Eradicating Polio one step at a time

By Vikas Pandey

Sita Devi outside a market stallSita Devi says she is committed to keeping India polio-free
A few years ago, India accounted for half the world's cases of polio. Today it is officially clear of the disease. This remarkable feat is largely down to an army of women who, one step at a time, have crisscrossed the country on foot to give the under-fives polio vaccines.
Sita Devi is one of India's "polio aunties". The 57-year-old often walks miles in the searing heat to find children in remote villages and communities who need vaccinating.
She is one of the hundreds of thousands of women working in Aanganwadis - health care centres - in India which provide free basic services to those who cannot afford to pay.
They are part of the Pulse Polio Initiative that was started in 1995 with the aim of eradicating the disease from the country.
Feet walkingSita Devi often walks long distances in the heat to reach families in need of the vaccine
Since then, 12.1 billion doses of polio vaccine have been administered here.
In 2006 India still accounted for half of all global cases of polio - but earlier this year it recorded three years without a new reported case.
This achievement allowed the World Health Organization (WHO) to finally declare its entire South East Asia region polio-free.
'New problem'

Countries in WHO SE Asia region

  • Bangladesh
  • Bhutan
  • Democratic People's Republic of Korea
  • India
  • Indonesia
  • Maldives
  • Myanmar
  • Nepal
  • Sri Lanka
  • Thailand
  • Timor-Leste
But now Ms Devi is worried. She doesn't know if she can persuade the families she works with in the rural areas around Allahabad in northern India to have their children immunized again.
She airs her concern at a morning meeting of Aanganwadi workers in one of Allahabad's regional health offices.
It's 45C (113F) outside and a rusty fan isn't doing much to cool the room down.
Ms Devi's worry is partly down to the success of the eradication programme - the next round of immunisations is due in June but many families do not see the logic in repeated vaccinations now that India is polio-free.
"This is a new problem. We must deal with it carefully so that people understand why we are giving the anti-polio drops," she tells Rajesh Singh, the regional health officer.
As a chorus of similar worries erupts, Mr Singh encourages the Aanganwadi workers to tell the families regular immunisation is important to keep the disease away.
Meeting of Aaganvadi workersAanganwadi workers play a crucial role in India's fight against polio
He has to speak loudly to be heard among the debate and the creaking of the fan.
But his pep talk seems to work as the women enthusiastically prepare to leave for their respective areas.
'Committed to the cause'
"These women often cover more than 500 houses a day and they walk for miles. It's not money that drives them. These women work tirelessly because they feel committed to the cause," Mr Singh explains.
After the meeting Ms Devi steps out into the heat of the day and walks to the main road to find a public bus.
As we move slowly through the traffic towards a slum area, she says she mostly works in poorer areas to educate families about polio.

Child being given polio dropsIndia's Pulse Polio Initiative started in 1995 and in 2014 India recorded three years without a new polio case
It was a terrible disappointment that they couldn't help him, but it made her decide to join the fight against polio.
"I immediately signed up because I had seen how this disease destroys life. One family member always had to be with my nephew and we could never go out as a family.
"He has grown up now but still faces difficulty in moving around because India is not a disability-friendly country," she says.
'Polio aunty'
When we reach our destination, Ms Devi points out the lack of basic facilities like sanitation, electricity and even drinking water - typical of many Indian villages.
As she moves from house to house, I start to understand how the programme succeeded in the daunting task of eliminating the disease in a country of more than a billion people.
Her friendly nature helps villagers open up about their lives and problems.
Five young children smiling at the cameraThe children love their "polio aunty" who brings them sweets as well as anti-polio drops
"It is easier for people to trust me once they have shared some details about themselves with me.
"After speaking about their lives for a while, I can explain how they can protect their children against polio, which would be an additional burden to them," she explains.
As she walks through the slum, the children run barefoot after her, calling out to "polio aunty" for more sweets.
The high corruption levels in India make it difficult for people to trust government initiatives but Ms Devi insists that the polio programme is different.
One family is not keen on immunising its young ones, so she brings out the vaccination kit and explains how the drops are safe from contamination in the cool box.
She gives the children chocolates before she carries on.
Two women talking, one with a large ice boxMost polio workers carry large ice boxes to protect the vaccine
"I often get tired walking for eight to 10km [four to six miles] in the blistering heat to reach them.
"But I will continue to work as long as my health allows," says Ms Devi, smiling as she watches me wipe the sweat off my brow.
'We cannot afford to rest'
Her story is typical of many Aanganwadi workers who travel for miles to reach the areas they work in.
One of her colleagues, Ritu Tripathi, works 70 kilometres (41 miles) from home and stays away during the week.
She only sees her two young children on weekends, with her mother taking care of them in her absence.

