No Step too Steep
India, the Philippines, the USA and Pakistan
Our World United to End Polio profiles individuals from around the globe who have committed their expertise, time and passion to the world-wide effort to eradicate polio. It's a journey that began in the Americas in the 1980s, has crossed every continent, and is now focussed on a handful of countries still facing polio outbreaks.
In this immersive series, engage with photos, videos, animation and stories about people who have given everything to end a disease.
Meet Martha Dodray, an Indian health worker who has forged trust with the families who live in one of India's harshest climates.
Hear from Gladys Lingat, who is dedicated to bringing the latest global guidance to the families she serves.
Learn how Dr. Cara Burns tracks polio from all over the world, and stays ahead of a virus that has taken some surprising twists.
Meet Aziz Memon, a Rotarian who works every day to take the politics out of polio eradication.
To experience these stories, simply scroll down.
To skip to a new story, click on a title in the menu bar.
Stopping Polio Beyond
the End of the Road
Lessons from India's Kosi River Basin
When Martha Dodray spent her days immunizing children against polio, she looked forward to waking up in the morning. "I was excited about the job. I couldn't sleep the night before."
Not everyone would share Dodray’s enthusiasm, as her job involved reaching communities in one of the most remote and challenging areas of India’s polio eradication program.
“Sometimes I’d have to walk by foot or travel by boat and reach these areas, and sometimes I’d have to wade through water to reach my destination. It was quite challenging to face the elements,” Dodray remembers.
Watch the video below to see how Martha Dodray served hard-to-reach communities in an effort to end polio in India. Continue scrolling to learn more about stopping polio in India's Kosi River Basin area.
Martha Dodray is a government health worker. Her station is in Darbhanga, a district in India’s Kosi River Basin area and one of the last bastions of polio in India.
"Darbhanga has all the diseases and all the difficulties,” says Dr. Rajendra Kumar Singh, who supervises the World Health Organization’s work in Darbhanga, as part of the WHO National Polio Surveillance Project (known widely as NPSP). Child malnutrition is a problem. So is cholera – a condition linked to challenges with water and sanitation. So was the presence of poliovirus.
The vast, flat nature of the terrain in the Kosi River Basin is hard to fathom. In the dry season, the basin stretches in endless dusty swathes as far as the eye can see. Intermittent clumps of trees shelter villages of a few dozen people. Hindu temples mark the high points, which stand no more than 40 metres above sea level.
About three hundred kilometres away loom the Himalaya of Nepal. Each spring, in a startling show of watery force, the snowmelt races down the mountains towards the Kosi River Basin.
The river paths can change each year, but the result is the same: the dry basin transforms into an ocean several metres deep; with racing currents that can sweep boats and people away.
But the dry season was even more difficult. When the waters recede, they reveal fertile soil. People descend from the villages and spread across the basin to claim a plot of land. Families settle for months at a time, living in small temporary huts. These can be kilometres from the nearest road. Every year, the huts are washed away by the floods. Every year families rebuild, often in new places. These temporary settlements are called ‘basas.’
“In Kosi Basin there is no organised structure of where people will be living,” explains Dr. Sunil Bahl, of WHO. “In these periods it was a huge challenge to reach every child with polio vaccine. We were missing 10 to 20 % of children in the area."
Health workers were trying, but it was hard to monitor the quality of their work. There aren’t many roads into the Kosi River Basin area. There are no guesthouses or hotels. So typically, the polio surveillance medical officers (called SMOs) would base themselves at the nearest town. They would wake early to travel for several hours to monitor polio campaigns, and then travel several hours back on the same day.
“We would travel sometimes for 12 hours in one day – by motorcycle, boat, on foot, and could then only spend a few hours onsite,” recalls Dr. Bahl. This made it impossible to connect with the health workers and the communities and to plan polio campaigns properly.”
The Kosi River Basin area was a sanctuary for poliovirus at a time when India was working hard to eliminate polio in the country.
We had to come up with a new strategy. Fast.
“We had to be systematic,” explains Dr. Bahl.
He and the team divided the area into grids based on the river patterns. They set up new offices in larger villages and equipped them with field necessities: generators to run fans and charge mobile phones, cooking facilities, a mattress and mosquito net, clean drinking water and latrines. This way, SMOs could spend several days in the area. They could meet with village leaders, form relationships with the health workers, and draw up ‘microplans’ that included the thousands of temporary communities.
