Reaching the Last Mile

By Aidan O’Leary, Director for Polio Eradication, World Health Organization, and
Chair of the Global Polio Eradication Initiative Strategy Committee

2023 is a critical year for the Global Polio Eradication Initiative (GPEI). It is the target year to interrupt all remaining wild poliovirus type 1 (WPV1) and circulating vaccine-derived poliovirus type 2 (cVDPV2) transmission chains, per the GPEI Polio Eradication Strategy 2022-2026. A rigorous independent review will be undertaken by the third quarter of 2023, to assess whether the programme is on track to meeting Goal 1 and Goal 2 of the Strategy: permanently interrupt all poliovirus transmission in endemic countries; and, stop transmission of cVDPV2 and prevent outbreaks in non-endemic countries.

Despite the detection last year – the first operational year of the Polio Eradication Strategy – of several high-profile polio emergences, including in places such as New York and London, 2022 saw perhaps some of the most significant progress in the programme’s history, and has set up the global polio effort for a unique opportunity to achieve success in 2023. A unique, but limited, epidemiological window of opportunity exists at the beginning of 2023. Key to success is reaching remaining ‘zero dose’ children (children who are either un- or under-vaccinated) in seven, subnational ‘most consequential geographies’. These geographies – eastern Afghanistan, the southern area of Khyber Pakhtunkhwa in Pakistan, Tete province in northern Mozambique, north-western Nigeria, eastern Democratic Republic of the Congo (DR Congo), northern Yemen and south-central Somalia – which now together account for 80% of all polio cases worldwide (WPV1 – 100%, cVDPV2 – 80% and cVDPV1 – 76%) over the past 12 months (as at 28 March 2023).

As the first quarter of 2023 draws to a close, the GPEI’s analysis is that the programme remains on track to interrupt all remaining wild poliovirus transmission in 2023 – both endemically in Pakistan and Afghanistan, and in the outbreak setting of south-east Africa. Not-withstanding the challenging operational contexts in eastern Afghanistan and the southern area of Khyber Pakhtunkhwa, intensified country efforts have resulted in a historically-low number of biologically-distinct virus lineages remaining in circulation and an ever-shrinking number of infected districts.

The situation with interrupting cVDPV2 transmission is more mixed. Compared to other most consequential geographies, increased efforts in Nigeria have yielded positive results through 2022 and beyond. The country’s main historical transmission chain, the Jigawa lineage, which was responsible for the majority of cases and international spread, appears to have been effectively halted. New cases continued to decline in the second half of 2022. As a result, the virus is currently confined primarily to specific regions in the north-west. In Somalia, where we have witnessed unbroken transmission since 2016, the numbers of inaccessible districts have been reduced to zero and inaccessible children to <80,000 by the end of the first quarter of 2023.

Polio Eradication Strategy 2022-2026 planning and budgeting timeline, 2021-2027+

In eastern DR Congo and northern Yemen, ongoing issues of access, acceptance and the delivery of high quality immunisation activities to maximise coverage remain concerning as both outbreaks continue to expand (including internationally) at the start of 2023. Both contexts are protracted, complex humanitarian emergencies. The programme at all levels is in the process of implementing a range of corrective course measures to urgently reverse this trend and get outbreak response in both contexts onto a footing to achieve success. Pending the effective and sustained impact of these measures, it is unlikely that the end-2023 interruption target would be successfully met.

Independent review to provide clearer and independent assessment of status

At the time of the launch of the GPEI Strategy, a commitment was made to undertake a rigorous review of its implementation. This review will be conducted by the Independent Monitoring Board (IMB), an independent group of public health experts established at the request of the World Health Assembly in 2010, to monitor and independently verify progress towards the achievement of a lasting polio-free world.

The IMB has a long history in evaluating the GPEI’s cross-cutting work, and recommending measures to help strengthen strategic approaches. Its long-standing and independent input and analyses has over the years significantly contributed to sensitising strategic approaches. At the same time, again thanks to its long-standing engagement with the GPEI, IMB members have in fact become ‘polio’ experts, and not simply public health experts.

