On 28-29 June 2022, the Global Commission for Certification of Poliomyelitis Eradication (GCC) met in-person in Geneva, Switzerland, to review the global criteria set for poliovirus certification. The work of the GCC, and the six Regional Certification Commissions (RCCs) is critical to independently verifying the achievement of a world free of all polioviruses. Five of six WHO Regions are certified wild poliovirus-free and two of three strains of wild poliovirus are certified as globally eradicated.
The GCC reviewed the latest global epidemiology, both of wild and vaccine-derived polioviruses (VDPVs), and examined remaining challenges such as subnational surveillance and immunity gaps, and recent and high-profile virus detections, including from Malawi, Mozambique, the UK, Israel and Ukraine.
The GCC noted the epidemiological opportunity that has presented itself in Pakistan and Afghanistan to finally interrupt wild poliovirus. The group cautioned, however, that any remaining immunity gap now poses a significant risk to success, as evidenced by the recent outbreak of wild poliovirus type 1 in North Waziristan, Khyber Pakhtunkhwa, Pakistan.
Recognizing programme advancements in genomic analysis and that widespread use of environmental surveillance in many countries means that confidence in achievement of eradication could come sooner than the traditional three years, the Commission concluded that the traditional approach to certification may no longer be justifiable to verify the absence of wild poliovirus transmission. Historically, Regions had to provide evidence of three years, without detection of wild poliovirus, from any source. Instead, the GCC is recommending the adoption of a ‘flexible’ approach to certification, by examining traditional surveillance indicators in a broader geo-political, area-specific context.
“The world has seen tremendous changes in this third decade of the 21st century, and the old rules may no longer necessarily apply,” commented Professor David Salisbury, Chair of the GCC. “We have to recognize that different geo-political realities affect countries – and subsequently health system performance – in very individual manners. Therefore, we must also look at each area in a very individual and targeted manner, to determine the most effective certification criteria that should be applied. Our aim must be clear: to fully verify, independently and in the most certain manner, that wild polioviruses have indeed been eradicated. And how to do that, is precisely what our group’s discussions this week have focused on.”
The aim of the global eradication effort is of course to ensure that no child will ever again be paralysed by any form of poliovirus, be it wild- or vaccine-derived. To this effect, another focus of the meeting was to discuss concrete criteria for the eventual verification of VDPVs, including the necessary timelines that might be needed without detection of circulating VDPV from any source, following the global cessation of use of oral polio vaccines from routine immunization programmes.
Dr Pascal Mkanda, Director for the Polio Eradication Programme in the World Health Organization’s Regional Office for Africa (AFRO), also famously known as our ‘villager in polio’, is this month (February 2022) entering a well-deserved retirement. Pascal’s contribution over the years to polio eradication in Africa, and indeed broader immunization, is second to none.
Under Pascal’s stewardship and leadership, wild polioviruses were successfully eradicated from the continent, the polio infrastructure integrated into broader public health efforts, new technologies and innovations for reaching the most marginalized children established and new vaccines successfully rolled-out. His expertise, knowledge, dedication, zeal, and passion to work and more importantly his mentorship to fellow colleagues and health workers to alleviate the lives of vulnerable children across the continent, will be sorely missed.
“I have worked with Pascal for close to 7 years, and during that time, I have witnessed first-hand Pascal’s dedication, and what he often refers to as ‘tough’ decision making, which we owe to the successes we have seen in the polio program” said Dr Matshidiso Moeti, WHO Regional Director for Africa.” My first interaction with Pascal was during the first meeting for Program Managers in the region, in Johannesburg, South Africa, in 2016. During this meeting Pascal expressed very passionately that the only way we can get results in Polio is by holding everyone accountable. To use his words, global health, very much like soccer, requires a coach to put his best players on the field. Throughout the continent, children are healthier and better protected from infectious diseases, most notably of course from polio, thanks to the tremendous efforts and tireless work of Pascal. This continent owes a huge debt of gratitude to Dr. Mkanda. On behalf of all mothers of Africa, I can simply only say one thing: Thank you, Pascal!”
“Rotary and Rotary members across Africa have been at the forefront in the fight against polio since President Nelson Mandela shouted his rallying call in 1996 to ‘Kick Polio Out of Africa’,” according to Dr Tunji Funsho, Chair of Rotary’s Nigeria National PolioPlus Committee and one of TIME Magazine’s 100 Most Influential People in 2020. “We went from 75,000 children paralyzed each year, all over Africa in 1996, to Zero wild polio cases since 2016. An unparalleled public health achievement, which could not have happened without Pascal’s leadership, engagement, and expertise. On behalf of Rotary members across Africa, Pascal – thank you so much for everything that you have done. We all wish you a more than well-deserved retirement.”
“I can only echo what others have already said,” commented Professor Rose Leke, Chair of the African Regional Certification Commission, which independently certified Africa as wild poliovirus free in 2020. “It was my great honour, and together with my fellow Commission Members, to certify our continent free of all wild polioviruses. Dr Mkanda and his team across the continent were absolutely instrumental in this. As Director of Polio in the Region, he exhibited great leadership. He and his team helped us verify the absence of wild poliovirus, even from the most inaccessible and remote areas of Africa. They helped ensure that children everywhere, no matter where they lived, were reached with the life-saving polio vaccine. Dr Mkanda demonstrated truly the best of Africa. All I can say is a tremendous ‘thank you’ to him and his team. I wish him well in all his future endeavours.”
Dr Mkanda’s career started from humble beginnings in a small and remote village, Chintheche in northern Malawi, with virtually no infrastructure. Pascal, son of a stay-home mother and a primary school teacher in Nkhata Bay, started making ‘tough decisions’ very early in life. At a tender age of 13, he and his elder brother Justin left their home on foot, and walked 18 miles with no shoes, to look for what would eventually be their family’s home in search of a better education for him and his siblings.
This was only the beginning of the ‘tough decision making’ that Dr Mkanda is well-known for today. The young Pascal Mkanda continued with his education and was eventually identified as his district’s best performing student. At the time, the president of Malawi, His excellency Dr Hastings Kamuzu Banda, had initiated a programme offering the brightest pupils (top 2.5%) from each district in Malawi irrespective of sex or socio-economic status, the opportunity to attend higher education, at the prestigious Kamuzu Academy, and through this educational opportunity, Dr Mkanda performed exceptionally and was awarded a full sponsorship to study Medicine in the United Kingdom where he attained a medical degree at the Imperial University College London.
To just show how intelligent he was – Pascal was afforded an opportunity to also study for a degree in microbiology/infectious diseases at the London School of Hygiene and Tropical Medicine while at the same time pursuing a degree in medicine. In later life he went to the Rollins School of Public Health at Emory University in Atlanta, USA, and obtained a Master of Public Health.
Putting his theoretical knowledge into practical experience, it was not long before Dr Mkanda began making a very real impact on Malawi’s public health system, improving the health and lives of remote communities. He rapidly developed a reputation for solid, practical and effective work. Here he developed the traits that would characterize his entire career and for which he became so respected: the courage of standing up for his convictions; an ability to identify and promote new and excellent talent, that would help him establish relevant and pragmatic support teams across the region; a fearless dedication to step out of group thinking even if it meant standing alone against adversity; and, an absolute and unwavering commitment to achieving results.
Respected by peers and more importantly communities themselves, he rapidly caught the attention of the international development community while working in some of the most remote communities in Malawi. During a visit by the USAID Mission in Malawi to Nsanje District Hospital in the south of Malawi, Dr Mkanda’s work caught the attention of the Country Representative who immediately recommended him for a USAID-sponsored Global Health Programme which subsequently led to the beginning of his international career.
Starting out as a National Programme Officer in Malawi for the World Health Organization, and moving on to Zambia as an international staff, he met and established a long-term friendship with Dr Francis Kasolo (former VPD Regional Virologist). By the year 2000, Dr Mkanda was managing immunization activities for Eastern and Central Africa and would eventually lead polio activities in Nigeria and Ethiopia.
It was during his time as WHO Polio team leader in Nigeria and Ethiopia that these countries were able to make significant inroads in interrupting wild polio transmission. One contributing factor for this achievement was the introduction of the famous accountability framework that held every staff accountable for their work with those underperforming being replaced by “fresh legs on the football field”, in Pascal’s own words.
It was therefore not a surprise that when the position of WHO African regional polio coordinator was advertised, that Dr Moeti – then the new Regional Director for Africa – appointed Pascal to lead the fight against this disease in the Region.
Never losing focus on the need to reach every last child with polio vaccines, with support from Dr Moeti and the Bill and Melinda Gates Foundation, Dr Mkanda established a regional center for the Geographic and Information Systems (GIS). According to Dr Joseph Cabore, Director of Programme Management at WHO’s African Regional Office: “One very critical contribution by Pascal to the regional office, is the introduction of innovative technologies and solutions. It’s amazing to see in real time, where our frontline workers can reach during mass campaigns and outreach activities. Pascal, thank you for ensuring that we remain accountable to our African children and their families.”