Children in Tilkeshwar village.
“This new strategy was a game-changer.”
They also established several dozen ‘stay points’ in villages – locations that were just one or two hours – rather than twelve hours –from the new village offices. These may have been as basic as a sleeping mat at the temple, but they allowed SMOs and health workers to sleep in the areas where they needed to vaccinate children, wake the next morning and get back to work rather than lose time traveling.
A woman waits to have a baby immunized.
Dr. Rajendra Kumar Singh, the SMO in Darbhanga district, remembers the days very well.
“To vaccinate the people, we had to be one of them. We had to form bonds of trust with the communities. When we stayed in the communities, we could do that.”
“I learned quickly that the community would really embrace you,” says Singh. “I learned not to be afraid to ask for things, including to ask for food. People were always generous.”
Martha Dodray, the health worker who was used to walking for hours just to vaccinate a few children, also remembers the change in the community. “We got to know people well. In the beginning they would sometimes reject the vaccine, but I built a good relationship with the community, and they accepted it. This was how we could end polio.”
With the new plan of village offices and stay points, the numbers of children vaccinated grew exponentially. “Within a few months we had accelerated from vaccinating children in hundreds of field huts, to reaching 250,000 of them," remembers Sunil Bahl.
"The numbers of missed children were reduced to under two percent. It was an incredible leap.”
The team used data to adjust their plans. When settlements moved, the teams moved with them. Within two years, the data told them that there was no more polio in the Kosi River Basin, or anywhere in India. The last polio case in the country was identified in West Bengal on January 13, 2011.
The Government of India was instrumental in the success of the Kosi River Basin operational plan and ultimately the eradication of polio in the country.
The government provided strong leadership, spent up to $300 million a year, and equipped tens of thousands of health workers and community mobilizers. Partners including Rotary International, the US Centers for Disease Control and Prevention, UNICEF and the Bill & Melinda Gates Foundation worked closely with government and WHO-NPSP.
Today, the groundwork laid in the Kosi River Basin has opened the door for improved health for all children.
In addition to continuing to protect children against polio, intense microplanning helps to deliver more vaccines, such as measles-rubella, pentavalent and pneumococcal vaccines, and fractional doses of inactivated polio vaccine.
WHO-NPSP is using their network to conduct surveillance for several vaccine-preventable diseases including measles, pertussis, diphtheria as well as visceral leishmaniasis and lymphatic filariasis.
Dr. Rajendra Kumar Singh sums up how his polio experience in the Kosi River Basin has informed the surveillance work he leads in Darbhanga today.
Everything I know, I learned from polio eradication.
A Global Polio Laboratory Network
What is a polio case?
When the polio eradication effort began in the 1980s, it was a question with more than one answer.
"In the early days in Peru we didn’t wait for laboratory results,” says Peter Carrasco, a polio eradicator who worked with the Pan American Health Organization's team of polio eradicators.
“Our job was to break the chains of transmission as fast as possible. If it looked and smelled like polio, we started a mop-up vaccination campaign within a week.”
Anyone with smallpox developed a rash. But only one in 200 people infected with polio become paralysed. The poliovirus can otherwise circulate silently for long periods of time.
Polio diagnosis in the early days depended on a physical examination in a doctor's clinic. This wasn't reliable, as other diseases could cause polio-like paralysis. In wealthier countries, a polio case would be examined by a panel of experts.
Dr. Ciro de Quadros, the legendary Brazilian polio coordinator for the Americas, wanted polio to be identified in a laboratory.
“Ciro didn’t want neurologists to be debating whether a child had polio,” remembers the CDC’s Dr. Mark Pallansch, who helped to develop the global polio laboratory network. “He felt we needed to isolate a poliovirus to really demonstrate the presence of polio.”
The idea seems obvious today. But at the time, it was revolutionary. It posed several problems. How to standardize the laboratory identification of polio in every country in the world? What kind of sample could be collected from children in the field, and sent safely back to a laboratory for analysis?
It’s not a dinner table conversation, but over time, the story of polio eradication would be told through laboratory results from stool samples.
