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Pure Appl. Biol., 8(2): 1801-1808, June, 2019 http://dx.doi.org/10.19045/bspab.2019.80123

Review Article

Polio phases in a decade’s journey at one glance: A succinct report

Rizwana Akhter Memon1*, Farah Naz Memon2, Rana Saba Sultan1 and Hafeez Ahmed Memon3 1. Department of Sociology.University Road, Karachi, 7400, Pakistan 2. Pakistan Health Research Council, Islamabad-Pakistan 3. Pakistan Institute of Medical Sciences (PIMS), Islamabad-Pakistan *Corresponding author’s email: [email protected] Citation Rizwana Akhter Memon, Farah Naz Memon, Rana Saba Sultan and Hafeez Ahmed Memon. phases in Pakistan a decade’s journey at one glance: A succinct report. Pure and Applied Biology. Vol. 8, Issue 2, pp1801- 1808. http://dx.doi.org/10.19045/bspab.2019.80123 Received: 01/04/2019 Revised: 20/06/2019 Accepted: 24/06/2019 Online First: 28/06/2019 Abstract Poliomyelitis (Polio) is one of the ancient diseases, based on its strong infectivity and permanent deformities/deaths among under-five age children is still considered as a major threat globally. On historical timeline, Polio is divided into three phases; phase, Epidemic phase, and phase. To explore all historical phases in brief concerning the current scenario so that decade’s journey can be assessed at once for future planning. Secondary data from authentic internet sources were gathered to find out key points, and a brief report is prepared. Actual origin of the disease is unknown, but its endemic phase remained in overcrowded areas where human’s agglomeration was increased. Endemic phase remained scattered in different areas of the globe from antiquity era until the mid of nineteenth century when relatively fewer paralytic cases were noticed. After that, outbreaks occur on a larger scale by crossing many geographical areas. This epidemic phase remained violent until mid of the twentieth century. The third phase started with the introduction of vaccines in 1955. After advancements in vaccines and the launch of Global Initiative (GPEI) in 1988, polio prevalence started reducing in richer countries followed by poorer countries around the globe. Currently, there is a 99.9% reduction in polio cases around the world; however, it remains in the endemic phase in Pakistan and . The situation is a continuous threat for our country as it could be converted from endemic to epidemic phase. However, Pakistan government’s efforts on the application of additional strategies of Global Polio Eradication Initiative (GPEI) such as; active surveillance, real-time risk assessment, assurance of high -quality data have shown a great hope that it will be the world’s fourth and final phase of “Polio Eradication Phase”. Keywords: Decades; Global Polio Eradication Initiative (GPEI); Pakistan; Phases; Polio Introduction based on capsid proteins named PV1, PV2, Polio (also known as poliomyelitis) is a viral and PV3 [1]. Poliovirus is disease caused by a virus that belongs to usually via the fecal-oral route. Though polio Enterovirus C, family Picornaviridae. is preventable, once contracted, it can lead to Poliovirus is a RNA (Ribonucleic Acid) virus mortality or major morbidity because of that had been classified into three serotypes onset of acute-flaccid paralysis [2]. Two

