History of the eradication of Poliomyelitis

Today we are going to talk about polio, a disease that many of us know at least by name. Since its first clinical description, this disease has had many names and is now known as polio or infantile paralysis. Polio is an infectious and contagious disease caused by the poliovirus. This virus belongs to the picornaviridae family and the enterovirus subgroup. It has no envelope and its diameter is between 25 and 30 nanometers, making it a relatively small virus. For comparison, the diameter of the new coronavirus is reported to be between 70 and 150 nanometers. Poliovirus is highly contagious and is transmitted through food and water contaminated with the feces of infected people. Infection occurs when the virus enters the body through the mouth, multiplies in the throat and intestine, and spreads through the bloodstream to the central nervous system. At this stage, the virus is able to attack nerve cells, which can lead to paralysis. Although children under 3 years of age account for the majority of cases, polio can affect anyone. It is a serious condition that can cause permanent paralysis. However, this complication occurs in less than 1% of infected people. People infected with polio who do not suffer from paralysis may experience flu-like symptoms, which has made it difficult to detect for much of history.

 

Polio is a special disease in historical terms because there is almost no trace of it in the stories of the past, until a certain Sir Walter Scott brought it to light. Before him, no historian, storyteller, essayist, or physician had, through the ages, accurately described the symptoms of this viral disease. If that was the case, the writings are yet to be discovered. However, thanks to the work of many archaeologists, we now know that polio is a disease that has afflicted humanity for millennia. As such, as often in the history of science and medicine, we owe much to Egyptian civilization. It is indeed important to point out that ancient Egypt is a gold mine for scientists and the medical field. Since the 19th century, the numerous archaeological finds have allowed us to learn much more about this vast period. First of all because the mummification process has allowed us to study the bodies found, and to confirm that many diseases already existed at the time, such as cancer. Secondly, because many works of art were also found and gave us some valuable clues about certain diseases, such as polio.

In this context, we can mention in particular the discovery of the Egyptologist William Matthew Flinders Petrie. And, before saying more about his discovery, let’s make it clear that Flinders Petrie is not just anyone. It is notably thanks to him that modern Egyptology was born, since it was he who introduced stratigraphy into his work, i.e. the study of strata containing archaeological material, which allows precise dating. Flinders Petrie was recognized and renowned, and often had a considerable impact in the training of a whole generation of Egyptologists, including the very famous Howard Carter, who discovered the tomb of a certain Tutankhamen in 1922.

In 1897, Flinders Petrie, then 44 years old, led an expedition to Deshasheh, on the western slope of the Nile, about 100 km south of Cairo. As the search progressed, he soon realized that the terrain would allow him to make many discoveries. His team found many graves and several artifacts. But what interests us here are the remains of one tomb in particular. In this one, which dates from about 3,700 BC, there is the mummy of an elderly man, probably from the ruling class, and a 120-centimetre long stick, which appears to be a cane. The characteristics of the mummy would soon arouse curiosity because it is quickly realized that the lower left side of the body is not “normal.” The left femur is in fact 8 centimeters shorter than the right femur. The circumference of the neck of the femur concerned is also 4 centimeters shorter. There is also a slight size deficit on the left tibia and fibula. So, did this mummy, which is now on display at the Philadelphia Archaeological Museum, suffered from polio during her lifetime? To this question, I quote the very nuanced answer of Dr Amin Rida, who was Professor of Orthopaedic Surgery at the Alexandria Faculty of Medicine, and who in Cahier d’Alexandrie, published in 1964, told us:

John Mitchell, who described this mummy, concluded that the cause of these manifestations was Infantile Paralysis. We must add that this diagnosis is acceptable, although it is difficult to imagine a paralysis severe enough to shorten the femur and at the same time leave such pronounced muscle marks. The mummy may have had an isolated paralysis of the femoral quadriceps, the muscle most frequently affected in infantile paralysis. »