For years, two stool samples have been collected from every child suspected to have polio, no matter where they live, and sent for analysis in a national laboratory. And each of those laboratories have the same level of training and same equipment.
In 1989 Mark Pallansch and CDC scientist Olen Kew travelled to Geneva to create a global plan of action for laboratory networks. A key principle was for the network to build standard methodologies in countries around the globe.
“Core capacities to isolate poliovirus in cell cultures would be built in as many countries as possible,” Pallansch explains. “There would be regional laboratories that could differentiate between wild polio and vaccine viruses. And finally, specialized laboratories that could conduct more sophisticated molecular epidemiology, including genetic sequencing.”
The CDC worked closely with the WHO and other well-resourced laboratories to train and equip national staff to the same standard.
“The target was the same for every country, whether it was Cameroon or Cambodia. If it didn’t work everywhere, the system simply didn’t work.”
The network in the Americas was strengthened to the point where polio – and its absence – could be demonstrated in every country, leading to the certification of a polio-free Americas in 1994.
By 1997 there were about 60 laboratories in the polio laboratory network, which was testing around 50,000 stool samples every year.
Dr. Cara Burns, now the head of the CDC polio surveillance laboratory, joined the team in 1998.
The laboratory was conducting more genetic sequencing – allowing specialists to map the way the virus was spreading and changing. They could tell for example, when a virus from southern India traveled to Turkey based on the genetic characteristics.
“Poliovirus changes about 1% of its genetic make-up every year. This is enough for us to be able to track the virus using the tools of molecular epidemiology," says Cara Burns.
Burns and her colleagues worked to group “families” of poliovirus that had similar characteristics. They developed detailed dendrograms – like a family tree – that showed the relationships of viruses - the further from the main “trunk” – the greater and older the genetic drift. The sequencing could show when poliovirus families had been extinguished, and which ones were thriving, and possibly traveling to other countries.
In 2000, Burns and her colleagues were studying genetic sequences of poliovirus from the Caribbean and made a shocking discovery- an unusual cluster of viruses on the island of Hispaniola.
This new discovery showed that, very rarely, the weakened virus in oral polio vaccine could change over time into a form that caused polio disease.
CDC together with global specialized labs refined new methodologies and then helped to transfer them to other laboratories in the network.
“We came up with a definition of a certain amount of mutation that had gone on that typically was linked with a more dangerous virus," says Cara Burns. "We adapted the laboratory techniques so we could identify these outbreaks."
Currently about 100 laboratories in the network have the capacity to identify circulating vaccine-derived polioviruses.
This capacity continues to serve the polio eradication program well - allowing it to distinguish between wild poliovirus and circulating vaccine-derived poliovirus outbreaks. This in turn allows the program to tailor vaccine campaigns and other strategies to stop transmission of polio.
Global Coordination and Cooperation
The Global Polio Laboratory Network can not only identify changes in poliovirus, it also coordinates to understand how and where viruses are spreading. An enormous database of more than 10,000 virus sequences allows the laboratory network to rapidly compare viruses from different countries and regions.
In 2011, for example, there was a polio outbreak in China, a country which had last seen indigenous polio in 1994.
Cara Burns hopes to have a consolidated sequence database so that any future polioviruses can be rapidly compared to previous viruses – whether wild or cVDPV.
More than polio
Today the Global Polio Laboratory Network is not only working on polio, but 84% of the polio laboratories are also accredited to identify measles and rubella, and similar laboratory techniques can also be used for influenza.
“When we talk about issues such as global health security, having all of that breadth of the polio laboratory network is really important. Molecular sequencing is important, but having the capacity to isolate viruses in countries is really critical not only for polio, but for other diseases.”
Polio Vaccine Switch
The Experience in the Philippines
The Global Polio Eradication Initiative has managed some impressive feats: ending polio in 99% of the world; mobilizing vaccinators to reach children trapped in conflict; raising upwards of $1 billion every year.
But even by polio eradication standards, the work to prepare for a vaccine switch in April 2016 was a huge challenge.
That month, 155 countries and territories using a longstanding ‘trivalent’ oral polio vaccine (tOPV) would switch every vial in every health centre for the ‘bivalent’ polio vaccine, or bOPV. Production of the traditional ‘tOPV’ would end, and any unused tOPV would have to be found, accounted for and safely destroyed.
