Case 5 Eliminating Polio in Latin America and the Caribbean Geographic area: Latin America and the Caribbean Health condition: In the 970s, Latin America had an estimated 5,000 paralysis cases and ,750 deaths each year due to polio. The oral polio vaccine was introduced in the region in 977. Global importance of the health condition today: Today, polio is on the verge of being erased from the globe. As recently as 988, 25 countries were endemic for polio, with an estimated 350,000 cases. Through the first half of 2006, just four countries were reported endemic for polio, and fewer than 700 cases were reported worldwide. This dramatic reduction is the result of massive oral polio vaccine immuni- zations through a global eradication campaign. Intervention or program: In 985, the Pan American Health Organization began a polio eradication cam- paign in Latin America and the Caribbean, to complement the routine immunization efforts of the newly formed Expanded Programme on Immunization. To increase immunization coverage in areas with weak routine health services, all endemic countries in the region implemented national vaccine days twice a year to immunize every child under 5, regardless of vaccination status. In the final stages of the campaign, “Operation Mop-Up” was launched to aggressively tackle the disease with house-to-house vaccinations in communities reporting polio cases and with low coverage. An extensive surveillance system helped track outbreaks. Cost and cost-effectiveness: The first five years of the polio campaign cost $20 million: $74 million from national sources and $46 million from international donors. Taking into consideration the savings from treatment, these donor contributions would pay for themselves in just 5 years. The administration of the vaccine is highly cost-effective, at just $20 for a healthy year of life in a high-mortality environment. Impact: In 99, the last case of polio was reported in Latin America and the Caribbean. The disease reemerged briefly in 2000 when 20 vaccine-associated cases were reported in Haiti and the Dominican Republic, but no other cases have been reported since 99. Today, polio has been eliminated from Latin America and the Caribbean. s the world struggles to wipe out the last the Caribbean shines a light on what can be done when traces of polio, one region has been polio regional cooperation and support are strong, funding free for more than a decade. The experience is sufficient, and the strategy covers all the bases. As Aof polio eliminationa in Latin America and a result of these factors, polio—which used to cripple a Whereas eradication refers to the reduction of worldwide incidence of a disease to zero, elimination refers to zero transmission in a specific geographic area or region. Case drafted by Molly Kinder. ELIMINATING POLIO IN LATIN AMERICA AND THE CARIBBEAN thousands in the region each year—is now becoming a the world were endemic for polio, with an estimated distant memory. 350,000 polio cases. Through the first half of 2006, only four were endemic, and there were fewer than 700 A Mighty Disease reported cases.3 This is due to the coordinated efforts of regional and international polio eradication campaigns Polio, short for poliomyelitis, is one of history’s most that have immunized hundreds of millions of children feared infectious diseases. It is caused by the intestinal against the deadly scourge. The regional polio campaign poliovirus, which enters its victim through the mouth in Latin America and the Caribbean, in particular, is or nose and multiplies in the lymph nodes. Polio’s most an outstanding success and eliminated polio from the distinguishing symptom, paralysis, develops in less than region in just six years. 1 percent of all victims and is caused when the virus invades the central nervous system and irrevocably kills Road to a Vaccine the nerve cells responsible for muscle movement. If enough nerve cells are destroyed, the victim is left with In the first half of the 1900s, polio was most promi- lifeless limbs (primarily the legs) in what is called acute nent in industrialized countries in Europe and North flaccid paralysis. In as few as four days, a previously America. Tens of thousands of children became infected healthy person can become stricken with paralysis and with the disease each year in the United States, and condemned to a lifetime of crutches and wheelchairs. thousands more died. Each summer the disease would Quadriplegia occurs when extensive paralysis develops cause widespread panic when its indiscriminate path in the trunk and muscles of the thorax and abdomen. left a trail of paralysis and death. Public pools, movie theaters, and beaches were shut down out of fear of the The most serious form of the disease, called bulbar disease, and crippled children supported by crutches polio, occurs when the virus invades