The end of the 19th century was a period rich in archaeological discoveries, and the year following the discovery of Flinders Petrie was no exception. Here again, a possible trace of polio was found on a mummy, and not just any mummy. It was the mummy of Pharaoh Minephtah Siptah, which is now on display in the Cairo Museum. The mummy of Siptah was discovered in 1898 by the French archaeologist Victor Loret in Biban-el-Molouk, near Thebes. Minephtah Siptah ruled Egypt around 1200 BC and is believed to have been afflicted with polio. Examination of the pharaoh’s body reveals that his lower right limb is shorter than his left, and his right foot is deformed. I quote again Dr. Amin Rida who explains these physical peculiarities very precisely:

“His deformity comprises the three elements of the equine varus clubfoot, i.e. It is in plantar flexion, inversion and adduction. But it should be noted that equinus is the most marked element, so that the foot is in a straight line with the leg. The toes are in hyperextension, which shows that the Pharaoh forced them in this position while walking, because of the extreme equinism. The shortening of the right lower limb is such that, in spite of the extreme equinism of the right foot, its toes do not exceed the level of the sole of the left foot. All these points contribute to prove that Pharaoh Siptah had suffered during his childhood from an Infantile Paralysis, which delayed the growth of the right lower extremity, and which caused this paralytic club foot. »

It should also be noted that there are representations of the pharaoh at the entrance of the tomb where we can see Siptah receiving life, power and strength from the god Horus. However, no trace of polio is visible on this representation where the pharaoh is represented as young and in full physical shape. In a paper presented to the Anthropological Society of Paris on April 7, 1927, Herman Christian Slomann said: “it is obvious that the realistic representation no longer goes as far as the audacity of reaching the physical appearance of the monarch. »

The third and final trace of polio in ancient Egypt is probably the most telling. It is now in the Ny Carlsberg Glyptothek in Copenhagen. It is a stele 27 centimetres high and 18 centimetres long, which is now the emblem of the Danish National Society against Infantile Paralysis. Its origin is not really known. It is said to have been bought in a shop in Giza in the 1890s and to have originated in Memphis. This stele would have been manufactured during the nineteenth dynasty, i.e. between 1580 and 1350 BC. It is dedicated to the goddess Astarte, who represents fertility, and could be roughly related to the Greek Aphrodite and the Roman Venus. She is also related to a healing deity, which is very important to understand the stele. Three figures are depicted on it. The guardian of the temple, his wife and his son. The character we are interested in here is the guardian of the temple, who, according to the translations, would be called Ruma, Roma or Luma. If you have the opportunity while listening to this podcast or afterwards, check out images of this stele that can easily be found on the internet. What is striking when looking at it is the clear difference between Ruma’s right and left leg. One can also easily see a long stick, which is almost the same size as the guard. Ruma’s left knee appears to be slightly hyperextended, which can be explained by the fact that most of the body weight was supported by the left leg only. It can also be seen that the right leg is much thinner than the left, especially at the thigh and calf. The hip and knee are flexed, and the foot is in extreme plantar flexion, which means that only the tips of Ruma’s toes touch the ground, and his heel is raised, so that there is a fairly large distance between the ground and his heel. The stick therefore confirms that our subject’s possibilities of movement are extremely complicated and that this object is more than necessary for Ruma. To decipher a little more this stele, it then appears obvious, taking into account the Egyptian beliefs of the time, that the artist who made it wanted to show that Ruma came to solicit the goddess so that his infirmity would be gone for his second life.

But as already stated in the introduction, it is almost impossible to find a trace of polio in the history between ancient Egypt and a certain Sir Walter Scott. However, there are a few works that date back to the Renaissance that perhaps show cases of polio at that time. This is the case of a pencil drawing from the early sixteenth century, entitled Beggars and Cripples. This drawing, attributed to Jerome Bosch, depicts 32 figures, most of whom have had lower limb amputations. But a few of the characters have the same physical characteristics as our guard at the Egyptian temple Ruma. It is also possible to cite the painting entitled The Fight Between Carnival and Lent, painted in 1559 by the famous Bruegel. In the centre left of the painting, it is indeed possible to see two interesting characters for our purpose. One moves around on crutches while the other, whose legs are obviously more atrophied and deformed than his companion’s, crawls around on the ground with handles. It is therefore likely that polio was present at that time, although it is extremely difficult to confirm this 100%.

