The end of polio?

Is the end nigh for polio? It could well be according to those involved in the global eradication movement. Since the Global Polio Eradication Initiative (GPEI) was launched in 1988, the World Health Organisation (WHO) says that worldwide polio cases have dropped by 99 per cent.

And despite the disease remaining active in Pakistan and Afghanistan and outbreaks in war-torn Syria in recent years, there seems to be much optimism that polio could soon join smallpox in the dustbin of disease history.

<h3 class=”p4″>Current experience </h3> There is no cure for polio – it can only be prevented through immunisation. Routine immunisation was introduced in Ireland in 1957, but people born before then may not have been immunised.

Before the introduction of the polio vaccine in 1957, polio used to be common in Ireland. By the mid-1960s few cases were reported and the last Irish case of polio was reported in 1984.

Polio vaccines are given as part of the routine childhood schedule at two, four, and six months of age and a booster is given at four to five years of age. Unimmunised adults are recommended three doses of polio vaccine. Partially immunised adults should complete the course, according to the HSE.

Some 7,000 polio survivors are still living in Ireland with disabilities from this disease. Those who work with this community worry that doctors and other medical professionals may no longer have adequate knowledge about the disease (see panel).

In a recent interview with the Medical Independent (MI), Dr Brenda Corcoran from the HSE National Immunisation Office (NIO) spoke of her own experience of working in medicine and seeing patients with polio.

“Many patients fortunately haven’t seen the diseases that we now have vaccines for,” says Dr Corcoran.

“People who have been around quite a while would have seen these diseases and know the devastation they can cause. I can remember patients with iron lungs in Cherry Orchard Hospital, I’ve seen measles infection, Men C, again a devastating disease, all now prevented by vaccination.”

Organisers of a Sanofi Pasteur, (the largest polio vaccine producer) event on World Polio Day (24 October) at the Institut Pasteur, Paris, have said that it “will probably be the last event of its kind before the world is polio free”.

At the event the work of Pakistani workers “killed or maimed as they work to protect their nation’s children from the crippling disease” are due to be recognised. There will also be an Irish angle to the event: “These workers together with Jim Costello, one of Europe’s most impressive polio survivors and a founding member of the polio support group, will be presented with the Louis Pasteur Medal during this major meeting of scientists, ministers, and NGO leaders.”

<div style=”background: #e8edf0; padding: 10px 15px; margin-bottom: 15px;”> <h3>Continuing impact of polio on survivors </h3> For many young people in Ireland polio may seem to be part of a bygone era, consigned to a dark medical folk memory. However, older people have vivid memories of when polio was a serious issue on the island. But its impact is not only historical, the effects of polio still shape the lives of many Irish people.

‘We’re still here’ is one of the mottos of the Post-Polio Support Group (PPSG), a charitable organisation set up by polio survivors to assist their fellow survivors.

In fact, as many as 7,000 polio survivors in Ireland are still living with disabilities from this disease.

The PPSG says the people they represent have continuing medical needs.

“In consultation with our members, we believe one of the greatest needs is that medical and social care professionals know and understand the late effects of polio and are aware of the impact of post-polio syndrome on polio survivors,” a PPSG spokesperson told MI.

“Other pressing needs are free and available medical care, the provision of appropriate aids and appliances when required due to the progressive nature of their condition.

“As a consequence of the late effects of polio, including post-polio syndrome, polio survivors are extremely intolerant to cold and at risk of hypothermia in winter – staying warm is a major concern.”

The PPSG spokesperson states that Irish polio survivors also feel there is a greater need for doctors and other healthcare professionals to be aware of the impact of the disease.

“Given that polio is eradicated in Ireland, we understand that medical and social care professionals are not familiar with polio,” says the PPSG spokesperson.

“However, we would ask that the medical profession is aware that polio survivors have needs in relation to the late effects of polio and post-polio syndrome – both conditions are continuing to impact an estimated 7,000 people in Ireland today,” said the spokesperson.

“Medical professionals should be aware, for example, that consideration needs to be given to the level of anaesthetic used on polio survivors, who may have difficulty waking after anaesthesia.

“They are also liable to increased pain, intolerance to cold, and certain drugs should be applied with special care.”

“The PPSG provides services, information, and support to polio survivors in Ireland, as well as information to health professionals. Our ‘Blue Book’ – Management and Treatment of Post Polio Syndrome in Primary Care – can assist any medical practitioner treating a polio survivor.”

*Doctors can contact 01 889 892 or email info@ppsg.ie, or see www.ppsg.ie to get a copy of the ‘Blue Book’.

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<h3 class=”p4″>Bye, bye polio?</h3> So will this be the final World Polio Day before the world is polio free, as some of those working in the field are suggesting?