Start Quote"I cannot afford to travel by train very often and

Post Polio Litaff, Association A.C _APPLAC Mexico

The Polio Crusade

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Erradicación de La poliomielitis

Polio Tricisilla Adaptada

March Of Dimes Polio History

Dr. Bruno




A 41-year-old man developed an acute illness at the age of 9 months during which, following a viral illness with headache, he developed severe weakness and wasting of the limbs of the left side. After several months he began to recover, such that he was able to walk at the age of 2 years and later was able to run, although he was never very good at sports. He had stable function until the age of 18 when he began to notice greater than usual difficulty lifting heavy objects. By the age of 25 he was noticing progressive difficulty walking due to weakness of both legs, and he noticed that the right calf had become larger. The symptoms became more noticeable over the course of the next 10 years and ultimately both upper as well as both lower limbs had become noticeably weaker.

On examination there was wasting of the muscles of upper and lower limbs on the left, and massively hypertrophied gastrocnemius, soleus and tensor fascia late on the right. The calf circumference on the right exceeded that on the left by 10 cm (figure1). The right shoulder girdle, triceps, thenar eminence and small muscles of the hand were wasted and there was winging of both scapulae. The right quadriceps was also wasted. The wasted muscles were also weak but the hypertrophied right ankle plantar flexors had normal power. The tendon reflexes were absent in the lower limbs and present in the upper limbs, although the right triceps was reduced. The remainder of the examination was normal.

Figure 1

The patient's legs, showing massive enlargement of the right calf and wasting on the left


What is that nature of the acute illness in infancy?
What is the nature of the subsequent deterioration?
What investigations should be performed?
What is the differential diagnosis of the cause of the progressive calf hypertrophy?



An acute paralytic illness which follows symptoms of a viral infection with or without signs of meningitis is typical of poliomyelitis. Usually caused by one of the three polio viruses, it may also occur following vaccination and following infections with other enteroviruses.1 Other disorders which would cause a similar syndrome but with upper motor neurone signs would include acute vascular lesions, meningoencephalitis and acute disseminated encephalomyelitis.


A progressive functional deterioration many years after paralytic poliomyelitis is well known, although its pathogenesis is not fully understood.2 It is a diagnosis of exclusion; a careful search for alternative causes, for example, orthopaedic deformities such as osteoarthritis or worsening scoliosis, superimposed neurological disorders such as entrapment neuropathies or coincidental muscle disease or neuropathy, and general medical causes such as respiratory complications and endocrinopathies.3


Investigations revealed normal blood count and erythrocyte sedimentation rate and normal biochemistry apart from a raised creatine kinase at 330 IU/l (normal range 60–120 IU/l), which is commonly seen in cases of ongoing denervation. Electromyography showed evidence of denervation in the right APB and FDI with polyphasic motor units and complex repetitive discharges, no spontaneous activity in the left calf and large polyphasic units in the right calf consistent with chronic partial denervation. Motor and sensory conduction velocities were normal. A lumbar myelogram was normal. Magnetic resonance imaging (MRI) scan of the calves is shown in figure2.

Figure 2

Axial T1 weighted MRI scan (TR 588 ms, TE 15 ms) of the calves, showing gross muscle atrophy and replacement by adipose tissue on the left, and hypertrophy of the muscles on the right, with only minor adipose tissue deposition


The differential diagnosis of the progressive calf hypertrophy is given in the box.

Causes of calf muscle hypertrophy

Chronic partial denervation

  • radiculopathy

  • peripheral neuropathy

  • hereditary motor and sensory neuropathy

  • spinal muscular atrophy

  • following paralytic poliomyelitis

    Neuromyotonia and myokymia

  • Isaac's syndrome

  • generalised myokymia

  • neurotonia

  • continuous muscle fibre activity due to: chronic inflammatory demyelinating polyradiculopathy, Guillain Barre syndrome, myasthenia gravis, thymoma, thyrotoxicosis, thyroiditis

    Muscular dystrophies



  • tumours

  • amyloidosis

  • cysticercosis

    Link here