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Polio eradication: A new strategy for the final mile

A polio worker in Mazar, Balkh province, Afghanistan

The global incidence of polio cases has declined by 99% since 1988, but eradication of this devastating disease has remained elusive. On June 10 the Global Polio Eradication Initiative (GPEI) is launching a new strategy, supported by Germany, which aims to end polio once and for all.

When the Global Polio Eradication Initiative (GPEI) was founded in 1988, polio was endemic in 125 countries. Roughly 1000 children were paralysed by polio every day. More than three decades later, thanks to a massive effort to immunise young children with the oral polio vaccine, wild poliovirus has been eradicated from all but one region of the world. According to the World Health Organization (WHO), 110 cases were reported in 2020, all in Afghanistan and Pakistan, the two countries where it remains endemic.

As the result of the sustained efforts of national governments, the WHO, UNICEF, Rotary International, the Bill and Melinda Gates Foundation, the Centers for Disease Control, Gavi, development partners and millions of volunteers, the goal of completely eradicating polio is now tantalizingly close. But this final mile may be the most difficult yet: Not only does wild poliovirus type 1 continue to circulate in parts of Afghanistan and Pakistan, but outbreaks of vaccine-derived poliovirus are becoming more frequent in areas of polio-free countries where there is low immunisation coverage. 

Making sure the poliovirus has ‘nowhere to hide’

Acknowledging that new approaches are needed to accelerate progress against polio and to protect the gains which have already been made, GPEI is launching its Polio Eradication Strategy 2022-2026 to guide efforts over the coming five years. The dual aims of the strategy are to permanently interrupt all poliovirus transmission in endemic countries by 2026, and to stop transmission of vaccine-derived poliovirus and prevent further outbreaks in polio-free regions.

Marking a child’s fingernail following vaccination
Marking a child’s fingernail following vaccination

The new strategy reflects the realisation that existing approaches to eradicate polio have been yielding diminishing returns. For every major achievement – such as the certification of Africa as wild poliovirus-free in August 2020 – there have been worrying setbacks. 

Declining population immunity in high-risk countries, for example, has contributed to outbreaks of vaccine-derived poliovirus which now affect 11 countries in Africa and the Eastern Mediterranean region. As a result of the COVID-19 pandemic, polio vaccine campaigns had to be suspended for several months in 2020. In a positive development, however, more than 30,000 polio workers were able to contribute to COVID-19 responses in partner countries.

In a recent interview, Aidan O’Leary, the Director for Polio Eradication at WHO, defended the ambitious goals, noting that ‘the only yardstick for an eradication program is zero.’ GPEI’s priority, he has explained, is to ‘find and vaccinate every last child. If we do that, poliovirus will have nowhere to hide.’

Germany: a long-standing partner in efforts to eradicate polio 

Germany has been a strong backer of polio eradication efforts for more than 30 years. As part of its contributions to GPEI, the Federal Ministry of Economic Cooperation and Development (BMZ) has also provided bilateral support through KfW Development Bank to Afghanistan, India, Nigeria and Pakistan in the fight against polio.

As the third-largest donor to polio eradication efforts, Germany welcomes this new strategy which seeks to inject renewed urgency into the fight against polio by increasing accountability and country ownership, broadening and strengthening partnerships, and ensuring that all available opportunities are used to immunise children in both endemic and polio-free regions. It endorses the new strategy’s focus on enhancing collaboration and partnerships at all levels of the polio programme in the quest to find and vaccinate every last child. 

‘We can achieve a lot if we jointly commit ourselves,’ noted Dr Gerd Müller, Germany’s Minister for Economic Cooperation and Development, in response to the certification of Africa as wild poliovirus-free. The new strategy’s call for greater collective ownership of polio eradication efforts is squarely in line with Germany’s commitment to multilateral cooperation in pursuit of shared goals.

Greater ownership, and deeper engagement with communities 

Although polio was designated as a Public Health Emergency of International Concern in 2014, it does not always receive the attention it deserves in relation to other health challenges and threats. Reasserting the importance of polio as a top health priority is another one of the major objectives of the new strategy. This will include, among others, systematic political advocacy to gain and sustain access to communities in southern areas of Afghanistan where restrictions on house-to-house campaigns have left some children with no access to essential immunisations. Intensified advocacy with national and provincial authorities in Pakistan ensure that commitment to the polio programme remains high.

Misconceptions and misinformation about vaccines have contributed to widespread vaccinehesitancy, particularly in Pakistan. To overcome these challenges, the new strategy places particular emphasis on understanding what drives mistrust in vaccines and on developing differentiated approaches which engage local leaders and other community stakeholders. It also foresees expanded cooperation with non-governmental organisations as a way to reach children in inaccessible and under-served areas.  

Integrating polio vaccine delivery with other health programs and initiatives

Under the new strategy, GPEI will also strengthen the integration of polio immunisations into other essential healthcare and community services – as opposed to delivering them solely through stand-alone campaigns – should help to improve both programme reach and cost effectiveness. 

A child is vaccinated as part of national polio and measles vaccination campaign in Mogadishu, Somalia on Tuesday 01 September 2020
A child is vaccinated as part of national polio and measles vaccination campaign in Mogadishu, Somalia on Tuesday 01 September 2020

This shift towards greater integration will require a deepening and broadening of partnerships between GPEI and other programmes and health initiatives, including the Expanded Programme on Immunization (EPI) and Gavi, the Vaccine Alliance, whose work is also supported by Germany. Close cooperation with Gavi is already well underway: at least one dose of inactivated polio vaccine (IPV) has been integrated into the routine immunisation schedules in all Gavi supported countries. This is particularly important for maintaining immunisation levels necessary to sustain polio eradication once it has been achieved.

From 99% to 100% polio-free

The measures outlined in the Polio Eradication Strategy 2022-2026 will go a long way towards making GPEI ‘fit for purpose’ to travel the last mile in the fight against polio. The COVID-19 pandemic poses a significant threat to the achievement of this goal, however, and places decades of concerted effort at risk. This is why greater collective ownership of polio eradication efforts is needed now more than ever in order to finish the job.

Karen Birdsall, June 2021

© WHO Afghanistan/Roya Haidari
© WHO Somalia/Ismail Taxta
© Ismail Taxta / Ildoog/WHO SOMALIA
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