A guide to vaccinology: from basic principles to new developments

Opinion: He Died In An Iron Lung And Showed Us The Value Of Vaccines

On March 11, a man named Paul Alexander died at the age of 78. He held the world record for number of years living inside an iron lung.

Alexander contracted polio in 1952, at the age of six. His terrified parents brought him to Parkland Hospital in Dallas, where Alexander, paralyzed below the neck, was placed in an iron lung because he could not breathe without one. Poliovirus, with its predilection for attacking the spinal cord, had stolen his ability to breathe by paralyzing his diaphragm. He spent months living in the coffin-like metal cylinder that exerted alternate positive and negative pressure on his tiny body to inflate and deflate his lungs. Later, he learned breathing techniques that allowed him to survive outside the iron lung for hours at a time, but he would never be free of it.

Health officials push to get schoolchildren vaccinated as more US parents opt out

Alexander was especially unlucky because just three years later, in 1955, Jonas Salk's polio vaccine was introduced, saving millions of lives as cases of polio plummeted. The vaccine also gave Americans blessed relief from crippling fear that gripped communities each summer. Fear of poliovirus' spread forced closure of theaters, swimming pools, and libraries. Public gatherings were banned. Parents kept children indoors and forbade playing with other kids. Neighbors avoided neighbors. A 1955 survey showed that Americans feared polio more than any other calamity except nuclear war.

Hospital ward with children in iron lungs. FDA photo.

It should be easy for us to understand this fear because we experienced it during the COVID-19 pandemic. With both contagions, vaccines were our saviors. But whereas in the mid-twentieth century the polio vaccine was considered a godsend and doctors like Jonas Salk and Albert Sabin (who developed a separate polio vaccine) were lauded as heroes, today COVID vaccines, and vaccinations in general, have become controversial.

US childhood vaccination exemptions reach their highest level ever

Anti-vaccine activists sow doubt about the very miracle treatments that undergird the health and stability of our society. Because we are not dying from highly contagious infectious diseases like mumps, measles, and rubella, we are free to live longer, healthier lives and pursue our personal and economic goals. To forgo vaccinations is to invite disaster. We see such consequences today at schools in Florida, a shelter in Chicago, and in 15 other states where measles outbreaks among the unvaccinated have caused healthcare emergencies.

Too many have forgotten the fear, chaos, and tragedy that infectious diseases have wrought throughout history. We forget that, without a polio vaccine, any one of us could have been Paul Alexander, living 70 years in an iron lung. Four years ago, the United States went into lockdown. COVID vaccines, created at warp speed, enabled the resumption of our lives. And yet, the surgeon general of Florida has called for a halt to COVID vaccine use.

It is not only that we take vaccines for granted. We are also guilty of selfishness in the name of individualism and "personal rights." The power of vaccination in a community far exceeds the benefits to any individual. When young, healthy people eschew vaccinations because they deem their personal risk of death from infection to be slight, they forget that reducing the burden of infection in a community saves countless lives, particularly among those unable to receive or respond to a vaccine due to medical reasons. A college student may survive a bout of severe COVID, but the elderly or immunocompromised person he passes it to may not.

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In 2021, Henrique Gouveia e Melo, a Portuguese naval officer in charge of his nation's COVID vaccination drive, appealed to his countrymen's sense of duty by saying: "We are at war, and this is a war against the virus, so what side [do] you want to be on? With the virus, 'cause you are crazy and you are helping the virus to spread? Or are you on our side, the community?"

Sadly, COVID is the disease that took Paul Alexander's life this month. Despite his infirmity, he lived an inspiring life. Through homeschooling, he became the first person in Dallas to graduate from high school without attending a class in person. He earned a bachelor's degree from the University of Texas. Then he added a law degree and became a practicing attorney. In 2020, he published a memoir called "Three Minutes for a Dog: My Life in an Iron Lung," that took him eight years to dictate and write using a plastic stick to tap out words on a keyboard.

In a 2020 interview, Alexander recalled times when his disability caused him to seem invisible to the able-bodied. To those spared his affliction, he wanted to say, "You should get down on your knees and thank God it wasn't you."

Vaccines allow us to cheat death. We must use them.

Dr. Andrew Lam is a practicing retina surgeon from Longmeadow, Mass., and an assistant professor at the University of Massachusetts Medical School. He is the author of "The Masters of Medicine: Our Greatest Triumphs in the Race to Cure Humanity's Deadliest Diseases."