The independent review now planned will be geared specifically to:

evaluate progress towards Goals 1 and 2 of the Polio Eradication Strategy 2022-2026;
assess whether the strategic plan is a) on track, b) at risk, c) off track or d) missed; and,
identify areas where corrective action plans are required and evaluate the quality, implementation and impact of corrective action plans.

The GPEI will work closely with the IMB to ensure that it has all the necessary inputs, analytics and modelling required to inform its deliberations during a planned meeting during 11-13 July 2023. The IMB is anticipated to present its findings and recommendations to the GPEI Polio Oversight Board (POB) for decision at its face-to-face meeting in September/October 2023. Our collective aim is clear – to redouble all efforts and focus on the critical path to zero and delivering on the promise of a polio free-world.

For many of the women and men who spent their careers fighting polio, retirement offers not rest and relaxation, but a continuation of their life’s work towards eradication. Across the Eastern Mediterranean Region, once and forever polio fighters are inspiring the next generation of eradicators with their commitment to the cause, and belief in the benefits of a polio-free future.

Meet some of the Region’s most beloved polio fighters as they look back on their careers and try to capture their unusual motivation to continue their quest, as long as it takes.

Dr Ali Farah, Somalia

Back in 1997, during the devastating civil war, Dr Ali Farah started a pilot project to conduct Somalia’s first-ever national immunization days. Today, that pilot project is one of the reasons Somalia hasn’t seen a case of wild poliovirus in more than seven years.

Dr Farah retired in 2015 after years of hard work in a highly complex, volatile, and risky context. Yet he continues to fight polio by providing technical support to the polio programme team, participating in social mobilization activities and training district-level polio officers and vaccinators.

“I always feel that we must keep working to fight polio. It’s a humanitarian action,” he said. “Technical staff still call me occasionally to receive guidance about AFP cases and other technical areas. I feel so happy to provide advice and support when needed.”

Dr Farah has also utilized his long experience with the polio programme to support COVID-19 immunization in Somalia.

“This COVID-19 campaign wouldn’t succeed if there was no polio infrastructure. We used the polio system and network to make it happen,” he said.

Professor Elsadig Mahgoub, Sudan

After completing his bachelor’s degree in 1969, Professor Elsadig Mahgoub trained as a physician and epidemiologist. He devoted his career to infectious diseases, largely focusing on disease surveillance. In February 2000, he focused his efforts on polio, particularly surveillance for acute flaccid paralysis (APF), the primary symptom of paralytic polio.

Although he retired four years later, Prof Elsadig hasn’t stopped working or providing his technical support to polio programmes in Sudan and across the Region.

“I’m obliged to continue working. My enjoyment is when I see progress towards polio eradication,” he said. “The service we’re providing is critical. We always need to be vigilant to avoid any setback to our achievements towards polio eradication. When we end polio for good, then I will truly resign.”

Dr Mohammed Hajar, Yemen

Yemen’s Dr Mohammad Hajar is one of the oldest, most veteran health professionals in Yemen, having served the health sector and combated infectious diseases, including polio, for around 50 years.

In 1977, Dr Hajar was one of the founders of Yemen’s expanded programme on immunization. He played a major role in planning and conducting the first-ever polio campaigns in the country, and he contributed substantially to setting up the epidemiological surveillance system for polio and other diseases.

“Even after reaching retirement age in 2009, I continued to work for the polio programme, which I consider as one of my sons. Until now, I follow up and evaluate the activities of the immunization programme and polio campaigns,” said Dr Hajar.

“I had the privilege of working with nine WHO representatives and more than ten ministers of health in Yemen to help Yemen reach a polio-free status.”

Dr Ibrahim Barakat, Egypt

When Dr Ibrahim Barakat was appointed as a manager of Egypt’s expanded programme on immunization in 2000, he was determined to achieve something remarkable – a polio-free Egypt.

“It was a hard journey, but we did it. Egypt was declared polio-free in 2006,” he said.

In 2009, Dr Barakat retired, but he hardly rested. “I cannot stop working when it comes to polio eradication. I take great comfort in working hard to combat this disease whether in Egypt or any place in the world.”