And one of the things that would help to bring polio to the forefront is the testimony of Sir Walter Scott, a famous Scottish poet and writer who wrote, amongst others, the novel Ivanhoe. Sir Walter Scott was born in 1771 in Edinburgh. At the age of 18 months, he was taken by a violent fever, which his entourage believed to be due to teething. But on the fourth day of the fever, the child was found to have lost the mobility of his right leg. The damage was done, and Walter Scott would now limp for the rest of his life. The story of Sir Walter Scott is also interesting because, as an adult, he himself was very inclined to talk about his condition, and also, because at the time, polio had not yet been identified. And it is precisely in such cases that it is interesting to see what medicine had to offer in the face of conditions that it did not understand. For example, at the age of four, he was sent to Bath in southern England for almost a year. At that time, in the middle of the Georgian era, the city of Bath was being transformed into a spa. Little Walter would therefore enjoy treatments based on baths and massages. However, at the end of this stay, no effect on his right leg infirmity were felt.  Other treatments were then envisaged. His maternal grandfather, John Rutherford, who was Professor of Medicine at the University of Edinburgh, advised the family to enjoy the fresh country air and exercise as a treatment. Rutherford also broke new ground by trying to stimulate the muscles affected by the paralysis. His method included placing shiny objects, or things that young Walter particularly wanted, in places where the young boy could only reach them with considerable effort, an effort that also allowed the muscles affected by the paralysis to be used. And, in Walter Scott’s case, it was a success. By the persistent use of this method, the young boy regained some power in his muscles, which allowed them to increase in size. Although still “lame”, Walter Scott could now move around without too much problem, indicating that his paralysis was not total and that his muscles had retained some of their motor skills. But the most original treatment he underwent was influenced by his paternal grandfather, Robert Scott. Walter himself would later describe this rather peculiar treatment:

“Among the odd remedies…to aid my lameness, someone had recommended that each time a sheep was killed for the use of the family, I should be stripped and swathed in the warm skin as it was taken from the carcass ofthe animal. In this tartar-like habiliment, I remember lying upon the floor of a little parlor in the farmhouse while my grandfather, a venerable old man with white hair, used every excitement to make me crawl.”

As Sir Walter Scott was slowly entering adulthood, it was a British doctor, Michael Underwood, who first described polio. In 1789, Underwood published A Treatise on the Diseases of Children, in which he notably evoked infantile paralysis by mentioning “the debilitations of the lower limbs.” He stated that the disease “usually attacks children previously weakened by fever; rarely those under one year of age, or over four years of age.” Our British doctor also made suggestions to help patients with the disease regain some mobility: “Nothing seems to have done any good, except for iron leg braces to support the limbs and to enable the patient to walk.” A few years later, another description of polio came from Italy, from a surgeon named Giovanni Battista Monteggia. And his description of the symptoms will remind you of someone we’ve just mentioned. In his 1813 publication entitled Paralysis and Atrophy, he stated:

The paralysis begins with two or three days of fever, after which one of the lower extremities is quite paralyzed, immobile, flaccid, dangling, and no movement is made when the sole of the foot is tickled.”

Listening to Monteggia’s description, it’s hard not to think of Sir Walter Scott’s case. But the first REAL clinical description would come to us from Germany and was the fact of Jacob Heine, a name which would quickly be inseparable from another. Jacob Heine was born in April 1800. He is an orthopaedic surgeon and did in fact make the same remarks and observations as his predecessors. But above all, he went much further in the analysis and studied the disease in detail at each of its stages. In 1840, he published a 78-page monograph in which he first described the onset of polio as sudden, accompanied by fever, congestion, tears, mood swings and drowsiness, among other things. Although remission is possible, victims suffer from permanent weakness of one or more limbs. He also noted that the skin temperature of the affected limb drops rapidly after the onset of the disease. The longer the paralysis lasts, the lower the temperature. As the paralysis progresses, Heine noted that scoliosis, which in most cases is painless, develops. In very rare cases, bowel and bladder dysfunction may also occur. He was also the first to notice that the symptoms suggest spinal cord damage. This theory was confirmed by the Swiss neurologist Jean-Louis Prévost in 1865, who located the lesions in the anterior horn of the spinal cord. Anxious to be able to provide, if not a treatment, at least solutions, our German orthopedist tried to find ways to restore muscle function. According to his remarks, he considered that the treatment should be carried out according to the degree of paralysis. For him, this is a crucial factor. He then advocated three approaches to therapy. First, he tried to stimulate and increase the viability of the affected parts. To do this, he recommended a treatment based on plants with stimulating properties, complemented by massages with vomitus extracts, alcohol and concentrated ammonia. Secondly, in an attempt to restore the normal shape of the affected limbs, and to help the mobility of the patients, he prescribed physical exercises specifically aimed at the affected limbs. He also recommended the use of mechanical contraction devices and orthopaedic appliances. Thirdly, he recommended a nutritious and easily digestible diet, so that the patient could have all the strength possible to give every chance to the treatment. With Heine, it is possible to consider that the disease was formally identified. It is notably he who gave it the name Infantile Spinal Paralysis in 1860. A term that would be widely adopted at that time.