Published by Bolan Society for Pure and Applied Biology 1801 Memon et al. types of polio vaccines are currently effective Netherlands [11]. In the current review, we to inhibit the onset of disease, i.e., an have assessed the polio history and inactivated injectable poliovirus (IPV) and a eradication progress in Pakistan that is in line live attenuated oral poliovirus vaccine (OPV) with the directions of WHO to make the area [3]. Poliovirus has been eliminated from all entirely free from polio. over the world except Pakistan, Nigeria, History Afghanistan, Cameroon, Syria, Ethiopia, Poliomyelitis, although eliminated from most Israel, Equatorial Guinea, and Somalia [4]. of the world, remained a major public health In order to control the polio disease on the challenge in Pakistan. Poliomyelitis, globe, the Global Commission for the generally called Polio, is one of the ancient Certification of the Eradication of crippling diseases of children under five Poliomyelitis (GCC) was constituted in 1995 years of age, having potential to paralyze [5]. This commission (GCC) framed the vital limbs, damaging brain and often the death of strategies and monitoring operations to the affected child [12]. In the early to mid- certify polio eradicated zones. The twentieth century, polio was one of the commissions’ basic principles were based on epidemic diseases fearing most of the the World Health Organization (WHO) industrial countries around the globe by directions for the abolition of wild poliovirus paralyzing a huge number of children per (WPV), which were: (a) to expand year. During those days, medical surveillance systems (including AFP practitioners and researcher struggled to find surveillance); (b) to attain and continue high out the cause and the remedies for prevention routine immunization coverage and (c) to and treatment of that fatal condition [13, 14]. manner supplementary immunization Epidemic in the United States created a activities (SIAs), together with national challenge to fight against this disease at immunization days (NIDs) in all widespread priority bases therefore in 1938 National zones and mopping-up immunization in high Foundation for Infantile Paralysis was risk zones in little incidence countries [6]. established by American President Mr. Significant growth was made to achieve Franklin D. Roosevelt to begin the research universal abolition. Nevertheless, some on that issue [15]. Funding was supported by (specific) areas remain to cause distress. By American people’s generosity by creating a the commencement of 2015, Pakistan and funding campaign. Mr. John Salk was the Afghanistan sustained to have a rotation of person who found different polioviruses and Wild Poliovirus (WPV) type 1 (WPV1) [7]. him along with his team he soon became In 2002, WHO declared Europe as polio-free successful in discovering a vaccine which is that has maintained this status until today [6]. after his name as “Salk Vaccine”, after that In 2010, WPV1 imported from Pakistan vigilant work was done around the globe for caused a significant occurrence of disease in the elimination of this fatal disease [16, 17]. Tajikistan that was also leaked to Polio epidemiology neighboring countries [8]. In 2013-14, WPV1 In the history of polio epidemiology, a was identified in sewage water in Israel [9]. considerable variation is seen in different In the same years, Syria, as well as Iraq, also decades, keeping in view polio history is recognized the poliovirus circulation and divided into three phases; endemic phase, reported cases in their territories [9, 10]. In epidemic phase, and vaccination phase [16]. 2014, WPV was mistakenly released into a Phase One or the “Endemic Phase” started river from a factory in Belgium that flows from the earliest times of human society till through densely populated areas of the end of the nineteenth century. It is

1802 Pure Appl. Biol., 8(2): 1801-1808, June, 2019 http://dx.doi.org/10.19045/bspab.2019.80123 assumed that poliovirus remained endemic Lameness, survey finding conducted in for centuries because during early days there 1970s routine immunization was initiated were scattered small group societies; under a national immunization program therefore, people were hardly getting a larger around the world to control the disease. number of transmissions of most of the Factors responsible for Polio incidence communicable the diseases. For that reason, around the globe Vs Pakistan the diseases like polio, , and A study [24] reported that percent of forest other respiratory tract infections remain cover, percent of people with contact to better isolated until the civilization of human sanitation services, and population thickness societies to live in larger population areas were observed as the topmost three where, hygiene, food scarcity, animals and imperative variables with the contribution of pets close contacts attributes the spread of 43%, 54%, and 64% respectively for the microorganisms [18]. Since there were no globe (Table 1). For only 29 percent of vaccines available during those days, virus countries, percent urban population growth transmission became rapid [19]. Hence, from and per capita unvaccinated births were also endemic to “epidemic phase” was observed recognized as noteworthy factors for in the late nineteenth to the early twentieth incidence of polio. Climatic changes steadily century in some countries such as the United had the least important factor among the States, Norway, and Sweden [20]. predictors on the globe. The single random Control on epidemic was initiated by the forests model fitted to countries altogether introduction of very effective vaccines also exhibited comparable outcomes to those “Vaccination Phase” by the joint action of for country-specific fits. However, the many countries on the poliovirus and other percentage of alteration elucidated by the attributable factors to break the chain of single model was only 21%. Since 2015, the transmission of infection [18]. As a result, occurrence of polio had been limited to polio was soon eliminated from most of the Africa continent and Pakistan and world [21]. Afghanistan as well [25]. In correlation of After that, rapid progress has been noticed epidemiological theory [26], Noori et al. [24] until 2017 when the number of paralytic detected a significant relationship between cases has been reduced by 99.9%; however, the rate of unvaccinated births and polio poliovirus remained prevalent in only three incidence. Thus, increased vaccination had countries of the world, named Nigeria, been regarded as a tool for the reduction of Afghanistan, and Pakistan [20]. polio incidences. This theory could be In the developing countries, especially in validated through the available data from tropical areas it took longer time to remain a some African countries like Mali, Burkina major public health issue. To find out the Faso, and Afghanistan was a threshold in status, several surveys were conducted, unvaccinated births was recognized and which proves polio prevalence in the being related to polio cases [27]. developing countries. Findings of Lameness On the other hand, a number of factors are survey [22] conducted in 1970s revealed that responsible for increasing incidence and 1 child in every 100 to 200 children was prevalence of such as; paralyzed in every year in those countries United State and India supported war on which were a huge burden and according to terror, cross-border movement with World Health Organization estimated cases neighborhood country Afghanistan, lack of of paralytic disease/year were approximately funds because of investment on security 650,000 /year [23]. On the bases of issues, illiteracy of local people, lack of

