Henrietta Lacks was diagnosed with cervical cancer in 1951, at the age of 31. Doctors in Baltimore, USA took a small sample of her tissue during the treatment to remove her tumour, without her knowledge – a not uncommon way to treat minorities at that time. Up to that point, attempts to grow human cells outside the body had failed. However, Lacks’ cells were different: they were able to divide and replicate indefinitely. These cells became the source of the HeLa cell line – one of the most important cell lines in medical research – and contributed to developing the first polio vaccine. While the world has benefited greatly from Henrietta Lacks’ cells, the unethical use of her cells raised concerns about longstanding medical racism towards marginalized or minority communities – and has contributed to the movement towards more people- and community-centred care.
Margaret C. Snyder is often called the UN’s First Feminist. Her pioneering career refocused the mechanisms of global development aid to include women. As she wrote last year: “There was a failure to realize that the most serious problems of development defy solution without the involvement of women.” When she began working at the UN, in the early 1970s, most women did secretarial work. Under her influence, that began to change. By 2021, women make up a significant portion of UN professional staff, and applying a gender lens to the UN’s work has become essential. This thinking was foundational to the systematic adoption of gender-based planning that has underpinned polio eradication. Margaret C. Snyder died earlier this year at the age of 91.
As the sun sets across Sindh province, exhausted polio eradication volunteers head home after a busy vaccination campaign. Each has personally vaccinated hundreds of children. In total, it has taken just a week for 9 million children under the age of five to receive two drops of oral polio vaccine, boosting their immunity against the virus.
In the crowded office of Jan Sayyed, Ali Raza and Muhammad Bilal Wasi Jan however, work is only just beginning. They work in the Polio Eradication Data Support Centre, located in Pakistan’s biggest city Karachi. During the campaign, vaccinators fill in paperwork every time they distribute vaccine drops. They record the number of children reached with vaccines, their existing vaccination status, any vaccine refusals and whether the children are local to the area, or visiting.
Across a typical vaccination campaign, this generates data referring to over two million children, recorded on thousands of forms. It is the challenging job of Jan, Ali, and Bilal to label and classify all this data so that it can be uploaded to an online system and analyzed to improve the next campaign.
Data is the lifeblood of the polio programme
Waqar Ahmad, Technical Officer for Data at WHO Pakistan, believes that if immunization and disease surveillance represent the heart of the programme, then data is the lifeblood that helps the programme inch closer to vaccination.
Different kinds of reliable data help the programme make decisions based on evidence. For instance, data that shows a high rate of vaccine refusals in one area allows the programme to investigate the cause further and act to persuade parents of the importance of vaccination.
But creating effective systems for gathering, sorting, and analyzing high-quality data hasn’t been easy. It has required rethinking approaches, overcoming bumps in the road, and thinking beyond the usual parameters of data management.
Pakistan’s polio data journey
Data collection and record keeping in Pakistan’s polio eradication programme began in 1997. Originally, data was collected only in very specific circumstances, such as when cases of Acute Flaccid Paralysis were detected. Such limited data collection meant that broader programme activities could not be analyzed, which increased the chances that vaccination campaigns could be ineffective. Data on other aspects could ensure that logistics were right-sized, and that human resources were deployed where they were most needed.
In November 2015, the programme introduced an online database designed to provide real-time data, named the Integrated Disease Information Management System (IDIMS).
The IDIMS database is used to store pre-, intra- and post-campaign data relating to multiple areas, including vaccination, disease surveillance, human resource planning, logistics planning, and mobile data collection. Data inputted into IDIMS is directly available for viewing and analysis at the provincial, national, and regional level. It can be cross-referenced with other polio eradication databases.
Young Pakistanis like Jan, Ali and Bilal are part of the workforce that keeps the whole system online. Once they have labelled and classified the paper forms, they pass the data onto their colleagues to be digitized and analyzed.
What’s next for polio eradication data management?
Open Data Kit software
In the Data Support Centres, employees are constantly thinking about how to further improve the IDIMS system. Jan, Ali and Bilal note that digitizing the whole data collection and management process would make the system more efficient, as well as environmentally friendly.
Data collection using Open Data Kit (ODK) software offers a way to do this. The data collection process is the same as with paper forms, except information is recorded in a mobile based application. Once vaccinators are in an area with internet, the data is directly uploaded to the ODK server and the IDIMS server. The ODK system has been rolled out in some areas of Pakistan.
Gender-disaggregated data represents a new area of work for the data management teams. Data included in the IDIMS database assists with gender-conscious campaign planning at the provincial level, while a separate system analyses gender-disaggregated information at the country level. Ensuring female vaccinators are recruited for campaigns is crucial, as women can often vaccinate children in places where for cultural reasons, men cannot.
Increasing user-friendly interfaces
As part of efforts to make systems user friendly, one year ago the polio programme launched online data profiles for Union Councils (UCs), the smallest administrative units in Pakistan. These profiles are available on the National Emergency Operation Centre data dashboard and allow polio programme staff to easily extract sizeable amounts of data about the local epidemiological situation within 30 seconds, as well as compare and analyze data for the past six years.
One of the most useful, innovative aspects of the UC profiles is that they collate information on children who were persistently missed during the last six campaign rounds, with information like contact details and the immunization history of the child. Such information assists the programme in follow-up engagement with the child’s parent or caregiver to encourage vaccination.
This requires speedy information sorting and uploading. Jan notes that his team is filing information more efficiently than they used to. This helps to ensure that details are up to date for nearly every town and village.
Over the coming months and years, further innovations will be introduced to improve data efficiency, range and quality.
Campaign by campaign, form by form, data handlers like Jan, Ali, and Bilal are helping to end polio.
Environmental surveillance teams in Mogadishu access the underground closed drainage system to collect sewage waste water samples, which they package and send to the laboratory for testing. If poliovirus is identified in a sample, epidemiologists know that the disease is likely to be circulating amongst the community whose sewage drains into that part of the system. This process is called environmental surveillance and is one of the most important tools for the polio programme to help detect poliovirus.
Vaccinating every child and conducting disease surveillance to know where the poliovirus is circulating are key strategies to end the outbreak. Low immunization coverage has led to an outbreak of vaccine-derived poliovirus in Somalia. This can occur in places where not enough children have received their full vaccine doses.
The teams must follow best practice to collect samples, to ensure that any poliovirus present can be detected.
Click through this photo gallery to learn more about the sample collection process.
First, Mohamed Sharif’s team put on face masks, aprons, and gloves. They are collecting untreated sewage waste water, so it’s crucial that they wear protective clothing to protect themselves from bacteria and viruses that they may encounter during their work.
Their next task is to detect the atmospheric temperature of the site, and record this on the lab request form.
The officers try to collect a high-quality sample from a pipe with running waste water. The sample must be free of contaminants, such as detergent liquids or rubbish, which could kill the virus before it is detected.
Mohamed Sharif explains that collecting a high-quality sample can be a challenge in Mogadishu, “The sewage system is old and poorly maintained. Often, rubbish is visible. Despite this, we try our best.”
Once the sample is collected, it is drained into a secure screw-cap container, which is sealed, cleaned with liquid bleach, and labelled with a unique ID code.
The ID code references this specific environmental collection site.
“Mogadishu is the first region in the country to establish environmental surveillance for polio,” Mohamed Sharif says. “The community, Ministry of Health, and the Mogadishu Municipality are aware of the hard work we are doing.”