“It has been a privilege to work alongside Dr. Mkanda in pursuit of a polio-free world,” said Dr. Chris Elias, President of Global Development, the Bill & Melinda Gates Foundation. “His commitment and dedication to eradicating polio have been vital to helping protect millions of children from this debilitating disease and helped achieve a WHO African Region that is now free of wild polio – a monumental achievement in global health. I am forever grateful to Dr. Mkanda for his work and partnership on ending polio.”
Michael Galway, Deputy Director Polio at the Bill & Melinda Gates Foundation, added this personal comment: “Working with Pascal over the past decade has been one of best parts of the job in helping to get rid of polio in Africa. I’ve always appreciated the passion and conviction he’s brought to the work, and his keen understanding of how to get the polio programme to perform at its best in some of the most difficult places. He’s been a role-model and a friend, and I’m grateful for both!”
It was in Nigeria – for a long time the global epicentre for polio – that Pascal’s leadership really came into its own.
Dr Faisal Shuaib, Executive Director of the National Primary Healthcare Development Agency in Nigeria, said: “Pascal Mkanda’s contribution to making Nigeria free of wild poliovirus cannot be overstated. It took innovative strategies and approaches to ensure that every child could be reached, and virus transmission effectively tracked, in hard-to-reach and inaccessible areas. Pascal helped develop and trailblaze novel approaches which ultimately led to our success. It really took rewriting the strategic rulebook, and these approaches are now being implemented in other high-risk polio areas. All for the benefit of the most marginalized children. Thank you, Pascal, we could not have done it without you and your leadership. We will miss you!”
Indeed, it is this same leadership by Dr Mkanda that led to the establishment of the Rapid Response Team (RRT), coordinated by Dr Ndoutabe Modjirom in the WHO Regional Office in Brazzaville to tackle the remaining form of polio, the circulating vaccine-derived polioviruses (cVDPVs): “Pascal, you are leaving big shoes to fill. We will need your kind of leadership to end all remaining forms of polio in our region once and for all. It will not be easy to finish this job without you.”
Pascal will be missed, as underscored by Aidan O’Leary, Director for the Global Polio Eradication at WHO Geneva. “On behalf of all partners and stakeholders, the Global Polio Eradication Initiative wishes you all the very best in your retirement and/or in your next chapter of life. We know of course that you will stay engaged in one capacity or another in this fight, and we look forwards to one day, very soon, to celebrate together with you the victory over all forms/types of polio worldwide once and for all. A big thank you, in particular for your leadership in certifying the Region free of wild polioviruses and for facilitating the introduction and roll-out of novel oral polio vaccine type 2.”
Congratulations on your retirement! Now you’ll have more time for sleeping in, fishing, reading, golfing and if you want to be a DJ-from G22, where it all started!
Shine on, le Mystique Dr Mkanda!
Before polio vaccines existed, polio affected thousands of children around the world every year. Not so long ago it was common for a healthy child to suddenly be unable to walk, and those who were fortunate enough to recover from the disease were left with lifelong sequelae. Those less fortunate spent their days in hospital wards hooked up to huge machines — known as steel lungs — that allowed them to keep breathing. Many others lost their lives. Polio was endemic in all countries, and when there was an outbreak, communities had to close schools and other public spaces to protect the children.
Discovery of the polio vaccine in the mid-1950s changed the world forever. Once vaccinations began, the disease quickly started to wane. It was clear that vaccines worked, and that they could be used to prevent the disease. After several countries succeeded in controlling polio, leaders decided that eliminating polio permanently was possible, but only if it was done in a coordinated way in all countries of the Region. And so, in 1985, all the Region’s countries committed to eradicating polio. In 1988, the rest of the world joined this massive effort.
The political commitment to end the disease was furthered by the work of vaccinators, who travelled to the farthest reaches of the continent, by land, sea, and air, so that no one would be left unvaccinated. Along with these efforts, on-site personnel worked to investigate all probable cases, one by one; laboratory staff worked to confirm the absence of cases; and numerous other health workers helped in combating the disease, so that no one would ever again suffer from polio. Participating in this great effort were community leaders, politicians at all levels, partnerships with international organizations, and parents who were convinced that vaccination saves lives.
In 1991, in a show of Pan-Americanism and commitment to health, the countries of the Americas conquered polio, and the Americas became the first world region to eliminate the disease.
It is not enough, however, to have eliminated the disease in the Region, because as long as there are cases somewhere in the world, all children remain at risk. Keeping the Region polio-free for 30 years has been a titanic effort, one requiring that all children be vaccinated against the disease, while at the same time maintaining sensitive surveillance systems, an increasingly challenging task given the range of other health priorities.
Today we are closer than ever to eradicating polio worldwide. However, the COVID-19 pandemic has significantly affected health services around the world, including routine vaccination and epidemiological surveillance of vaccine-preventable diseases, putting at risk the progress achieved.
Health workers around the world must commit to completing the eradication process. Today more than ever, we must learn from past experiences and, with renewed determination, look to the future to fulfill the promise of a world permanently free of polio
In 1996, wild poliovirus was paralysing more than 75 000 children in the African Region every year, and Nelson Mandela and Rotary International issued a call to “Kick Polio Out of Africa!” The task was daunting. Polio staff had to deal with highly mobile populations, restricted access to children because of conflict and insecurity, fragile health systems and a fast-moving virus. Nigeria, as recently as 2012, accounted for more than half of all wild polio cases worldwide.
Ridding Africa of the wild poliovirus in the face of such daunting obstacles was, in the words of WHO Director-General Dr Tedros Adhanom Ghebreyesus, “one of the greatest public health achievements of our time”. It is an achievement built on the dedication of health workers – mainly women – who traveled by every available means – foot, car, boat, bike and more – to reach children with the polio vaccine.
One of the greatest public health achievements of our time.
One of those workers, Lami Isah Kyadawa, supported polio “immunization plus days” for almost 12 years before joining the network of volunteer community mobilizers in Sokoto State, Nigeria, in 2015. In her time fighting polio, she has overcome vaccine hesitancy, countered misinformation and even lost the sight in one eye in an accident returning from a polio mobilization campaign. But, for Lami, the sacrifices have all been worth it:
“It makes me proud to know that I was part of those that ensured the eradication of polio came to pass in Nigeria and now we can focus on improving routine immunization and other diseases.”
Eradicating wild polio in the African Region is a monumental feat, not just because of the scale of the task but because of the coordination and leadership required at all levels of the Global Polio Eradication Initiative (GPEI) to get the job done. It involved strategists with imagination, who found solutions to reaching children in regions rife with conflict and insecurity. It required constant surveillance to test cases of paralysis and check sewage for the virus, and it relied upon the commitment of all 47 countries in the African Region.
Since 1996, nine billion doses of oral polio vaccine have been provided, averting an estimated 1.8 million cases of wild poliovirus on the continent. Building on this success, countries in the African Region are now using the polio eradication infrastructure’s robust immunization and surveillance capacities to strengthen their health systems. The infrastructure, with thousands of health workers and volunteers, community and religious leaders, parents and families mobilized to “Kick Polio Out of Africa”, provides a strong foundation for countering other public health threats.
Responding to the pandemic and laying a foundation for the future
Long before the coronavirus pandemic, stopping wild polio brought far-reaching benefits beyond saving children from paralysis, including protecting them from other vaccine-preventable diseases and detecting and responding to outbreaks.
Thus, when COVID-19 struck, the GPEI’s staff and infrastructure were in place and equipped to be the first to respond. Thousands of polio workers in the WHO’s African, Eastern Mediterranean and South-East Asian Regions shifted their focus to COVID-19. Polio emergency operation centres quickly adapted to respond to the pandemic through surveillance, contact tracing and specimen transport, provision of soap and hand sanitizer, distribution of training materials for medical personnel and front-line workers and coordinated engagement with community and religious leaders and media on mitigation measures.
Polio staff have long been the eyes and ears of national health systems. In one example, polio laboratories in Pakistan provided COVID-19 testing and sequencing, while the polio eradication call centre became (and remains) the national COVID-19 hotline, dealing with up to 70 000 calls a day
Polio staff trained more than 18 600 health professionals, and polio community mobilizers engaged 7000 religious leaders and 26 000 influencers to provide information on COVID-19 to their communities. Through messaging applications, mosque announcements and public address systems on motorbikes and rickshaws, polio community outreach networks have reached millions of households.
How polio staff in Pakistan shifted their focus to COVID-19:
The pandemic has shown that the polio network can continue to serve other public health programmes, especially in health emergencies. For instance, in Pakistan, active polio surveillance at high-priority sites helped to confirm more than 1000 COVID-19 cases, more than 4400 suspected cases and nearly 500 probable cases. Staff have also used their expertise in data management to improve the quality and timeliness of data during the pandemic. This adaptable skill set makes polio personnel invaluable to health systems and communities.
Looking ahead, transition of polio personnel and infrastructure into public health systems is being planned in countries with large polio eradication programmes, led by national authorities. In places where there is insufficient national capacity, critical immunization, disease detection, emergency preparedness and response capacities will be supported by WHO’s immunization and emergencies programmes until national authorities can fully take over. Sustaining these capacities will require sustainable funding, but, as Africa’s remarkable achievement confirms, the wisdom of investing in polio eradication and sustaining its legacy is clear, as the networks set up for polio eradication will prove vital to advancing global public health security and achieving healthier populations.