After 12 years of retirement, Dr Barakat still considers his office in the Ministry of Health as “a second home.”

“I continue going to the office every working day to plan, supervise and evaluate different polio activities, including polio vaccination campaigns, risk assessment and AFP surveillance. I can never be complacent,” he said.

“This is my life. My real retirement starts when I see this disease completely wiped out from all parts of the world.”

Mr. Alam and Mrs. Fatima, Pakistan

Khursheed Alam, 68, and Kaneez Fatima, 56, are a married couple who have spent 25 years working in the polio eradication programme in Batagram district of Khyber Pakhtunkhwa province, Pakistan.

Rain or shine, Mr. Alam and Mrs. Fatima have taken part in countless door-to-door vaccination campaigns, helping to vaccinate thousands of children.

“Now those little children have grown up, some have gotten married and had children who we have also vaccinated. This is fascinating and rewarding for us,” said Mr. Alam. “Wherever we go, people welcome us and don’t let us go without offering food.”

Mrs. Fatima personally knows every child in her neighborhood, including the newborns. She maintains close relationships with the mothers in her community and gives them health and hygiene advice.

Despite their age and medical complications such as asthma, their commitment to the polio programme remains strong.

“We take our work as a divine duty to serve our community for the sake of God. To see healthy children with smiles on their faces is our reward. This has kept us going for so long,” said Mrs. Fatima.

Dr Faten Kamel, Egypt

Dr Faten Kamel took a leading role in polio eradication efforts in the 1990s and early 2000s – years where the Global Polio Eradication Initiative made considerable gains against polio.

Growing up in Alexandria, Egypt, Dr Faten was exposed to the life-altering effects of polio on the people around her. She saw the human toll of the disease, and was inspired by the work of her father, a surgeon and Rotarian.

“We pushed the boundaries to make the programme more effective, shifting to house-to-house vaccination, detailed microplanning and mapping, retrieval of missed children and independent monitoring,” she said.

For Dr Faten, every child can, and must, be reached.

“If someone comes and says this area is inaccessible, this is not an answer for me. I ask: What should we do to reach? I like to make use of the ideas and experience that come from local people,” she said.

Dr Faten is proud to continue to be part of the polio eradication programme and looks forward to the day when polio eradication is achieved. After that, she plans to spend more time with her family in Australia.

“As a grandmother, I am especially determined to finish the job. I want my grandkids to grow up in a world free of polio. This will be my contribution to their futures.”

148th session of the WHO Executive Board in Geneva, Switzerland. ©WHO / Christopher Black

Meeting virtually at this week’s WHO Executive Board (EB), global health leaders and ministers of health urged for concerted and emergency efforts to finally rid the world of polio, noting a global and collective responsibility to finish the disease once and for all. Delegates also reiterated their support for the sustainable transitioning of polio assets, recognizing that successful polio transition and polio eradication are twin goals.

Noting that endemic wild poliovirus is now restricted to just two countries – the lowest number in history – with the African region being certified as wild polio-free in August 2020, delegates urged intensified efforts to wipe out the remaining chains of transmission of this strain and prevent global resurgence. The representatives of both Pakistan and Afghanistan demonstrated strong commitments to this goal and urged collective responsibility to achieve success. Delegates also expressed strong appreciation for the establishment of the Eastern Mediterranean Ministerial Regional Subcommittee on Polio Eradication and Outbreaks, by WHO Regional Director Dr Ahmed Al-Mandhari, which focuses on critical barriers to overcome to achieve zero poliovirus.

The EB urged all stakeholders to follow WHO and UNICEF’s joint emergency call to action, launched 6 November 2020, including by prioritising polio in national budgets as they rebuild their immunization programmes in the wake of COVID-19, and urgently mobilising additional resources for polio emergency outbreak response. To address the increasing global health emergency associated with circulating vaccine-derived poliovirus (cVDPV) outbreaks, delegates expressed appreciation of new strategic approaches, including the roll-out of novel oral polio vaccine type 2 (nOPV2), a next-generation OPV aimed at more effectively and sustainably addressing these outbreaks. This vaccine, which was recently granted a WHO Emergency Use Listing recommendation, is anticipated to be initially rolled-out in the first quarter of 2021. The GPEI is working with countries affected and at high risk of cVDPV2 to prepare for possible use of the vaccine.