The sample is put into a cool box for transportation to the WHO office. From there, it will be immediately flown to Kenya Medical Research Institute (KEMRI) in Nairobi, where there is a specialized poliovirus laboratory. This lab tests samples from countries across the Horn of Africa.
The sample should be kept at 4°c throughout the four-hour journey to the laboratory. This is known as the ‘reverse cold chain’ and prevents the virus deteriorating during transportation.
Carrying a sample collected from Egyptian Hospital site
Mohamed Sharif explains what motivates him to continue this challenging work: “It is our hope that in future, when polio eradication is achieved, our names will be written in the offices of the Eastern Mediterranean region of the World Health Organization.”
“We will be part of the legacy of polio-free Somalia.”
On 9 September 2019, the Global Polio Eradication Initiative (GPEI) partners and the United Arab Emirates co-hosted an informal reception as a pre-event ahead of the Polio Pledging Moment in the United Arab Emirates’-hosted Reaching the Last Mile Forum in Abu Dhabi, in November 2019. The GPEI also presented the 2019-2023 GPEI Investment Case.
The reception brought together GPEI stakeholders including, Rotary International, His Excellency Obaid Saleem Saeed Al Zaabi, UAE Permanent Representative to the United Nations (UN), representatives from the UAE; WHO Director-General and Chair of the GPEI Polio Oversight Board, Dr Tedros Adhanom Ghebreyesus; partners, and representatives from donor countries.
Following the GPEI Endgame Strategy 2019-2023, which spells-out a comprehensive five-year plan to ‘finish the job,’ the 2019-2023 Investment Case presents an economic case for investing in polio eradication as an important public health cause. Committing to eradication and achieving the goal of reaching every last child with the polio vaccine, an estimated US$ 14 billion are expected in cumulative cost savings by 2050, with efforts to eradicate polio having already saved more than US$27 billion since 1988. The need of the hour now is a bold financial and political commitment from leaders, donors, and governments around the world to rally behind a polio-free future.
As the GPEI launches its new investment case for 2019-2023, it recognizes important stakeholders who have gotten the programme to where it is today. One of the most notable donors is His Highness Sheikh Mohamed bin Zayed Al Nahyan, Crown Prince of Abu Dhabi.
His Highness Sheikh Mohamed bin Zayed has been a critical partner and champion of the GPEI. His support has helped spur significant progress toward stopping polio in the remaining endemic countries, with a specific focus on strengthening immunization efforts in Pakistan and Afghanistan. In 2018, the GPEI was proud to announce that His Highness’ support for polio eradication activities through the GPEI and the UAE Pakistan Assistance Programme and helped deliver 417 million vaccines to protect some of the most vulnerable and hard-to-reach children in the highest risk districts across the country.
Starting off the reception, His Excellency Obaid Saleem Saeed Al Zaabi, UAE Permanent Representative to the United Nations (UN), gave insight into the UAE’s long-standing commitment to polio eradication efforts: “UAE, together with its partners, has played a leading role in polio eradication, has supported the delivery of vaccines to protect over 16 million children…and supported polio outbreak efforts in Afghanistan, Pakistan, Somalia, Ethiopia, Kenya and Sudan. For the implementation of the GPEI Endgame Strategy 2019-2023, which aims for a world free of wild poliovirus, the UAE in cooperation with the WHO will host a pledging event in Abu Dhabi in November 2019.”
WHO Director-General and Chair of the GPEI Polio Oversight Board, Dr Tedros Adhanom Ghebreyesus, also recognized the strong political and financial will of the donors —spanning over decades— which have helped the GPEI mark important milestones on the road to global polio eradication. “We have made good progress in accessing hard-to-reach communities…increasing cross-border efforts, enhancing surveillance, improving Supplementary Immunization Activities (SIAs), and focusing on social and behavioural change.”
“Unfortunately, we have seen an increase in the number of cases this year. This is a reminder that polio eradication is not a forgone conclusion…the last mile is the hardest. This will take a determined and unrelenting effort from all of us. Global progress to end polio would not be possible without partners like the UAE. On behalf of our partners at the GPEI, I would like to thank His Highness, Sheikh Mohammed bin Zayed Al Nahyan, Crown Prince of the Emirate of Abu Dhabi, and the UAE – a long-time supporter of the polio programme – for agreeing to host the GPEI pledging event on 19 November.”
Rounding off the event, Chair of Rotary International Polio Eradication Advocacy Task Force, Judith Diment, officially presented the GPEI 2019-2023 Investment Case and called for concerted global efforts —both political and financial— to ensure that the hard-won gains in the fight against polio see us through the finish line. “Building on past progress and overcoming remaining hurdles requires continued support and (polio eradication) is a sound value-added investment. Today, we are proud to present the new 2019-2023 GPEI Investment Case…and thank all our partners for their input. This support and engagement are invaluable, given that this is a document that argues that polio can be eradicated but only with sufficient financial and political support. To ensure success, the Initiative needs US$ 3.27 billion through 2023… any investor is looking for measurable progress, tangible dividends, and return on investment— the GPEI has all of these. Rotary looks forward to joining all partners to make a funding pledge in Abu Dhabi, and to continued collaboration towards the fulfilment of a polio-free world from which we will all reap the dividends in perpetuity.”
The informal reception serves as a pre-event to the Reaching the Last Mile (RLM) Forum in November 2019, which will convene global health leaders to find solutions, best practices and eradication strategies to the most pressing health concerns of our times, including the global eradication of poliovirus. On the sidelines, the GPEI will also be hosting the Polio Pledging Moment to secure funding for the implementation of the Polio Endgame Strategy 2019-2023.
Exciting research is underway on a novel oral polio vaccine for type 2 polio (nOPV2), which – if further trials are successful – could be a potential new tool to provide the same level of protection against poliovirus as the current oral polio vaccine (OPV), but without the same risk of mutating into vaccine-derived poliovirus in under-immunised populations.
Results from a phase I study to test two nOPV2 candidates were published in The Lancet in early June 2019. The study, led by the University of Antwerp in partnership with a global consortium of researchers and funded by the Bill & Melinda Gates Foundation, was conducted in 2017 at a unique container park named “Poliopolis” at the University of Antwerp. To test the vaccine, 30 individuals volunteered to spend a month living in the container park – complete with private, air-conditioned rooms, a lounge area and foosball table, fitness room, dining area, daily schedules of entertainment, exercise and health check-ups.
The initial findings from this study are promising, showing that the two vaccines tested at Poliopolis are safe and produce the immune response needed to protect individuals against polio. Results from phase II trials are expected in the coming months, which is when the program will learn whether nOPV2 is a tool that can ultimately be deployed for children at risk of poliovirus transmission.
The nOPV2 vaccine candidates were designed by a consortium of scientists from the UK National Institute for Biological Standards and Control (NIBSC), the US Centers for Disease Control and Prevention (CDC) and the University of California, San Francisco (UCSF), and manufactured by Bio Farma – with several other institutions playing key roles in the development process. Current clinical trials testing the vaccine candidates are taking place in Belgium and Panama. If ongoing and future trials are successful, nOPV2 could be kept in stockpiles and used in case of a VDPV2 outbreak in the near future or after eradication. This would make it a potentially vital tool for keeping the world free of all forms of the poliovirus.