Paralympic medalist and TV presenter Ade Adepitan, who co-hosts this year’s programme, says that the eradication of wild polio in Africa was personal for him. “Since I was born in Nigeria, this achievement is close to my heart,” says Adepitan, a polio survivor who contracted the disease as a child. “I’ve been waiting for this day since I was young.”
He notes that, just a decade ago, three-quarters of all of the world’s polio cases caused by the wild virus were contracted in Africa. Now, more than a billion Africans are safe from the disease. “But we’re not done,” Adepitan cautions. “We’re in pursuit of an even greater triumph — a world without polio. And I can’t wait.”
Rotary Foundation Trustee Geeta Manek, who co-hosts the programme with Adepitan, says that World Polio Day is an opportunity for Rotary members to be motivated to “continue this fight.”
She adds, “Rotarians around the world are working tirelessly to support the global effort to end polio.”
Now that the World Health Organization (WHO) has declared that its African region is free of the wild poliovirus, five of the WHO’s six regions, representing more than 90 percent of the world’s population, are now free of the disease. It is still endemic in Afghanistan and Pakistan, both in the WHO’s Eastern Mediterranean region.
“This effort required incredible coordination and cooperation between governments, UN agencies, civil organizations, health workers, and parents,” says Manek, a member of the Rotary Club of Muthaiga, Kenya. “I’m proud of what we’ve accomplished.”
A collective effort
Dr. Tunji Funsho, chair of Rotary’s Nigeria PolioPlus Committee and a member of the Rotary Club of Lekki Phase 1, Lagos State, Nigeria, tells online viewers that the milestone couldn’t have been reached without the efforts of Rotary members and leaders in Africa and around the world.
“Polio eradication is truly a collective effort … This accomplishment belongs to all of us,” says Funsho.
Rotary and its members have contributed nearly $890 million toward polio eradication efforts in the African region. The funds have allowed Rotary to award PolioPlus grants to fund polio surveillance, transportation, awareness campaigns, and National Immunization Days.
This year’s World Polio Day Online Global Update is streamed on Facebook in several languages and in a number of time zones around the world. The programme, which is sponsored by the Bill & Melinda Gates Foundation, features Jeffrey Kluger, editor at large for TIME magazine; Mark Wright, TV news host and member of the Rotary Club of Seattle, Washington, USA; and Angélique Kidjo, a Grammy Award-winning singer who performs her song “M’Baamba.”
The challenges of 2020
It’s impossible to talk about 2020 without mentioning the coronavirus pandemic, which has killed more than a million people and devastated economies around the world.
In the programme, a panel of global health experts from Rotary’s partners in the Global Polio Eradication Initiative (GPEI) discuss how the infrastructure that Rotary and the GPEI have built to eradicate polio has helped communities tackle needs caused by the COVID-19 pandemic too.
“The infrastructure we built through polio in terms of how to engage communities, how to work with communities, how to rapidly teach communities to actually deliver health interventions, do disease surveillance, et cetera, has been an extremely important part of the effort to tackle so many other diseases,” says Dr. Bruce Aylward, Senior Adviser to the Director General at the WHO.
Panelists also include Dr. Christopher Elias, President of the Global Development Division of the Bill & Melinda Gates Foundation; Henrietta H. Fore, Executive Director of UNICEF; and Rebecca Martin, Director of the Center for Global Health at the U.S. Centers for Disease Control and Prevention.
Elias says that when there are global health emergencies, such as outbreaks of other contagious diseases, Rotarians always help. “They take whatever they’ve learned from doing successful polio campaigns that have reached all the children in the village, and they apply that to reaching them with yellow fever or measles vaccine.”
Theprogramme discusses several pandemic response tactics that rely on polio eradication infrastructure: Polio surveillance teams in Ethiopia are reporting COVID-19 cases, and emergency operation centers in Afghanistan, Nigeria, and Pakistan that are usually used to fight polio are now also being used as coordination centers for COVID-19 response.
The online programme also includes a video of brave volunteer health workers immunizing children in the restive state of Borno, Nigeria, and profiles a community mobilizer in Afghanistan who works tirelessly to ensure that children are protected from polio.
Kluger speaks with several people, including three Rotary members, about their childhood experiences as “Polio Pioneers” — they were among more than a million children who took part in a huge trial of Jonas Salk’s polio vaccine in the 1950s.
The future of the fight against polio
Rotary’s challenge now is to eradicate the wild poliovirus in the two countries where the disease has never been stopped: Afghanistan and Pakistan. Routine immunizations must also be strengthened in Africa to keep the virus from returning there. The polio partnership is working to rid the world of all strains of poliovirus, so that no child is affected by polio paralysis ever again.
To eradicate polio, multiple high-quality immunization campaigns must be carried out each year in polio-affected and high-risk countries. During the COVID-19 pandemic, it is necessary to maintain populations’ immunity against polio while also protecting health workers from the coronavirus and making sure they don’t transmit it.
Rotary has contributed more than $2.1 billion to polio eradication since it launched the PolioPlus programme in 1985, and it’s committed to raising $50 million each year for polio eradication activities. Because of a 2-to-1 matching agreement with the Bill & Melinda Gates Foundation, each year, $150 million goes toward fulfilling Rotary’s promise to the children of the world: No child will ever again suffer the devastating effects of polio.
He is the first Rotary member to receive this honor for work toward eradicating polio.
A Rotarian for 35 years, Funsho is a member of the Rotary Club of Lekki, Nigeria, past governor of District 9110, and serves on Rotary’s International PolioPlus Committee. Funsho is a cardiologist and a fellow of the Royal College of Physicians of London. He lives in Lagos, Nigeria with his wife Aisha. They have four children; Habeeb, Kike, Abdullahi and Fatima; and five grandchildren.
TIME 100 comprises individuals whose leadership, talent, discoveries, and philanthropy have made a difference in the world. Past honorees include Bono, the Dalai Lama, Bill Gates, Nelson Mandela, Angela Merkel, Oprah Winfrey, and Malala Yousafzai.
After the World Health Assembly passed a resolution to eradicate polio worldwide in 1988, the Global Certification Commission led the way in establishing a formal certification process, asking each of the six WHO regions to set up a Regional Certification Commission. Then in 1996, the WHO Regional Director for Africa created the Africa Regional Certification Commission (ARCC) for Polio Eradication: a 16-person independent body tasked with overseeing this process, and later on containment activities in the African region.
Professor Rose Leke, an infectious disease specialist, has been the chairperson of the ARCC since it was set up in 1998. A trailblazer for women in global health, Leke has fought throughout her career to improve women’s representation in science and global health leadership. In 2018, she was one of nine women honored with a Heroine of Health award, recognizing her outstanding contribution to health care.
Stopping the ‘havoc’ of polio in Africa
Professors Leke explains her motivation to join the polio eradication cause, “When I was invited to be part of the ARCC in 1998, I was not involved in any polio-related work. But I could see the havoc that polio was reaping on the continent. I had a nephew who was paralyzed from polio and suffered brain damage, and another relative who contracted polio and continues to inspire me. Back then, you saw so many paralyzed young people on the streets. You don’t see that today.”
Ridding the African continent of wild poliovirus is a huge achievement, many years in the making. Nigeria, the last bastion of the wild virus, proved a particularly tough setting in which to vaccinate every child and ensure that no trace of the virus remained.
Professor Leke reflects, “It’s been such a long road. When Nigeria didn’t report any cases of wild polio for two years between 2014 to 2016, we were apprehensive but satisfied. We were so close to eradication as a region, everything was going so well, and then wild polio was reported again in Nigeria in August 2016, and certification had to go on the back burner.”
“The Nigerian response to their outbreaks has been extraordinary. Everyone is committed and highly involved. In Sokoto and Kano states, where I was recently for a field verification visit, and in all other states, everyone – from government officials, traditional leaders, health staff and field teams, community health workers and informants, polio survivors to traditional birth attendants – was heavily engaged in the response. The innovative technologies that have emerged have similarly been incredible. The Nigerian Emergency Operations Centre is a well-coordinated structure that is behind Nigeria’s success. Other disease programs in Africa are learning from this.”
Personal commitment to end polio
Professor Leke never lost her drive to end polio, even during difficult years and despite the tough choices her role sometimes presented.
“When we started, we were aiming for wild polio to be eradicated by 2000; the thought of this success really kept me motivated and still does. At times it has been a huge sacrifice; as Temporary Advisers, ARCC members are not paid, and I’ve sometimes given up consultancies to do this work. My husband, children and grandchildren will tell you, there was a huge amount of traveling and many meetings. But I don’t regret the time spent for a moment on such a cause.”
“When Dr Moeti was appointed as WHO Africa Regional Director in 2011, this was further motivation to continue: I wanted to support a fellow woman. In the beginning, I was the only female in the Global Certification Commission. The commission has addressed this imbalance and we are now two females out of the six members. We need more women in senior positions on the African continent.”
Fighting for gender equality in global health and science
In 2011, Professor Leke won the Kwame Nkrumah Award for the best female scientist in Central Africa for her research on malaria. As part of her acceptance of the award, she took a pledge “to help promote the participation of women in science in Cameroon.”
