Poliomyelitis Eradication and End Game
Musa Mohd Nordin FRCP, FRCPCH, FAMM
Cyberjaya University College of Medical Sciences (CUCMS)
Introduction
Polio is the common and abbreviated name of poliomyelitis derived from the Greek polios, "gray,"
and muelos, "marrow," meaning "inflammation of the gray matter of the spinal cord."
The earliest cases of polio predates recorded history. An Egyptian stone carving, between 1580-1350
B.C. depicts a young man with a deformity of his limb which might have been caused by polio (1).
There were numerous outbreaks in the 18th century and the English physician Michael Underwood
first clinically described polio as "debility of the lower extremities." The German physician, Jacob
Heine's 78 page monograph in 1840 described the clinical features of the disease and suggested an
underlying pathology in the spinal cord.
The first major polio epidemic in the United States occurred in 1894 and reported 132 cases. Various
causes were suggested including "overheating, chilling, trauma, fatigue, and such illnesses as typhoid
fever, whooping cough, and pneumonia" (2). Two Austrian physicians, Karl Landsteiner and E.
Popper first identified the polio virus in 1908 and polio became a notifiable disease entity.
Jonas Salk first developed the inactivated polio vaccine (IPV) and Albert Sabin the oral polio vaccine
(OPV) between 1954-57. In 1952 and 1953 there were 58,000 and 35,000 polio cases respectively in
the United States. After the introduction of the IPV in 1956, the rate dropped to about 5,600 cases in
1957 (3).
The World Health Organization (WHO) included the Sabin OPV under the auspices of the Expanded
Program of Immunization (EPI) due to its lower cost and long-term efficacy. By the early 1970s most
of the world was using Sabin's oral vaccine.
There was an estimated 350,000 cases of polio in the world in 1988. In the same year, the World
Health Assembly resolved that polio would be eradicated by the year 2000 (4). WHO’s Plan of Action
for Polio Eradication anticipated that 2000 would witness the last case of polio caused by wild
poliovirus and that global eradication would be certified in 2005. This has been a moving target,
since various issues including wars, natural disasters, and poverty in many of the developing
countries in Asia and Africa have prevented this polio-free world objective from being completely
achieved. The Global Polio Eradication Initiative (GPEI), a partnership spearheaded by national
governments, WHO, UNICEF (United Nations Children’s Fund), the US Center for Disease Control
(CDC), Rotary International has since adopted a new strategy, the "Eradication and Endgame
Strategic Plan", which has set to reach and sustain polio eradication by 2018 (5).
The Polio Virus
Polio is a highly infectious disease caused by a RNA enterovirus. The three serotypes, 1, 2 and 3 have
minimal heterotypic immunity between them. They are rapidly inactivated by heat, formaldehyde,
chlorine and ultra-violet light (6).
The portal of entry is orally. The virus replicates in the pharynx, gastro-intestinal tract and
lymphatics. Hematologic spread via the lymhpatics and central nervous system facilitates its spread
along the nerve fibres with selective destruction of the motor neurones.
Ninety to ninety five percent of poliovirus infections are subclinical. A febrile episode or an upper
respiratory tract infection occurs in 4-8% of the infections and 1-2% have non-paralytic poliomyelitis.
Paralytic poliomyelitis is seen in only 0.1-1% of cases of poliovirus infections. One third of these
recover completely whilst the other two thirds have varying degrees of motor weakness. The
mortality rate is between 4-6%.
The Polio Vaccines
The Salk trivalent IPV was first discovered in 1955. The Sabin trivalent OPV became first available in
1963. The IPV was responsible for the initial decline in the incidence polio in the US. It has since been
replaced by the enhanced potency eIPV in 1987 (7).
The OPV is a live attenuated oral vaccine and has been responsible for the global decline in polio. It
is associated with beneficial contact spread. However, it causes the rare vaccine associated paralytic
poliomyelitis (VAPP) and in developed countries has been largely replaced by eIPV.