Watch the video below to learn how the Philippines managed the tOPV to bOPV switch, and continue scrolling to read more.
Why the switch?
Since Albert Sabin’s trivalent oral polio vaccine came into commercial use in 1961, billions of doses had been safely and effectively administered to children in almost every country of the world. Created by combining weakened forms of the three types of poliovirus, the vaccine conferred protection by activating the immune system, stopping the virus from replicating and spreading to the central nervous system.
As poliovirus survives and multiplies in the gastrointestinal tract, tOPV was not only effective in preventing polio disease, but also in stopping wild virus from replicating in the gut, then shedding and spreading further in communities.
The weakened vaccine virus however can be shed in stool, and this is almost always an advantage. In daily life – playing with a ball that had been in an open gutter for example - children might ingest the vaccine virus, resulting in “passive” immunization of neighbourhood children who have not been vaccinated.
But, in extremely rare cases where immunization rates were particularly low, and in conditions of poor sanitation, the weakened virus originally contained in OPV itself can continue to be shed and spread. If this virus circulates for a long period of time, it can eventually mutate into a form that causes polio disease. The phenomenon was first recorded on the island of Hispaniola in 2001 when 21 cases of polio were confirmed. Scientists dubbed this “circulating vaccine-derived poliovirus” or cVDPV.
From 2001 until 2015, about 800 cases of cVDPV paralysis were recorded. There were larger outbreaks in Nigeria and the Democratic Republic of Congo, and a handful of cases in other countries. By contrast, in that same timeframe, the use of tOPV had prevented more than six million cases of polio.
Then something else happened.
Type 2 wild poliovirus was declared eradicated in September 2015. It hadn’t been detected anywhere in the world since 1999.
The data showed that the overwhelming majority of cVDPVs (86%) were caused by the type 2 component in tOPV (called cVDPV2) and that this type 2 vaccine virus strain had the ability to mutate more easily into a disease-causing virus. The evidence was clear.
As type 2 poliovirus was eradicated, the continued use of tOPV containing type 2 would effectively propel the program into a cycle of using a vaccine to protect against the rare risks associated with the same vaccine. Type 2 had to be withdrawn from the polio vaccine.
In accordance with WHO recommendations, 155 countries and territories using tOPV switched to bOPV in two weeks in April 2016.
In the Philippines, the Department of Health had initially made other plans. Before the World Health Assembly in 2015, the country had already ordered tOPV for 2016.
“The procurement for 2016 was for tOPV. It is a one-time procurement for the entire country for the year. That’s a major commitment on the part of the government,” notes Dr. Maria Wilda Silva, the national immunization programme manager in the Philippines.
Dr. Maria Wilda Silva manages the Philippines' national immunization program.
But when the Secretary of Health returned from the World Health Assembly, she decided the Philippines would have to switch at the same time as every other country.
Dr. Silva says that as soon as that decision was made, her team started planning for the switch. The country’s regional health directors received the message, and they in turn informed their staff in the provinces, cities, towns and villages.
A mother signs in to an immunization session.
With just a few months to ‘switch week’ in April, the national health department worked closely with the regional offices to plan training, which would be stepped-down to the provincial and local health workers.
“It was important that everyone involved in the switch should be aware of it and why it was happening. So we invested a lot in the orientation,” says Dr. Lailani Mangulabnan
Gladys Lingat, the head nurse leading immunization in Mabalacat city in Region III says the message was clear.
“We really followed the regional health office and the provincial health office very strictly. We followed their memos and guidelines about what we were going to do, when we are going to do it and how we are going to do it.”
Lingat herself helped to provide training to junior health staff, who required more explanation about the technical aspects of the reasons for the switch. Why should they stop using a vaccine they’d been using for years? The training helped to clarify those issues.
“With the polio endgame we’re not just eradicating the poliovirus, we’re also managing vaccine-associated polio including circulating vaccine-derived polio virus. We needed to stop that risk from the oral polio vaccine itself.”
During switch week, Gladys Lingat remembers bOPV arriving right on time. She collected the new vaccine from the provincial cold store one day before the traditional Wednesday immunization session.