Prof Gareth Williams, Emeritus Professor of Medicine and Senior Research Fellow in English University of Bristol, UK, is a leading expert in the history of polio.

His recent book Paralysed with Fear: The Story of Polio (Palgrave: MacMillan, 2015) is a comprehensive and global account of the disease. When he assesses the chances of eradicating polio in the short-term, he describes himself as possessing “cautious optimism”.

“But we’ve been close before and it’s slipped away,” Prof Williams tells MI.

“The current setback is in Nigeria, which had been polio-free for a couple of years.

“Now mass vaccination is back in train [and] political opposition there is largely settled, but it’s still volatile so [we] can’t assume success.”

However, there are not only challenges on the African continent.

“Other big obstacles are in Pakistan, where vaccination workers are still being threatened and killed by hard-line anti-Western forces,” he notes.

Prof Williams has previously written about the rise and eradication of smallpox in his book Angel of Death: The Story of Smallpox (Palgrave: MacMillan, 2010) and he believes if polio transmission is ended soon, then there will be a period of waiting and watching for those in the eradication campaign, similar to what happened in the case of smallpox.

“With lots of luck, next year might be the one in which wild-type polio transmission finally ceases,” he says.

“Then we have to wait three years. This was a tense time in the smallpox eradication campaign, and it will be again for polio.”

There are particular political problems in Pakistan regarding the country’s polio vaccination programme. According to the BBC: “Islamist militants oppose vaccination, saying it is a Western conspiracy to sterilise Pakistani children.”

However, many observers also point to the US government’s high-profile use of fake vaccinators, in its 2011 operation to track down and kill former al Qaeda leader Osama bin Laden, as a source of local anger and one of the reasons behind the violent attacks on those working in the Pakistani vaccination programme.

<h3 class=”p4″>Progress</h3> The GPEI was launched in 1988, when the 41st World Health Assembly adopted a resolution for the worldwide eradication of polio. The campaign has both support from the public and private sector involving national governments, the WHO, Rotary International, the US Centres for Disease Control and Prevention (CDC), UNICEF, and is also supported by key partners including the Bill and Melinda Gates Foundation.

The aim to eradicate polio came in the wake of the excitement that followed the certification of the eradication of smallpox in 1980.

“In 1994, the WHO Region of the Americas was certified polio-free, followed by the WHO Western Pacific Region in 2000 and the WHO European Region in June 2002,” reports the WHO.

“On 27 March 2014, the WHO South-East Asia Region was certified polio-free, meaning that transmission of wild polio virus has been interrupted in this block of 11 countries stretching from Indonesia to India.

“This achievement marks a significant leap forward in global eradication, with 80 per cent of the world’s population now living in certified polio-free regions.

“Failure to implement strategic approaches, however, leads to ongoing transmission of the virus. Endemic transmission is continuing in Afghanistan, Nigeria, and Pakistan. Failure to stop polio in these last remaining areas could result in as many as 200,000 new cases every year, within 10 years, all over the world.”

<div style=”background: #e8edf0; padding: 10px 15px; margin-bottom: 15px;”> <h3>Polio — the Irish experience </h3> Ireland, like much of the world, suffered greatly in the face of polio outbreaks in the first six decades of the 20th century.

This year marks the 60th anniversary of one of the most infamous epidemics on the island.

“The 1956 polio epidemic in Cork was the largest localised epidemic in the history of the State,” said Mr Stephen Bance, a PhD student at the Centre for the History of Medicine in Ireland in UCD.

Mr Bance is currently working on a Phd that is looking at the Irish experience of polio in Ireland from 1942 until 1970.

“Of the 499 notified cases that were recorded in the 1956 Annual Report of the Registrar General, 220 of these occurred in Cork city and county.

<blockquote> ‘At times the incidence rate in Ireland was higher than in the US, where polio was considered a national crisis’

</blockquote> “Cork is the location most readily associated with polio in the public consciousness and previous historical studies of polio in Ireland have focused on the epidemic there in 1956.

“Numerous public health figures attempted to quell public anxiety about the polio epidemic. Minister for Health T F O’Higgins visited Cork in late July during the height of the epidemic, where he reasoned that there were ‘no grounds for panic’, given that the general character of the outbreak was of a mild nature and the mortality rate was low.

“Gerald McCarthy, the Cork County Medical Officer, stated in The Irish Times that the strain of polio affecting Cork ‘was a comparatively light form of the disease’, and the epidemic was of a ‘trifling’ nature.

“Despite these assurances, the prevalence of polio in Cork during 1956 had a terrific impact on the local community. Business and tourism trades were harmed, sports and recreational activities were banned or abandoned, and the school system was temporarily shut down.”

But despite significant public health events like this, Mr Bance says it took some time before Irish public health authorities got to grips with polio.

