Comment
Global poliomyelitis eradication: status and implications
The Global Polio Eradication Initiative (GPEI) is among
the most ambitious programmes ever undertaken
by WHO. Begun in 1988, it has made extraordinary
progress, reducing the global incidence of poliomyelitis
by more than 99%.1,2 Wild poliovirus is now regarded as
endemic in only four regions of the world. In Afghanistan
and Pakistan, security problems have hampered
vaccine delivery. In northern Nigeria, there has been
a loss of public confidence in the vaccine, low uptake,
and consequent outbreaks which have seeded virus
into several other countries. And in the Indian states
of Uttar Pradesh and Bihar, the wild virus has proven
extraordinarily well entrenched, partly because of low
efficacy of conventional trivalent oral poliovirus vaccine
(tOPV) in that environment.3 Other problems have arisen
that could threaten the feasibility of stopping all poliovirus
transmission: the recognition of circulating virus derived
from oral vaccine,4 persistent excretion of poliovirus by
immunodeficient individuals,5 and difficulties in ensuring
containment of all potential sources of reintroduction.6
These difficulties have led to a recommendation that the
programme abandons its eradication goal in favour of a
control approach.7 Two papers in today’s Lancet provide
important perspectives on this debate and on the current
stage of the programme.
Nicholas Grassly and colleagues analyse recent data
from India to compare the effectiveness of a monovalent
oral type 1 poliovirus vaccine (mOPV1) with that of tOPV.8
There are problems in inferring absolute vaccine efficacies
in such circumstances. But the relative efficacy estimates
should be valid, and they indicate that the newer mOPV
is more effective than the older tOPV. Let us hope this
difference is sufficient to terminate the remaining chains
of transmission of type 1 wild poliovirus.
Kimberly Thompson and Radboud Duintjer Tebbens
use a dynamic model to show that a decrease in
immunisation intensity in endemic areas will result in a
rapid accumulation of susceptible individuals and many
more cases of paralytic poliomyelitis (northern India
is used as an example).9 In addition, they argue that
both the cumulative number of patients with paralytic
poliomyelitis, and the financial costs, that would occur
with various control options are higher than with any of
four policies suggested for the era after “poliomyelitis
eradication” (defined by these authors as interruption of
www.thelancet.com Vol 369 April 21, 2007
wild virus transmission). The cost difference between the Published Online
April 12, 2007
posteradication and control scenarios is used to conclude DOI:10.1016/S0140-
that “we should be willing to invest more than $8000 6736(07)60533-9
million to achieve eradication”. The authors conclude See Comment page 1322
See Articles pages 1356
that even a policy that included global introduction
and 1363
of inactivated poliomyelitis vaccine (IPV) after the
“eradication” of poliomyelitis will, over 20 years, cost
less than implementing any of the modelled control
strategies. Readers may note that Thompson and Duintjer
Tebbens’ use of the phrase “poliomyelitis eradication” for
interruption of wild poliovirus transmission is confusing,
and exacerbates a semantic problem which has haunted
the GPEI since its inception. The termination of wild
virus transmission does not guarantee eradication of
poliomyelitis disease, considering that OPV viruses are
transmissible and are known to revert back to wild-
type phenotype.4,10 WHO has recognised this problem
and declared that OPV will have to be discontinued if
poliomyelitis is to be eradicated.1,2 The essential step
of terminating transmission of all OPV-derived viruses
remains untested.
These two papers provide encouraging insights into
the current methods and long-term economics of the
GPEI. The demonstration of superior effectiveness of
mOPV vaccine adds to the evidence that termination of
wild poliovirus transmission is technically feasible, given
enough time, continued funding, political stability,
and continued political support in the affected areas
of the world. The modelled illustration of the financial
The printed journal
includes an image merely
for illustration
Science Photo Library
Coloured transmission electron micrograph of polioviruses
1321
 Comment
implications of managing patients with paralytic polio-
myelitis and continuing to control poliovirus with
supplemental immunisation activities is based on a
large number of assumptions, but it supports arguments
against abandoning the goal to eradicate wild virus at
least.
Despite its established efficacy against wild virus,
the usefulness of mOPV in combating transmission of
vaccine-derived viruses, after the eradication of wild
virus, is unclear. Such future use of this vaccine implies
fighting fire with fire, with the risk of seeding additional
live viruses into the population.11 As of now, the only
other available technology to help curtail transmission of
OPV-derived viruses is IPV; but this use of IPV has yet to be
assessed in the difficult areas of the world. IPV should at
least help (IPV has been sufficient to arrest transmission
of all polioviruses in several countries with high levels of
hygiene), but only if used at coverage levels which are far
higher than currently achieved in several of the poorest
countries of the world. The needs of the GPEI might thus
become coincident with those of the GAVI Alliance, which
has set a target of 90% routine vaccine coverage in low-
income countries by 2010.12 This sharing of interests could
prove a powerful lobby for public health. A world in which
all children, everywhere, receive all the recommended
vaccines could and should be among the legacies of the
programme that was started to eradicate poliomyelitis.