1803 Memon et al. modern communication tools, lack of misconception regarding polio vaccines that commutation and transportation in far-away it is causing infertility and is not halal. On the areas, deliberately cutting this region from other hand, spread of rumors in the the other parts of modern world, self- religiously conscious people and spread of proclaimed religious scholars, poor opposite research related to negative health governmental policies which don’t restrict effects of polio vaccines, inactive role of the activities of unauthentic religious media and television and insecurity of scholars, propaganda of Indian-supported vaccinators in the field nailed negative media. Another most important issue is effects on polio eradication efforts [28].

Table 1. Countries (%) having each predictor as their top three vital factors among regions and within each region based on the random forests model [24] All Eastern South- Western Variables African Americas Europe Regions Mediterranean East Asia Pacific % of people with access to improved 0.54 0.53 0.31 0.57 0.67 0.83 0.67 sanitation facilities 0 % Forest land 0.43 0.53 0.15 0.14 0.33 0.83 0.67 % Arable land 0.2 0.18 0.31 0.43 0 0 0.33 per capita GDP 0.25 0.24 0.31 0.29 0.33 0 0.33 Population density 0.64 0.71 0.62 0.43 0.5 0.67 0.67 % Rural population 0.26 0.26 0.23 0.57 0.33 0 0 growth % Urban population 0.29 0.21 0.46 0.14 0.5 0.33 0.33 growth Average temperature 0.06 0.09 0.8 0 0 0 0 Total precipitation 0.04 0.06 0.08 0 0 0 0 per capita 0.29 0.21 0.46 0.43 0.33 0.33 0 unvaccinated births

Progress of Polio eradication programme flaws in health systems deliveries [31]. In Before Global Polio initiative in 1988, polio Pakistan, polio eradication summary from paralyzed more than 1000 children each day 1970 to 2018 has been summarized in (Figure worldwide, however, after that initiative and 1) [32]. with the help of more than 200 countries Overall discussion on polio & Pakistan along with 20 million volunteers, about 2.5 Pakistan is one the two countries where polio billion children had immunized against is still an endemic phase and remains a major poliovirus. In this initiative, more than 11 threat for the word to convert into an billion US$ has been utilized till recent past epidemic at any point in time keeping in view [29, 30]. that if a single child remains infected the risk In spite of passing decades in the utilization to infect other children around the world will of many resources for advancements in remain constant. Government of Pakistan is immunization programs, the story in few struggling hard to achieve polio-free status countries like Pakistan is still going on from with the support of WHO, UNICEF, and endemic to epidemic phases. According to other key partners of Global Polio WHO there are only two countries (Pakistan Eradication Initiative GPEI. With the result and Afghanistan) which are still showing of that hard struggle, the incidence of polio is some local context of challenges such as successfully decreasing from 20,000 political conflicts, hard to reach areas and

