2015. This means that only two more years remain before the African continent may be declared polio-free. India was removed from the list of polio-endemic countries in 2012, and in 2014 India achieved polio-free status. India, long considered the country facing the greatest challenges to eradication, demonstrates that global eradication is possible. However, some countries that had achieved elimination are experiencing outbreaks of polio, partly due to political instability, which has impacted vaccination rates. For example, Syria was polio free from 1999 to October 2013 when imported cases of polio closely related to strains circulating in Pakistan were confirmed in Deir ex-Zor and Aleppo. This demonstrates the importance of maintaining a high vaccination rate in every country until the disease is eradicated. 

Current polio distribution around the world. Graphic courtesy of Global Polio Eradication Initiative. 

Achieving eradication through eliminating polio in the last few countries will not be easy. The areas with endemic polio transmission face several challenges including conflict and political instability, hard-to-reach populations, and poor infrastructure. Furthermore, community workers trying to administer polio vaccine are being attacked by groups who oppose polio vaccination. The CIA providing vaccinations as a cover for searching for Osama bin Laden certainly eroded trust between health workers administering vaccines and community members, making poliovirus vaccination campaigns that much harder. However, focusing on strengthening all routine immunization delivery, helping locals take ownership of polio eradication in their communities, working directly with community members and leaders, and building trust by keeping a lower profile on international deadlines may help overcome the remaining challenges.

Humanity is on the cusp of another great infectious disease achievement, eradicating polio by 2018. Polio eradication is achievable; however continued focus and resources are required to interrupt transmission in the hardest to reach places. Eradicating polio will save many lives and prevent countless children from paralysis; a goal that can be achieved in our lifetime.

Global Health Insights from the 2015 Gates Annual Letter

-Written by Adenike Onagoruwa, PhD (Contact: adenike.onagoruwa@gmail.com)

For the seventh consecutive year, Bill and Melinda Gates have released an annual letter, discussing the Gates Foundation’s activities and sharing progress on the fight against poverty and disease. An organization headed by two of the world’s most powerful philanthropists, the Gates Foundation funds global health, development and advocacy efforts aimed at reducing poverty and eradicating preventable diseases that disproportionately affect the developing world population.

Through its grant-making and operational activities; the Foundation has, especially in the past decade, set the health agenda for aid organizations, research institutes and even governments around the world. It is therefore quite important to pay attention to the insights, priorities and goals outlined by these primary players in the global health and development arena. With the upcoming expiration of the Millennium Development Goals (MDGs), this year’s letter evinces the momentousness of 2015.

Released at the start of the year, the 2015 Gates Annual Letter titled “Our Big Bet for the Future” makes ambitious predictions regarding the next 15 years. The big bet is this: “The lives of people in poor countries will improve faster in the next 15 years than at any other time in history. And their lives will improve more than anyone else's.” Acknowledging the absurdity of this bet in the face of seemingly worsening world problems (they do add a caveat that a handful of the worst-off countries will continue to struggle); the two give these reasons why they think there has never been a better time to accelerate progress, resulting in longer lives and better health:

●     “There will be unprecedented opportunities to get an education, eat nutritious food, and benefit from mobile banking.”

●     “These breakthroughs will be driven by innovation in technology — ranging from new vaccines and hardier crops to much cheaper smartphones and tablets — and by innovations that help deliver those things to more people.”

The key global health breakthrough they foresee happening by 2030 is that “Child deaths will go down, and more diseases will be wiped out”. Here’s how:

Cutting the number of children who die before age 5 in half again. The percentage of under-five deaths worldwide has been cut in half (1 in 10 children in 1990 to 1 in 20 today). 1 in 40 children by 2030 can be achieved by

●     scaling proven, existing interventions for saving newborn lives such as: immediate and exclusive breastfeeding for the first six months; delivering injectable antibiotics immediately a baby appears ill; basic training for resuscitating a struggling-to-breathe newborn with a hand-pumped oxygen mask; immediately drying and warming the newborn after delivery through skin-to-skin contact; and topical application of chlorhexidine to the umbilical cord for prevention of sepsis specific mortality.

