Polio transition involves repurposing polio assets – knowledge, network and infrastructure – to strengthen the broader public health functions of a country within the overall context of strengthening the national health system. These wider functions include immunization, vaccine-preventable diseases surveillance, and emergency preparedness and response.
To safeguard polio essential functions through sustainable resources, it is crucial to achieve the full transition by shifting from external to domestic financing. In turn, successful polio transition and the integration and maintenance of polio assets to strengthen routine immunization, disease surveillance and outbreak response have social and economic benefits and offer a very high return on investment.
In Somalia, integrated public health teams, built on the polio network, deliver a broad range of health services, despite challenges posed by ongoing polio outbreaks and the impact of the COVID-19 pandemic. In the Central African Republic, thanks to strong advocacy by the civil society, sustaining polio eradication remains on the health agenda. Meanwhile, India’s significant progress, builds on transforming the networks built initially to eradicate polio to strengthen the country’s essential immunization programme.
From 25 – 26 April, national, regional and global stakeholders, including country representatives, global health partners and donors, and members of civil society, gathered in Geneva to share their experiences of polio transition. The objective of the two-day forum was to agree on the future direction of polio transition, including adjustments that are needed, building on lessons learned.
In his opening remarks at the forum, Dr. Tedros Adhanom Ghebreyesus, the Director General of the World Health Organization (WHO), underscored the rationale for the transition process, “As we move closer to a polio-free world, we must work to sustain the incredible infrastructure that has been set up to eradicate polio.”
“A transformation of this scale and complexity has never been done in public health. We have a huge challenge, and a huge opportunity.”
The challenges and opportunities of a successful transition were recurring themes during the forum. Although much progress has been made since 2018, the COVID-19 pandemic, political and economic instability and a more constrained fiscal environment have complicated transition efforts and strained health systems in many countries. To overcome this, countries have continually adapted transition planning for their contexts, guided by national health priorities, towards strengthening health outcomes, especially in the areas of essential immunization, health emergencies, and primary health care.
Reflecting on these lessons, stakeholders agreed that the renewed global vision for transition should be inspiring, actionable, practical and relevant to all countries. They emphasized that providing coordinated technical and financial support, aligned with country priorities, is critical for success. At the national level, countries should adapt flexible strategies, with realistic milestones.
Strong essential immunization programmes were recognized as crucial for achieving and sustaining polio eradication. Meanwhile, maintaining the poliovirus surveillance system and laboratory network was identified as a critical priority to protect a polio-free world and strengthen broader disease surveillance efforts. It was recognized that there is scope to systematically integrate gender, equity, human rights and the health of refugees and migrants into transition planning, aligned with the country context. Stakeholders also discussed the potential ‘enabling factors’ to make transition a success, and ‘risks’ that need to be mitigated during transition, as well as the specific responsibilities of different stakeholders.
The outcomes of the forum will inform the new Global Vision for Polio Transition that will be shaped by the end of 2023. The vision is an essential component of the post-2023 strategic framework, alongside Regional Strategic Plans, tailored to regional and national context, and a Monitoring and Evaluation Framework to track progress and ensure transparency and accountability.
Dr Tedros concluded his remarks by noting the potential to strengthen health systems through a successful transition.
“Eradicating polio and safeguarding its legacy with stronger health systems will be a gift for our children, and our children’s children.”
Following the forum, Member States offered further guidance on transition during the 76th World Health Assembly, building on interventions made during the 152nd Executive Board meeting. Member States highlighted that the polio transition strategic framework should aim to integrate polio functions into Primary Health Care towards Universal Health Coverage, align with WHO’s evolving work on pandemic preparedness, resilience and response, and focus on strengthening routine immunization, surveillance, outbreak management and response, national capacity building and partnerships. Considering the ongoing risk of spread of polio, Member States emphasized to have a risk-based approach to transition, backed up by realistic timelines and clear milestones.
The strategic framework will be developed through a consultative process to ensure that the next phase of transition is fit for purpose.