For much of the second half of the 19th century, polio was still not much talked about. It should be noted that the urgency seemed to lie elsewhere. Many other, much better-known diseases were wreaking havoc and mobilizing the scientific community. Examples include the plague, tuberculosis and cholera. However, some scientists began to take an interest in it. This is the case, for example, of the French surgeon Cordier, who highlighted the epidemic nature of the disease in 1888. Then followed a certain Karl-Oscar Medin, a brilliant Swedish paediatrician. It was thanks to Medin that polio was to come to the forefront of the international scene. In 1887, this pediatrician studied a wave of 44 cases. Very quickly, he understood that all 44 cases were related to polio, which destabilized him in a way. Before that date, Medin was certain that the cases of polio that presented themselves at the Polyclinic Hospital in Stockholm were all isolated and above all occasional. He established a rigorous follow-up of his patients and divided the cases into two groups. Those involving the spinal cord, which consisted of 27 cases, and those with less common signs of the disease, since the lesions were in places not usual for polio, which consisted of 17 cases. Medin, a renowned scientist in his country, was to make himself known to the world through his observations, which he presented at the 10th International Congress of Medicine in Berlin in 1890. He described four types of poliomyelitis: bulbar (which concerns the medulla oblongata), ataxic (which concerns the nervous system), polioencephalitis (which concerns the grey matter of the brain stem) and poly-neuritis (which concerns peripheral nerves). Also, its follow-up of the 1887 epidemic earned Sweden the unfortunate reputation of being the center of the world with regards to polio cases. But soon, the rest of the world would discover that the disease was not unique to Sweden.

Medin’s influence was strong, and his pupil and disciple, Ivar Wickman, quickly became one of the world’s leading experts on the disease. It was he who, in 1907, proposed that polio be called “Heine-Medin’s Disease,” a term that was widely adopted by the scientific community, thus demonstrating the preponderance of the work of Jacob Heine and Karl-Oscar Medin. As for Wickman’s work, it was very interesting, since he was one of the first to take an interest in the epidemiological question. Wickman was particularly concerned about how the disease was spreading. Indeed, from the beginning of the 20th century, many epidemic waves appeared, particularly in Scandinavia, and raised the concern of the international community. In 1905, an epidemic wave of 1031 cases was recorded. Wickman then went to a village at the centre of the epidemic. He quickly realized that more than half of the positive cases were non-paralytic. The symptoms he observed in these people were stiffness in the neck or back, pain or simply fever. He therefore hypothesized that these people who are positive but not paralyzed were, in his opinion, the main spreaders of the disease. His theory was however greeted with great skepticism by his peers, who thought that a diagnosis of Infantile Paralysis without paralysis was ridiculous. This didn’t stop Wickman from pushing for polio to be considered a highly contagious disease, and for cases that could be considered almost asymptomatic to be taken seriously and considered as contagious as cases where paralysis was present. He was right, but unfortunately, he was a little too far ahead of his time.