the motor neurons and breathing through imposing iron lung machines of the brain stem and paralyzes the relevant muscles so were common sights. that the victim loses the ability to swallow, breathe, and speak. Respiratory support is needed to keep bulbar po- In the 1930s and 1940s, following a series of prominent lio victims alive, and fatality runs as high as 40 percent.1 outbreaks, the American public rallied behind the drive for a vaccine. The mobilization effort was led by polio’s During the virus’s incubation period, ranging from 4 most famous victim, US President Franklin D. Roos- to 35 days, infected individuals are extremely conta- evelt, who was left permanently paralyzed after suffering gious and can spread the virus to others through their a bout of polio in 1921. In 1938, President Roosevelt contaminated feces. The virus can live for as long as created the National Foundation for Infantile Paralysis, two months outside the body and resides in swimming later renamed the March of Dimes, to support health pools, drinking water, food, and clothing. Transmission care for sufferers and to raise funds “a dime at a time” is silent; 90 percent of the carriers show no sign of the for the urgent quest for a vaccine. disease at all, thanks to their development of protective antibodies. Of the 9 percent of victims who develop Fourteen years later, in 1952, the millions of nickels and nonparalyzing symptoms, their fever, fatigue, headache, dimes collected through the grassroots March of Dimes vomiting, or stiff neck rarely point conclusively to polio. campaigns finally paid off. Dr. Jonas Salk made history As a result, for each case of distinctive polio paralysis that year with his discovery of an inactivated polio vac- reported in an area, the community is further threat- cine (IPV), made from a deactivated (“killed”) version ened by another 2,000 to 3,000 contagious carriers, who of the poliovirus. Administered through an injection, may show no further sign than a fever—rendering even the IPV is capable of protecting against the ravages of a single documented case indicative of an epidemic.2 polio. The successful results from large community trials were printed in exuberant headlines around the world, Today, polio is on the verge of being erased from and mass immunization led to a rapid and dramatic the globe. As recently as 1988, 125 countries around reduction in disease incidence over the next few years. ELIMINATING POLIO IN LATIN AMERICA AND THE CARIBBEAN Between 1955 and 1961, more than 300 million doses to regular immunization in 1977 as part of the new were administered in the United States, resulting in a 90 Expanded Programme on Immunization (EPI). At percent drop in the incidence of polio.4 the program’s outset, immunization in Latin America for the six targeted diseases in the EPI—diphtheria, In 1961, a second scientific breakthrough presented the tetanus, pertussis (which are collectively known as world with a new form of the vaccine, which would lat- DTP), plus polio, measles, and tuberculosis—was quite er prove ideally suited for widespread use in developing low at 25 percent, with OPV coverage among children countries. Dr. Albert Sabin’s oral polio vaccine (OPV) less than 1 year of age higher, at 38 percent. With the is made from a live attenuated (weakened) virus and is support of a broad coalition of both international and administered orally. Just three doses of OPV, properly national partners, EPI promoted the delivery of immu- spaced, can confer lifetime immunity to both the user nization services for polio and the five other principal and his or her close contacts. The vaccine works like diseases through the routine basic health services of the IPV by producing antibodies that stop the spread Latin American countries. By 1984, coverage with OPV of the poliovirus to the nervous system, thus prevent- grew to an impressive 80 percent, the highest of all EPI ing paralysis. OPV goes a step further, however, by vaccines. Between 1975 and 1981, the incidence of po- reducing the multiplication of the virus in the intestine, lio in the region was cut almost in half, and the number thereby helping to halt person-to-person transmission. of countries reporting cases of polio dropped from 19 At approximately 5 cents per dose, OPV is consider- to 11.1 See Box 5–1. ably cheaper than its predecessor.5 Because no needles are required, administration of OPV is also easier, and The success of EPI in reducing polio in Latin America volunteers can do it on a wide scale. during the 1970s and 1980s inspired Dr. Carlyle Guerra de Macedo, then director of the Pan American Health The power of the new oral vaccine was first demon- Organization (PAHO), to propose the eradication of strated during a trial in Chiapas, Mexico, which suffered indigenous wild poliovirus in Latin America and the a polio outbreak in 1961.