Within a year, she had helped set up HIGHER Women, a mentoring programme for senior female scientists to deliver hard and soft skills training to their early career counterparts. To support the programme, Professor Leke contributed some of her own funds.
Professor Leke says, “As a woman I encountered blocks on the way during my career – at times men asked me to leave the laboratory space I was working in.”
“Science can be a pyramid – there are many early women researchers, but far fewer at the top of the field. Research and academia have a ‘publish or perish’ culture which disadvantages women who have responsibilities outside of the lab – such as raising a family.”
Professor Leke has continually used her position to promote women in science and global health, even sharing her favorite motivational track about women’s empowerment.
Whilst great progress towards gender balance has been made since she started her career, Professor Leke is firm in noting that there is more to do. In the African regional polio programme, women still lead only a small number of national committees.
A lasting legacy
Professor Leke is proud of the public health legacy that the polio eradication programme will leave in the African region. She says, “The polio response has brought many skilled technicians into Africa’s health systems. The GPEI paved the way for working closely with traditional healers and community leaders and has really helped to strengthen the systems that report on other diseases. The polio laboratory network is being used for other diseases, giving capacity in the region for doing all sorts of other diagnostics. You’ll find the one person in the health center who was there for polio is reporting on many other diseases.”
“After we declare Africa as free of the wild poliovirus, the ARCC will work with countries to ensure they keep up good quality surveillance, and improve routine immunization, keeping population immunity as high as possible. We will also continue to guide countries in continuing to monitor population immunity to prevent importations of wild poliovirus from outside the African region, while ensuring that the threat of circulating vaccine derived polio viruses (cVDPVs) is addressed.”
“Our work continues until all forms of polio have been eradicated globally.”
GENEVA, 25 August 2020 – Today, the Africa Regional Certification Commission certified the WHO African Region as wild polio-free after four years without a case. With this historic milestone, five of the six WHO regions – representing over 90% of the world’s population – are now free of the wild poliovirus, moving the world closer to achieving global polio eradication.
Only two countries worldwide continue to see wild poliovirus transmission: Pakistan and Afghanistan.
The Global Polio Eradication Initiative (GPEI) congratulates the national governments of the 47 countries in the WHO African Region for today’s achievement.
“Ending wild polio virus in Africa is one of the greatest public health achievements of our time and provides powerful inspiration for all of us to finish the job of eradicating polio globally,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “I thank and congratulate the governments, health workers, community volunteers, traditional and religious leaders and parents across the region who have worked together to kick wild polio out of Africa.”
Strong leadership and innovation were instrumental in stopping the wild poliovirus in the region. Countries successfully coordinated their efforts to overcome major challenges to immunizing children, such as high levels of population movement, conflict and insecurity restricting access to health services, and the virus’s ability to spread quickly and travel across borders.
In addition, the continued generosity and shared commitment of donors – including governments, the private sector, multilateral institutions and philanthropic organizations – to achieving a polio-free world helped build the infrastructure that enabled the African region to reach more children than ever before with polio vaccines and defeat wild polio.
“During a challenging year for global health, the certification of the African region as wild poliovirus-free is a sign of hope and progress that shows what can be accomplished through collaboration and perseverance,” said Rotary International President Holger Knaack. “Since 1996, when Nelson Mandela joined with Rotary, the Global Polio Eradication Initiative, and governments of the African region we’ve achieved something remarkable. Today’s milestone tells us that polio eradication is possible, as long as the world remains committed to finishing the job. Let us work together to harness our collective energies to overcome the remaining challenges and fulfil our promise of a polio-free world.”
The resources and expertise used to eliminate wild polio have significantly contributed to Africa’s public health and outbreak response systems. The polio programme provides far-reaching health benefits to local communities, from supporting the African region’s response to COVID-19 to bolstering routine immunization against other vaccine-preventable diseases.
While this is a remarkable milestone, we must not become complacent. Continued commitment to strengthening immunization and health systems in the African region is essential to protect progress against wild polio and to tackle the spread of type 2 circulating vaccine-derived poliovirus (cVDPV2), which is present in 16 countries in the region. Pockets of low immunity mean such strains continue to pose a threat and the risk is magnified by interruptions in vaccination due to COVID-19, which have left communities more vulnerable to cVDPV2 outbreaks.
The GPEI calls on countries and donors to remain vigilant against all forms of polio. Until every strain is eradicated worldwide, the incredible progress made against polio globally will be at risk.
The WHO African Region’s success against wild polio has shown the world that progress against some of the biggest global health challenges is possible. The GPEI is grateful for every person, partner, donor and country who helped bring about this incredible achievement.
Communications Officer, World Health Organization
Tel: +41 79 500 6536
The Global Polio Eradication Initiative is a public-private partnership led by national governments with six core partners – the World Health Organization (WHO), Rotary International, the US Centers for Disease Control and Prevention (CDC), UNICEF, the Bill & Melinda Gates Foundation and Gavi, the Vaccine Alliance.
For information and multimedia content on the WHO African Region’s efforts to eradicate wild polio, please visit africakicksoutwildpolio.com.
The WHO African Region is expected to be certified free of wild poliovirus on 25 August 2020. Chair of the WHO’s International Health Regulations Emergency Committee and of the AFRO Regional Immunization Technical Advisory Group Helen Rees explains the current cVDPV situation in Africa and its implications ahead of regional wild polio-free certification.
Q. Fifteen countries (as of 14 August 2020) in the World Health Organization’s African region have reported cases of circulating vaccine-derived polio type 2 (cVDPV2) in 2020. The total number of outbreak countries is 16. How does that impact the region’s upcoming wild polio-free certification?
First, it’s important to clarify that cVDPV is a different virus from the wild poliovirus, and will undergo a separate process to validate its absence once wild polio has been eradicated globally.
Second, I want to underscore that the ongoing cVDPV2 outbreaks in Africa do not affect the programme’s confidence that wild polio is gone from the region. Certification is backed by extensive data and a thorough evaluation process that demonstrates wild polio transmission has been interrupted on the continent.
In Africa, an independent body of experts called the African Regional Certification Commission for polio eradication (ARCC) oversees this process by carefully reviewing country documentation and analyzing the quality of surveillance systems and immunization coverage. With this intensive monitoring of polio programmes across the continent, the ARCC is able to confirm with 100% certainty that wild polio is gone from the region.
But for the ARCC, national polio programmes and GPEI partners, the work does not end here. Stopping cVDPVs remains an urgent priority. African countries will need to strengthen their efforts to reach all children with polio vaccines to protect them from cVDPVs and any importation of wild polio from the remaining endemic countries, Pakistan and Afghanistan.
How do cVDPV outbreaks happen?Andwhy has the number of cVDPV cases in Africa increased more rapidly in the past couple years while wild cases have not?
cVDPVs can occur if not enough children receive the polio vaccine. In under-immunized populations, the live weakened virus in the oral polio vaccine (OPV) can pass between individuals and, over time, change to a form that can cause paralysis—resulting in cVDPV cases. This means that the cVDPV outbreaks we’re seeing today are revealing pockets across the continent where immunization rates are too low.
The reason for the increase in cases can be explained by low immunity to type 2 poliovirus, which causes the vast majority of cVDPV cases. This is in part due to a global vaccine switch that occurred in 2016, when countries stopped using the trivalent OPV (which protects against all three forms of polio) and replaced it with the bivalent OPV (which protects against just type 1 and 3).
The GPEI, following the advice of the Strategic Advisory Group of Experts, decided to make this vaccine switch based on extensive evidence that showed it would decrease the number of cVDPV outbreaks. However, immunity to type 2 poliovirus was lower than predicated at the time of the switch and so there were actually more cVDPV2 outbreaks. In response to the cVDPV2 outbreaks monovalent oral polio vaccine type 2 (mOPV2) has been used to interrupt transmission. But with increasing numbers of children who do not have type 2 immunity, mOPV2 vaccines have had to be used longer and in larger quantities than was initially anticipated. This larger and more extensive use of mOPV2 vaccines has seeded new outbreaks especially in areas of low immunization coverage and on the borders of outbreak response zones.
All this said, mOPV2 is an effective tool to stop cVDPV outbreaks if children are properly immunized.
If cVDPV outbreaks can only affect under-immunized communities, doesn’t the increasing number of outbreaks indicate that polio immunity levels are too low across the region? Why were countries able to stop wild polio then?
For years, the wild poliovirus has only existed in a small area on the continent. Nigeria reported its last case of paralysis due to wild polio four years ago, but most other countries haven’t seen a wild polio case in quite some time.
Across the continent, population immunity levels to type 1 polio (the only type of wild polio that remains in the world) and surveillance networks have continued to protect against any wild polio importation from remaining wild polio endemic countries.
However, the increasing number of cVDPV outbreaks across Africa is a reminder that countries cannot afford to let their guard down, and must continue reaching every child with the polio vaccine.
What is the programme doing to address cVDPVs in Africa?