In 1908, Poliovirus was finally discovered by Karl Landsteiner and Erwin Popper in Vienna. They managed to transmit the disease to the animal by injecting spinal cord from a young boy who had died of polio. Both the rhesus monkey and the baboon in the experiment showed signs of clear polio, one after two weeks and the other after seven days. From this key date on, progress was rapid. Landsteiner then collaborated with the Pasteur Institute and Dr. Constantin Levaditi to confirm the discovery and consecrate the causative agent as a virus. A few years later, Levaditi was also the first to confirm that the infection could be transmitted through the digestive tract by infecting a chimpanzee through the mouth. At the same time, in the United States, and particularly in New York, polio was beginning to take its toll. From the beginning of the 20th century, American scientists began to take a very serious look at the disease. Simon Flexner of the Rockefeller Institute would, on this subject, confirm the results of his European colleagues and isolated the virus in 1912. It was he who concluded that the virus could attack the nervous system directly through the olfactory plaque. That same year 1912, a Swedish trio composed of Kling, Pettersson, and Wernstedt managed to confirm the hypothesis formulated by Wickman seven years earlier. To do so, they isolated the virus from the stools of two patients. One paralyzed, the other not. Unfortunately, this confirmation, which can be considered fundamental today, went completely unnoticed.

As you can see, the period from Karl-Oscar Medin to Simon Flexner saw a great deal of progress in the understanding of the disease. This period also coincided with an upsurge in the number of diagnosed cases. At a time when treatments and even vaccines had been found for some of the greatest diseases that have affected humanity, polio was now public enemy number one, especially in North America, where it was heavily concentrated in Canada and the United States. It terrorized the population because of its lethality and the concerns raised by the possible physical sequelae. The regular waves of epidemics that occurred in the United States during the first half of the 20th century were brutal. Tony Gould, in his 1995 book Polio and its Survivors, even described it as a “modern plague.” But all the groundwork had been laid to begin the search for an effective treatment and a vaccine.  Unfortunately, however, this research was, in its early hours, somewhat chaotic. In 1916, a polio epidemic hit New York City hard. Several thousand people were infected, and more than two thousand died. In order to contain the epidemic, the city put in place a series of measures that today seem very familiar to us, such as quarantine, the closure of public spaces and many businesses such as cinemas, and the disinfection of areas where proven cases had been identified. The following year, the New York City Department of Health published a 400-page monograph on this health crisis. The document was divided into several very detailed sections. But the section we are interested in here is the treatment section. In this part of the document, a number of treatments recommended by New York physicians were referenced, but it was clearly stated that a large majority of these were ineffective. Just as during the Black Death, the population, frightened and unable to understand what was really happening, then found scapegoats. In the case of New York City, the city’s cats and dogs were accused by a large number of inhabitants of being responsible for the spread of the virus. In total, nearly 72,000 cats and 8,000 dogs were killed during the crisis.

Soon after the New York epidemic, another plague struck the world. It was the Spanish Influenza, which lasted almost two years and killed nearly 50 million people. This influenza traumatized the world’s population, putting the work on polio in the background for a few years. But the disease continued to strike. In 1921, Franklin Delano Roosevelt, who was elected President of the United States in 1933, contracted polio at the age of 39. An influential man who was already well known to Americans, Roosevelt then provided funding and put a spotlight on the fight against polio in the United States. During his presidency, he created the National Foundation for Infantile Paralysis, now known as the March of Dimes, in 1938. This Foundation was also a reconstitution of the Georgia Warm Springs Foundation, which Roosevelt had founded with several of his friends in 1927. The principle for raising funds was very simple and can be likened to France’s “Les pieces jaunes.” The goal was to encourage Americans to donate their dimes, hence the name March of Dimes. It is also important to note that a 2003 study revealed that Roosevelt may have suffered from Guillain-Barré Syndrome, an autoimmune inflammatory disease of the peripheral nervous system. However, Roosevelt had indeed been diagnosed with polio in 1921.