Amid the new COVID-19 reality, the EB also expressed deep appreciation for the GPEI’s ongoing support to COVID-19 response. In December 2020, the heads of the GPEI core partners at their final Polio Oversight Board (POB) meeting of the year, confirmed that the polio infrastructure will continue to provide such support, including to the COVID-19 vaccine roll-out.

Member States additionally reiterated their support of polio transition, emphasising the need to ensure sustained, robust public health programming. Several EB members urged for strengthening the links built between the polio, immunization and emergencies programmes during COVID-19 response in the next phase of the pandemic, including for the effective rollout of the COVID-19 vaccine.

Children waiting at a polio vaccination campaign in Al-Mualla district, Yemen. ©WHO/EMRO

Director-General of WHO, Dr Tedros Adhanom Ghebreyesus, commented, “We share the understanding that polio eradication and transition are equally important targets: as we work towards eradication we must think about the future. This is how we will ensure that health systems retain capacity and are strengthened long after polio is ended.”

WHO’s Deputy Director-General, Dr Zsuzsanna Jakab, noted the increasing cross-programmatic integration between polio and other public health programmes, including the introduction of integrated public health teams in countries prioritized for polio transition, bringing together polio, emergencies and immunization expertise. The Regional Director for the African Region, Dr Matshidiso Moeti, emphasised that the work of polio personnel to support the pandemic response, “highlight[s]… the importance of working in interconnected ways going forward.” Dr Al-Mandhari, addressing the delegates, said: “Polio continues to be a public health emergency of international concern. Now is the time to be shoring up the polio programme and mobilizing funding, including domestic funds, so that this remarkable public health and pandemic response mechanism can remain robust and can be integrated into broader public health services across the region. Now is the time for full regional solidarity and mobilization.”

Speaking on behalf of children worldwide, Rotary International – the civil society arm of the GPEI partnership – thanked global health leaders for their continued dedication to polio eradication and public health, sentiments echoed by several other partners, including the United Nations Foundation (UNF). UNF expressed concern about the drop in population immunity, especially for polio and measles, declared support for the joint emergency call to action to prioritize investments for preventing and responding to polio and measles outbreaks, and urged continued focus on strengthening immunization programmes.

The EB discussion will also help inform the finalization of the new strategic plan. This strengthened strategic plan – being developed in broad consultation with partners, stakeholders and countries – is based on best practices and lessons learned, and focuses on fully implementing approaches proven to work. It is expected to be presented to the World Health Assembly in May.

“If we did not know it before, we certainly know now how quickly infectious diseases can spread across the world and wild polio is one such infectious disease. Unlike with COVID-19, where many medical and scientific questions remain unanswered, we know precisely what it takes to stop polio,” said Aidan O’Leary, newly-appointed Director of the Global Polio Eradication Initiative at WHO. “We know how polio transmits, who is primarily at risk and we have all the tools and approaches needed to stop it. That is what this strengthened strategic plan is all about – to bring all the solutions together into a single roadmap to achieve success and through focusing on more effective implementation. What discussions at the EB this week clearly displayed is a strong global sense of commitment and solidarity to do just that: better implementation of what we know works. Together, if we do that, success will follow and we will be able to give the world one less infectious disease to worry about, once and for all.”

Speaking more broadly on global public health issues, the EB welcomed confirmation by the United States of its intention to remain a member of WHO. In a statement by the United States, the country underscored WHO’s critical role in the world’s fight against COVID-19 and countless other threats to global health and health security, confirming it would continue to be a full participant and global leader in confronting such threats and advancing global health and health security.

Three-year-old Madsa is carried by her sister after receiving a polio vaccine during a door-to-door campaign in Maroua, Cameroon. ©Gates Archive/Dominique Catton

ABU DHABI, 19 November 2019 – Today, global leaders convened at the Reaching the Last Mile (RLM) Forum in Abu Dhabi to affirm their commitment to eradicate polio and pledge US$2.6 billion as part of the first phase of the funding needed to implement the Global Polio Eradication Initiative’s Polio Endgame Strategy 2019-2023.