The same tactics that stop wild polio can be used to stop cVDPVs – high vaccination coverage and strong surveillance. The polio programme in Africa has proven experience and strategies to address cVDPV outbreaks. But we know that we cannot rely only on existing tactics, which is why the programme is innovating and adapting its strategies to address the challenge of cVDPVs specifically.
In early 2020, the GPEI released a comprehensive new strategy to stop cVDPV outbreaks currently affecting countries in Africa, Asia and the Middle East.
This includes revising outbreak response standard operating procedures to improve response time, doubling the size of the African Rapid Response Team, forming a global Rapid Response Team and prioritizing the GPEI’s ground presence in high-risk areas.
To raise immunization coverage, the GPEI partners – including Gavi, the Vaccine Alliance – are working to build and strengthen immunization systems in at-risk countries and expand routine immunization with the inactivated polio vaccine (IPV).
The strategy also includes the development of an additional tool to help stop cVDPV2 outbreaks – novel oral polio vaccine type 2 (nOPV2). nOPV2 is a modified version of the existing mOPV2 used to respond to cVDPV2 outbreaks that is less likely to change to a form that can cause paralysis.
The GPEI is confident that with strengthened commitment from country governments and full implementation of the tactics laid out in its strategy, cVDPVs can be wiped out across Africa.
Has COVID-19 affected the programme’s ability to stop cVDPV outbreaks in the region?
The recent pause in house-to-house polio campaigns to help control the spread of COVID-19 is expected to increase cVDPV transmission across affected countries.
The GPEI is taking a number of steps to get back on track. Even while campaigns were paused, surveillance activities continued so that as immunization activities ramp up the programme can target campaigns in areas that are most at risk.
The GPEI recently recommended that all countries with active polio transmission resume vaccination activities as soon as it is safe to do so, in line with WHO and national COVID-19 guidance. Burkina Faso and Angola were among the first countries to start implementing cVDPV outbreak response campaigns after the pause.
These campaigns are closely following safety guidelines and social distancing measures to protect communities and health workers against COVID-19. Measures including the use of masks and gloves, frequent handwashing and no-touch vaccination.
COVID-19 undoubtedly represents a setback for polio eradication, but not the first one the programme has faced. The GPEI and African countries’ national polio programmes are committed to ensuring that countries are ready to tackle the remaining challenge of cVDPVs and to recover lost ground once polio activities can safely ramp up.
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25 October 2019, Geneva, Switzerland
My fellow Polio Eradicators,
Yesterday was World Polio Day, a global awareness-raising day on the need to complete the job of polio eradication, and here at the World Health Organization (WHO) headquarters, it was my great honour to make a truly phenomenal announcement: that wild poliovirus type 3 has been certified as globally eradicated, by the Global Commission for the Certification of Poliomyelitis Eradication.
This is the second of the three types of wild poliovirus to have been globally eradicated. Only wild poliovirus type 1 remains in circulation, in just two countries worldwide. Africa has not detected any wild poliovirus of any type since September 2016, and the entire African Region is eligible to be certified free of all wild poliovirus next June.
Global wild poliovirus type 3 eradication is a tremendous achievement and is an important milestone on the road to eradicate all poliovirus strains. This shows us that the tactics are working, as individual family lines of the virus are being successfully knocked out.
But the job is not finished until ALL strains of poliovirus are fully eradicated – and stay eradicated. We must achieve final success or face the consequences of renewed global resurgence of this ancient scourge. We must eradicate the remaining strains of WPV1 and also address the increasing circulating vaccine-derived poliovirus outbreaks, in particular in Africa.
And here too we are making strong inroads. New strategies are helping us reach the most vulnerable populations, particularly in the remaining reservoir areas. New tools, including a brand-new vaccine, are being developed, to ensure the long-term risk of vaccine-derived polioviruses can be comprehensively addressed.
But these tools and tactics only work if they are fully funded, and fully implemented.
And so today, on the day after this tremendous announcement, I really have two messages for you.
The first is a simple and whole-hearted ‘thank you’. Thank you for making a world free of wild poliovirus type 3 a reality. Thank you to all countries, to all donors, to all stakeholders, partners, advisory and oversight groups, policy makers, Rotarians. Most importantly, thank you to all communities, to all parents. To all frontline health workers. They are the real heroes of this achievement.
And my second message is: please do not stop now. The Reaching the Last Mile Forum, hosted in the United Arab Emirates this November by His Highness Sheikh Mohamed bin Zayed Al Nahyan, Crown Prince of the Emirate of Abu Dhabi, will provide an opportunity for many of our stakeholders to recommit their efforts to a polio-free world. I urge all of you to stay committed and redouble determination in this final push to the finish line.
Together, the partners of the Global Polio Eradication Initiative (GPEI) – WHO, Rotary International, the US Centers for Disease Control and Prevention, UNICEF, the Bill & Melinda Gates Foundation and Gavi, the Vaccine Alliance – stand ready to support this global effort. But it will take collective and global collaboration, from all public- and private-sector stakeholders, to ensure every last child is reached and protected from all polioviruses.
Together, let us achieve history: let us ensure that no child anywhere will ever again by paralysed by any poliovirus.
24 October 2019 – In a historic announcement on World Polio Day, an independent commission of experts concluded that wild poliovirus type 3 (WPV3) has been eradicated worldwide. Following the eradication of smallpox and wild poliovirus type 2, this news represents a historic achievement for humanity.
“The achievement of polio eradication will be a milestone for global health. Commitment from partners and countries, coupled with innovation, means of the three wild polio serotypes, only type one remains,” said Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization and Chair of the Global Polio Eradication Initiative (GPEI) Polio Oversight Board “We remain fully committed to ensuring that all necessary resources are made available to eradicate all poliovirus strains. We urge all our other stakeholders and partners to also stay the course until final success is achieved,” he added.
There are three individual and immunologically-distinct wild poliovirus strains: wild poliovirus type 1 (WPV1), wild poliovirus type 2 (WPV2) and wild poliovirus type 3 (WPV3). Symptomatically, all three strains are identical, in that they cause irreversible paralysis or even death. But there are genetic and virologic differences which make these three strains three separate viruses that must each be eradicated individually.
WPV3 is the second strain of the poliovirus to be wiped out, following the certification of the eradication of WPV2 in 2015. The last case of WPV3 was detected in northern Nigeria in 2012. Since then, the strength and reach of the eradication programme’s global surveillance system has been critical to verify that this strain is truly gone. Investments in skilled workers, innovative tools and a global network of laboratories have helped determine that no WPV3 exists anywhere in the world, apart from specimens locked in secure containment.
At a celebration event at the headquarters of the World Health Organization in Geneva, Switzerland, Professor David Salisbury, chair of the independent Global Commission for the Certification of Poliomyelitis Eradication, presented the official certificate of WPV3 eradication to Dr Adhanom Ghebreyesus. “Wild poliovirus type 3 is globally eradicated,” said Professor Salisbury. “This this is a significant achievement that should reinvigorate the eradication process and provides motivation for the final step – the eradication of wild poliovirus type 1. This virus remains in circulation in just two countries: Afghanistan and Pakistan. We cannot stop our efforts now: we must eradicate all remaining strains of all polioviruses. We do have good news from Africa: no wild poliovirus type 1 has been detected anywhere on the continent since 2016 in the face of ever improving surveillance. Although the region is affected by circulating vaccine-derived polioviruses, which must urgently be stopped, it does appear as if the continent is free of all wild polioviruses, a tremendous achievement.”
Eradicating WPV3 proves that a polio-free world is achievable. Key to success will be the ongoing commitment of the international development community. To this effect, as part of a Global Health Week in Abu Dhabi, United Arab Emirates, in November 2019, the Reaching the Last Mile Forum will focus international attention on eradication of the world’s deadliest diseases and provide an opportunity for world leaders and civil society organizations, notably Rotary International which is at the origin of this effort, to contribute to the last mile of polio eradication. The GPEI 2019–2023 Investment Case lays out the impact of investing in polio eradication. The polio eradication efforts have saved the world more than US$27 billion in health costs since 1988. A sustained polio-free world will generate further US$14 billion in savings by 2050, compared to the cost countries would incur for controlling the virus indefinitely.
With no wild poliovirus type 3 detected anywhere in the world since 2012, the Global Commission for the Certification of Poliomyelitis Eradication (GCC) is anticipated to officially declare this strain as globally eradicated. This would be a significant milestone in the global effort to rid the world of all poliovirus strains and ensure that no child will ever again be paralysed by any poliovirus anywhere.
In anticipation of this announcement, on 24 October 2019 – World Polio Day – the Global Polio Eradication Initiative is organizing a celebratory event marking this achievement, to be held in the Executive Board at the World Health Organization (WHO) headquarters, in Geneva, Switzerland, from 17.30-18.30hrs (central European time).
The event will bring together WHO Director-General and Chair of the Polio Oversight Board (POB) Dr Tedros Adhanom Ghebreyesus, GPEI partners, the Chair of the GCC Professor David Salisbury, Rotary International, donors and representatives from key countries.
The GPEI partners would be pleased to welcome all stakeholders personally to this event. Registration details.
Stakeholders unable to participate personally are invited to participate in the event via live web-streaming, via WebEx.