Community Sensitization for the Whole Family Approach (WFA) activities in Abuja, Nigeria. Photo: Vaccine Network for Disease Control (VNDC)
According to the United Nations, a civil society organization (CSO) is any non-profit, voluntary citizens’ group which is organized on a local, national, or international level. CSOs have a vital role to play in the control of infectious diseases. Some CSOs play an advocacy role to sustain commitments of governments, communities, and donors, some support implementation of program activities, and some do both.
The UN Foundation’s new report, “Leveraging CSO Contributions to Advance Polio Transition and Integration Efforts in the African Region” outlines specific areas where CSO support can be of value for polio transition and integration. In particular, this report describes the initiatives implemented by four CSOs supported by the UN Foundation to enhance polio transition and integration efforts in the Democratic Republic of the Congo (DRC), Ethiopia, Nigeria, and South Sudan.
STATUS OF POLIO IN THE AFRICAN REGION
The African region was declared free of wild poliovirus (WPV) in August 2020. This incredible achievement was a result of decades of work by a coalition of international health bodies, national and local governments, civil society and community volunteers. Notwithstanding this significant milestone, the African Region is still experiencing outbreaks of the non-wild variant of poliovirus, known as circulating vaccine-derived poliovirus (cVDPV) in 25 countries. Furthermore, in 2022, WPV importations were reported in two countries that had been polio-free for over three decades, Malawi and Mozambique. These detections highlight that until all forms of polio are eradicated everywhere, the risk of importation remains a constant threat. This further emphasizes the importance of maintaining the Global Polio Eradication Initiative (GPEI) infrastructure in order to both achieve and maintain a polio-free world.
On 19 January 2023, representatives from the World Health Organization (WHO), United Nations Children’s Fund (UNICEF), and the Ministry of Health of Syria concluded a three day joint mission on polio transition planning.
The team conducted various meetings with national counterparts, United Nations agencies and other stakeholders to assess the current situation, and identify the needs and resources required to maintain polio-essential functions and strengthen routine immunization to maintain Syria’s polio-free status. As part of the mission, the team agreed on the way forward to design a roadmap to support and sustain the ongoing integration of polio assets to ensure long-term benefits for immunization and emergency response.
While Syria is a polio-free country, it is at very high risk of imported polio outbreaks. In the last decade, the country experienced two polio outbreaks, including an outbreak of wild poliovirus following an importation from Pakistan in 2013, that paralyzed 36 children. In addition, a 2017 outbreak of circulating vaccine-derived poliovirus type 2 (cVDPV2) left 74 children paralyzed. In both cases, the country managed to contain the poliovirus and stopped the outbreak in less than a year using intensive polio vaccination campaigns and surveillance.
WHO is working closely with the Government and other stakeholders to maintain highly sensitive surveillance for polio and capacities to detect and respond to polio outbreaks swiftly. Furthermore, WHO and UNICEF are supporting the country to leverage the capacity and rich legacy built from years of polio operations to strengthen the essential immunization programme and capacities to detect and respond to other disease outbreaks.
“The main goal of this mission is to ensure that the polio essential functions are well preserved,” said Dr Rana Hajjeh, Director of Programme Management at WHO’s Regional Office for the Eastern Mediterranean. “We at WHO emphasize the importance of strengthening essential programmes like the national routine immunization and also strengthening the emergency response to take advantage of all the polio assets and building health systems. Overall, Syria has integrated polio functions very well in their national immunization programme and we will do our best to continue supporting them as needed,” she added.
Polio essential functions are managed by the Ministry of Health, with the technical and logistical support of WHO. Given the importance of ensuring the sustainability of functions, with support from Gavi, the Vaccine Alliance, both partners have been able to cover critical programme needs pertaining to routine immunization, including polio.
“While protecting the success achieved in containing the poliovirus outbreaks in record time, we should combine our efforts at all levels to maintain the high levels of immunity of the Syrian people against this life-threatening disease,” said Dr Iman Shankiti, WHO Representative a.i. for Syria. “WHO is working closely with the Ministry of Health and all other partners to resume the robust immunization programme in Syria,” she added.