Global Eradication Of Polio 'tantalisingly Close' With UK Urged To Keep Up Funding

The world is "tantalisingly close" to eradicating polio – with no confirmed cases of wild polio anywhere so far this year. But experts warn that vaccination efforts – and funding – must not falter if the world is to rid itself of a human infectious disease for the second time in history, after smallpox.

There have been no reported cases of wild polio infection in people for the last 19 weeks. Figures from the World Health Organization reveal that the last confirmed cases were on the borders of Pakistan and Afghanistan in October and September 2023 respectively; these are the last nations on Earth where polio is endemic.

"To have gone 19 straight weeks … is a long period to go without a single case, that's why there is some hope [of eradication]," Gordon McInally, president of Rotary International, a founding partner in the Global Polio Eradication Initiative (GPEI), told the Observer. "All of us who are involved in this, every week we get an email giving us the updated figures … and every week when I click open that email my heart rate goes up until I see the number in the hope that it will be zero and not one, or worse. But we take it week by week."

But those involved in eradication efforts are taking nothing for granted. The programme has come under fire before for its "almost-there narrative", as described in a report last September by the Independent Monitoring Board, led by Liam Donaldson, a former chief medical officer for England.

Still, said McInally, if they can get through another 33 weeks (one full year after the last case), they will be "celebrating cautiously", and if the world stays two years disease-free they can officially declare the global eradication of polio.

While the absence of confirmed cases is "really encouraging", Aidan O'Leary, director for polio eradication at the WHO, said: "It's important we don't call the figures great." The campaign needs to be aggressive in closing any immunisation gaps, he added.

The latest WHO figures do reveal 34 samples of wild poliovirus detected from environmental and other sources in the first three months of this year, including from surveillance samples of sewage (where shed virus may circulate). "We are identifying environmental isolates which does indicate there's some transmission," said O'Leary, adding this needs to be zero too.

Backers of the polio programme have pushed Andrew Mitchell, the minister of state for development and Africa, to extend UK funding. Photograph: James Manning/PA

O'Leary, McInally and other stakeholders met Andrew Mitchell, the minister for development, and his team on Wednesday to update them on polio, and ask the UK government to continue with its funding, which ends this year. They are asking the Foreign, Commonwealth and Development Office for £100m for the next two years. GPEI's goal is to eradicate polio by 2026.

The UK government has been the second biggest contributing government after the US towards eradicating polio, said McInally. He said funding is crucial because "we're at that challenging point in time where because of the geography, the nomadic nature of many of the people we're trying to reach, it's not easy to reach everybody to get it finished, and there is a realisation that unless we finish it completely we run the risk of it bubbling up again."

If they fail to eradicate polio in Afghanistan and Pakistan, WHO modelling suggests there could be a "global resurgence" resulting in some 200,000 new cases of polio each year within 10 years. Until this is done, McInally said, polio is only a "plane-ride away". Imported polioviruses caused alarm in 2022 when an unvaccinated adult in New York was paralysed by the disease, and poliovirus was detected in sewage in London.

But McInally is hopeful, in part because of the programme's success in India – 27 March will mark the country's 10-year anniversary since it became officially polio-free. There are some parallelswith rural India which give him hope. "Many people said 'you will never get rid of polio from India'…and it was done."

Immunisations have been stepped up in Afghanistan and Pakistan; with the programme extending its target age for immunising children from under five to under 10, said O'Leary, and synchronising on both sides of the border.

Another crucial challenge is "vaccine-derived" poliovirus transmission. This derives from the oral polio vaccine, still used in some regions, which harnesses live but weakened poliovirus.

This would not cause issues of itself, but if immunisation rates are low in a population, the vaccine strain can circulate and genetically change over time, and in rare cases cause paralysis like wild polio.

"Any case is a worry," said McInally. "But once we can eliminate wild virus then the vaccine-derived cases will clear up relatively quickly."

O'Leary notes that there were 1,000 cases of polio a day in 125 countries in 1988 when the GPEI started. He likens the polio programme to running a marathon – with a few hundred metres to go. Nonetheless he remained cautious: "Eradication is a zero-sum game. We have to be very clear-eyed – when we look back and everything is zero, then we can say it's great."