“The success of public health policy in dealing with polio was by no means rapid,” he notes.

“Though a significant number of polio cases were occurring throughout the 1940s and early 1950s (for example in 1942 there were 361 notified cases), a series of regional centres to treat polio in its acute stages was not established until 1955.

“These centres were located in St Finbarr’s Hospital, Cork, Cherry Orchard Hospital in Dublin, and Galway Regional Hospital. The rehabilitation of polio survivors was dominated by philanthropy, as organisations such as the Central Remedial Clinic and the Cork Polio and Aftercare Association sought to provide rehabilitative services for polio survivors in the absence of a State-run scheme.

“The first polio vaccination scheme, using a Salk type vaccine imported from Britain, was introduced to Ireland in the summer of 1957.

“This was significantly later than Britain, the US, and a host of European nations. Initial vaccination programmes were unsuccessful for a myriad of reasons, including problems in the supply chain, financial shortages, and public reticence to present for vaccination, partly because of a failure to make the public aware of the importance of vaccination and partly because, following the introduction of a means-tested vaccination scheme after 1958, many found vaccination to be prohibitively expensive.”

But by the mid-1960s the Irish health system has begun to get on top of polio, says Mr Bance.

“The failure of these early programmes was summated by the Medical Research Council in 1962. While preparing the groundwork for the introduction of an orally administered vaccine, the Council stated that health authorities would essentially be dealing with an ‘unvaccinated population’.

“Oral polio vaccine was successfully introduced to Ireland on a universal basis in 1965 and in 1967 Ireland had its first polio-free year since the disease began to be recorded in the Reports of the Registrar General in 1935.”

Mr Bance says his “research provides new insights into the history of infectious disease and public health in mid-20th century Ireland. It charts the epidemiological impact of polio at a national and regional level, exploring the individuals and areas that were most susceptible.”

“This underlines the importance of examining the effect that polio had on the social fabric, as at times the incidence rate in Ireland was higher than in the US, where polio was considered a national crisis.

“My research also explores whether the rhetoric of improved social health policy in mid-20th century Ireland translated into an effective treatment system for polio.”

But does research like this provide any help or guidance to those involved in public health now, particularly medical staff currently working in vaccination programmes?

“I will simply, cautiously, state that in relation to current policy, public health histories can help to prevent repetition of past mistakes,” Mr Bance tells MI.

“For example, the early polio vaccination programmes in Ireland highlights many of the potential pitfalls in successfully importing and using medical technologies.

“The unsuccessful nature of the early programmes also underlines how crucial it is to create public awareness about the need for vaccination and the potential consequences of introducing means-tested vaccination schemes where vaccination is not provided on a universally free basis.”

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<h3 class=”p4″>Wrong goal?</h3> However, there have been some dissenting voices within international public health circles, over whether the focus on polio eradication has meant other health goals have fallen by the wayside. Some critics argue the many billions spent on this eradication programme could have been much better diverted into other public health projects.

In 2012 Prof William Muraskin wrote a book entitled Polio Eradication and Its Discontents (Orient Blackswan, 2012).

Speaking to MI a year after the publication, the Professor in the Urban Studies Department of The City University of New York, US, said that the “top down priority setting from the global level, which this programme represents, distorts the public health programmes of the Global South”.

“Their priorities have been replaced with someone else’s. That is the biggest negative impact of the programme.

“The obvious lesson from polio eradication is that there are unintended consequences to massive programmes. Costs spiral, unexpected obstacles appear, lack of knowledge about conditions on the ground in individual countries constantly frustrate planners, the scientific knowledge of the disease is usually incomplete and surprises constantly appear, and the programmes subordinate country priorities in ways that infringe on their sovereignty,” Prof Muraskin told MI in 2013.

“Countries do want things like measles under control. But countries never think in terms of global eradication. Bottom up never thinks that way. Global eradications think that way.

“One size doesn’t fit all. Countries are different; what they want and need is different.”

The debate over whether the eradication of polio was the correct focus of the international public health community will continue says Prof Williams. However, whatever the rights or wrongs on both sides, he argues that much benefit has come from the eradication campaign.

“Polio is a horrible disease and the world will be a better place without it,” Prof Williams tells MI.

“People will continue to argue that the money, tens of billions, could have been spent more effectively and could have saved more lives and reduced more human suffering than beating an infection, which had become a minor player, on the global scale, into total extinction.”

Yet despite this, he believes that so much progress has been made in the fight against polio, that to halt now and refocus elsewhere, would not be sensible.

“Personally, I feel that having gone this far, it would make no sense to stop now before total eradication,” he says.

“As an example of how different organisations with different goals and ways of working can function together, it’s hard to beat.”

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