●     Comprehensive immunization - almost all countries will include vaccines for diarrhea and pneumonia, two of the biggest killers of children, in their programs.

●     Improved hygiene and sanitation to reduce disease spread - through simple hand-washing and innovative toilets specially designed for the poor.

●     Leveraging on the work that has been done to strengthen country-level health systems in many poor countries.

Reducing the number of women who die in childbirth by two thirds. The number of mothers dying will go down by:

●     Increasing the number of women that give birth in healthcare facilities instead of at home.

●     Making sure that caregivers at healthcare facilities are well-supplied and well-trained.

●     Improving access to contraceptives and to information about pregnancy spacing.

Wiping polio and three other diseases off the face of the earth. Polio, elephantiasis, river blindness, and blinding trachoma can be eradicated by 2030 through:

●     Free medicines made possible by continuing donations from pharmaceutical companies.

●     Strategic delivery of these medicines aided by advances in geographic information systems for disease surveillance.

Finding the secret to the destruction of malaria. While the two are not optimistic about the elimination of malaria by 2030, they believe that all the tools for its complete eradication will be available by then. By 2030, based on early versions of these tools currently in development, it is anticipated that:

●     There will be a vaccine that will prevent the transmittal of the malaria parasite from infected persons to the mosquitoes that bite them, thus halting the spread of the disease.

●     There will be a single-dose cure that will completely clear the parasite from infected persons.

●     There will be a diagnostic test that can provide immediate results on infection status.

Forcing HIV to a tipping point. Alongside efforts to develop a vaccine or cure for HIV, HIV will be forced to a tipping point globally when:

●     The number of people beginning anti-retroviral treatment in sub-Saharan Africa surpasses the number of newly infected people.

●     The high HIV transmission rate in sub-Saharan Africa is arrested, leading to a worldwide reduction in HIV cases.                 

Progress towards these health breakthroughs will be complemented by parallel progress in agriculture (innovations to increase yield and improve nutrition content in order to increase earnings and reduce malnutrition); education (the creation of better technology to revolutionize learning, make online education easily accessible and reduce the gender literacy gap); and banking (increased access to mobile banking that gives the poor more control over their finances, makes transactions more efficient, less time consuming and makes it easier to borrow and save).

What does this letter mean to the health and development community? Well, as one of the biggest funders, the letter provides a projection of what we can expect to see in global health programming in the years to come. For instance, there will be an emphasis on scientific and technological discoveries aimed at reducing maternal and child mortality. Organizations working to develop vaccines as well as rapid, low-cost diagnostic tests and medical devices will receive priority funding. Just as the MDGs have been used as a framework for driving actions and policies in development, the goals outlined in the 2015 Gates Letter will certainly have impacts on programs and policies in many developing countries, as well as on the funding directions of other donor agencies.

The master plan of the Gates touches on several vital issues that are central to health and development and is sensitive to the gender applications and implications of proposed activities. It galvanizes public engagement with the introduction of a “Global Citizens” program that invites and provides a platform for “global citizens” to “lend their voice, urging governments, companies, and nonprofits to make these issues a priority”. Certainly, their big bet can only be attained by building collaborations within existing structures and breaking down walls between nonprofit sectors. Monetary and R&D investments by the private sector coupled with international political support will be paramount for achieving any progress. Political will and better bureaucracy at the country level is a huge determinant of success. However, it is noted that the letter does not focus much, if at all, on the development of structures that sustain interventions such as legal, policy, financial and governmental environments. The focus is rather on straightforward solutions that can be achieved while bypassing these systems and institutions.

All-in-all, the letter provides a credible, multi-sectoral agenda and it is hoped that the Post-2015 Sustainable Development Goals will be as practical as the 2015 Gates Annual Letter in providing achievable goals for improving global health in the next 15 years.

References:

Bill and Melinda Gates. 2015 Gates Annual letter. www.gatesnotes.com/2015-annual-letter