The world is zeroing in on the end of polio — by stopping people at bus stops, airports and train stations
This year will likely be the last to see new cases, and only in Afghanistan and Pakistan. It’s a huge step toward official eradication, which has only ever happened once before.
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When Ramesh Ferris was born in southern India in 1979, there were an estimated 300,000 to 400,000 new cases of polio being recorded around the globe each year.
At 6 months of age, he became one of them.
“The polio virus paralyzed my legs,” he says.
Then, two things happened that were tantamount to miracles, says Ferris, who would become an activist in the fight against the disease.
“I came to Canada, where I received corrective surgery … and learned to walk for the first time at the age of three and a half,” says Ferris, who was adopted at age 2 by Anglican bishop Ron Ferris of the Yukon.
More remarkably, the disease that was once a global scourge — a thief of childhood everywhere — has been all but eradicated from the earth. This year could see its complete disappearance outside of virus labs, experts say.
Last year, there were only 22 reported new cases of polio, which has been confined now to just a pair of nations: Pakistan and Afghanistan.
But 60 years ago, it held this country and much of the world in terror, with images of children in iron lungs plastered in newspapers everywhere — and no vaccine or cure in sight.
In the Canada of the 1950s, hundreds died and thousands — mostly youngsters — were paralyzed by the disease. In 1953 alone, some 9,000 Canadians contracted polio, which left 500 dead that year.
“Eradication of a disease does not happen often,” says Oliver Rosenbauer, a spokesperson for the World Health Organization in Geneva.
“In fact it’s only ever happened once before, with the eradication of smallpox. So that’s what we’re after.”
While two cases of the disease have already been reported in Afghanistan since Jan. 1, Rosenbauer is confident that 2018 will see its ultimate demise.
“The aim is certainly that this year is the year where we finally interrupt the person-to-person transmission of the virus so that we’re not going to see any more cases in the future,” he says.
“That’s certainly what we are all working towards; to make sure that this year is finally the year that we are going to eradicate this virus once and for all.”
Rosenbauer works with the Global Polio Eradication Initiative, which has paired the WHO with UNICEF, Rotary International and the U.S. Centers for Disease Control and Prevention since 1988.
That group was joined in 2007 by the Bill and Melinda Gates Foundation, which has given more than $3 billion (U.S.) to the cause — including a donation of $76 million announced last month to pay off loans Nigeria incurred in its successful polio fight.
“Looking at the impact of the program over the last couple of years, yeah, you can say that we’re closer than ever to getting rid of it for good,” says Dr. Jay Wenger, who leads the Gates polio project from its Seattle headquarters.
“There’s been a lot of work done to reach every child with the polio vaccine,” Wenger says.
Those efforts have been hindered by conflicts in Afghanistan and Pakistan, the two countries where it appeared last year — in particular by the movement of refugees and migrants across the countries’ 4,200-kilometre border.
And it’s that fluid population that has been a key target in the final eradication push.
To reach these mobile kids, the initiative — coupled with the two national governments — has set up vaccine “transit stations” on the roads and trails that they are likely to use, and in bus stops, airports and train stations.
“It’s a little complicated, as you might imagine,” says Wenger, who has manned such stations in India and Pakistan in the last few years. “It often involves lots of people milling around at a bus station, for example. It’s a pretty hectic situation.”
Over the years, vaccine administrators have evolved strategies to minimize such chaos, Wenger says. These include sending teams — usually made up of three people — onto the buses or trains before they empty.
On board they will identify families with kids and administer doses of the oral vaccine on the spot. They will also mark the children’s fingers with a non-toxic, indelible ink that will identify them as having been inoculated across the rest of their journeys.
And acceptance by parents of the vaccine program — even in such ad-hoc forms — has generally been high, says Dr. Rana Muhammad Safdar, head of the polio eradication program in Pakistan.
Safdar says a recent survey indicated that 95 per cent of approached families agreed to allow the vaccinations across the country.
“This is the highest vaccine acceptance (rate) recorded anywhere in the world,” he says.
Safdar, who has done extensive fieldwork himself in Pakistan, says the country has set up some 387 permanent transit stations along routes that mobile populations are known to use. Last year Pakistan, which recorded just eight new cases in 2017, also deployed more than 1,000 temporary transit teams along interior routes used frequently by migrant workers travelling between Pakistani cities.
Last September, a massive effort vaccinated 38.2 million children across Pakistan, “from the coast of Karachi to the highest mountain . . . house to house, hut to hut,” Safdar says. The blitz involved 250,000 frontline workers.
Whether at home or on the move, however, there are those who still refuse vaccines, and Ramesh Ferris has seen such intransigence first hand.
