In the drive to end polio, a plague of doubt and exhaustion

By Celia W. Dugger and Donald G. McNeil Jr. The New York Times

May 1, 2006

BAREILLY, India The cry went up the moment the polio vaccination team was
spotted: "Hide your children!"

Some families slammed doors on the two volunteers going house to house with
polio drops in this teeming city's decrepit maze of lanes, saying that they
feared the vaccine would sicken or sterilize their children or simply that they
were fed up with the long drive to eradicate polio.

Nearly 18 years ago, in what they described as a "gift from the 20th century
to the 21st," public health officials and volunteers around the world committed
themselves to eliminating polio from the planet by the year 2000.

Since then, two billion children have been vaccinated, cutting incidence of
the disease more than 99 percent and saving five million from paralysis or
death, the World Health Organization has estimated.

But six years beyond the deadline, even optimists warn that total eradication
is far from assured. The drive against polio threatens to become a costly
display of all that can conspire against even the most ambitious efforts to
eliminate a disease: cultural suspicions, logistical nightmares, competition for
resources from many other afflictions and simple exhaustion.

So monumental is the challenge that in the history of humanity only one
disease has been eradicated: smallpox.

As the polio campaign has shown, even the miracle of discovering a vaccine is
not enough.

Not least among the obstacles is that many poor countries that eliminated
polio have now let their vaccination efforts slide, making the immunity covering
much of the world extremely fragile, polio experts warn.

They compare it to a vast, tinder-dry forest: If even one tree is still
burning, a single cinder can drift downwind and start a fire virtually anywhere.

Here in northern India the embers are still glowing. And northern Nigeria,
another densely populated, desperately poor region, is aflame.

In a calamitous setback in mid-2003, Nigeria's northern states halted the
vaccination campaign for a year after rumors swept the region that the vaccine
contained the AIDS virus or was a Western plot to sterilize Muslim girls.

Since then, 18 once polio-free countries have had outbreaks traceable to
Nigeria. Though most have since been tamed, Indonesia and Nigeria itself remain
major worries.

In 2001, there were fewer than 500 confirmed cases of polio paralysis in the
world. Last year, the number jumped to more than 1,900 and each paralyzed child
means another 200 "silent carriers" spreading the disease. This year in addition
to India and Nigeria, cases have been reported in Somalia, Niger, Afghanistan,
Bangladesh and Indonesia.

Yet no effort against any disease has been as well financed or as absorbing as
the polio drive, which has cost $4 billion so far. In the balance is not just
whether polio will be extinguished, many public health officials say, but
whether a world that could not quite conquer polio will have the stomach to try
to wipe out other diseases, like measles.

Here and elsewhere, eradicating polio means finding ways to get polio drops in
the mouths of every last child under 5, over and over and over. Because it can
take many doses to effectively immunize a child in parts of the world where the
disease circulates intensely, eradication requires repeated sweeps.

The collapse of Nigeria's drive has become an object lesson in the
unpredictable ways eradication campaigns can go terribly awry. "Nigeria is
clearly far and away the greatest risk to the eradication effort," said Dr.
Stephen Cochi, a senior adviser in the U.S. Centers for Disease Control and
Prevention's immunization program.
The quality of its campaigns is worst in Africa. "They're just missing lots
and lots of kids."

While Nigeria struggles with its campaign, India, whose need is such that it
uses more than half the world's two billion polio vaccine doses each year, has
long made an extraordinary commitment to wipe out polio.

Teams like the one that faced scorn in squalid warrens of Bareilly have made
repeated sweeps in the state of Uttar Pradesh, home to 180 million people, which
Cochi of the Centers for Disease Control described as "historically the center
of the universe for the polio virus."

Nowhere are the prospects for conquering polio more intimidating. Living
conditions are so dense, public health services so awful, summer heat so
sweltering, and open sewers and monsoon floods so commonplace that a more
perfect breeding ground could hardly be conjured.

The state, populous enough to make it the world's sixth largest nation, has
endured more than two dozen campaigns in recent years. In 2004, teams went door
to door eight times. They came eight more times last year.

International leaders of the global drive were hopeful last year that the
country would finish off the disease, but it still registered 66 cases. That was
the lowest tally ever, but not zero.

And so this year, India must repeat its consuming effort yet again, with
special focus on Uttar Pradesh and other regions still trying to extinguish the
last cases.
Polio spreads through oral-fecal contact. In warm or tropical climates, many
similar viruses can attach to the same receptors in the intestine as the polio
virus does, making it even harder to immunize a child. It can take up to 10
vaccine doses, spaced months apart.

With great anticipation, India and other countries began trying a new
eradication strategy last year, using a "monovalent" vaccine that focuses only
on the most common strain of polio, but gives immunity in fewer doses. The old
vaccine attacked three strains of the virus, two of them less common. "The great
hope was that monovalent vaccine would be the magic bullet and melt all polio
cases away, but that hasn't happened," Cochi said.

While the new vaccine has brought India closer than ever to eradication,
vaccination teams have not been able to let up their efforts.

As the worldwide polio campaign has dragged on, the voices of skeptics have
grown louder. Dr. Donald Henderson, renowned for leading the successful war on
smallpox, and now a professor of medicine and public health at the University of
Pittsburgh, said he believed the polio campaign was all but doomed. He suspects
that the official caseload figures on www.polioeradication.org are incomplete
and that the World Health Organization may not actually know every pocket of
virus in the world.
But even if it does, and even if all the world's polio cases can be wiped out,
he argued, problems that are now being nearly ignored in the all-out effort to
corral the last few cases will suddenly loom large.

For example, as a precaution, vaccination must be continued for many years
after the last case is found, polio experts agree. But in about one in three
million doses, the live oral vaccine used in poor countries can mutate back into
a wild-type virus that can infect and paralyze victims.


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