Surveillance of acute flaccid paralysis in India
See Comment page 1321 Poliomyelitis eradication requires surveillance for acute
See Articles pages 1356 flaccid paralysis (AFP), and in all countries children with
and 1363
AFP who are younger than 15 years are investigated
for poliovirus in stool. However, collection of two
8-g stool samples 24 h apart and within 14 days of
onset of paralysis is not easy. Samples need to be stored
below 8°C, documented properly, and tested in an
accredited laboratory.
Individuals without adequate stool samples are exam-
ined by a neurologist with electromyography and nerve-
conduction and other tests. A national expert committee1
reviews these cases, decides whether any are poliomyeli-
tis, and labels them as compatible poliomyelitis in accor-
dance with WHO’s recommended virological classification
scheme.1,2 The occurrence of compatible poliomyelitis
suggests a failure of the surveillance system.3
1322
*Paul E M Fine, Ulla Kou Griffiths
London School of Hygiene and Tropical Medicine,
London WC1E 7HT, UK
Paul.fine@lshtm.ac.uk
We declare that we have no conflict of interest.
1 WHO. Conclusions and recommendations of the Advisory Committee on
Poliomyelitis Eradication, Geneva 11–12 October 2006, part I.
Wkly Epidemiol Rec 2006; 81: 453–60.
2 WHO. Conclusions and recommendations of the Advisory Committee on
Poliomyelitis Eradication, Geneva 11–12 October 2006, part II.
Wkly Epidemiol Rec 2006; 81: 465–68.
3 Grassly NC, Fraser C, Wenger J, et al. New strategies for the elimination of
polio from India. Science 2006; 324: 1150–53.
4 Kew OM, Sutter RW, de Gourville EM, Dowdle WR, Pallansch MA.
Vaccine-derived polioviruses and the endgame strategy for global polio
eradication. Ann Rev Microbiol 2005; 59: 587–635.
5 MacLennan C, Dunn G, Huissoon AP, et al. Failure to clear persistent
vaccine-derived neurovirulent poliovirus infection in an immunodeficient
man. Lancet 2004; 363: 1509–13.
6 Dowdle W, van der Avoort H, de Gourville E, et al. Containment of
polioviruses after eradication and OPV cessation: characterising risks to
improve management. Risk Anal 2007; 26: 1449–69.
7 Arita I, Nakane M, Fenner F. Public health: is polio eradication realistic?
Science 2006; 312: 852–54.
8 Grassly NC, Wenger J, Durrani S, et al. Protective efficacy of a monovalent
oral type 1 poliovirus vaccine: a case control study. Lancet 2007; published
online April 12, 2007. DOI:10.1016/S0140-6736(07)60531-5.
9 Thompson KM, Duintjer Tebbens RJ. Eradication versus control for
poliomyelitis: an economic analysis. Lancet 2007; published online April 12,
2007. DOI:10.1016/S0140-6736(07)60532-7.
10 Fine PEM, Carneiro IM. Transmissibility and persistence of oral polio vaccine
viruses: implications for the global polio eradication initiative.
Am J Epidemiol 1999; 150: 1001–21.
11 Fine PEM, Sutter RW, Orenstein WA. Stopping a polio outbreak in the
post-eradication era. Dev Biol 2001; 105: 129–47.
12 GAVI. Annex 1: 2007-10 GAVI roadmap. Nov 11, 2006: http://www.
gavialliance.org/resources/2007_10_Roadmap_final.pdf (accessed April 4,
2007).
Poliomyelitis eradication in India is a huge challenge.
The National Polio Surveillance Project,2 established in
India in 1997 to guide public-health experts, has been
a successful model for surveillance activities globally.
In India, it was hoped that poliomyelitis would be
eradicated quickly, but the virus resurged in 2006.
It seems that India did everything according to the
surveillance rulebook.
To avoid missing cases of paralytic poliomyelitis,
the prevalence of non-poliomyelitis AFP should be at
least 1 per 100 000 in children younger than 15 years.
To ensure that we identify the virus, 80% of AFP cases
should have adequate stool samples. If these criteria
are met and no cases of poliomyelitis are identified for
3 years consecutively, we can conclude fairly certainly
that the country is free of poliovirus. However, if the
www.thelancet.com Vol 369 April 21, 2007