Conflict and risk
Working in Karachi several years ago, Ferris and Pakistani businessman and Rotary executive Aziz Memon faced closed doors during a vaccination tour through a six-floor apartment building.
Ferris “was with me and was wearing shorts, and one could see his limbs were (withered) because he had suffered polio,” says Memon, chair of Rotary’s Polio Plus project in Pakistan.
“So when (the mother in one apartment) saw this man she said ‘if that’s what happens, please come inside and give drops to all of my children.’ ”
Memon also says vaccine acceptance in Pakistan has become much greater since 2015, when police arrested hundreds in the country for refusing to have their children inoculated.
Vaccination teams do face dangers in conflict zones, and many were attacked several years ago during insurgencies in Pakistan and Afghanistan, Wenger says.
“As a result of that the program has learned (or) basically adjusted to make sure that we do whatever we can to ensure the safety of vaccinators,” he says. “That involves … having intelligence on the ground about what the local situation is like (and) making sure you work closely with whatever security forces are operative in the area.”
Still, a mother-and-daughter team of polio vaccinators was gunned down in the western Pakistani city of Quetta late last month. Each was shot in the head by assailants on a motorcycle as they were administering drops to children, National Public Radio reported.
Conflict has long been a key obstacle in the global eradication project, Wenger says.
And, he says, different countries have come up with their own strategies to overcome it.
In Latin America during the volatile 1990s, for example, warring sides declared days of truce in their conflicts so that polio vaccinators could go in and do their jobs, Wenger says.
“That was sort of a classic example,” Wenger says. “But there’s been a lot of other ways to do it.”
Polio is a uniquely human ailment that has no other animal or environmental reservoir where it can lurk — making it a candidate for vaccine eradication.
“Tetanus, for instance, is not eradicable because it survives in soil,” says Dr. Allison McGeer, an infectious disease specialist at Toronto’s Mount Sinai hospital. “As long as it can survive in soil and there’s this huge reservoir out there, there’s just no prospect that we can get rid of it.”
The polio virus, on the other hand, is spread solely by humans, she says. Living in the human gut and sewage, it is passed along through “fecal-oral” transfer — from unwashed hands or sewage-contaminated food, for example.
“To the extent that people can come into contact with the virus in stools or in surfaces that have been contaminated with stools and then put their hand to their mouths … they can become infected,” McGeer says.
The vast majority of polio infections, however, do not cause paralysis, being confined fairly benignly to the gut area, she says. And where the disease still exists, most adults have contracted the milder forms and are immune.
Thus inoculation initiatives centre on small children who have had no contact with the disease. Once enough children are inoculated with effective vaccines, the disease can be stopped in its tracks.
In the global eradication effort, each of the major players has developed specialized roles.
The WHO, for example, has taken on surveillance responsibilities — identifying new polio cases and certifying eradication.
The U.S. Centers for Disease Control provides scientists and public health specialists, while UNICEF is charged with vaccine purchasing and distribution and public information campaigns.
In addition to its billions in funding, the Gates foundation provides co-ordination services and research into new and cheaper vaccines.
The Rotarians took up the polio fight in 1979, when the disease was still endemic to much of the world and more than 300,000 people contracted the disease worldwide on average.
Memon says the service club has provided hundreds of millions to the project since and specializes in fundraising, promotion of vaccine programs and vaccination team recruitment.
“We have put in $1.8 billion, and now you can see we have almost completed the job.”
Keeping the virus
When the virus is eradicated from human populations, it will join the smallpox pathogen in a laboratory existence, Wenger says.
These test-tube reservoirs, he says, will be kept to ensure we retain a knowledge of the virus should it somehow re-emerge decades hence.
There are still vaccine manufacturers that produce vaccines using the live virus, says Wenger, an epidemiologist who trained at the CDC.
“And we would still keep, essentially as insurance, vaccines around in stockpile in case something unusual was to happen.”
As well, Wenger says, surveillance programs would continue after new cases cease to be reported in the coming years.
“We’ll continue to watch in the years after eradication just to make sure nothing slipped through the cracks,” he says.
This surveillance would continue for “a couple of years” after the world is certified polio-free.
A precise strategy for a post-polio world is being developed now and will be discussed at length at the 71st World Health Assembly in Geneva at the end of May.
“It’s called the post-certification strategy, which lists a couple of key polio essential elements that are going to have to continue even though the polio program as a whole … will basically shut down,” Wenger says.
Wenger says vaccination would continue unabated in most of the world through 2021 should the current year actually see the last case of polio in Afghanistan and Pakistan. Vaccination in Canada and elsewhere would also come to an end.