Meeting number: 846 266 504
Join by phone: +41-43456-9564
21 August 2019 marks three years since Nigeria last reported a case of wild poliovirus. This is an important public health milestone for the country and the entire Africa Region, which is now a step now closer to polio-free certification.
At the press conference in Abuja, the Executive Director of the National Primary Health Care Development Agency (NPHCDA), Dr Faisal Shuaib, acknowledged that the three-year mark is an important moment in the fight against polio but also emphasized the need for vigilance ̶ “one which we must delicately manage with cautious euphoria.”
“This achievement would certainly not have been possible without the novel strategies adopted in the consistent fight against polio and other vaccine preventable diseases. We commend the strong domestic and global financing and the commitment of government at all levels,” the Executive Director stated.
Innovation, partnership and resolve have all underpinned advancements made in Nigeria, together with the commitment of tens of thousands of health workers. “Since the last outbreak of wild polio in 2016 in the northeast, Nigeria has strengthened supplementary immunization activities and routine immunization, implemented innovative strategies to vaccinate hard-to-reach children and improved acute flaccid paralysis (AFP) and environmental surveillance. These efforts are all highly commendable,” said WHO’s Officer in Charge for Nigeria, Dr Peter Clement.
However, despite progress, there is still much left to be done. Continued work to reach every last child with the polio vaccine, as well as strengthening surveillance and routine immunization across the region, will be key to keeping wild polio at bay and protecting the gains achieved.
Should there be no more cases in Nigeria or from countries in the Africa Region, and surveillance data submitted by countries meets evaluation criteria, the Africa Regional Certification Committee (ARCC) could certify the Region as wild polio-free as early as mid-2020.
The press briefing was attended by country representatives of all GPEI partners: WHO, UNICEF, CDC, Rotary and the Bill & Melinda Gates Foundation; as well as USAID, Government of Germany, EU and Canada. The Emir of Jiwa, representing the Northern Traditional Leaders Committee was also in attendance.
Reposted with permission from Rotary International
Five core partners— Rotary International, World Health Organization (WHO), Rotary International, the US Centers for Disease Control and Prevention (CDC), United Nations Children’s Fund (UNICEF), and the Bill & Melinda Gates Foundation— 20 million volunteers, over 2.5 billion children vaccinated, and an initiative spanning over 30 years across 200 countries.
These are the impressive numbers, people power, and the resources behind one of the biggest public-private partnerships in history: The Global Polio Eradication Initiative.
But why is polio eradication a global public health cause transcending generations, geographical boundaries, and socio-cultural constructs? Read on:
Poliovirus causes acute, non-persistent infections
The virus causes acute, short term infections, meaning that a person infected with polio can only transmit the virus for a limited amount of time. Prolonged infection with wild polioviruses has never been documented and in most cases infected people can only transmit the virus for 1-2 weeks.
Virus is transmitted only by infectious people or their waste
Some diseases can be transmitted in a multitude of ways, which can make a disease an impossible candidate for eradication. But the poliovirus is typically transmitted just one way: through human waste. Eradicating polio is not an easy task, but the way polio is transmitted simplifies our ability to tackle the disease.
Survival of virus in the environment is finite
Did you know there’s just one strain of wild poliovirus that continues to infect humans? (There used to be three strains of poliovirus that regularly infected humans.) The wild poliovirus cannot survive for long periods outside of the human body. If the virus cannot find an unvaccinated person to infect, it will die out. This is why we have to keep every single child vaccinated—so the virus cannot find any humans to infect. The length of poliovirus survival varies according to conditions like temperature, and the poliovirus infectivity decreases over time.
People are the only reservoir
Hundreds of diseases can be transmitted between insects, animals and humans. One of the things that makes polio eradicable is the fact that humans are the only reservoir. No poliovirus has been found to exist and spread among animals despite repeated attempts to document this.
Immunization with polio vaccine interrupts virus transmission
Not only are there two safe and effective polio vaccines, but vaccination against polio generates herd immunity, which increases the percentage of the population that is immune to the disease.
Mass campaigns using oral polio vaccine, where all children in a specified geographic area are immunized simultaneously, interrupts wild poliovirus circulation by boosting population immunity to the point that transmission of polio cannot be sustained.
But what truly drives our conviction in numbers results. Since the world took up the cause of eradicating polio globally in 1988: we have eliminated polio from 125 countries and reduced the global incidence of polio cases by 99%; and, successfully eradicated certain strains of the virus.
There are now only 3 countries that have never stopped polio transmission. This marathon of a public health endeavour is in the last mile.
On the long road to global polio eradication, the programme has achieved four important milestones, representing four out of six WHO regions that have been certified as having interrupted transmission of wild poliovirus (WPVs): Region of the Americas (1994), the Western Pacific Region (2000), the European Region (2002), and the South-East Asia Region (2014).
At present, only the Eastern Mediterranean and African regions— no WPV reported in Africa since 2016, the African region may be eligible for regional certification as early as late 2019—remain to be certified in the path towards global eradication and hence constitute a key priority.
But who decides that a region is free of WPV?
The Eastern Mediterranean Regional Commission for Certification of Poliomyelitis Eradication (ERCC) is an independent body appointed in 1995 by the WHO Regional Director for Eastern Mediterranean to oversee the certification and containment processes in the region. It is the only body with the power to certify the Region free from wild polio, which convenes annually. Here are the outcomes of the recent ERCC meeting:
Urgent need to address regional priorities
The Commission noted with concern the need to stop the ongoing wild poliovirus type 1 transmission in the only two remaining polio-endemic countries in the Region: Afghanistan and Pakistan. The RCC acknowledged the on-going eradication efforts but strongly recommended the full implementation of the respective national emergency polio programmes through complete political and programmatic support to tackle the WPV1 transmission in the common Pak-Afghan epidemiological corridor, which remains unabated. The Commission also expressed concern about the current circulating vaccine-derived poliovirus type 2 and 3 transmissions in Somalia.
Wild poliovirus type 3certification prospects
The Commission, however, marked the good progress made towards curbing wild poliovirus type 3 (WPV3). Extensive analyses of the stool and environmental surveillance samples provided evidence that no WPV3 is in transmission in the Region. Based on the epidemiology, EMRO – along with the rest of the world – may be up for global WPV3-free certification by the GCC, potentially certifying two of three poliovirus strains eradicated—WPV2 strain was certified as globally eradicated in 2015.
Stepping-up is the need of the hour
So far, sixty cases of WPV1 are reported from two countries (Pakistan and Afghanistan) in 2019. Given the existing WPV1 transmission in the two remaining endemic countries of the Region, the RCC asked that the Member States undertake a firm commitment necessary for reaching zero.
Eastern Mediterranean Regional Commission for Certification of Polio Eradication (ERCC)
The Thirty-third meeting of the EMRO RCC was held in Muscat, Oman, to discuss the Regional progress towards a polio-free certification. The meeting brought together members of the RCC, chairpersons of the National Certification Committees, polio programme representatives of 21 countries, and WHO staff from the headquarters, regional, and the endemic countries. Representatives from Rotary International and the Centers for Disease Control and Prevention were also in attendance.
Comprised of public health and scientific experts, the regional certification commissions are independent of the WHO and national polio programmes. Global certification will follow the successful certification of all six WHO regions and will be conducted by the Global Certification Committee (GCC).
Final reports of the annual Eastern Mediterranean Regional Certification Commission intercountry meetings.
After concerted efforts spanning decades, polio eradication efforts are in the homestretch and experts are advising how to fast-track the last mile.
The SAGE convened in Geneva from 2-4 April 2019 to discuss all things related to vaccines and immunizations, including poliovirus and the global eradication efforts around it. SAGE reviewed the latest global polio epidemiology, the new Global Polio Eradication Endgame Strategy 2019-2023, and what the post-eradication world could look like.
Double down and escalate the fight to end wild poliovirus
While SAGE noted the achievements and the progress of the Global Polio Eradication Initiative—reducing the incidence of polio by 99%, absence of wild polio virus type 3 cases, and evidence of Nigeria being wild poliovirus free for over two years—the group displayed cautious optimism about meeting the timeline set out for global eradication of wild poliovirus.
The remaining challenges to fill vaccination coverage gaps—including restricted access, socio-political challenges, and large mobile populations—complicate the efforts to rid the world of poliovirus. However, the GPEI has developed a clear-cut five- year plan to secure a decisive win, the GPEI Polio Endgame Strategy 2019-2023, developed in broad consultation with stakeholders, including SAGE members.
Inactivated Polio Vaccine (IPV)—progress in roll-out continues
From the public health standpoint, Inactivated Polio Vaccine (IPV) can be used indefinitely even after polio eradication. As of April 2019, all 33 countries which had not yet introduced IPV into their routine immunization activities have now done so.
The projected IPV supply is thought to be sufficient enough for the introduction of a two-dose IPV schedule in all countries by 2022, and to catch-up all children missed due to earlier supply shortages, by 2020/2021.
As per SAGE recommendations made in October 2016, GPEI developed guidelines for poliovirus surveillance among persons with primary immunodeficiency. After reviewing the guidelines, the SAGE endorsed the guidelines for implementation in high priority countries.