OpinionIndia's 10 Years As A Polio-Free Nation

For decades, public health officials expected India to be the last country in the world to stop the potentially life-threatening and disabling disease of polio. After 23 arduous years of nationwide campaigns led by legions of volunteers and healthcare workers who immunised millions of children against polio in the far reaches of the country, India has defied these bleak expectations.The last poliovirus case was reported in Howrah district, West Bengal, in 2011, and three years later, India was officially certified polio-free as part of the South-East Asia Region of the World Health Organization (WHO).

This year marks a decade of a polio-free India - one of the country's most profound public health achievements to date.

India's Journey to End Polio: A Battle of Sheer Scale

A hard-won fight of epic proportions, the effort to end polio in India was beset with overwhelming challenges. From misinformation and myths about the polio vaccine to high population density, poor sanitation, and inaccessible terrains, the country overcame what many considered impossible. As recently as 2009, India was a polio hotspot, accounting for more than 60% of all polio cases in the world.

Yet, India responded with resilience, launching one of the largest and most comprehensive vaccination campaigns in history. Through the pulse polio immunisation programme, the government of India conducted multiple rounds of national immunisation days (NIDs) and sub-national immunisation days (SNIDS), where every child up to age five received the polio vaccine. Additionally, complementary health services, such as Vitamin A drops, were included to protect children further and engage parents and families in support of the programme.

Vaccinating millions of children was an arduous task for many reasons, one of which was weather. During seasonal floods in Bihar, thousands of children were trapped in crowded and unsanitary makeshift camps on small islands surrounded by floodwaters. Although this state previously reported the second-highest number of polio cases in the country in 2006 and 2007, healthcare workers were undeterred, reaching the stranded children by boat to ensure they were vaccinated.

Remote terrain was also an obstacle, as was the case in the hills of Himachal Pradesh and Rajasthan. Due to their nomadic lifestyles, migrant populations were difficult to reach. This remained an ever-present concern, as children within these communities were consistently at risk of being either left out of immunisation efforts entirely or of not receiving the required total doses of the polio vaccine.Healthcare workers trekked for hours, and some rode camels to reach children with the polio vaccine.

They thoughtfully collaborated with communities that held fears about the vaccine. With the support and encouragement of local political and religious leaders and celebrities, they were able to educate parents about the vaccine and calm their fears enough to allow their children to be immunised against polio.

Moreover, the pulse polio programme was backed by India's multi-pronged surveillance and environmental surveillance network, a highly sensitive laboratory-backed system that monitored the circulation of poliovirus strains in stools of paralytic cases and sewage samples. The network enrolled more than 40,000 health facilities across the country to report paralytic cases to help limit the chances of an outbreak. Through real-time, credible data, the nation adapted its immunisation strategies to focus on high-risk areas and vulnerable communities.

Polio immunisation campaigns were a nationwide mission that spanned decades. Millions of vaccinators were united by a singular goal: to protect every child from polio, transcending geographical, logistical, and cultural barriers.

Even today, over 170 million children are immunised during NIDs, and 77 million are immunised during SNIDs every year to ensure India remains polio-free, thus preventing millions of children from possible paralysis and death.

Collaboration: Key To The Endgame

Ending polio in India was achieved through the mass development and distribution of billions of vaccines - all made possible through a strategic alliance with the Global Polio Eradication Initiative (GPEI) and its partners - the WHO, Rotary, the US Centers for Disease Control and Prevention (CDC), the United Nations Children's Fund (UNICEF), Bill & Melinda Gates Foundation and Gavi, the Vaccine Alliance.

While polio has been eliminated in India, the latest data from the National Family Health Survey (NFHS-5) revealed that only 77% of children (aged one-two years) received all basic vaccinations. While 92% of children (aged one-two years) received the first dose of the polio vaccine, only 81% received the last dose. Additionally, 4% of this demographic received zero vaccinations. Given India's proximity to the remaining two polio-endemic countries, as well as other social and environmental factors, the country cannot let its guard down. It must continue with its polio vaccination activities to sustain population immunity.

Thanks to Rotary and its partners, the incidence of wild polio globally has been reduced by 99.%, and most of the world's children now live in polio-free countries. To ensure every child is protected from polio, all parties must remain united behind this goal.

With robust vaccination and monitoring efforts, the world can finally bid farewell to polio and create a new future where no child will face the threat of this disease. The journey continues, fuelled by optimism, determination, and the shared belief that a polio-free world is not just a dream but an achievable reality.

(The author is Chairperson, Rotary International's India National Polio Plus Committee)  Disclaimer: These are the personal opinions of the author.

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