OPV, which has been responsible for reducing the number of global polio cases by over 99% since the launch of the Global Polio Eradication Initiative (GPEI) in 1988, remains the best available tool to eradicate wild poliovirus. It is a safe and effective vaccine that will continue being used widely.
This exciting research on nOPV, however, is just one more way in which the GPEI has continued to innovate to overcome hurdles over the past three decades. We look forward to seeing the results of further research that will tell us if we can add this vaccine to our “toolbox” to protect all children from polio.
From the epidemics in the 1950s to the 1000 cases per day in the 1980s, polio’s devastation has seeped across generations. That is, until Global Polio Eradication Initiative and anchoring partners, Rotary International, WHO, UNICEF, CDC, and most recently, the Bill & Melinda Gates Foundation, united efforts and resources to develop a comprehensive polio eradication infrastructure.
Ranging from cutting edge research to dedicated laboratories to community engagement to sewage sampling, the polio infrastructure is as widespread as it is comprehensive. With presence in over 200 countries, the polio programme is second to none, making it one of the largest public-private health partnerships in history.
While the polio eradication infrastructure helps get us closer to a polio-free world, did you know that it is also used to fight and protect against other diseases, too? Here are five examples of the polio infrastructure at work:
The cold chain
The Oral Polio Vaccine (OPV) requires constant refrigeration and vaccine must be kept cool between 2-8 degrees, or it risks losing its effectiveness. This is no easy task in countries and areas where electricity is either unavailable or unreliable.
So, the programme developed what is known as a cold chain system — made up of freezers, refrigerators, and cold boxes — to allow polio workers to store the vaccine and transport it over long distances in extremely hot weather. In Pakistan, a measles immunization program now relies on the same system. With the help of the cold chain, Sindh province recently reached its goal of immunizing more than 7.3 million children against measles.
A critical component in immunizing more children against polio, especially in remote regions, is microplanning. A microplan allows health workers to identify priority communities, address potential barriers, and develop a plan for a successful immunization campaigns.
The workers collect as many details as possible to help them reach and vaccinate all the children. This strategy has helped keep India polio-free for five years. Now the Mewat district of India is using microplanning to increase its rates of vaccination against measles and rubella.
The polio surveillance system helps detect new cases of polio and determines where and how these cases originated. Environmental surveillance, which involves testing sewage or other environmental samples for the presence of poliovirus, helps workers confirm polio cases in the absence of symptoms like acute flaccid paralysis (AFP).
In Borno state in Nigeria, the AFP surveillance system is now being used to find people with symptoms of yellow fever and was one of many tactics used during a 2018 yellow fever outbreak that resulted in the vaccination of 8 million people.
Since polio is a transmittable disease, health workers use contact tracing to learn who has come in contact with people who might be infected. Contact tracing was also critical to containing an Ebola outbreak in Nigeria in 2014. When a traveller from Liberia was diagnosed with Ebola, Nigerian officials were able to quickly trace and isolate the traveller’s contacts, helping prevent the disease from spreading further.
Emergency operations centres
An important part of the polio infrastructure that Rotary and its partners have built is the emergency operations centres network. These centres provide a centralized location where health workers and government officials can work collaboratively and generate a faster, more effective emergency response. The emergency operations centre in Lagos, Nigeria, which was originally set up to address polio, was adapted to handle Ebola, and it ultimately helped the country respond quickly to an Ebola outbreak. Only 19 Ebola cases were reported, and the country was declared Ebola-free within three months.
On 15 March 2019 in Islamabad, representatives from the Embassy of Japan and the Japan International Cooperation Agency (JICA) were given a general update on the progress of the Polio Regional Lab and the surveillance network. Thanks to Japan’s funding, 70% of the latest molecular biology equipment has been procured, installed and made operational. JICA representatives also toured the facility and the works in process.
The Government of Japan through JICA is a long-standing and committed donor to the polio eradication efforts by funding initiatives and broader immunization activities in Pakistan since 1996.
As a part of its more recent commitment, JICA is supporting Pakistan in strengthening disease surveillance through a state-of-the-art equipment of the Regional Reference Laboratory at the National Institute of Health in Islamabad.
The Pakistan Regional Polio Lab will go a long way in facilitating poliovirus detection in stool samples and the environment. At present, the lab tests more than 30,000 stool samples from people with paralysis and 950 environmental samples each year, including samples from both Afghanistan and Pakistan. The new soon-to-be operational lab equipment will speed up the ability to process and respond quickly wherever the poliovirus may be hiding. This is critical work in ensuring Pakistan targets its last remaining core reservoirs of poliovirus.
In this last mile of polio eradication, support from JICA is crucial and much appreciated. Pakistan is one of the last remaining polio endemic countries in world, along with Afghanistan and Nigeria. The political and financial commitment from the Government of Japan over the years has already helped Pakistan in reducing the number of polio cases by 96% since 2014. With only 12 cases reported in 2018, Pakistan has a fighting chance of finally consigning polio to the history books.
The Japan International Cooperation Agency (JICA) assists and supports developing countries as the executing agency of Japanese ODA. In accordance with its vision of “Inclusive and Dynamic Development,” JICA supports the resolution of issues of developing countries by using the most suitable tools of various assistance methods, such as technical cooperation, ODA loans and grant aid in an integrated manner.
The Endgame Plan through 2018 brought the world another year closer to being polio-free. While we had hoped to be finished by now, 2018 set the tone for the new strategic plan, building on the lessons learned and mapping out a certification strategy by 2023. 2018 was also marked by expanded efforts to reach children with vaccines, the launch of innovative tools and strategies, critical policy decisions and renewed donor commitment to the fight.
Cornering wild poliovirus
Circulation of wild poliovirus (WPV) continues in the common epidemiological block in Afghanistan and Pakistan. However, both countries steadily worked to improve the quality of their vaccination campaigns in 2018 through National Emergency Action Plans, with a particular focus on closing any immunity gaps to put the countries on track to successfully stop WPV in the near future. Given the priority on polio eradication, WHO Director General, WHO Regional Director for the Eastern Mediterranean and President, Global Development at Bill & Melinda Gates Foundation started off the new year with a four-day visit to meet the heads of state and have a first-hand experience of the on-the-ground eradication efforts in both the countries.
In August, Nigeria marked two years since detecting any WPV. With continuing improvements in access to the country’s northeast, as well as efforts to strengthen surveillance and routine immunization, the entire African region may be eligible for being certified WPV-free as early as late this year or early 2020. What’s more, the world has not detected type 3 WPV since 2012 and the strain could be certified eradicated sometime this year.
The programme is constantly developing new ways to more effectively track the virus, vaccinate more children and harness new tools to help end the disease for good.
In Nigeria and the surrounding region, health workers launched new tools to enable faster, more comprehensive disease surveillance. e-Surve, a smartphone app, guides officers through conversations with local health officials, offering prompts on how to identify and report suspected cases of disease. Then, with the touch of a button, responses are submitted to a central database where health officials can analyze and track outbreaks across multiple districts in real-time.
Beyond surveillance, health workers worked tirelessly to bring the polio vaccine to the remote communities of Lake Chad. Dotted with hundreds of small islands, the lake is one of the most challenging places on earth to deliver health services. Vaccinators must travel by boat on multi-day trips to deliver polio vaccines to isolated island villages, using solar-powered refrigerators to keep their precious cargo cool. In 2018, vaccination campaigns on the lake reached thousands of children for the first time – children who would otherwise have gone unprotected.
