On March 27, 2014, India was officially certified polio-free by the World Health Organization (WHO). Thanks to an aggressive and adaptable vaccination campaign that lasted years and reached every corner of the massive country, millions of children have been given the opportunity to escape the virus that, at its peak, paralyzed more than 350,000 people around the world annually.
Today, polio cases have decreased by over 99% since 1988, and the virus is now endemic in just two countries: Pakistan and Afghanistan.
India’s success in immunizing such a large population against polio remains an incredible feat. A population of 1.4 billion people, India was considered one of the most difficult places to eradicate the wild poliovirus from its borders, owing to how the virus was spread, poor surveillance methods, and the large number of inaccessible communities.
It was too easy for children to not be vaccinated and for the virus to spread among community members. For many public health experts who grew up in India or were involved with the country’s vaccination efforts, the reality is that polio seemed far too common to escape.
“Growing up, I remember that every now and then, a child from the neighborhood wouldn’t turn up to play cricket in the afternoon, and we’d later learn that it was because they were having polio-like symptoms,” Dr. Ananda Sankar Bandyopadhyay, who is currently a deputy director of the polio team at the Bill & Melinda Gates Foundation, told Global Citizen. “[The threat of polio] was very real for us back then.”
Despite these obstacles, India was able to defy the odds largely due to sustained coordination from a variety of stakeholders, which included volunteer vaccinators, public health experts, international organizations, the private sector, and the Indian government; in 2011, the country recorded its last case of polio.
As we celebrate the 10-year anniversary of India being certified polio-free, Global Citizen spoke to public health experts about efforts to vaccinate every child in the country, as well as the wider implications India’s campaign has for eradicating polio everywhere.
How India Became Polio-Free
Vaccinators involved in CVT (Continuous Vaccination Team) activity are photographed at Patna Railway Station in Patna, Bihar, India at the beginning of their shift in Dec. 21, 2011.
Polio, or poliomyelitis, is a highly-infectious disease that mainly affects children under 5 years old. The virus that causes polio invades the nervous system and, in some cases, causes total paralysis in a matter of hours.
“[Polio] is also a highly outbreak-prone disease,” Dr. Bandyopadhyay told Global Citizen. “It can spread really fast from one child to another, one community to another, and one country to another, so eradicating it everywhere is of international concern.”
After the World Health Assembly passed a resolution to eradicate polio in 1988, progress to make sure vaccines reached every corner of the world accelerated. The Global Polio Eradication Initiative (GPEI) — a public-private partnership led by national governments and the WHO, Rotary International, the U.S. Centers for Disease Control and Prevention (CDC), the United Nations Children’s Fund (UNICEF) and the Bill & Melinda Gates Foundation — was launched to initiate a global vaccination campaign and respond to obstacles that allowed the virus to continuously circulate.
“After years of pushing, the government of India organized its first ever National Immunization Day (NID) in 1995 and adopted a strategy of supplementary immunization,” Deepak Kapur, the chairman of Rotary International’s India National PolioPlus Committee, told Global Citizen. “We expected [India to reach no-polio status] in a few years, but we were in for a shock.”
In 2001, Kapur joined Rotary International’s efforts to eradicate polio in India and witnessed the success of immunization activities in drastically reducing the number of polio cases. By 2002, however, the number of reported polio cases jumped up to 1600, almost 500% more than the previous year.
It quickly became clear that while supply of polio vaccines was high, efforts to track cases, prevent outbreaks, and ensure children completed their vaccination schedules needed to improve before polio left India’s borders.
“The success of India in reaching zero polio transmission occurred because of a type of shoe leather epidemiology,” Dr. Bandyopadhyay told Global Citizen. “Polio vaccinators led the way by going door-to-door to ensure that every child was vaccinated. Even if there were natural disasters such as flooding, these activities were at the core of stopping polio transmission.”
India Polio Campaign
In this photo taken on Jan. 23, 2011, polio vaccination team members make their way through fog towards Tilkeshwar village for a vaccination campaign early morning, some 180 kilometers (113 miles) from Patna, India.
India Polio Campaign
In this photo taken on Jan. 23, 2011, polio vaccination team member Sanjana Shoba marks the finger of a child with indelible ink after she was administered polio drops at Tilkeshwar village, some 200 kilometers (125 miles) from Patna, India.
India Polio Campaign
Polio vaccination team members disembark from a boat, which was used to transport them across the Ganges river from Gyaspur Ghat, and carry their cold box to get to their area of work in Kala Diara on the last day of the polio campaign, Dec. 23, 2010.
India Polio Campaign
In this photo taken on Jan. 25, 2011, a polio vaccination team member enquires whether a child on a train has been administered polio drops, at the railway station in Patna, India.
In addition to grassroots-level vaccination efforts, which were primarily led by women vaccinators across the country, public health officials also tried to associate vaccination campaigns with fun. Giveaways, banners, and efforts to enlist Bollywood celebrities to educate the public about the efficacy of vaccines all helped improve vaccination rates.
“‘Polio Sundays’ were essentially a festival for the entire nation to come out and get their children vaccinated,” Dr. Bandyopadhyay said.
Increased surveillance of polio cases was also essential in tracking clusters of the virus. Because the poliovirus is primarily transmitted through a fecal-oral route, environmental sampling of sewage systems allowed public health officials to be aware of outbreaks and ensure every eligible child in a community was being vaccinated.