The Global Epidemiology of Polio
Against an estimated global burden of 350,000 cases in more than 125 endemic (presence of
indigenous wild poliovirus) countries, the World Health Assembly launched the Global Polio
Eradication Initiative (GPEI) in 1988. Within 15 years, polio had been eliminated from all but 6
countries and fewer than 1,000 children had been paralysed by polio in 2003.
Today more than ever, the goal of a polio-free world is a tangible reality. 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. Of the three serotypes of wild poliovirus (WPV), type 2 WPV
transmission has been successfully stopped since 1999.
As of 1 January to 15 May 2013, there were 33 cases of WPV compared to 55 this time last year
(Table I). There are only 3 remaining polio endemic countries; Nigeria, Pakistan and Afghanistan
reporting 22, 8 and 2 cases respectively. One case of polio was reported from Somalia compared to
3 cases reported from Chad this time in 2012. (8)
The Global Polio Eradication Initiative Strategic Plans
The GPEI employed the following key strategies to achieve its polio-free world objectives:
1.
Maintain a high routine infant immunization coverage.
2.
Mass immunizations campaign though National Immunization Days (NID).
3.
Localised mopping up campaigns.
4.
Ensure high quality Acute Flaccid Paralysis (AFP) surveillance.
After the eradication of wild poliovirus, the continued use of OPV would compromise the goal of a
polio-free world. The use of OPV if continued will result in a predictable burden of polio disease due
to VAPP and will result in a predictable rate of polio outbreaks due to circulating vaccine-derived
polio viruses (cVDPVs) (9). cVDPVs are vaccine strains that have mutated and recovered the wildtype poliovirus capacity to cause to cause paralytic disease and outbreaks through person-person
transmission. Between 2000 and 2011, there were 20 cVDPV outbreaks resulting in 580 polio cases.
(10)
If the worldwide utilization patterns of OPV continued after confirmation of the eradication of WPV,
it is expected that there would be 250 to 500 cases of VAPP per year and up to one polio outbreak
due to a cVDPV per year. (11)
Acknowledging the inherent risks of continued OPV use to the goal of a polio-free world, the GPEI
Strategic Plan 2004-2008 included among others the coordinated cessation of OPV use or a phased
replacement of OPV with IPV.
Polio Endemic Countries and the Religious Dimension
India was once considered as the most difficult challenge to the GPEI strategic plans towards a poliofree world. India has interrupted the transmission of WPV for the past two years and was removed
from the list of polio endemic countries in February 2012. India’s achievement reinforces the fact
that polio can be eliminated even in the most challenging of circumstances.
Since 2003, Nigeria has served as the major reservoir for WPV1 and WPV3 circulation in West Africa
and Central Africa. Over the past few years, WPV of Nigerian origin has been imported into 26
countries in Africa, the Middle East, and Asia, and has led to re-established transmission (>12
months) in Chad and Sudan.
A complex interaction of multiple factors contributed to the vaccine boycott in Nigeria (12). Among
others, this included rumours and misinformation regarding OPV which was being spread and
preached in the name of Islam. The OPV was alleged to contain substances which were not safe and
which can lead to infertility. It was also alleged that the OPV was made with haram constituents (not
permissible by Islamic Law).
Similar loss of public confidence in OPV was observed in the two other endemic countries, namely
Pakistan and Afghanistan with consequent low OPV uptake and Supplementary Immunisation
Activities (SIAs) that failed to reach >80% of children in high-risk states.
The East Mediterranean Regional Office of the WHO (EMRO) submitted the issue of the
permissibility of the OPV to the European Council of Fatwa and Research (ECFR) in 2003. The ECFR in
its 11th regular session from 1-7 July 2003, at Stockholm, Sweden addressed it as follows; “Out of
piety, some Muslim brothers in various parts of the world, particularly in East Asia, have made the
fatwa (religious edict) that it is not permissible to administer this vaccine to children, due to the fact
that porcine trypsin is used in preparing it.”