The programme also took important steps in developing new tools including, novel oral polio vaccine (nOPV), if studies show to be successful, could provide a safer form of OPV that provides the same level of protection without the small risk of vaccine-derived polio in under-immunized populations.
Battling circulating vaccine-derived poliovirus
In 2018, the Democratic Republic of the Congo, Niger, Nigeria, Papua New Guinea, Kenya, Somalia and Mozambique experienced outbreaks of circulating vaccine-derived polio (cVDPV). Although these cases are still rare – and only happen in places where immunity is low. The polio eradication initiative has two urgent tasks: eradicate WPV quickly as possible and stop the use of OPV globally, which in tandem will prevent new cVDPV strains from cropping up.
The program uses the same proven strategies for stopping wild polio in responding to cVDPV cases. These strategies, coupled with the rapid mobilization of resources on the ground, can bring outbreaks under control.
In December, an international group of public health experts determined that the 2017 cVDPV2 outbreak in Syria has been successfully stopped. This news follows 18 months of intensive vaccination and surveillance efforts led by the GPEI and local partners in conflict-affected, previously inaccessible areas. In Papua New Guinea, the programme carried out 100 days of emergency response this past summer and is continuing to vaccinate and expand surveillance across the country.
Bringing an end to ongoing cVDPV outbreaks remains an urgent priority for the program in 2019.
New policy decisions
At the World Health Assembly in May, Member States adopted a landmark resolution on poliovirus containment to help accelerate progress in this field and ensure that poliovirus materials are appropriately contained under strict biosafety and biosecurity handling and storage conditions. The programme also finalized a comprehensive Post-Certification Strategy that specifies the global, technical standards for containment, vaccination and surveillance activities that will be essential to maintaining a polio-free world in the decade following certification.
Recognizing the ongoing challenge posed by cVDPVs, the Global Commission for the Certification of Poliomyelitis Eradication (GCC) met in November and recommended an updated process for declaring the world polio-free. This plan will start with the certification of WPV3 eradication, followed by WPV1, and include a separate independent process to validate the absence of vaccine-derived polio.
Comprised of members, advisers, and invited Member States, the 19th IHR Emergency Committee met in November. The Committee unanimously agreed that poliovirus continues to be a global emergency and complacency at this stage could become the biggest hindrance. “We have the tools, we need to focus on what works, we need to get to every child,” commented Prof. Helen Rees, Chairperson of the Committee. “The reality is that there is no reason why we should not be able to finish this job, but we have to keep at it.” “We have achieved eradication of a disease once before, with smallpox,” Rees concluded. “The world is a much better place without smallpox. It’s now more urgent than ever that we redouble our efforts and finish this job once and for all as well.”
Spotlight on gender
In 2018, the GPEI took major steps in adopting a more gender-responsive approach and strengthening gender mainstreaming across its interventions. The GPEI Gender Technical Brief highlighted the programme’s commitment to gender equality and included a thorough analysis of various gender-related barriers to immunization, surveillance and communication.
The programme introduced new gender-sensitive indicators to ensure that girls and boys are equally reached with polio vaccines, to track the timeliness of disease surveillance for girls and boys, and to monitor the rate of women’s participation as frontline workers in the endemic countries. The GPEI continues to regularly collect and analyze sex-disaggregated data and conduct gender analysis to further strengthen the reach and effectiveness of vaccination campaigns.
Donor countries made new financial contributions to the programme in 2018. Polio-affected countries also demonstrated continued political commitment to eradication efforts. The Democratic Republic of the Congo signed the Kinshasa Declaration committing to improve vaccination coverage rates in sixteen provinces throughout the country, and Nigeria approved a $150 million loan from the World Bank to scale up immunization services and end polio.
Looking ahead: 2019 and beyond
Over the last five years, the programme has been guided by the 2013-2018 Polio Eradication & Endgame Strategic Plan, helping to bring the world to the brink of polio eradication. This spring, the programme will finalize a new strategy –GPEI Strategic Plan 2019-2023– which will aim to sharpen the tools and tactics that led to this incredible progress. In 2019, the GPEI will also launch its first-ever Gender Strategy to further guide its gender-responsive programming and to increase women’s meaningful and equal participation at all levels of the programme.
Success in the coming years will hinge on harnessing renewed financial and political support to fully implement the plan at all levels, with our one clear goal in sight: reach every last child with the polio vaccine to end this disease once and for all. Echoing similar sentiments, Chairs of the effort’s main advisory bodies issued an extraordinary joint statement, urging all to step up their performance to end polio. 2019 may very well be the watershed year that the world will finally eradicate polio, thanks to the global expertise and experience over 3 decades.
“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.
In April 2016, the polio programme embarked on a massive, coordinated effort to withdraw Sabin type-2 from routine use, through a synchronized switch from the trivalent formulation of the oral poliovirus vaccine (tOPV) to the bivalent form (bOPV). Over a two-week period, 155 countries and territories successfully made this change, marking the largest and fastest vaccine rollout in history.
Referred to as simply “the switch,” this global undertaking was a major programmatic achievement, but it was also a necessary step on the road to eradication. That’s because, in rare cases, the live, weakened virus contained in OPV can mutate and spread, resulting in cases of circulating vaccine-derived polioviruses (cVDPVs). The vast majority of these cases are caused by just one of the three components contained in tOPV (Sabin type-2 virus), so switching to a bivalent form that doesn’t contain this component was an attempt to significantly minimize the risk of further cVDPV2 cases – a decision that was endorsed by the global health community. Further, with Sabin type-2 responsible for 40% of vaccine-associated paralytic polio (VAPP) occurrences – a much rarer phenomenon at 2-4 cases per 1 million ‒ there was even stronger justification for the switch.
To assess whether the switch was successful, a group of researchers from Imperial College London, the World Health Organization and the Bill & Melinda Gates Foundation analysed stool and sewage samples from 112 countries collected in the first 15 months after the switch. The results, published in The New England Journal of Medicine, show that VDPVs and Sabin type-2 excreted into the environment after vaccination disappeared rapidly after the switch, shrinking to a much smaller geographic area.
These findings validate the GPEI decision to withdraw tOPV and demonstrate that the switch achieved its desired goal of reducing VDPVs and VAPP. This research also provides important evidence that the complete withdrawal of OPV after eradication of all wild polioviruses will eventually eliminate the risk of VDPVs, provided high immunity and effective surveillance are maintained. Eradication is simply not compatible with continued use of OPV.
The study also showed, however, that while some outbreaks of VDPV were expected post-switch, the number and magnitude of some of these outbreaks in different geographies has proven more difficult to control than expected. Type-2 VDPV outbreaks outside of Africa have been responded to with monovalent type-2 OPV (mOPV2) and controlled. However, outbreaks in the Horn of Africa, DR Congo and Nigeria have been very difficult to bring to a rapid close.
VDPV outbreaks emerge in areas with very low population immunity, due to low immunization coverage. Factors which enable them ‒ insecurity and resulting inaccessibility, weak health systems, and poor campaign performance – are the same that need to be addressed to stop their transmission. While the programme is aware of these risk factors and has proven experience and strategies to respond to them, the longer outbreaks persist, the harder they can be to stop.