1804 Pure Appl. Biol., 8(2): 1801-1808, June, 2019 http://dx.doi.org/10.19045/bspab.2019.80123 cases/year in 1990 to 12 cases in 2018 [17, published in January 2019 [29] there is about 33]. 96% reduction in polio cases since 2014. Even though most of the areas of Pakistan are According to that update, four cases were free of poliomyelitis, yet the challenge to reported out of them three cases were from eradicate it is still on the top of priorities, (Bannu, Hangu, and since there is always a risk to overlook the Bajour) and one case from Punjab (Lahore). threat of transmission of this dangerous virus Moreover, in quick response to the highly to the polio-free zones of Pakistan. On and sensitive surveillance system enable the off confirmation of cases of this crippling program to detect 45% positive samples of condition and positive results from sewage is wild poliovirus from the environment. Based being reported from different regions of on said surveillance, a detailed field Pakistan; keeping the alarming condition for investigation on gap analysis was carried out, the national as well as concerned and a fully accountable strategic plan is international authorities [34]. Moreover, initiated to target around 13.32 million under- resistance from the people to vaccinate their five children for vaccination. children especially, against polio is remained Way forward a major obstacle due to lack of knowledge Currently, along with the global partners to and awareness. On the other hand, lack of work as a team under one umbrella, polio interest in major hospital facilities, staff program is working on active surveillance, absenteeism, and overburdened lady health high-quality data, real-time risk assessment workers created the situation worst [35]. The and many other strategies to response on restraints of the polio eradication program routine immunization and outbreak have been summarized in (Figure 2) [36]. Till management to systematically address the recent past, apart from the continuous support policy to reach all missed children [30]. from the Global Polio Eradication Initiative “Vaccinating children on the move” the new (GPEI) the targeted achievements of Pakistan initiative started in the strategy across the Polio eradication program remained country will vaccinate the children at the unsatisfied [37]. Community behaviors, transit points at highways, railways and bus beliefs, cultural myths, political stations will no doubt help to add a good commitments, nonseriousness of the private number vaccinated children [31]. sector, conflicts, and security of staff Pakistan government’s continuous efforts remained some of the reasons behind the along with support from GPEI, 260,000 failure of the initiative strategies in the past. frontline workers, 2,100 social mobilizers As far as peoples concern regarding halal or and with 95% vaccine acceptance rate; the haram vaccine it is now clearly reported by polio program will hopefully be successful in WHO Summary report by consultative the near future to eradicate this crippling Islamic scholars that oral is disease from the region and enjoy polio-free neither haram, nor causing infertility, early status [30]. adulthood or any health hazard [38]. In this way, it can be only possible for the Currently great progress is noted, and world to see the fourth and the final phase of according to the Pakistan Polio update sheet the “Polio eradication phase”.

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Figure 1. Timeline summary of polio eradication in Pakistan [31].

Figure 2. Research model showing constraints of the polio eradication program in Pakistan [35]. Note: EPI stands for extended program for immunization

Conclusion the public by religious leaders to cut the In 2015, 54 cases of polio were reported all over misconception of peoples and truthful dialogues Pakistan, followed by 20 in 2016 and 12 in 2018. with the parent groups refusing vaccination is This seems a tremendous achievement of necessary to achieve the target of polio-free government initiatives. However, again Pakistan. occurrence of 10 cases by 2019 indicted that Authors’ contributions Pakistan’s Polio Eradication Program still Conceived and designed the experiments: RA required more intention and efforts, particularly Memon & FN Memon, Analyzed the data: RA in terms of strict monitoring and surveillance of Memon, HA Memon & RS Sultan, Wrote the high-risk areas. Additionally, the motivation of paper: RA Memon & FN Memon.

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