(Nigeria is the only other nation still on the list of countries where polio is endemic, but it has not seen a new case since 2016 so is well on its way to being certified as polio-free.
"After a three-year watching period, then we would declare the world free of wild polio virus,” Wenger says.
Following that, distribution of the oral vaccinations — which use a genetically weakened version of the live virus and can still cause disease in a few cases — would be phased out.
The oral vaccine has been used because of its ease of distribution. In 1955 Dr. Jonah Salk’s vaccine was introduced, using a killed virus. That type of vaccine is now given to children in Canada — which was officially declared polio-free in 1994.
But 60 years ago, the disease bathed the nation, and wider world, in terror with young children being at highest risk.
Though it has been around for untold centuries, polio made its recorded debut in Europe during the early1800s, with the first known Canadian case appearing in Hamilton in 1910, according to the Canadian Public Health Association.
When it was at its peak between 1949 and 1954 about 11,000 Canadians would be left with polio-caused paralysis. The last major outbreak in this country occurred in 1959, when some 2,000 people were paralyzed.
“In Canada, our last case was about 1977,” says Dr. Shelley Deeks, the chief of communicable diseases at Public Health Ontario.
Deeks says that globally, only one of the three strains of polio virus that were present during the eras of mass infections — Type 1 virus — is still active in the world.
Children in Canada today still receive the polio shots as part of their normal array of inoculations, Deeks says.
“You have to keep vaccinating until it’s been eradicated around the globe,” she says.
During her medical career, McGeer has not seen a new case of polio in Toronto. But she remembers how people in the city and beyond were affected when the disease raged.
“I was born in 1952 (and) my best friend’s dad died in the polio epidemic of 1953,” she says.
“My high school principal was partially paralyzed from polio. Everybody in North America had someone they knew who had been seriously affected by polio … and it was terrifying.”
There are still some 31,000 Canadians who suffer from post-polio effects like paralysis and other neurological ailments.
Ferris, now a case manager in Whitehorse for the Yukon’s workers’ compensation board, is one of these.
Given up to a Canadian-founded orphanage after contracting the disease in India, he was adopted by visiting bishop Ron Ferris and his wife, Jan, his arrival in Canada made newspapers across the country.
He returned to India 2002 to meet his grateful birth mother, Lakshmi, who was overjoyed that he could now walk.
But it was there that his commitment to help in eradicating the disease took shape, says Ferris, a graduate in social work from the University of Regina.
“I saw polo survivors crawling in dirt … using cut-up pieces of tires to pad their knees,” the 38-year-old says.
“I don’t believe that any person should be living a life doomed to dirt and believe that every child everywhere should have access to vaccines.”
In addition to joining in vaccination and polio awareness trips to Afghanistan, Pakistan, India and elsewhere, Ferris rode a hand-pedalled bike across Canada in a 2008 “Cycle to Walk” campaign that raised $300,000 for eradication efforts.
And he is encouraged that the world is on the brink of elimination.
But he fears that whiff of victory might cause leaders, here and elsewhere, to take their eye off the ball before it’s achieved.
“Diseases like polio don’t respect borders or walls.”
HOW POLIO GOT ITS POWER
Polio, a disease of filth, has likely been with us for millennia.
But it only became a global plague when we began to clean up as the 20th century dawned.
“Polio is actually a disease of better hygiene,” says Dr. Allison McGeer, an infectious disease expert at Toronto’s Mount Sinai hospital.
The virus that causes it is found in human feces and raw sewage, and polio is known as a fecal-oral route disease. That means it’s passed on when stool particles on food or a hand are transmitted to other people and find their way into their mouths.
The vast majority of people who contract the polio virus, however, don’t end up getting the paralytic version of the disease, McGeer explains. For these people, the infection is confined, relatively benignly, to the gut. Yet these fortunate polio carriers still develop immunity to the disease.
And in less hygienic times almost everyone would have this immunity — and mothers could pass it on to their newborns.
“If you get infected with polio viruses from raw sewage when you’re less than 6 months old, then you have you mother’s antibodies and you are protected from paralytic polio,” McGeer says.
“You develop a gut infection, you develop immunity in your gut, but you don’t get paralytic polio.”
The immunity the baby develops to the gut infection on their own, however, will remain with them for life.
“So the reason polio became such a problem in the 20th century is because we started having safe food and water for large segments of the population in the developed world,” McGeer says.
Cleanliness meant fewer mothers were able to pass on immunity to their babies. And those children did not develop a lifelong resistance themselves.
“In the 16th and 17th century, pretty much everybody would have been exposed to polio very early in life and would have developed immunity to it and would have been fine,” McGeer says.
“Mind you, they were exposed to lots of other things in the sewage that would have killed them in between.”