On the long road to global polio eradication, the programme has achieved four important milestones, representing four out of six WHO regions that have been certified as having interrupted transmission of wild poliovirus (WPVs): Region of the Americas (1994), the Western Pacific Region (2000), the European Region (2002), and the South-East Asia Region (2014).
At present, only the Eastern Mediterranean and African regions— no WPV reported in Africa since 2016, the African region may be eligible for regional certification as early as late 2019—remain to be certified in the path towards global eradication and hence constitute a key priority.
But who decides that a region is free of WPV?
The Eastern Mediterranean Regional Commission for Certification of Poliomyelitis Eradication (ERCC) is an independent body appointed in 1995 by the WHO Regional Director for Eastern Mediterranean to oversee the certification and containment processes in the region. It is the only body with the power to certify the Region free from wild polio, which convenes annually. Here are the outcomes of the recent ERCC meeting:
Urgent need to address regional priorities
The Commission noted with concern the need to stop the ongoing wild poliovirus type 1 transmission in the only two remaining polio-endemic countries in the Region: Afghanistan and Pakistan. The RCC acknowledged the on-going eradication efforts but strongly recommended the full implementation of the respective national emergency polio programmes through complete political and programmatic support to tackle the WPV1 transmission in the common Pak-Afghan epidemiological corridor, which remains unabated. The Commission also expressed concern about the current circulating vaccine-derived poliovirus type 2 and 3 transmissions in Somalia.
Wild poliovirus type 3certification prospects
The Commission, however, marked the good progress made towards curbing wild poliovirus type 3 (WPV3). Extensive analyses of the stool and environmental surveillance samples provided evidence that no WPV3 is in transmission in the Region. Based on the epidemiology, EMRO – along with the rest of the world – may be up for global WPV3-free certification by the GCC, potentially certifying two of three poliovirus strains eradicated—WPV2 strain was certified as globally eradicated in 2015.
Stepping-up is the need of the hour
So far, sixty cases of WPV1 are reported from two countries (Pakistan and Afghanistan) in 2019. Given the existing WPV1 transmission in the two remaining endemic countries of the Region, the RCC asked that the Member States undertake a firm commitment necessary for reaching zero.
Eastern Mediterranean Regional Commission for Certification of Polio Eradication (ERCC)
The Thirty-third meeting of the EMRO RCC was held in Muscat, Oman, to discuss the Regional progress towards a polio-free certification. The meeting brought together members of the RCC, chairpersons of the National Certification Committees, polio programme representatives of 21 countries, and WHO staff from the headquarters, regional, and the endemic countries. Representatives from Rotary International and the Centers for Disease Control and Prevention were also in attendance.
Comprised of public health and scientific experts, the regional certification commissions are independent of the WHO and national polio programmes. Global certification will follow the successful certification of all six WHO regions and will be conducted by the Global Certification Committee (GCC).
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.
Surveillance
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.
Contact tracing
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.
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.
After concerted efforts spanning decades, polio eradication efforts are in the homestretch and experts are advising how to fast-track the last mile.
The SAGE convened in Geneva from 2-4 April 2019 to discuss all things related to vaccines and immunizations, including poliovirus and the global eradication efforts around it. SAGE reviewed the latest global polio epidemiology, the new Global Polio Eradication Endgame Strategy 2019-2023, and what the post-eradication world could look like.
Double down and escalate the fight to end wild poliovirus
While SAGE noted the achievements and the progress of the Global Polio Eradication Initiative—reducing the incidence of polio by 99%, absence of wild polio virus type 3 cases, and evidence of Nigeria being wild poliovirus free for over two years—the group displayed cautious optimism about meeting the timeline set out for global eradication of wild poliovirus.
The remaining challenges to fill vaccination coverage gaps—including restricted access, socio-political challenges, and large mobile populations—complicate the efforts to rid the world of poliovirus. However, the GPEI has developed a clear-cut five- year plan to secure a decisive win, the GPEI Polio Endgame Strategy 2019-2023, developed in broad consultation with stakeholders, including SAGE members.