The key to stopping these outbreaks will be to increase the focus on improving the quality of vaccination campaigns in accessible areas. In inaccessible areas, we need to use all available means to negotiate access and implement vaccination campaigns. Achieving high quality campaign activities will give us the best chance to stop all types of poliovirus for good and prevent any child from being paralysed by the virus ever again.
A new study published this month in the Journal of Infectious Diseases has shown that a single dose of fractional dose inactivated poliovirus vaccine (fIPV) boosts mucosal immunity to a similar degree as a full dose of IPV, in children previously immunized with oral polio vaccine (OPV). During the current IPV shortage, this vaccine is not recommended for outbreak response, however, if it is used, then this finding provides further evidence in support of fIPV rather than full dose IPV at a time of IPV global supply shortage.
The efficacy of fIPV in boosting humoral immunity (offering individual protection against paralytic disease) in comparison to full-dose IPV had already been established, and this dose-sparing approach for routine immunization programmes was subsequently recommended by the Strategic Advisory Group of Experts on immunization (SAGE). Thanks to an increasing number of countries adopting this approach, including Bangladesh, India, Nepal, Sri Lanka, Cuba and Ecuador, there have been significant improvements in the global supply of this vaccine.
These latest findings show that fIPV also has a significant role to play in outbreak response. Mucosal immunity is needed to interrupt person-to-person spread of the virus in a community, so is a critical factor in outbreak response. Used in conjunction with OPV, even a single dose of this formulation could now play a key role in such settings, by rapidly boosting mucosal immunity at a similar level to a full-dose IPV while using a fifth of the vaccine amount. This has clear benefits both on cost and supply.
“Globally, demand for IPV is high and the supply is constrained,” commented Dr Tahir Yousafzai from Aga Khan University in Karachi, Pakistan. “As polio eradication is gradually eliminating OPV, countries will eventually rely solely on IPV, further increasing demand. Fractional IPV can stretch the limited IPV supply and provide similar humoral and mucosal protection when compared to full-dose IPV in children vaccinated with OPV. In addition, it will play an important role in stopping poliovirus transmission, and hence help in the eradication of wild poliovirus and circulating vaccine-derived poliovirus.”
For the post-polio era, the Global Polio Eradication Initiative and its partners are continuing to explore new IPV approaches to ensure an affordable and sustainable supply following global polio eradication, including through the use of IPV vaccine manufactured from Sabin strains or non-infectious materials such as virus-like particles.
To supplement Global Action Plan III for the containment of polioviruses, WHO has published guidance for non-polio facilities to help them identify, destroy, or safely and securely handle and store sample collections potentially infectious for poliovirus.
Dr Mark Pallansch from CDC explains what the guidance means for facilities worldwide.
Poliovirus potentially infectious materials (PIM) include fecal, nasopharyngeal, or sewage samples collected in a time and place where wild polioviruses/vaccine-derived polioviruses (WPV/VDPV), or OPV-derived viruses were circulating or oral polio vaccines (OPV/Sabin) were in use. Non-polio research facilities with a high probability of storing such materials include those working with rotavirus or other enteric agents, hepatitis viruses, influenza/respiratory viruses, and measles virus. Other facilities could include those conducting nutrition research or environmental facilities.
Welcome to Poliopolis! You’ll spend the next 28 days in a container village to help us test a new polio vaccine. Poliopolis is equipped with all the amenities to make your stay comfortable: air-conditioned private rooms with workstations and sinks, a lounge area with a flat screen TV and foosball table, a fitness room with a variety of exercise equipment, and a bright, sunny dining area. Enjoy your stay!
Sounds like a scene from a science fiction story, right? But this is a real polio vaccine trial that took place in a parking lot at the University of Antwerp, Belgium in mid-2017. The study, funded by the Bill and Melinda Gates Foundation, evaluated two novel oral polio vaccine candidates. These vaccine candidates were developed by scientists from the US Centers for Disease Control and Prevention’s polio laboratory, the National Institute for Biological Standards and Control in the United Kingdom, and the University of California, in San Francisco, with support from the US Food and Drug Administration.
Once fully developed and tested, these new, more genetically-stable, live, attenuated vaccines will prove a critical resource to ensure global polio eradication.
Surveillance is one of the main pillars of the polio eradication initiative. By testing stool samples collected from children suffering acute flaccid paralysis – the clearest symptom of the virus – as well as samples taken from sewage water, we are able to find the poliovirus wherever it is hiding.
Pakistan’s polio surveillance system is one of the largest ever established in the world. Click through these pictures to learn about the journey of a stool sample there: From a child with suspected polio to the laboratory.
In Pakistan, a wide network of health workers, teachers, and other community members vigilantly look out for signs of polio in children in their area. These volunteers detect and report to the polio surveillance system children showing possible symptoms of the virus, often floppy or weakened limbs with rapid onset of paralysis, known as acute flaccid paralysis. Every suspected case acts as a signal that polio might be circulating in the area, and triggers an investigation.
The poliovirus lives in children’s intestines, where it multiplies, and is finally excreted. When a child with acute flaccid paralysis is reported to the surveillance system, health workers collect the child’s stool samples and transport them to the lab in specially designed cool boxes. The boxes ensure a constant temperature of between 4 to 8 °C, so that the viruses in the samples remain high enough quality to test. Once collected, stool samples from all corners of the country must reach the Pakistan Regional Reference Laboratory for polio eradication, based in Islamabad, within 72 hours.
The Regional Reference Laboratory was established in 1991 and tests around 30 000 stool samples each year from both Pakistan and Afghanistan. More than 99% of these stool samples come back negative for polio. This is because most cases of acute flaccid paralysis are not caused by poliovirus. However, the tiny fraction of positive results tells the programme where the virus may be hiding.
Dr Salmaan Sharif is a Molecular Biologist, and the Coordinator of the Regional Reference Laboratory in Islamabad. He supervises a team of 34 lab staff, each responsible for a different component of surveillance sample testing. With an increase in reported acute flaccid paralysis cases, and environmental sampling sites, the workload of Dr. Sharif and his team is increasing. This is a sign that the polio surveillance system is working well, as a large number of reported acute flaccid paralysis cases and environmental samples gives us our best chance of finding the virus.
Each sample is then processed in a centrifuge, which separates the components of the sample. Solids will drop to the bottom and liquids will remain at the top. Any poliovirus will remain in the liquid component. Once separated, a scientist is ready to inoculate a healthy cell.
From the processing room onwards, extensive biosafety measures are taken to ensure that all virus is kept in the controlled environment, that contamination of other samples does not occur, and humans are not at risk of exposure. During the primary screening, healthy cells are mixed with the liquid component of the processed stool sample, and are then grown in an incubator at 36 °C for up to ten days. An incubator mimics the natural environment of the virus, creating the ideal conditions for the virus to grow. If the virus is present in the processed stool sample, it will infect the healthy cells.
A daily microscopic examination is performed to determine whether poliovirus is present in the processed stool sample. Infected cells are visibly broken in pieces, while healthy cells are seen as long strands.
If poliovirus is isolated in a stool sample, further tests are carried out to determine what type of virus this is and where the strain may have originated. A Polymerase Chain Reaction (PCR) machine is used to determine the kind of poliovirus detected (known as the serotype), and to distinguish further between wild poliovirus and that related to the vaccine-derived.
The next step is genetic sequencing. By reading the genetic code of the virus, wild viruses can be compared to others and classified into genetic families. From this, the geographic origin of the virus can be determined. This helps to guide the programme when deciding the best immunization strategies to stop transmission, and to prevent further spread of the poliovirus.