This pledging event comes on the heels of a major announcement last month that the world has eradicated two of the three wild poliovirus strains, leaving only wild poliovirus type 1 (WPV1) still in circulation. Additionally, Nigeria – the last country in Africa to have cases of wild polio – has not seen wild polio since 2016 and the entire WHO African region could be certified wild polio-free in 2020. Thanks to the dedicated efforts of health workers, governments, donors and partners, wild polio only circulates in two countries: Pakistan and Afghanistan.

“From supporting one of the world’s largest health workforces, to reaching every last child with vaccines, the Global Polio Eradication Initiative is not only moving us closer to a polio-free world, it’s also building essential health infrastructure to address a range of other health needs,” said Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization and Chair of the Polio Oversight Board. “We are grateful for the generous pledges made today and thank governments, donors and partners for standing with us. In particular, I would like to thank His Highness Sheikh Mohamed bin Zayed Al Nahyan, Crown Prince of Abu Dhabi for hosting the GPEI pledging moment and for his long-term support for polio eradication.”

The commitments announced today come at a critical time for the polio eradication effort. Barriers to reaching every child – including inconsistent campaign quality, insecurity, conflict, massive mobile populations, and, in some instances, parental refusal to the vaccine – have led to ongoing transmission of the wild poliovirus in Pakistan and Afghanistan. Further, low immunity to the virus in parts of Africa and Asia where not all children are vaccinated has sparked outbreaks of a rare form of the virus. To surmount these obstacles and protect 450 million children from polio every year, governments and donors announced significant new financial commitments toward the $3.27 billion needed to support the Polio Endgame Strategy.

Pledges are from a diverse array of donors, including: US$160 million from the host of the pledging moment His Highness Sheikh Mohamed bin Zayed Al Nahyan, Crown Prince of Abu Dhabi; countries, including US$215.92 million from the United States, US$160 million from the Islamic Republic of Pakistan, US$105.05 million from Germany, US$84.17 million from the Federal Government of Nigeria, US$10.83 million from Norway, US$10.29 million from Australia, US$7.4 million from Japan, US$2.22 million from Luxembourg, US$1.34 million from New Zealand, US$116,000 from Spain, and US$10,000 from Liechtenstein; GPEI partners, including US$1.08 billion from the Bill & Melinda Gates Foundation and US$150 million from Rotary International; philanthropic organizations, including US$50 million from Bloomberg Philanthropies, US$25 million from Dalio Philanthropies, US$15 million from the Tahir Foundation, US$6.4 million from the United Nations Foundation, US$2 million from Alwaleed Philanthropies, US$1 million from the Charina Endowment Fund, and US$1 million from Ningxia Yanbao Charity Foundation; and the private sector, including US$1 million from Ahmed Al Abdulla Group, US$1 million from Al Ansari Exchange, and US$340,000 from Kasta Technologies. Earlier this month, the United Kingdom announced it would contribute up to US$514.8 million to the GPEI.

“We are proud to host the GPEI pledging moment in Abu Dhabi and thank all the attendees for their continued commitment to the eradication of polio,” said Her Excellency Reem Al Hashimy, UAE Cabinet Member and Minister of State for International Cooperation. “Since launching in 2014, the Emirates Polio Campaign has delivered more than 430 million polio vaccines in some of the most remote areas of Pakistan. We remain firm in our mission to reach every last child and believe together we can consign polio to the pages of history.”

In addition to overcoming barriers to reach every child, this funding will ensure the resources and infrastructure built by the GPEI can support other health needs today and in the future. Polio workers deliver Vitamin A supplements, provide other vaccines like those for measles and yellow fever, counsel new mothers on breastfeeding, and strengthen disease surveillance systems to anticipate and respond to outbreaks. As part of its commitment to advance gender equality and women’s empowerment, the GPEI is also working to ensure equal participation of women at all levels of the programme.