Rotarian and India PolioPlus Committee Chair Deepak Kapur, World Health Organization Project Manager Sunil Bahl, and Rotarian Manjit Sawhney review vaccine distribution points at the National Polio Surveillance Project's headquarters in Delhi in 2008.
“You need to find out where the virus is and who is getting it,” Dr. Walter Orenstein, Professor Emeritus at Emory University, told Global Citizen. “That also allowed for changes in monitoring efforts; for example, using ink to mark vaccinated children so someone could come into a specific community to find out whether it was well-immunized, and if not, take action to do that.”
Dr. Orenstein is a former director of the United States' National Immunization Program and well-acquainted with global polio eradication efforts. Having worked on India’s smallpox eradication campaign in the 1970s, he understands the unique circumstances that impact mass vaccination efforts in the country.
In addition to setting up improved surveillance techniques, public health officials came to understand that certain communities experienced a severe distrust of the polio vaccine. As such, vaccine hesitancy was another obstacle that experts recognized they needed to overcome.
To address vaccine misinformation, members of GPEI coordinated efforts to educate community leaders about the polio vaccine so they could then disseminate that information.
“For one, [Rotary International] organized a committee made up of leaders from every revenue district in Uttar Pradesh [where the wild poliovirus was endemic] and helped them understand that immunization was a good thing,” Kapur told Global Citizen. “After that, we started to see [vaccination] booths set up at mosques, and Muslim leaders encouraged their communities to get vaccinated.”
As religious leaders, particularly associated with Muslim community, became part of immunization efforts, resistance to vaccination began to break down.
“Getting community leaders involved in advocacy is important,” Dr. Orenstein also told Global Citizen. “Trust can overcome vaccine hesitancy. You need the right message delivered by the right messengers to the right communication channel.”
Continuing Progress in Pakistan and Afghanistan
India’s success in eradicating polio from its borders proved that mass vaccination campaigns could be successful when given the right attention and resources. As such, bringing that level of commitment to Pakistan and Afghanistan can help stamp out polio once and for all.
Currently, the wild poliovirus is endemic in just seven of 180 districts in Pakistan and two of 34 provinces in Afghanistan. As case counts and genetic clusters of the virus decrease in these areas, public health experts continuously highlight the need to respond to region-specific obstacles.
A health worker administers a polio vaccine to a child in Karachi, Pakistan, Monday, Nov. 27, 2023.
In Pakistan, inconsistent access to high-risk, nomadic communities makes it difficult to track cases and ensure children are being vaccinated. In addition, vaccine hesitancy has proven to be a bigger issue in the country, as some community members boycott vaccine drives or threaten vaccinators with violencebecause of misinformation that the polio vaccine is a method of forced sterilization.
Afghanistan faces similar challenges. Immunity gaps resulting from under-vaccinated communities and missed vaccine appointments allows the poliovirus to continuously circulate. Additionally, the country’s complex humanitarian crisis has caused many residents to be hesitant about any person who comes knocking at their door, even as community-based vaccinators risk their lives to do so.
Initiatives from GPEI, national governments, and the international community continue to support polio eradication efforts by responding to region-specific trends. Taking lessons from India’s vaccination campaign, mobile vaccinations, house-to-house vaccine drives, and a strong commitment to environmental surveillance are proving to be some of the most effective means of reducing cases of the wild poliovirus.
The Need to Eradicate Polio Everywhere
Polio vaccinator Rekha Devi holds up the polio vaccine in Kuseswarsthan Block, Darbhanga District, Bihar, India in December 2011.
Even though the number of wild poliovirus cases are trending downward, we cannot let our guard down. The eradication of polio requires sustained action from everyone, everywhere, particularly as more cases are attributed to VDPVs, which have occurred in under-vaccinated areas and are linked to oral polio vaccines (OPVs).
In the context of the world’s race to end polio, the launch of OPVs is generally considered one of the greater feats. While many infants receive doses of the inactivated polio vaccine (IPV) as part of their routine immunization schedule, OPVs enable public health officials to reach children who were not vaccinated as infants, since they can be administered quickly via a dropper, are easy to transport, and are inexpensive.
The difference is that OPVs contain a weakened strain of the poliovirus to help build immunity. In under-immunized populations, where community members are not protected against polio, this weakened strain can circulate for a prolonged period of time and genetically revert to a form of the poliovirus that can cause paralysis.
Currently, the type 2 variant poliovirus accounts for almost 75% of variant poliovirus cases in 2023.
Responding to this trend, health officials have started employing the novel oral polio vaccine type 2 (nOPV2), which contains improvements that help make the weakened strain of the poliovirus less likely to mutate and spread in areas with low immunization rates. While this strategy has proven effective at reducing cases of VDPVs, the fact remains that well-immunized communities can prevent these types of mutations from taking place.
The world has the tools to end polio. Right now, it’s a matter of employing those tools using whatever means we can to ensure no child faces the threat of contracting polio.
“It’s in the interest of all countries, no matter their income levels, to ensure polio is eradicated everywhere,” Dr. Orenstein said. “I always say, vaccines don’t save lives—vaccinations save lives.”
Disclosure: This article is part of a polio content series that was made possible with funding from the Bill and Melinda Gates Foundation.