The ECFR issued the following fatwa: “First, it has been medically established that the administration
of this medicine is useful, that, with God’s permission it immunizes children against polio; and that
so far there is no alternative vaccine. Consequently, it is permissible to use it for purposes of
treatment and prevention, especially since forbidding its administration results in great harm. Even if
it is admitted that this liquid vaccine is impure, there are ample cases in Islamic jurisdiction where
the prohibition of impurities is waived. In this case, the impurity is exhausted through lavation and
multiplication. Moreover, this is a case which involves a necessity or a need that amounts to a
necessity. It is well known that one of the principal purposes of Islamic Law is to achieve benefits and
ward off harm and corruption. Second, the Council urges Muslim leaders and officials at Islamic
Centres not to be too strict in such matters that are open to considered opinion and that bring
considerable benefits to Muslim children, as long as these matters involve no conflict with any
definite text.” (13)
Scientific Declaration for Polio Eradication and Endgame Strategic Plan
At FIMA's biannual executive committee meeting in Cairo, Egypt on 28 February 2013, one of the
agenda items was a meeting with the Director General of EMRO to discuss on current issues related
to the polio eradication program and the pivotal role of FIMA and its affiliates, notably in
Afghanistan, Pakistan and Nigeria.
FIMA viewed the GPEI 2013-2018 strategic plans seriously and favourably, and issued its Cairo
Declaration for Polio Eradication on 28 February 2013 following their executive deliberations
(Appendix I).
This FIMA executive committee meeting was also the precursor to the EMRO organised high level
consultation of Islamic scholars and organizations from 6 to 7 March 2013, in the WHO Regional
Office in Cairo, to identify the best strategies to enhance solidarity among Islamic scholars and
leadership to counter false propaganda about the polio vaccine, promote its use to protect children
of the Muslim Ummah against polio and call for urgent action to eradicate this paralysing disease in
Muslim communities (14).
To reaffirm its commitments to the global polio eradication campaign, FIMA joined the fraternity of
scientists and technical experts from 80 different countries to launch the Scientific Declaration on
Polio Eradication on 11 April 2013. The world’s scientists coalesced to endorse the Eradication and
Endgame Strategic Plan, a new strategy by the GPEI to reach and sustain eradication (Appendix II).
The declaration highlights 5 major issues:
a.
Polio eradication is doable considering the major progress that has been achieved thus far,
b.
The Eradication and Endgame Strategic Plan plots very clearly the roadmap to a polio-free
world,
c.
GPEI (2013-2018) emphasizes apart from polio vaccinations, the importance of universal
mass vaccinations against most other disease entities,
d.
Warned that any scaling back of vaccination programs and its funding would have disastrous
consequences and
e.
Emphasized the importance of close collaboration and partnerships to achieve the historical
milestone of polio eradication.
Conclusions
FIMA hereby calls on all Islamic religious and community leaders to provide a strong message of
support for polio eradication activities and the need to ensure all children are fully immunized
against polio and all other vaccine-preventable diseases.
We urge all levels of political, religious and civil society in Muslim countries to overcome any
remaining cultural, religious, political and security obstacles currently preventing all children from
being reached and immunized against polio and all other vaccine-preventable diseases.
We earnestly call on all political, religious and civil society leaders to ensure the safety and security
of frontline health workers, to enable them to perform their heroic tasks.
We plead to all governments in Muslim countries to prioritize and mobilize the necessary financial
resources to enable the full implementation of all polio eradication strategies.
We call upon all our FIMA affiliates in their respective countries to be active partners of the Global
Polio Eradication Initiative, providing leadership towards the creation of a world free from polio for
all our children. Our collective efforts towards the creation of a polio-free world will undoubtedly be
our legacy to future generations of children.
References
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3.
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What is polio? http://www.cdc.gov/polio/about/
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Ayodele Samuel Jegede. What Led to the Nigerian Boycott of the Polio Vaccination
Campaign? PLoS Medicine. March 2007, Volume 4, Issue 3, e73. www.plosmedicine.org
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14. http://www.fimaweb.net/cms/index.php?option=com_content&view=article&id=346:islamicscholars-and-organizations-call-for-urgent-action-to-complete-polio-eradication-in-muslimcommunities&catid=38:general-news&Itemid=212