Starting in the 1920s, research funding led to the creation of new and innovative ways to treat polio patients in a serious condition. At the time, many patients with paralysis died when their respiratory muscles stopped working. As such, it is difficult not to mention the famous “iron lung.” A massive, cylindrical device with an opening allowing the head to pass outwards. This iron lung also has glass windows on it to monitor what is happening inside. Much of the credit for this goes to Philip Drinker, who worked at Harvard University. At the time, he was working with the Rockefeller Institute to develop better resuscitation methods. To build his iron lung, he used a machine that already existed, which had been created in 1907 by the German Johann Heinrich Dräger: The Pulmotor. The Pulmotor was a ventilation device that used a mask and created alternating pressure ventilation. It was originally housed in portable wooden boxes and was used to try to resuscitate workers who had been electrocuted or drowned. Philip Drinker therefore, starting from this machine, imagined a respirator large enough to contain a human. To do this, he was helped by one of his Harvard colleagues, Louis Shaw. In 1926, the machine was ready, and the first test could begin. The first patient to use it came from a children’s hospital. She suffered from polio and was unconscious due to respiratory paralysis. And what happened was pretty incredible. They put the little girl in the machine. They started the ventilator, and within a minute, the child was conscious. This spectacular achievement would quickly propel the iron lung to the forefront of the stage. By the late 1920s, it was widely used throughout the world. In 2017, the American blog Gizmodo focused on the last three people in the United States to use these machines, which today seem to come from another time. All three were affected by polio as children. The case of Paul Alexander is probably the most striking. It is now 68 years since he contracted this disease, which had almost paralyzed him completely below the neck. He uses the machine daily, almost 24 hours a day. When he was younger and more robust, he needed the machine less, even though he used it every day. His condition did not, however, prevent him from studying law at the University of Texas and becoming a lawyer. For Gizmodo, he looked back on his time at the University, and I quote Paul Alexander:

When I transferred to University of Texas, they were horrified to think that I was going to bring my iron lung down, but I did, and I put it in the dorm, and I lived in the dorm with my iron lung.I had a thousand friends before it was over with, who all wanted to find out what’s that guy downstairs with a head sticking out of a machine doing here? »

These three Americans spent most of their lives in this iron lung because at the time they could not be vaccinated against polio. The vaccine did not yet exist, but it was close. This is an opportunity for us to talk about the vaccine race that would see the consecration of two men: Jonas Salk and Albert Sabin. However, the first polio vaccine did not come from these two men but from Hilary Koprowski. Born in Poland in 1916, Koprowski studied medicine at the University of Warsaw and received his PhD in 1939. He left Poland shortly after the German invasion of September 1939, which plunged the world into the Second World War. He first emigrated to Brazil before settling in the United States. In 1948, he succeeded in creating an orally effective live polio vaccine. He and his assistant, Thomas Norton, had obtained convincing results by testing it on monkeys. They then concocted a “polio cocktail”, using a blender to transform pieces of spinal cord and brain tissue from poliovirus-infected rats into a viscous, oily grey substance. A common practice at the time, the two men tested their concoction themselves. Just before that, they had grown the virus in a cotton rat, whose brain may be affected by poliovirus. With their success, the two seemed ready to test the vaccine in children. In particular, they did this by treating children from a residence for epileptics and mentally handicapped people, without any authorization. When Koprowski presented his results, they caused outrage among his peers. He realized that in order to get his vaccine accepted, he had to conduct a real clinical trial. But, he was no longer in the scent of sanctity in the United States. Koprowski then went to Northern Ireland and contacted George Dick, Professor of Microbiology at the University of Belfast. George Dick was a renowned person who had worked on polio in the past, and he jumped at the opportunity to associate his name with the first polio vaccine. Soon enough, trials began on children. But not everything went according to the plan. To be a little more specific, Koprowski’s solution, when inoculated by a monkey, did not cause paralysis. However, when the virus was collected in the feces of vaccinated children and passed to monkeys, paralysis did occur. In the end, the problem was immense because the virus extracted from the feces of the vaccinated children proved to be much more virulent than the virus ingested when the vaccine was taken. Koprowski quickly realized that his vaccine was not stable. George Dick commented, “The virus goes in like a lamb but comes out like a lion.”

