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FORUM Campaign Against Polio Faces Last High Hurdle Erica Seiguer Photo by Graham Ramsay Quietly and persistently, an eradication effort is nearing completion as public health workers aim to add polio to the (very) short list of diseases that no longer plague the earth. The only disease that has been eradicated thus far is smallpox, which succumbed to the 1966-1977 eradication campaign led by the World Health Organization. More than half of all cases of polio occur in children under the age of 3. Transmission is oral-fecal. Prior to the development of the two polio vaccines--the Salk vaccine in 1955 and the Sabin vaccine in 1961--the disease wreaked havoc on communities worldwide. In 1916, the virus swept through the U.S. with 27,000 reported cases in 26 states and 6,000 deaths. Many children who survived were left crippled. People who lived through that epidemic and the ones that followed can remember the widespread fear. In rural Argentina, where my father spent his childhood, two waves of polio claimed the lives of many, including his younger brother, then only a year old. The threat of polio was everywhere and imminent. In the capital, Buenos Aires, my mom grew up in a similar environment, a city waiting for the next epidemic to strike. And then came the vaccine. The development of the polio vaccines is a compelling story, and the urgency and fierce competition among different vaccine approaches have been well-documented. The development of the killed injected vaccine and then the live oral vaccine changed public health forever. Eradication Gains Momentum The concept of eradication came later, after the success of the smallpox eradication campaign and the realization that as long as virus reservoirs existed, the world would be at risk of a completely preventable epidemic. The Global Polio Eradication Initiative is a case study of the challenges of disease eradication and the creative and innovative approaches that can be applied to other public health efforts. The campaign began in 1988, a partnership among the WHO, Rotary International, the Centers for Disease Control and Prevention, and UNICEF, as well as national governments, private foundations, humanitarian organizations, corporate partners, and others. Success came early to the effort--between 1988 and 2000, incidence fell 99 percent. And since 1988, infrastructure built around the training of public health workers, refrigeration and transport of the vaccine, and improved communications has enabled the eradication coalition to plan and execute extraordinarily successful national immunization days--NIDs, for short. In one NID in India, for example, 152 million children were vaccinated. In addition to vaccination, the coalition has used the delivery infrastructure to distribute vitamin A supplementation during NIDs. In 2000, this effort prevented more than 240,000 childhood deaths. The development of a global public health laboratory network, which allows sequencing of all wild polioviruses, has not only enabled the eradication effort to respond quickly to emerging outbreaks, but will serve many other public health initiatives. The global initiative plans to eradicate polio by 2005. Though the Americas were declared free of polio in 1994, with Western Europe and the Asia-Pacific region following close behind, some of the greatest challenges continue in sub-Saharan Africa and the Indian subcontinent, where poliovirus is endemic, conflict has interrupted vaccination efforts, and the conditions of dense population, low immunization, and poor sanitation have contributed to increased transmission. It turns out that these small pockets of wild virus are proving the hardest to penetrate. Challenges Persist The initiative has highlighted several major challenges to "mopping up" the last cases of polio. Maintaining political commitment is seen as a key component to success, which may be more difficult to sustain as the number of cases falls. Moreover, for countries exposed to movements of displaced persons, the need for all countries within that area to maintain commitment to eradication is amplified. Going hand in hand with political commitment is the need for strong financial support of the last stages of eradication. A budget shortfall of $400 million is hampering the effort, and experts estimate that each year's delay will cost more than $100 million. Complacency comes at a high cost and threatens the health of people far beyond those nations where polio still lurks. --Erica Seiguer, a third-year MD-PhD student at HMS