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Progress Toward Poliomyelitis Eradication -- India, December 1995 and January 1996

Monitoring efforts to eradicate poliomyelitis by the year 2000 continues to indicate this goal can be achieved: in 1995, the incidence of reported polio cases worldwide was the lowest ever (6179 cases) -- representing an 82% decline from the 35,251 cases in 1988. In addition, from 1988 to 1995, the number of countries conducting national immunization days (NIDs) * increased from 17 to 62. In India (1994 population: 919 million), the first NIDs ("pulse polio immunization days" {PPIDs}) were conducted on December 9, 1995, and January 20, 1996, with a target of vaccinating approximately 75 million children aged less than 3 years with one dose of oral poliovirus vaccine (OPV) in each of two rounds. This report summarizes progress toward polio eradication in India and indicates that the target to vaccinate 75 million children aged less than 3 years with OPV was exceeded by 4.3 million (6%) during the first round of PPIDs and by 10.4 million (14%) during the second round.

In India, nearly 2 million health-care workers and volunteers participated in PPIDs and used a network of approximately 500,000 vaccination posts. Vaccination posts were the locations where OPV was offered to children by a staff consisting of at least one trained health-care worker and at least three volunteers (1).

On December 9, 1995, the government of India conducted the first round of PPIDs, vaccinating 87.8 million children with one dose of OPV. Of the children vaccinated, 79.3 million (91%) were aged less than 3 years, and 8.5 million (9%) were aged greater than or equal to 3 years. All but one of the 32 states and union territories reported coverage to be greater than 90% for children aged less than 3 years; Nagaland (population: 1.3 million) reported coverage of 86%.

During the second round of PPIDs on January 20, 1996, a total of 93.6 million children were vaccinated with one dose of OPV; of these, 85.4 million (90%) were aged less than 3 years and 8.2 million (10%) aged greater than or equal to 3 years. All 32 states and union territories reported coverage to be greater than 90% for children aged less than 3 years.

To monitor vaccination posts, on December 9, 1995, participating agencies (the Indian Ministry of Health and Family Welfare, the United Nations Children's Fund {UNICEF}, Rotary International, the World Health Organization {WHO}, and other partner agencies) surveyed a nonrandom sample of 1070 posts located in 25 of the 32 states and union territories. A standardized survey instrument was used to record information about the ages of children receiving OPV, staffing, vaccine cold chain, and vaccine supply. The findings suggested that 1) posts were adequately staffed; 2) cold chain was well-maintained; and 3) when vaccine supply diminished, contingency measures were initiated to ensure supplies were replenished. In addition, of the 3716 children observed receiving OPV, 605 (16%) were aged greater than or equal to 3 years, suggesting that measures to screen the age of children were incomplete, and substantial quantities of OPV were administered to children aged greater than or equal to 3 years.

From 1987 to 1991, reported cases of polio in India declined 79%, from 28,264 to 6028 (Figure_1). From 1991 to 1995, reported cases further declined 50%, from 6028 to 2993. As recently as 1994, however, large outbreaks of paralytic polio have occurred in the states of Gujarat, Karnataka, and Maharashtra, indicating that endemic and epidemic transmission of polio continued to occur despite substantial improvements in routine vaccination coverage with three doses of OPV among children aged 1 year (from 63% in 1988 to 90% in 1993).

Reported by: A Misra, Joint Secretary; K Banerjee, MD, Assistant Commissioner (Immunization), Dept of Maternal and Child Health, Ministry of Health and Family Welfare, New Delhi, India. Expanded Program on Immunization, South East Asia Regional Office, World Health Organization, New Delhi, India. Respiratory and Enterovirus Br, National Center for Infectious Diseases; Polio Eradication Activity, National Immunization Program, CDC.