This failure was the end of Koprowski’s hopes for a vaccine. For, at the same time, Salk, who started working on a vaccine much later than his colleagues, was quickly catching up. He was developing his inactivated polio vaccine, better known as IPV (Injectable Polio Vaccine). To do this, he inactivated the virus by pickling it in formalin, which prevented it from multiplying and reaching the spinal cord, thus avoiding paralysis. But the virus was not pickled long enough for this to alter its external chemical structure, which meant the immune system could still recognize it and create antibodies that would recognize the wild poliovirus. And it worked! The largest clinical trial in history at the time could now begin. It should also be noted that Salk was able to benefit from the remarkable work of some of his colleagues. Indeed, in 1951, the three strains of the virus were identified after a typing program launched in 1948 by the National Foundation for Infantile Paralysis. The Foundation, which had been co-created by President Roosevelt, redirected most of the funds raised to Salk’s researches, who had become a medical figure in the United States after working on a flu vaccine during the Second World War, and who had been widely used to vaccinate American troops. The huge wave of immunization that the US authorities and Salk were aiming for was also made possible in 1949 by the trio composed of Enders, Weller and Robbins, who succeeded in developing cell cultures on which they were able to multiply the poliovirus. It was this major breakthrough that made it possible to create and produce the vaccine in industrial quantities. The clinical trial, which lasted from April to June 1954, took up considerable resources. In all, nearly 20,000 doctors, 40,000 nurses and 60,000 teachers were mobilized. 1.8 million children were to be vaccinated in 200 different locations across 44 states in the United States in less than three months. It was a considerable logistical challenge that took more than a year to develop. A few months later, faced with more than encouraging results, Salk, who was convinced that his vaccine was perfect, was finally able to confirm its effectiveness. On April 12, his vaccine was declared effective by the U.S. Food and Drug Administration (FDA). On April 18, 1955, he was received by President Eisenhower at the White House, who affirmed the nation’s recognition of his achievements. Alistair Cooke, a British journalist based in Washington, D.C., wrote at the time in one of his Letters from America: ” the 166-year war against paralytic poliomyelitis is almost certainly at an end.” The triumph is total. Salk, who was already very famous in the United States, now had iconic status and even made the cover of Time Magazine. Mass immunization began. But a problem was soon to emerge in 1955. And this problem was known as the “Cutter incident. ” It was caused by the California-based pharmaceutical company Cutter. On its production line, the inactivated virus came into contact with live viruses, which were found in nearly 120,000 vaccines. The results were catastrophic, and the disease occurred in many children who had just been vaccinated. Some became paralyzed, others died. Worse, small epidemics occurred as the live virus infected other family members and acquaintances, again causing permanent paralysis and death in some adults. It was a real disaster and the reputation of Salk and his vaccine deteriorated. But Salk’s vaccine, apart from this big mistake, remained effective and the return to normal was fast, once the theory of vaccine contamination publicly confirmed. The number of cases of paralysis and deaths due to polio dropped dramatically in the United States over the next few years, and Salk’s vaccine was widely used across the globe.

In 1956, Salk’s great rival began to really make a name for himself. It was Albert Sabin. A brilliant scientist, who had also participated in the American war effort during the Second World War. He was indeed a Lieutenant-Colonel in the Medical Corps and helped develop a vaccine against Japanese encephalitis, which was very useful in the Pacific War. Jonas Salk and Albert Sabin did not get along at all. There was a great rivalry between these them. When they were both in the same place, they often refused to be in the same room. It should also be said that Salk was the preferred recipient of the research funds that were redistributed, and this created resentment in Sabin. Sabin was working at the same time as Salk on a polio vaccine, but it was an oral vaccine, better known as OPV: Oral Polio Vaccine. In particular, Sabin felt that his vaccine was much more effective than his rival’s vaccine. His work focused on a live version of the virus but weakened in the laboratory. The goal was to let the virus multiply and spread through the body by preventing it from reaching the spinal cord and thus causing paralysis. His vaccine was ready in 1956 after numerous tests on primates and volunteers. It had many advantages. As it travels through the digestive system, the vaccine provides progressive immunity. Salk’s vaccine, injected directly into the bloodstream, creates antibodies in the bloodstream, but not in the digestive system. Several weeks after vaccination, and once excreted, the Sabin virus could then spread to areas with poor hygiene, causing indirect immunization of people who had not been vaccinated and who came into contact with the virus. Another positive point for Sabin is that taking the vaccine orally has logistical and economic advantages, since it avoids the use of needles and syringes. And while this may seem trivial, taking a vaccine orally is much less frightening than the prospect of a needle stick. But Sabin’s vaccine was not perfect. Like Koprowski’s, in very rare cases the virus could regain strong virulence and cause paralysis. Another problem was that Sabin’s virus, like many viruses, was very sensitive to high temperatures, which posed problems for vaccinations in tropical environments. But with Salk’s incredible national, and even global, popularity, Sabin quickly realized that it would be difficult to get his vaccine ahead of his rival’s, at least in the United States. In the middle of the Cold War, Sabin then dared to enter into an agreement with the USSR, and his OPV was quickly developed in the Soviet Union. After having been used to vaccinate more than 100 million Soviets in a few years, his vaccine was finally widely used in the United States from the early 1960s, where it gradually replaced IPV. Properly administered, both Salk and Sabin’s vaccines protect against polio and are extremely safe. There is an extremely low risk (one in 500,000 vaccines) that Sabin’s OPV would revert to a crippling variant, a drawback that Sabin always refused to acknowledge. Finally, it should be noted that, beyond their respective involvement in World War II and in the search for a vaccine, Salk and Sabin have another, very important point in common. Both did not patent their vaccine, missing out on colossal personal fortunes, estimated at several billion dollars. The two American scientists always put service to the people first, believing that the vaccine was a good for all mankind. This financial disinterest helped to build the legend of Salk in the 1950s, but also that of Sabin a little later. Today, they are still widely regarded as champions of humanity.