The polio surveillance system stretches even further than stool sample testing. In carefully selected places where the virus could be hiding, surveillance officers collect sewage samples. These are also sent to the Regional Reference Laboratory for processing, using a method similar to the testing of the stool samples. Crucially, environmental surveillance can help find polio in the environment before it has a chance to paralyse a child.
In Pakistan, the programme has used environmental surveillance to test and detect the presence of poliovirus in the sewage in high-risk locations since 2009. The network has continued to expand over time with a wider coverage. Currently, there are 53 sampling sites in 33 districts and towns of the country, making it the largest environmental polio surveillance network ever established.
The sensitive polio surveillance system finds the poliovirus wherever it exists – from the most remote villages to huge cities. With the polio case count at the lowest level in the history of Pakistan, the country intends to make 2018 the year of poliovirus interruption, keeping current and future generations of children safe from this disease. Thanks to the generous support of the Government of Japan, the Islamabad laboratory is continuing to expand operations, now able to procure new state-of-the-art molecular biology equipment to help detect the last remaining reservoirs of the virus.
With polio at the lowest levels in history in Pakistan, the country has launched a powerful and hopefully final assault on the disease in 2018. A crucial part of this is to further strengthen the ability of the polio programme to detect virus in stool samples, thereby giving clear indications of where and how the virus is moving in areas where populations remain under-immunized.
To support this effort, the Government of Japan announced today that it will provide US$3.2 million for the procurement of equipment to the Regional Reference Laboratory for polio eradication, located in the National Institute of Health in Islamabad.
The funds will help support the purchase of state-of-the-art molecular-biology equipment, allowing the laboratory to significantly enhance and speed up its ability to process and detect poliovirus in environmental and stool samples. This is critical work – in 2017, the Islamabad lab tested 30 000 stool samples and 950 environmental samples from both Pakistan and Afghanistan, helping the programme better identify where the virus is hiding.
The Japanese grant will also be used to replace aging stocks of cold chain materials and other essential equipment needed to be able to accurately identify poliovirus in samples.
Speaking at the ceremony for the signing of the grant, the Federal Minister of National Health Services, Regulations and Coordination in Pakistan, Saira Afzal Tarar said: “The steady support of the Government of Japan and other partners, and the strong partnership have been crucial elements of the programme’s tremendous progress over the past two years. The new grant will help strengthen polio surveillance through adaptation of new technology and contribute towards polio eradication in the country.”
“These funds come at a crucial time in Pakistan’s eradication effort, and are being used in a strategically important manner,” commented Michel Zaffran, Director for Polio Eradication at the World Health Organization. “The country is on the cusp of being polio-free. What we now need is to urgently root out any last remaining spot where the virus might be hiding, and these funds will help strengthen the ability to do just that. Only by finding polio’s last remaining hiding places will we be able to eradicate it once and for all.“
The Government of Japan is a longtime supporter of the Global Polio Eradication Initiative, with contributions to end polio in Pakistan of approximately ¥24 billion (approximately US$ 224 million) since 1996. With only eight cases recorded in the country in 2017 from just a handful of districts – compared to more than 30 000 all over the country just 20 years ago – these additional funds come at a critical time for the country programme as it launches into the final intensified effort to finish the disease once and for all.
The Global Polio Eradication Initiative partners would like to extend their profound gratitude to both the Government of Japan and Pakistan for their collaboration, and for their tremendous support and engagement in the effort to end polio globally.
In Afghanistan this year, staff from the non-governmental organization Care of Afghan Families collected 420 blood samples from children under 4 at the Mirwais Regional Hospital in Kandahar province. The aim? To find out whether polio vaccination campaigns have been reaching enough children, and whether the vaccines have been generating full protection against this paralysing disease. These ‘serosurveys’ showed that immunity in Afghanistan is high – and also identified where vaccination campaigns need to reach out further.
Whenever a polio vaccination campaign takes place, a purple dot of ink is painted onto the little finger nail of every immunised child to show that they have received the lifesaving vaccine. This data is collected and allows people to monitor the campaign and know exactly where children have been reached.
Now, with more children being vaccinated than ever before, the polio eradication programme needs to know more than how many children are being reached: we need specific data on where children are being missed.
Serosurveys testing for immunity
Serosurveys are simple tests of the serum in a child’s blood, which measures their immunity (or seroprevalence) to different diseases. The polio eradication programme uses this test to see what level of protection a child has against wild poliovirus types 1, 2 and 3, allowing them to assess whether the vaccination campaigns are reaching enough children, enough times, to give them immunity.
At the Mirwais Regional Hospital, the children tested were from a diverse range of provinces. Their results were sent to Aga Khan University for initial testing, and then sent for further analysis to one of the Global Polio Eradication Initiative partners, the US Centers for Disease Control and Prevention in Atlanta. Through mapping both where they live and their immunity results, scientists at both institutions helped polio eradicators to discover the areas where a child is at most risk of being missed by vaccination campaigns.
Serosurvey results can be crucial for planning campaign strategies – making sure that every last child is reached, no matter where they live.
For Ondrej Mach, team lead for clinical trials and research in the WHO’s Polio Eradication Department, serosurveys “… are increasingly important for eradication efforts, allowing us to form an accurate picture of our progress so far, and the locations where we are being most effective.”
High immunity in Afghanistan
The Mirwais serosurvey proved that Afghanistan is closer than ever to eradicating polio, with more than 95% of children surveyed immune to wild poliovirus type 1, the virus type still circulating in some areas of Afghanistan, Pakistan and Nigeria, and more than 90% immune to type 3, which hasn’t been found anywhere in the world since November 2012. The tests also pointed to where gaps in immunity are, so that missed children can be found and protected.
These results are a strong reflection of the devoted work of polio vaccinators and community workers throughout the country, using their expertise to reach into every family, and spread awareness of the importance of polio vaccination.
Using serosurveys in at-risk countries
As in Afghanistan, serosurveys are increasingly used in other countries where polio remains or poses a threat, to help identify the last remaining pockets of under-immunized children in high risk areas. This is especially important because with polio in fewer places than ever before, it is these unreached children that will take us over the finishing line.
By getting an increasingly accurate picture of where vaccination campaigns are operating successfully, as well as where the programme needs to renew efforts, we can move further towards the goal of reaching every child.
This helps us reach our ultimate goal – ensuring that every last child, everywhere, can be polio free.
Research underpins the implementation of the Polio Eradication & Endgame Strategic Plan. It evaluates the effectiveness of existing strategies, strengthens tactical and operational implementation and pioneers new tools and approaches. The aim is to protect children from poliovirus in the best and quickest way possible.
The Global Polio Eradication Initiative, guided by its independent body of experts the Polio Research Committee, is issuing an urgent call for research proposals to help secure a lasting polio-free world.
In a promising development for keeping the world polio-free after eradication, a recent study has produced stable polio vaccine using virus-like particles (VLP) in the place of live poliovirus.
The study used VLPs made of empty viral capsids – the viruses’ protein coats – to produce the vaccine which, in initial testing, worked as well as traditional inactivated polio vaccine (IPV) made from inactivated wild vaccine-virus strains in protecting against polio.