The meeting report will be published in the WHO Weekly Epidemiological Record by May 2019.
The Strategic Advisory Group of Experts (SAGE) on Immunization was established by the Director-General of the World Health Organization in 1999 to provide guidance on the work of WHO. SAGE is the principal advisory group to WHO for vaccines and immunization. It is charged with advising WHO on overall global policies and strategies, ranging from vaccines and technology, research and development, to delivery of immunization and its linkages with other health interventions. SAGE is concerned not just with childhood vaccines and immunization, but all vaccine-preventable diseases.
In a control room at the World Health Organization (WHO) Regional Office for Africa in Brazzaville, the smart screen projects the South Sudan map with a scattering of red dots—and even more popping up every now and then. These red dots are geo-coded locations for every healthcare facility being visited by surveillance officers to document active case search in real-time as it happens.
By simply using an application on their smart phones, the surveillance officers send their reports, even without internet connection, to the centrally generated map. Here in the control room, public health experts can quickly analyze data, visualize surveillance gaps, and conduct active case searches for priority diseases and routine immunization assessments at health facility levels. This is a game changer.
“Since the advent of the mobile-based surveillance, it has made it possible to prioritize areas and the required interventions for immunization and surveillance,”, says Dr Atem Anyuon, Director General of the Primary Health Care Ministry of Health South Sudan. He also said that other stakeholders that support the EPI programme would have access and utilization of the mobile technology.
Bridging surveillance gaps through touch screens
Data collected by health workers and community informants from the field is aggregated on database servers, and then displayed on touch interactive screens. With just a touch, maps can be viewed, and charts and dashboards of data streaming in from the field can also be monitored.
Explaining the innovation, WHO Representative, Dr Olushayo Olu says, “Interacting with real-time data through the smart visualization screens helped us recognize gaps in surveillance and intuitively navigate the interactive maps of South Sudan”. Dr. Olu is optimistic that the platform will help inform actions to improve and support surveillance and other primary health services in the country.
Progress towards certification standard documentation
In South Sudan, the technology has made clear where there are gaps in surveillance of Acute Flaccid Paralysis (AFP) – a symptom of polio – in hinterlands without internet. It also makes it easier and more transparent for staff to report what they are doing. . One of the achievements for South Sudan has been the active identification of over 6,000 cases of priority diseases across all the counties, with 85% of the AFP cases validated through geo-coordinates.
Cutting cost of active surveillance
“For me, my enthusiasm about innovating on this has been the fact that we can collect data with geographic information in places that do not have any form of network coverage and it sends the information whenever the health worker gets an internet source”, Mr Godwin Akpan, Data Management Officer of the Regional Office for Africa says.
Akpan stresses that “There are the exciting possibilities of country teams having the freedom to slice and dice the data with various analytics on the smart screen; appropriate technology hitherto used for weather analyses by mega news conglomerates is being harnessed and is now available for use by countries in the African region – a first of its kind built around open source technologies at no recurrent cost except for the hardware.”
With the interactive smart screens, the Ministry of Health and WHO can now interactively analyze data from AVADAR (Auto visual AFP detection and Reporting), Esurv (electronic Surveillance), Immunization Campaign Monitoring, Mortality monitoring as well as the ‘Lots Quality Assurance’ survey.
The initiative is facilitated by the WHO Regional Office for Africa, with support from the Bill & Melinda Gates Foundation.
On 26-27 February 2019, the Global Commission for Certification of Poliomyelitis Eradication (GCC) met at the World Health Organization (WHO) headquarters in Geneva, Switzerland, to continue its intensified work on global certification criteria for poliomyelitis eradication and poliovirus containment. The work of the GCC is critical to verifying the achievement of a world free of all polioviruses.
The GCC reviewed the latest global epidemiology of all poliovirus transmission, examined remaining challenges such as subnational surveillance and immunity gaps, and evaluated current containment status.
The GCC expressed its concerns over the lack of progress in the interruption of transmission of wild poliovirus type 1 (WPV1) in Pakistan and Afghanistan and the spread of vaccine-derived polioviruses (VDPVs). As expressed in a recently-published letter from the four Chairs of the GPEI’s main global advisory bodies, it is essential that improvement is achieved in both routine immunization services and supplementary immunization activity (SIA) quality. Nevertheless, the GCC is continuing to accelerate its work, including taking into consideration circulating vaccine-derived polioviruses (cVDPVs), which continue to take on added significance as the time extends since the discontinuation of type 2 poliovirus in oral polio vaccine (OPV) with consequent loss of type 2 polio immunity. The GCC is also occupied with the urgent and increasing need for effective containment of polioviruses in laboratories and vaccine manufacturing facilities.
Noting that wild poliovirus type 3 (WPV3) has not been isolated anywhere since November 2012, the GCC re-affirmed its decision to undertake sequential certification of WPV eradication, meaning that WPV3 will be certified as eradicated prior to WPV1. The GCC has requested that the Director-General of WHO ask the Regional Directors of Africa and the Eastern Mediterranean respectively to confirm from their Member States that the last WPV3s in both Regions were identified more than six years ago. The GCC will review these data in conjunction with the final reports from the four Regions that have already been certified. This will permit the GCC to certify the eradication of WPV3.
The GCC noted progress in identifying the interruption of WPV1 transmission in the African Region, which will be eligible for regional certification when the African Regional Certification Commission is convinced of the evidence of absence of wild polioviruses that meets surveillance standards.
The outcomes and recommendations of the GCC will be presented to the WHO Director-General, and if accepted, incorporated into the Global Polio Eradication Initiative Strategic Plan 2019-2023. The full report from the GCC’s meeting will be made available at www.polioeradication.org.
The members of the GCC are independent of WHO and independent of involvement in national polio vaccination implementation or polio surveillance programmes. WHO Regions are eligible for certification following the absence of WPV from any country in that region from any population source in the presence of certification-standard surveillance. Regional certification is conducted by Regional Certification Commissions (RCCs). Global certification will follow the successful certification of all six WHO regions, and will be conducted by the GCC.
Four WHO regions have been certified as having interrupted transmission of WPVs: Region of the Americas (1994), the Western Pacific Region (2000), the European Region (2002), and the South-East Asia Region (2014).
WPV2 was certified as eradicated in 2015. WPV3 has not been isolated from any source since November 2012, making it eligible to be certified as eradicated. Thirty-three cases of WPV1 were reported from two countries (Pakistan and Afghanistan) in 2018 with 223 WPV1 isolates identified additionally through environmental surveillance. The verification of the elimination of VDPVs will occur after the global cessation of OPV use, which will happen after all remaining WPV strains have been certified as globally eradicated.
(Chair of Western Pacific RCC), Professor Yagoub Al-Mazrou (Chair of Eastern Mediterranean RCC), Professor Mahmudur Rahman (Chair of South-East Asian RCC), Professor David Salisbury (Chair of GCC and Chair of European RCC), Dr Arlene King (Chair of American RCC, and Chair of the GCC Containment Working Group); and, Professor Rose Leke (Chair of African RCC).
During a visit to WHO’s Regional Office for Africa (AFRO) in Brazzaville by a delegation of officials from the Korea International Cooperation Agency (KOICA), delegates received a first-hand demonstration of the ‘real-time’ surveillance system for polio on the continent.
Dr Pascal Mkanda, head of AFRO’s polio eradication effort and his team demonstrated the newly-launched and real-time innovative mobile surveillance system, aimed at strengthening polio surveillance across the continent. Thousands of medical officers and health officers across the continent are dispatched to health clinics to actively search for cases of acute flaccid paralysis (i.e children with polio-like symptoms). Results of visits are communicated right back from the field level to the regional office in real time, via mobile phone technology.
This system is providing valuable and real-time evidence of poliovirus circulation, and helps drive strategic implementation. At the same time, the system is now being used to conduct active surveillance for other diseases, including cholera, NNT, measles, HIV and yellow fever, allowing for rapid response.
Developed in close coordination with the Bill & Melinda Gates Foundation, and are part of ongoing efforts to fill remaining subnational surveillance gaps, particularly in the lead-up to potential regional certification of wild poliovirus eradication (which could occur as early as late 2019/early 2020).
Africa’s polio eradication effort is generally supported by key private and public sector partners, including Rotary International. The Republic of Korea is a key partner in the effort, having contributed more than US$6 million to the effort, directly through KOICA. Support has been strategically allocated to supporting outbreak response and strengthening disease surveillance, and this visit builds further on Korea’s support to the global eradication effort. Strong disease surveillance is the underlying key strategic strategy, enabling rapid outbreak response as needed.
As part of its work to keep the world safe from poliovirus, WHO is seeking input on draft guidance for managing human exposure to live polioviruses from poliovirus-essential facilities such as labs and vaccine plants. Countries where polioviruses are kept require this guidance. The guidance document is open for public comment and WHO is particularly seeking feedback from national authorities for containment – the national bodies overseeing work in poliovirus containment – and from others working in public health.
The guidance is aimed primarily at public health workers in countries where there are facilities designated to handle and store polioviruses for vaccine production, diagnostics and key research (poliovirus-essential facilities), and outlines public health measures to be taken in the event of a spill or containment breach.
