March 27, 2014, 8:50 pm IST in Treasure Hunt | World

‘Polio-eradication alone is not enough — we need to do a lot more’

The World Health Organisation’s South East Asia regional director Poonam Khetrapal Singh, the first woman to hold this position, had a proud moment when she declared the region polio-free on March 27. But, this is just the beginning; we need to deal with tuberculosis and measles as well, Singh points out to Narayani Ganesh

Q: The WHO declaring the South East Asian region as polio free has come nearly two decades after India first launched its anti-polio drive in 1995. Why did it take so long for India to do this?

A: Yes, India was the last country in the region to eradicate polio, thereby delaying the declaration considerably. First, the Americas did it in 1994, followed by the western Pacific in 2000 and the European region in 2002. And now, the polio virus is present in only three countries in the world: Nigeria, Afghanistan and Pakistan, all conflict-ridden areas and so posing challenges in terms of success in immunisation programmes.  To declare the world polio-free, we have to wait for these three countries to eradicate polio.

India is a large country with more than a billion people, with 170 million children under the age of five. There is a lot of moving population and an estimated eight million children too are on the move at any given time, so you can imagine how difficult it is to sustain the immunisation process. At one time we thought it might never happen! So it is no mean achievement, and we waited for the mandatory three year period before making the declaration. The last polio case in India was detected in 2011.

Q: What if polio reappears like it reportedly has in California recently? What’s the risk factor of recurrence of the disease?

A: Importation of the ‘wild’ polio virus does happen even if a region is declared polio-free, so long as there still are some countries that continue to battle the disease as importation can happen only from there. That’s the risk factor. That’s why you need to have a plan. You need to have good surveillance, first of all, to detect the importation of polio virus. India and other countries will continue with immunisation and also expect visitors to the country to have been vaccinated against polio. Immunisation has to be repetitive. India’s lab surveillance system is excellent – that is, the ability to detect a virus in the lab. Otherwise, often you might suspect a polio case and it may not be so.

Q: And when children get infected during immunisation? How often does that happen?

A: Sometimes this can happen; they can derive polio from vaccine since the virus is live. But the numbers are few, an estimated 53 to 100 in total, but even if there is one case it is indeed of great concern. Hence we are now moving to IPV or inactivated polio virus so you cannot get vaccine derived polio from it. It is as effective as the live virus but less used as it is expensive and given through injection as opposed to oral drops.

As part of WHO’s global polio eradication project, we’ve put in place an Endgame Strategy 2013-2018. They are advocating IPV now because once the Oral Polio Vaccine (OPV) transmission is stopped, it is safer to switch to IPV. 

There are three different types of polio strains: Type 1, Type 2 and Type 3. With OPV, Type 2, the most virulent form, got eradicated in 1999. So Type 2 was out and we’re now left with Type 1 and 2. The world is now moving toward monovalent vaccine to address one Type at a time.

Q: How important a role did civil society groups play in eradicating the virus?

A: India had three points in its favour: Strong political commitment, generous budget allocation and good partners like Rotary International, Unicef and others, including the Gates Foundation. And there has been a successful review of the programme. India was open to trying out different types of vaccine – monovalent, bivalent and trivalent. Then we had this big problem of underserviced areas. In areas where polio was persistent, like the Kosi River region in Bihar with high incidence, we had special strategies in place, with gradually evolving programmes.

Q: You’ve said that polio-eradication alone is not enough. What are your focus areas to make the region disease free?

A: I would like to focus on four major areas:  emerging epidemiological and demographic challenges; universal health coverage and robust health systems; strengthening emergency risk management for sustainable development and articulating a strong regional voice in the global health agenda.

Polio eradication is just the beginning; we still have to deal with other communicable diseases like TB. Since 1990, TB mortality has declined by 40 per centand Malaria, by 82 per cent. Maldives is already malaria-free. In most countries in the region, the HIV epidemic has been reversed. However, we do face challenges in terms of drug resistance and co-infections. And then we have recurrence of influenza, SARS and avian flu that travel the globe in a shrunken world. The answer is to scale up national capacity so as to prevent diseases from spreading out.

Apart from battling communicable diseases like TB, there is also increasing focus on non-communicable diseases that are major killers in the region, especially in India, responsible for more than half of the mortality figures. As you know, India has the largest incidence of cardio-vascular disease, diabetes, cancer and chronic respiratory diseases. One third of these deaths occur in people below 60 years of age. Tobacco use is a huge menace and other lifestyle factors play a huge role in increasing the spread of non-communicable diseases and this can only be reversed by taking multi-sectoral preventive action. Other important areas of focus are mental health and malnutrition.

Q: What would you say is the most important factor that can improve public health?

A: Universal health coverage with access, affordability and quality is important and this involves overcoming geographical, technological, social and financial challenges. The need is for quality preventive, promotive, curative and rehabilitative health services, and this can only be achieved with public-private partnership initiatives. And in a region that is extremely disaster prone, we need efficient disaster preparedness and management mechanisms in addition to strengthening emergency risk management. To achieve good health in the region, what we really need is a multi-pronged, holistic approach – to deal with both communicable and non-communicable diseases – and focus on creation of public awareness and preparedness with inter-regional cooperation since disease knows no borders.

(Poonam Khetrapal Singh served for over 20 years in the Indian Administrative Services,including as Health Secretary of the State of Punjab. She moved to WHO and in February 2013, she joined the ministry of health and family welfare of the Government of India as advisor for international health, where her principal task was to strengthen global health outcomes and provide guidance to the ministry to take forward the international health agenda. Since February 2014, she is regional director of WHO’s South East Asian region).

DISCLAIMER : Views expressed above are the author's own.
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