What did parents think? Given the technical complexities of the reasons for switching to bOPV, the Philippines agreed with the WHO’s global advice to keep things simple for caregivers.
“We gave a short lecture to parents about the switch to a new bivalent oral polio vaccine, and they accepted this easily,” recalls Lingat.
Using tOPV before the switch
One issue was how to use the tOPV that was already in health centres. Until April 2016, the trivalent vaccine remained an important tool to protect children against polio. It wouldn't make sense to waste it.
So, before the switch, the Department of Health implemented a tOPV catch-up campaign between February and March in areas where vaccination coverage was lower. Health workers identified communities that would benefit, including many living in places where families had to trek some distance to the health centre.
“We travelled out to those communities and we were systematic, going door-to-door from 8 am to 5 pm,” remembers Nurse Gladys Lingat. “The work is fairly hard and hot given the weather in the Philippines, but we’re used to it. The campaign went well.”
Within a couple of weeks, almost all stocks of tOPV were exhausted.
The Department of Health, partners including WHO, UNICEF and the Red Cross monitored health centres and cold stores following the switch to check for any remaining tOPV.
Disposing of any remaining tOPV safely was the final step. All vaccine vials were put in boxes, marked for destruction and sent to the regional and provincial coldstores. They were encased in concrete and buried.
The Philippines hasn’t had a single case of polio since 1993. The country is a member of the WHO Western Pacific Region which was certified polio-free in 2000.
All of the women interviewed for this story either have no memories, or distant memories of polio. But health leaders are aware that polio can always return. As estimated ten million Filipinos work overseas and many travel home frequently.
A baby receives the bivalent oral polio vaccine.
"Had we not completed the switch, the risk of polio including cVDPVs was real, says Dr. Lailani Mangulabnan. “We could have never properly eliminated the risk.”
One woman involved with the polio program, Cristina Bustamante, has seen what polio can do. Many years ago, her nephew became sick with a high fever. Within a day he had trouble walking. She tears up as she thinks of him. “His feet got smaller. He lost his muscles.”
Today Bustamante plays a role ensuring no one in the Philippines suffers polio again. She works in the national vaccine warehouse where she helps to manage the temperature and distribution of up to three million doses of bOPV stored in huge cold rooms.
“For Filipinos it’s so cold we can say we have been to Canada and Alaska when we go inside the walk-in freezer,” she jokes.
But she takes her job very seriously, checking freezer temperatures, expiry dates and vaccine distribution plans daily.
“It is very important for us to take care of all the vaccine because it is there to protect the people.”
Taking the Politics out of Polio
A Rotarian's work in Pakistan
Aziz Memon knows about the need to advocate at every level of government. The Rotary PolioPlus Chairman and industrialist devotes much of this time talking with the politicians of Pakistan about polio eradication.
“On a politician’s busy agenda, polio eradication can come if not last, then near to last,” he says, in an interview in his Karachi office. “One needs to remind them again and again that this task is not done until we reach zero polio, and even then we need to continue to be vigilant for years to be truly polio-free.”
I have just one agenda, that is to take care of the children and finish polio.’”
Watch the video below to see how Aziz Memon works to keep the politics out of polio, and continue scrolling to learn more.
The challenges to polio eradication in Pakistan have been many.
One was the devolution of powers, including health from the federal government to the provinces in 2011.
“It is just not only keeping the federal government engaged but it is having the provincial governments engaged – and they are run by different political parties,” explains Memon. “And the fact is, these political parties don’t get along with each other. But for polio we need to request that they sit on one table and talk about it.”
With elections on the horizon in 2018, Memon and his colleagues worked hard to have a declaration signed by all parties, promising to make polio eradication part of their election manifestoes. This took the politics out of polio.
Memon says he personally stays out of politics. He says it's important to stay neutral, allowing him to speak in good faith with anyone.
Memon presses on the big political issues, and smaller ones as well. For example, he describes the challenge of building managers forbidding polio vaccinators from entering their high-rise apartments, where dozens of young children who should be vaccinated might live.
“So we have to work our way around with them, ask the permission of the president or the secretary, and promise to be responsible for the activities of these vaccinators. We have been providing cards to the vaccinators so that they can show that they are not just trespassers, not just street criminals, they are bonafide vaccinators, and that’s helped a lot.”