From the late 1950s onwards, polio cases in developed countries became very occasional. In the United States, with the use of Salk’s IPV, the number of cases rose from 18,000 in 1954 to 1,000 in 1961. Sabin’s vaccine then finished the job. In 1967, only 40 cases of polio were reported in the country. In 1988, the Global Polio Eradication Initiative (GPEI) was created, composed of the World Health Organization, UNICEF, Rotary International and joined a little later by the Bill & Melinda Gates Foundation, with the ambition of a global immunization campaign. The hope was that polio would follow the example of smallpox, which had been eradicated through intensive global immunization in the late 1970s.  Since 1988, according to the WHO, the number of polio cases worldwide has decreased by more than 99%. The Organization also estimates that more than 16 million people have avoided paralysis as a result of this global effort. Polio has thus been largely defeated, but its eradication is not yet complete. In 2000, an epidemic broke out on the island of Hispaniola, caused by a genetic mutation of the OPV vaccine virus, known as Circulating Vaccine Derived Poliovirus. Between 2000 and 2012, 20 similar epidemics occured worldwide, paralyzing several hundred people. In 2003, polio cases were reported in only five countries: Afghanistan, India, Niger, Nigeria and Pakistan. But as eradication progresses thanks to WHO immunization campaigns, cases of re-exportation of the disease to areas where it had disappeared are being reported, such as in Egypt in 2005, or in the Democratic Republic of Congo and Tajikistan in 2010. In response to these unexpected outbreaks, the Global Polio Eradication Initiative established the Independent Surveillance Board in December 2010 to audit the programme. This board challenged the massive use of OPV and recommended the use of IPV in areas still affected by the disease. WHO took these suggestions into account in 2012, a year where more than one billion dollars were spent in the fight against this disease? In 2013, the number of endemic polio cases worldwide had fallen to 416, but the wild virus continued to circulate in Afghanistan, Pakistan and Nigeria.

 

In France, polio has been a notifiable disease since 1936, which means that it must be declared to the authorities in order to monitor a possible outbreak and take appropriate measures to contain it. Vaccination has been compulsory since 1964. In 1988, only one case of polio was reported to the authorities in the hexagon, whereas there were between 1,500 and 4,000 cases every year in the 1950s. The history of Polio is a story rich in discoveries, twists and turns. It is also marked by the late discovery of the disease and the strong attention devoted to it during the first half of the 20th century, when it caused devastation and was the source of much fear among the population. From the work of Jonas Salk, followed by that of Albert Sabin, polio was largely defeated. It is a worldwide success story that is also due to the work of many other great scientists such as Jacob von Heine, Karl-Oskar Medin and Karl Landsteiner. Today, in developed countries, it is a distant memory. Yet its eradication is not fully effective. It is close, almost at hand… And we all hope that this disease will be eradicated in the coming years.

 

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