The future of polio eradication hinges on support and engagement at all levels of the programme – from individuals to communities to local and national governments to donors. If the strategies needed to reach and vaccinate children are fully implemented and funded, we are confident that we can deliver a world where no child lives in fear of polio.

Pledge values are expressed in US dollars. View the full list of donors and pledge amounts.

Media contacts:

Oliver Rosenbauer

Communications Officer, World Health Organization

Email: rosenbauero@who.int

Tel: +41 79 500 6536

John Butler

Vice President, Global Health Strategies

Email: jbutler@globalhealthstrategies.com

Tel: +44 7502 203498

Related resources

Seven-month-old Abdihakim Osman receives double doses of the oral polio vaccine during a national immunization campaign in Hargeisa, Somaliland. G20 members are some of the most committed supporters of polio eradication efforts. ©WHO/Ilyas Ahmed

G20 Health Ministers met in Okayama, Japan, on 19 and 20 October 2019 to address major global health issues in order to pave the way towards a more inclusive and sustainable world, as envisioned in the 2030 Agenda for Sustainable Development.

Ministers put a strong emphasis on ending polio in the resulting declaration, reaffirming their “commitment to eradicate polio”, and recognizing the remaining challenges.

Ministers welcomed next month’s pledging event. With the support of G20 members and other important global donors, the Global Polio Eradication Initiative aims to successfully raise funds to overcome the remaining challenges that face the world as we work to end polio. The pledging event will be generously hosted by the UAE and His Highness Sheikh Mohamed bin Zayed Al Nahyan, Crown Prince of the Emirate of Abu Dhabi, as part of the Reaching the Last Mile Forum on 19 November 2019, and intends to secure the financial commitments needed for the programme to finish the job.

Ministers noted, “We are concerned with the rising number of vaccine-derived polio outbreaks. We call for a strong cross-border cooperation and strict implementation of vaccine requirements for travelers as specified in the International Health Regulations (IHR, 2005).”

The polio programme is currently responding to vaccine-derived poliovirus outbreaks in 18 countries. The encouragements of the G20 Health Ministers regarding the pledging event, IHR implementation and cross-border collaboration are welcomed as part of measures to ensure high quality comprehensive outbreak response and the ability of the programme to eradicate the virus.

In addition, Ministers expressed support for “the efforts of the Global Polio Eradication Initiative (GPEI), Gavi, the Vaccine Alliance (Gavi), WHO, UNICEF, and other stakeholders in strengthening routine and supplemental immunization,” and highlighted the “leadership role of WHO”. This year, Gavi has joined the Polio Oversight Board, becoming the sixth partner of the initiative. Ministers referred to the importance of “the transition of relevant polio assets” to other health programmes, a process that will be strengthened by Gavi’s partnership.

Polio eradication has an important role to play in the implementation of other global health goals. Considering this broader context, Ministers recognized that “high quality and safe primary health care including access to vaccination is a cornerstone for UHC”. Ministers noted, “We recognize that immunization is one of the most cost-effective health investments with proven strategies that make it accessible to all segments of the population with an emphasis on women and girls, the most hard-to-reach as well as the vulnerable and marginalized populations. We express our concern about vaccine hesitancy as mentioned in the WHO’s Ten threats to global health in 2019.”

Vaccination is the only way to eradicate polio and the GPEI is working tirelessly in some of the most challenging contexts to ensure all children, boys and girls, regardless of where they live, have access to life-saving vaccines.

This important statement from G20 Ministers of Health represents a continuation of the strong historical political support for polio eradication from both the G7 and the G20, at the highest levels.

The statement also follows the reaffirmation of support for polio eradication by G20 health leaders during their June 2019 summit. In this meeting, they discussed major challenges facing the world and once more communicated that “we reaffirm our commitment to eradicate polio”.

In 2020, Saudi Arabia will hold the presidency of the G20 and the US Government will hold the Presidency of the G7.

The Government of Japan, current host of the G20, is committed to the eradication of polio, providing US$ 563 million in grants to the GPEI since 1988.

Read the Okayama Declaration of the G20 Health Ministers.