Each of the lessons from polio have been hard-won in Pakistan.
Polio has been a thorny and, in some years, dangerous program.
It has withstood a murderous period when militants banned the program in some areas; dozens of vaccinators and several security officers killed; and community trust in polio vaccines plummeted. Rumours and mistrust grew after a CIA plan that involved a fake door-to-door vaccination campaign to locate Osama bin Laden.
In Waziristan, one Taliban leader banned polio vaccination campaigns and said he would restart them again only when drone attacks were stopped.
Memon tried various routes to reach him to change his mind, but finally had to travel to meet him one-on-one.
“I had to go there alone without my cell phone so it was scary, frightening,” he remembers. “I told them ‘I can’t stop the drone attacks. You must be joking.’ I gave them the message that these children could be your own children."
In Pakistan’s difficult recent history, this was one of many encounters.
“There were several other instances like that where we had to convey to various leaders that they were being misled, and that they were misleading the people and creating a generation of crippled children.”
Memon is relieved that today, those dangerous periods are mostly behind the program. In 2018, Pakistan is recording the fewest polio cases in its history. Continued political commitment and quality campaigns could soon end polio transmission in the country.
If there are problems, Memon will be there to help solve them. He looks forward to the day when polio is finished, and to the legacy that will leave his country.
“I think that for Pakistan the biggest message and victory in eradication of polio means that we have the capacity to improve routine immunization, we have the capacity to stop other vaccine-preventable diseases.
"Ending polio proves that we can do even more for children’s health.”
Our World United to End Polio is the result of a collaboration of the United Nations Foundation, with partners of the Global Polio Eradication Initiative. Christine McNab, an independent multimedia producer specialising in global health and development, produced the series. The project was made possible with funding from the Bill and Melinda Gates Foundation.
Executive producer, photographer, writer, narrator: Christine McNab
Video editing: Kathryn Dickson, OnFireFilms.tv
Graphic design and animation: Ron Sloan
Music, Re-recording Mixer: Michelle Irving, Soleil Sound
Colour correction: Mario Baptista
Ending Polio in India
Camera and sound: Rahul Negi
With special thanks to:
Dr Pradeep Haldar, Deputy Commissioner for Immunization, Ministry of Health and Family Welfare, Government of India
Dr. Sunil Bahl, Regional Advisor, WHO South-East Asia Region
Dr. Pauline Harvey, Team Leader, NPSP, WHO Country Office
Dr. Pankaj Bhatnagar – DeputyTeam Leader, NPSP
Dr. Vishesh Kumar – NPSP Regional Team Leader for Bihar
Dr. Rajendra Kumar Singh, SMO, NPSP Darbhanga
Martha Dodray – government healthworker, Darbhanga
Camera and sound: Derek Bauer, db Productions
Additional photographs from the CDC Public Health Information Library
With special thanks to: Dr. Cara Burns, Dr. Mark Pallansch, Dr. Olen Kew , Allison Maiuri and Holly Patrick at the US Centers for Disease Control
The Polio Vaccine Switch
Camera and sound: Joa Czagalla, 7000 Islands Film Production
With special thanks to:
Dr. Maria Wilda da Silva, National EPI Manager, the Philippines;
Dr. Lailani Mangulabnan, Division Chief, Dept. of Health, Region III;
Gladys Lingat, Nurse & EPI Coordinator, Mabalacat City Health Centre, Region III; Donna Samson – Cold Chain Manager of Bataan Provincial Health Office; Christina Bustamante and the whole team at Vaccine Storage & Distribution, Research Institute of Tropical Medicine.
WHO Philippines, in particular Maricel de Quiroz-Castro and Jun Ryan Orbina. WHO WPRO: Santosh Gurung, WHO WPRO
WHO HQ: Lisa Menning, Alejandro Ramirez Gonzalez, Oliver Rosenbauer.
Taking the Politics out of Polio in Pakistan
Camera and Sound: Haider Ali
With special thanks to:
Many at Rotary PolioPlus in Karachi, Pakistan including
Mr. Aziz Memon, Rotary PolioPlus Chairman
Ms Alina Visram, Rotary PolioPlus, Pakistan
Mr. Qaiser Shahzad and the teams of supervisors and vaccinators we spent time with in Karachi.