This breakthrough opens up the possibility of not needing to keep stock of wild poliovirus to manufacture polio vaccines. A virus-free production process would reduce the risks presented by keeping stocks of the virus, reducing the need for strict biosafety requirements and bringing down the cost of vaccine production. Such an approach could significantly increase countries’ capacity to produce their own national supply of the vaccine, including in developing country settings, due to the strict guidelines for any facility with stocks of live poliovirus.
The current method of producing polio vaccines uses live poliovirus, which means that vaccine production facilities will be one of the few places the virus will continue to exist in the post-eradication era. Currently, IPV is made by growing, then inactivating the virus. Because vaccination against polio must continue for a number of years after the world is certified polio-free, there will be a continued need to retain the live virus for vaccine production.
Strict containment regulations are being implemented for poliovirus-essential facilities that need to host the live virus, but there will always remain a risk of reintroduction into the environment, as was seen with the accidental release of the eradicated smallpox virus from a laboratory in the UK in 1978, which resulted in the death of a woman.
The risk of reintroduction after eradication is a source of concern for maintaining a polio-free world, but if vaccines can be produced without the need for any live virus, the risk of release from vaccine production facilities will be eliminated.
Past research in this area has indicated poliovirus capsids were too unstable and sensitive to temperature to be a viable option for vaccines. This study, conducted by researchers from the National Institute for Biological Standards and Control, represents a significant step forward in the development of a virus-free vaccine.
Roland Sutter, Coordinator of WHO’s Polio Research, Policy and Containment team, said he believes that VLPs could replace current polio vaccines, but there is a lot more work to be done. If successful, however, this could “make the world a much safer place,” he said.
The use of VLPs in vaccine production requires further research, evaluation and clinical trials. This will be conducted as part of a global consortium of collaborators, conducted by the University of Leeds, United Kingdom (UK), the National Institute for Biological Standards and Control, and funded by WHO through the Bill & Melinda Gates Foundation.
The Global Polio Eradication Initiative is finding new ways to administer vaccines to ensure that every last child is protected against polio. From new injection devices to injection-free modes of delivery, these innovations will be crucial in resolving some of the challenges of the next few years, both approaching eradication and beyond.
Since the 1950s, the world has been vaccinating children against polio, and as a result, numbers of children paralysed by the virus have fallen from 350,000 each year down to just 74 in 2015. The opportunity to eradicate a disease is not one encountered often in global health, and the rare chance that we face to end polio forever will bring many benefits. Not least on this list is the economic dividends; by removing the poliovirus from the face of the world for good, the world will reap savings upwards of US$50 billion, funds that can be used to address other pressing public health needs.
Good things come in small packages
In the Polio Endgame, the injectable inactivated polio vaccine (IPV) will eventually be the only vaccine in use, when the oral polio vaccine (OPV) is fully phased out. Yet IPV is substantially more expensive than IPV – up to 15 times per dose – and it is also harder to deliver, needing trained professionals to give the injection. In addition, global supply constraints stand in the way of the important task of ensuring that every child worldwide is receiving this vaccine.
Building on a growing body of research that shows IPV can be given in fractional doses, the Strategic Advisory Group of Experts on immunization (SAGE) recommended this October that countries consider using 1/5 of a dose delivered intradermally in both routine immunization schedules and vaccination campaigns. India and Sri Lanka have already adopted this methodology.
This innovative approach would reduce the cost of using IPV in the future, once OPV has been withdrawn from use. This is important: as even once eradication has been achieved, maintaining high immunity will be necessary for some years, in case of a circulating vaccine-derived poliovirus outbreak or a containment breach of a virus from a vaccine manufacturer or laboratory.
But developments to ensure that every child can receive the benefits of being vaccinated against polio have not stopped at reducing cost.
Making it easier to reach every last child
Fractional doses of IPV need to be delivered intradermally into the top layer of the skin, rather than into the muscle. This requires different administration methods, training and tools to deliver it, although all other aspects of storage and handling are the same. Until now this has been done using the needle typically used to deliver the BCG vaccine, which is short and narrow, making it easier it get the vaccine between the skin layers. This can be a challenge for health care workers used to deliver IPV into the muscle.
But new delivery devices could simplify this work, reducing one of the barriers to administration of fractional dose IPV. This could greatly alleviate the global IPV supply constraint, by maximising all available vaccine supply and enabling more children to be reached with it.
Following clinical trials, WHO has started stockpiling the Tropis needle-free injector, a device that can deliver the vaccine through a narrow, precise stream of fluid that penetrates the skin without the use of a needle, whilst still delivering a similar quality as the BCG needle.
Though health workers will still need special training, the use of these devices could make their lives much easier by making some of the huge advantages that applied to the oral polio vaccine available for IPV as well.
A second innovation could also potentially transform IPV delivery. Micropatch needles are also being researched, coming with the advantage that they could be delivered not only by healthcare professionals, but also by trained volunteers, like OPV. Each patch, about a square inch in size, contains 100 vaccine-filled needles each the diameter of a human hair. When pressed into the skin, the needles dissolve, leaving only the patch backing. This approach would also revolutionise GPEI’s ability to deliver IPV as quickly and easily as OPV. Being able to carry out house-to-house vaccination campaigns would be a game-changer, especially in areas where reaching every last child can be a challenge. WHO is looking forward to clinical studies to evaluate this new approach.
The Global Polio Eradication Initiative (GPEI) is highlighting the innovations that are helping to bring us closer to a polio-free world. Find out about other new approaches driving the polio eradication efforts by reading more in theInnovation Series.
As the GPEI moves closer to eradication, the original vaccine against polio – the inactivated polio vaccine (IPV) – is playing a central role in immunizing children against polioviruses. By finding innovative methods of delivering the vaccine in a fractional dose, the GPEI is exploring new ways to overcome global supply constraints, and could help to bring the benefits of IPV to children everywhere.
The role of IPV in the Polio Endgame
Thanks to major steps forward including the declaration of wild poliovirus type 2 as eradicated in September 2015, the phased removal of oral polio vaccines began in April 2016 with the withdrawal of the type 2 component. As an essential part of this, all countries agreed to introduce one dose of IPV into their routine immunization systems to boost immunity against poliovirus types 1 and 3 and provide a baseline of immunity against type 2 in case of an outbreak of type 2 vaccine derived polioviruses.
Despite the importance of this step towards the Endgame, there are challenges facing IPV introduction. Shortfalls in IPV supply globally have left more than 40 countries without sufficient IPV supply to vaccinate all children through their routine immunization systems.
Fractional dose IPV is an innovation that could help address this challenge.
Fractional dose IPV
Full dose IPV is delivered through an intramuscular injection. But IPV can also be given intradermally, into the skin. When delivered in this way, only 1/5 of a dose is needed to generate almost as much immunity as one full dose delivered into the muscle; and two fractional doses generates higher immunity than one full dose. This innovation is making financial savings by reducing the cost of IPV, and enabling the limited supply to go much further.
Rolling out fractional dose IPV
The feasibility of using this new approach to delivering IPV is supported by a growing body of research. This has led to the recommendation of the Strategic Advisory Group of Experts on immunization (SAGE) for countries to consider adopting fractional dose IPV in both their supplementary and routine immunization activities.
A new field study in Sri Lanka provided evidence that using fractional dose IPV is as effective as using a full dose in OPV primed populations to boost mucosal immunity. This joins a body of previous studies that had already shown it to be as effective as full dose at inferring humoral immunity. Mucosal immunity is critical in stopping the person-to-person spread of virus.