Editorial Note

Editorial Note: On January 20, 1996, the government of India vaccinated approximately 93 million children with OPV on 1 day -- marking the largest number of vaccinations ever administered during a single-day public health event. India is committed to sustaining the massive effort of conducting annual PPIDs (consisting of two rounds) for at least 3 consecutive years or until wild poliovirus circulation is eliminated from that country.

Although most cases of polio in India have occurred among children aged less than 4 years (88% in 1992 and 91% in 1993) (2), during 1992-1994, persons aged greater than or equal to 4 years accounted for 9%-12% of cases. Therefore, PPIDs scheduled for December 1996 and January 1997 will target children aged less than 5 years, increasing the total number of children in the target age group from 75 million to 125 million. Future efforts to focus measures for screening the age of children should assist in reducing vaccine costs during PPIDs.

The role of Rotary International, UNICEF, and other partner agencies has been critical in enabling polio eradication in the South East Asia Region (SEAR) (2-4). The estimated cost of India's first PPIDs was $30.3 million and included contributions from India ($18.0 million), the British Overseas Development Agency ($6.1 million), Rotary International ($5.0 million), and the United States Agency for International Development ($1.2 million). In addition to financial contributions, partner agencies have promoted evaluation efforts as a means for improving vaccination coverage during future PPIDs and have strengthened coordination between governmental and nongovernmental agencies. Surveillance systems also require strengthening to maximize the use of resources (2) to achieve the goal of polio eradication by the year 2000.

During August 1994-April 1996, seven of the eight SEAR member countries in which polio is endemic conducted their first polio NIDs; Thailand conducted NIDs first, followed by Bangladesh, Indonesia, Sri Lanka, India, Myanmar, and Democratic People's Republic of Korea. Nepal will implement NIDs in December 1996. During December 1996, six of eight contiguous SEAR member countries with endemic polio (Bangladesh, India, Myanmar, Nepal, Sri Lanka, and Thailand) will conduct NIDs synchronously. In addition, another contiguous country (in the Eastern Mediterranean Region), Pakistan, also plans to conduct NIDs again in December.

Progress toward polio eradication reported from the SEAR builds on the experience of the Americas (5) -- which has been free of wild poliovirus since 1991 (6) -- and the more recent substantial progress in the Western Pacific Region, including China (7). By the end of 1996, all polio-endemic countries in Europe and Asia, except Yemen, will have conducted NIDs, and approximately half of the children aged less than 5 years worldwide will have received supplemental OPV doses administered during NIDs. In addition, 29 countries in the African Region are planning to conduct NIDs or Sub-National Immunization Days in 1996. Progress reported from many areas of the world suggests the goal of global eradication of polio by the year 2000 is feasible.

References

  1. Ministry of Health and Family Welfare. Pulse polio immunization in India: operational guide. New Delhi: Ministry of Health and Family Welfare (India), 1995.

  2. Andrus JK, Banerjee K, Hull B, Mochny I. Polio eradication in South-East Asia by the year 2000: mid-way assessment of progress and future challenges. J Infect Dis 1996 (in press).

  3. CDC. Progress toward poliomyelitis eradication -- South East Asia Region, 1988-1994. MMWR 1995;44:791,797-801.

  4. World Health Organization. Progress towards poliomyelitis eradication, 1994. Wkly Epidemiol Rec 1995;70:97-104.

  5. de Quadros CA, Andrus JK, Olive J-M, de Macedo CG, Henderson DA. Polio eradication from the Western Hemisphere. Annu Rev Publ Health 1992;13:239-52.

  6. CDC. Certification of poliomyelitis eradication -- the Americas, 1994. MMWR 1994;43:720-2.

  7. Yang B, Zhang J, Otten MW, et al. Eradication of poliomyelitis in the People's Republic of China. Pediatr Infect Dis J 1995;14:308-14.

    • Mass campaigns over a short period (days to weeks) in which two doses of oral poliovirus vaccine (OPV) are administered to all children in the target age group, regardless of prior vaccination history, with an interval of 4-6 weeks between doses.



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