“On the way to global certification” was the theme of this year’s Regional Meeting on Polio, which convened on 6 December 2018 in Guatemala City. Pan American Health Organization (PAHO) urged collective action to not only ensure that there is no re-emergence of polio in the Americas, but also to lend support in the global fight against polio.
The last reported case of polio in the Americas was documented in 1991 and in 1994 the region became the first to be certified free of the disease. But that is not to say there is room for complacency. Echoing the Global Polio Eradication Initiative’s goal of a polio-free world, Cuauhtémoc Ruiz-Matus, Chief of the Comprehensive Family Immunization Unit at the Pan American Health Organization (PAHO) said, “As long as there is even one infected child, children in all countries are at risk of contracting polio,” during the inauguration.
With recent reports emerging that some of the countries in the Americas have vaccination coverage hovering below 95% — the minimum baseline required to prevent circulation — there is a real chance of outbreak through importation of virus or the emergence of circulating vaccine-derived poliovirus.
“We know that there is a risk of reintroduction of polio, which is why Guatemala has committed to adhere to PAHO’s strategic plan so that the Region remains polio-free,” said the Deputy Health Minister of Guatemala, Roberto Molina. The country recorded its last case of polio in 1990.
Reiterating the need for continued efforts, PAHO Representative in Guatemala, Oscar Barreneche, highlighted that “maintaining standards of surveillance, containment and response to outbreaks, and vaccination is key.”
As the world reaches closer to poliovirus eradication, the countries of the Americas will play an instrumental role in sustaining the momentum for the cause and preventing reintroduction of the disease in the continent.
From the 27 – 29 November, the Technical Advisory Group (TAG) met in Nairobi to review the outbreak response in Somalia, Ethiopia and Kenya, and preparedness measures in Yemen, Uganda, Tanzania, Sudan, South Sudan and Djibouti in case of international spread.
Jean-Marc Olivé, Chairman of the TAG, spoke to WHO about the recommendations made to address the challenges faced by countries, his hopes for eradication and his life in the programme.
What are the main challenges faced by the countries of the Horn of Africa in the drive to stop the outbreaks?
The major challenges have been the same for a long time – like, the issue of inaccessibility due to conflict and humanitarian crises. If we cannot access populations then it is very difficult to cover them properly during vaccination campaigns and so it is hard to stop poliovirus transmission. This is not a programme-related issue, it is a political one. Until we have access, it will be very difficult to make it.
I have said it before and I will say it again: access is success.
I think the second challenge is – and this is one of the reasons why we still have the transmission of circulating vaccine-derived poliovirus in the Horn of Africa – is persistently low vaccination coverage. There are still remote areas, rural areas, heavily populated urban areas where routine immunization has really never been able to offer the same services and coverage as in more accessible areas with fewer challenges.
Since last TAG meeting in the Horn of Africa, what progress have you seen?
I have seen the capacity really building up in the Horn of Africa. The biggest shift is that we now have collected a lot of data about surveillance, about immunization coverage, vaccination campaigns, communications, and also data by the type of population we are reaching and not reaching. What is missing now, and what was the focus of this TAG, is to use this data to monitor progress and orient the programme toward those difficult areas. We have to use the data to tell us a story about what is happening and what to do next.
What were the most important recommendations made by the TAG this time around?
I think the most important is to follow the plan that has been set up for the three outbreak countries to interrupt transmission. Secondly, the countries that have not been yet infected by the virus should have a preparedness plan to ensure that if there are any problems they can move swiftly into action.
The Horn of Africa has seen several outbreaks in the past. What must be done to break the pattern and keep the region polio-free once and for all?
They have identified the problems. They just have to implement the solutions! We need to be sharing and analysing knowledge, information, and building capacity at the local level to ensure that we are on the right track to success.
I say to all the countries, go to the areas where you know you have problems and engage local communities and health authorities. Most of the issues can only be addressed at local levels by local people who understand the situation. Help them to do that, and monitor progress.
This is your thirteenth TAG; what have you learned about the process of international review?
First, you have to work as one team in support of National Teams, all agencies together. There cannot be any agency that claims, “This is us, we are doing that, this is WHO, this is UNICEF…”; this is the Global Polio Eradication Initiative, working together with all committed partners, using the competencies that each of them has. If you don’t address issues comprehensively as one, effective interventions are much more difficult to implement.
How long have you worked on polio eradication? What lessons have you learnt from this experience?
I was involved in the eradication of polio in the Americas. We started in 1985. We did it from A to Z in 9 years. We had very good leadership, commitment from the Government and partners, clear guidelines, very strong monitoring, and solid and reactive support to the field. Then we moved on into measles elimination with the same engagement – and the same results.
Because I have seen it happen, I know it is feasible. I think this is what keeps me so motivated. Polio eradication is a fantastic initiative. If we focus on weak and problematic areas within countries, if Governments and Partners continue to be engaged, we will make it. It’s going to be tough, mainly because of inaccessibility.
Is there anything else you want to add?
The people working in this programme, particularly local people working in the countries are amazing. They are the basis of any future public health intervention. In Pakistan and Afghanistan, woman are more and more playing an important role. This is an incredible advancement and an incredible contribution that was previously thought to be impossible.
But nothing is impossible – you just push, go slowly and constructively you will manage to gain ground over the virus.
Efforts to end polio across the WHO African Region came under the microscope at a meeting of the Africa Regional Commission for the Certification of poliomyelitis eradication (ARCC) held in Nairobi, Kenya, from 12 – 16 November 2018.
Seven countries (Cameroon, Nigeria, Guinea-Bissau, the Central African Republic, South Sudan Equatorial Guinea and South Africa) made presentations to the ARCC on their efforts to eradicate polio, presenting evidence on their level of confidence that there is no wild polio in their borders, the strength of their surveillance systems, vaccination coverage, containment measures and outbreak preparedness. Kenya, the host country, alongside the Democratic Republic of the Congo and Namibia, presented updated reports on their efforts to maintain their wild poliovirus- free status.
A total of 109 participants including partners of the Global Polio Eradication Initiative, non-governmental organisations and Health Ministries were in attendance to hear the reports.
The ARCC is an independent body appointed in 1998 by the WHO Regional Director for Africa to oversee the certification and containment processes in the region. It is the only body with the power to certify the Africa region free from wild polio. The African Regional Office and the Eastern Mediterranean Regional Office are the two WHO regions globally that remain to be certified free from wild poliovirus.
Professor Rose Leke, Chair of the ARCC, reflected on the importance of this meeting: “The rich, open and in-depth discussions held this week with each of the ten countries will allow these countries to strengthen ongoing efforts to further improve the quality of surveillance and routine immunization including in security compromised and hard to reach areas as well as in special populations such as nomads, refugees and internally displaced persons.”
The ARCC, made up of 16 health experts, made recommendations to the ten countries. They noted with concern that outbreaks of circulating vaccine-derived poliovirus in the Democratic Republic of Congo, Kenya, Niger, Nigeria and Somalia were symptoms of low population immunity and varied quality vaccination campaigns. These countries were encouraged to conduct a high-quality outbreak response. Neighbouring countries were advised that they should assess the risk of spread or outbreaks within their borders. Low population immunity was identified as a significant concern, given the risk further emergences of vaccine-derived poliovirus strains.
Inaccessibility and insecurity were also flagged as a significant concern, with limits to the number of children who were being reached with polio vaccines and the coverage of surveillance efforts in affected areas. Countries were advised to scale up strategies that have proved in the past to be effective in the face of these challenges and to build relationships with civil society and humanitarian organisations who could provide immunization services.
Recommendations were made across the board to address chronic surveillance gaps, especially related to factors affecting the quality and transportation of stool samples reaching the laboratory for testing. The introduction of innovative technologies was commended, and a call was made for countries to expand their use, especially in inaccessible and hard-to-reach areas. Countries were also encouraged to accelerate their progress towards poliovirus containment.
In addition, all of the presenting countries received specific recommendations to support their efforts towards improving surveillance, immunization and containment in order to achieve a level that would give the ARCC the confidence needed to declare the region to have eradicated polio.
Dr Rudi Eggers, WHO Kenya Country Representative, said: “I commend all the countries on the efforts that have gone into achieving the results presented in their reports. It gives us hope that eradication is achievable in the midst of the unique challenges faced by all countries. We appeal to all the countries to fully implement all ARCC recommendations.”
Polio eradication efforts in Kenya
Dr Jackson Kioko, Director of Medical Services, the Kenyan Ministry of Health, said: “Kenya has worked hard to rid the country of wild poliovirus, and we will continue to do so until Africa and the world are certified polio-free.”
While Nigeria remains the only country in Africa to be endemic for wild poliovirus, responses are underway to stop outbreaks of circulating vaccine-derived poliovirus in the Democratic Republic of the Congo, Kenya, Niger and Somalia.
The circulating vaccine-derived poliovirus in Kenya was found in a sewage sample in Eastleigh, Nairobi, in March 2018, closely related to viruses found in Somalia. The Ministry Health, with the support of WHO, UNICEF and partners, has done several polio vaccination campaigns since then to ensure that every child’s immunity is fully built and no virus can infect them.