Further research is showing that this approach to IPV delivery can be used for both routine immunization and outbreak response, meaning that the supply that is available can be maximised. A recent pilot campaign in Pakistan gathered data on its use in campaigns, which led to the GPEI recommending its use in outbreak response to boost immunity alongside OPV. A few countries are already adopting this new approach. Recent campaigns in India and Pakistan gathered data on its use in campaigns, which demonstrated feasibility in outbreak response to boost immunity alongside OPV. In addition, India and Sri Lanka are beginning to use fractional dose IPV in their routine immunization schedules. More countries are to follow in the face of the global IPV shortage.
The GPEI is also continuing to explore additional delivery mechanisms to overcome potential operational challenges, such as adaptors and needle-free devices to make it easier to deliver the vaccine intradermally. With the progress being made in this arena, the benefits fractional dose IPV could provide for children far outweigh any challenges.
The Global Polio Eradication Initiative (GPEI) is highlighting the innovations that are helping to bring us closer to a polio-free world. Find out about other new approaches driving the polio eradication efforts by reading more in the Innovation Series.
The polio eradication programme is using technology in innovative ways to map the activities of polio workers on the ground, and ensure that expertise and support is getting to the areas where it is most needed.
More than 300 international consultants are deployed by the partners of the GPEI in some of the countries most vulnerable to polio. By strengthening surveillance, tracking the virus, identifying immunity gaps and supporting vaccination campaigns to fill them, these consultants provide an important boost to capacity in polio-affected or vulnerable countries. By using new technologies, the programme is mapping the activities of all consultants to capture the range of locations they travel to and the activities they carry out. These innovations ensure that countries receive the best support from these consultants, and that they are working where the need is greatest.
The introduction of this new technology means that each week, no matter where they are in the world, international consultants report on their activities using a smartphone application called Survey123. The report only takes a minute to complete, works offline and captures their location at the time of reporting. By answering questions on what activities and diseases they have been working on that week, this tool enables the GPEI to capture data in real-time and ensure international consultants are being efficiently deployed in high risk polio areas and being used to their greatest advantage.
In the below snapshot from the first week of October, reports from the consultants can be seen in Guinea, the Lake Chad region, Madagascar, Somalia, Afghanistan and Pakistan – the areas that are most vulnerable to the virus.
Getting people where they are most needed
Survey123 is also enabling the GPEI to identify changes in deployment over time. The recent notification of wild poliovirus in the Lake Chad region demonstrated the use of this clarity, by showing the movement of consultants into and around the Lake Chad region, despite insecurity and inaccessibility.
In depth analysis such as this provides greater clarity on what additional human resources are needed to respond to outbreaks or newly recognised risk areas, and indicates how rapidly GPEI resources can be used to fill important needs.
The broader benefits of polio eradication
Due to the scale of polio eradication activities even in the most remote and vulnerable areas to reach every last child, international consultants are sometimes present where other health infrastructure is weak. The capacity of the polio programme in these vulnerable areas is sometimes used to support other health initiatives, including improving routine immunisation, measles activities, communication for development and emergency response.
Analysing the collected reports from Survey 123 is giving us greater insight into the extent to which consultants are supporting other health programmes. The support provided to other health programmes shown in the map below highlights the continued benefits of the polio eradication infrastructure to other public health initiatives, giving the donors to the GPEI more bang for their buck when investing in polio eradication. The information gathered from this new technology is helping to inform transition planning efforts, providing information needed to country governments and GPEI partners as they look ahead to what should happen to the polio eradication infrastructure once the goal of a polio-free world has been achieved.
The Global Polio Eradication Initiative (GPEI) is highlighting the innovations that are helping to bring us closer to a polio-free world. Find out about other new approaches driving the polio eradication efforts by reading more in the Innovation Series.
The World Health Organization’s Global Polio Eradication Initiative (WHO/POL) is looking for Expressions of Interest from private or public sector vaccine manufacturers in developing countries interested in collaborating with WHO and Intravacc in the development, manufacture and distribution of a safe effective and affordable Sabin Inactivated Polio Vaccine (sIPV), that can be produced securely in developing country settings.
Safe and affordable inactivated polio vaccine for low-income countries.
One of the strategic priorities of the Global Polio Eradication Initiative is to enable low-income countries to produce Inactivated Polio Vaccine (IPV). To meet this objective, the World Health Organization is working with academia, government and industry to develop an IPV based on the non-infectious Sabin virus strain (sIPV). A range of manufacturers and research institutes have active programmes at various stages of development. The development and licensure of IPV produced from Sabin strains aims to reduce the number of manufacturing sites generating high volumes of high titre wild polioviruses for ”traditional” IPV production. Sabin polioviruses pose less of a threat in the event of an intentional or unintentional release from the production facility. This is a particular concern in low-income countries where the transmissibility of polioviruses is high.
As part of efforts to prepare for the polio post-eradication era, the World Health Organization (WHO) and its partners have facilitated the development of a new polio vaccine technology and will start soon the transfer of this technology to vaccine production facilities in China and India.
In collaboration with the National Institute for Public Health and the Environment (RIVM) in the Netherlands, clinical lots of inactivated polio vaccine (IPV) produced from Sabin poliovirus seed-strains have been prepared. Traditional IPV is manufactured using wild poliovirus seed-strains, and in such a case a biocontainment failure could lead to serious consequences in some areas of the world in the post-eradication era (i.e. areas with high population density, inadequate sanitation infrastructure and low population immunity levels). Therefore, the use of Sabin seed-strains for IPV has the advantage over wild polioviruses that they are attenuated, and hence are safer for handling and IPV production in developing country settings.
This new technology will now be transferred to China National Biotec Group (CNBG) and Serum Institute of India, which have confirmed its intention to use all efforts to apply for registration of their Sabin IPV product within four years. These transfers are part of a broader intended technology transfer programme, which already was initiated earlier last year by the selection of the first two manufacturers in India (Panacea Biotec, Ltd) and the Republic of Korea (LG Life Sciences). WHO and RIVM will continue the technology transfer programme with further manufacturers.
This transfer of technology is a significant milestone in preparations for the polio post-eradication era. Following the eradication of wild poliovirus globally, use of all oral polio vaccine (OPV) in routine immunization programmes will need to be stopped due to the risks associated with the continued administration, in the post-eradication era, of the live (attenuated, but not inactivated) polioviruses contained in OPV. These risks include vaccine-associated paralytic polio and the generation of new, circulating vaccine-derived polioviruses. Therefore, after the eradication of all wild polioviruses, and the eventual cessation of OPV for use in routine immunization programmes, any country choosing to continue to immunize its population against polio will need to do so with IPV, the only option which will be available to do so at that time.
Recognizing that the manufacturing costs and price of IPV are currently substantially higher than that for OPV, the Global Polio Eradication Initiative is studying a range of approaches to establish affordable strategies for IPV use in low-income settings following OPV cessation. The development, manufacture and distribution of a safe, effective and affordable Sabin IPV that can be produced securely in developing country settings is a key landmark in this programme of work. This technology transfer will also help to boost more broadly the domestic production capacity for vaccines and strengthening public health systems to ensure more equitable access to vaccines.
The development of Sabin IPV and the related technology transfer preparations have been generously supported by the Bill & Melinda Gates Foundation.