Inactivated Polio Vaccine (IPV)—progress in roll-out continues
From the public health standpoint, Inactivated Polio Vaccine (IPV) can be used indefinitely even after polio eradication. As of April 2019, all 33 countries which had not yet introduced IPV into their routine immunization activities have now done so.
The projected IPV supply is thought to be sufficient enough for the introduction of a two-dose IPV schedule in all countries by 2022, and to catch-up all children missed due to earlier supply shortages, by 2020/2021.
Guidelines Endorsed
As per SAGE recommendations made in October 2016, GPEI developed guidelines for poliovirus surveillance among persons with primary immunodeficiency. After reviewing the guidelines, the SAGE endorsed the guidelines for implementation in high priority countries.
The meeting report will be published in the WHO Weekly Epidemiological Record by May 2019.
The Strategic Advisory Group of Experts (SAGE) on Immunization was established by the Director-General of the World Health Organization in 1999 to provide guidance on the work of WHO. SAGE is the principal advisory group to WHO for vaccines and immunization. It is charged with advising WHO on overall global policies and strategies, ranging from vaccines and technology, research and development, to delivery of immunization and its linkages with other health interventions. SAGE is concerned not just with childhood vaccines and immunization, but all vaccine-preventable diseases.
World leaders gathered in Charlevoix, Canada last week to discuss the most critical issues facing the planet today, including their reaffirmed commitment to a polio-free world.
The final communique of the 44th G7 summit on 8-9 June 2018 highlighted global health as part of the foundation for investing in growth that works for all: “To support growth and equal participation that benefits everyone, and ensure our citizens lead healthy and productive lives, we commit to supporting strong, sustainable health systems that promote access to quality and affordable healthcare.” As part of this commitment, the communique refers to the important tasks of achieving the goal of polio eradication and ensuring a smooth post-eradication transition as key global priorities. World leaders stated: “We reconfirm our resolve to work with partners to eradicate polio and effectively manage the post-polio transition.”
The communique also stressed the importance of preparing for health emergencies and strengthening the implementation of the International Health Regulations. As emphasized in the 13th General Programme of Work of the World Health Organization, which was approved by the World Health Assembly in May 2018, the GPEI has “helped to strengthen health systems, and these wider gains must be maintained as the polio programme is being ramped down.” The programme has extensive experience in disease surveillance and quality laboratory networks, outbreak response, disease prevention through vaccination, and inter-country collaboration – all necessary components of emergency preparedness. As planning continues for the post-eradication era, it remains a priority that the infrastructure, data and tools built up over the past 30 years be transitioned effectively to support resilient health systems and public health infrastructure in the future.
Canada, the host of this year’s G7, continued in the footprints of its predecessors and maintained attention on health – as the country has throughout its G7 presidencies. Canada has been a longtime supporter of the Global Polio Eradication Initiative and plays an active role in keeping polio on the global agenda. In 2002, then-Prime Minister Jean Chrétien gathered his counterparts from the G8 in Kananaskis, Canada to pledge to provide sufficient resources for polio elimination in Africa – the first time polio was included in the communique. Since then, G7 countries have provided significant political and financial support for the global polio programme, and have repeatedly expressed commitment to polio eradication. Most recently, leaders’ statements at the 2016 G7 Summit and at a 2017 Group of 7 Health Ministers meeting included commitments to polio eradication. G7 leadership on the issue was expanded to the G20 in 2017. Polio was mentioned at both the G20 leaders’ summit and the first-ever G20 Health Ministers’ meeting, which recognized the historic opportunity that exists to end polio for good and the important role played by polio-funded assets in achieving broader health goals.
The communique also emphasized the need to advance gender equality and women’s empowerment. The polio programme recognizes women’s critical contributions to eradication and is constantly working to recruit more women to work as frontline workers in polio endemic countries. In Afghanistan, the polio programme accounts for one of the largest female workforces in the country. On a global level, the GPEI is working to analyze sex-disaggregated data to track progress towards eradication, echoing the communique in affirming women and girls as powerful agents of change.
The 2018 G20 Buenos Aires summit in November is next on the world stage, providing an additional opportunity for governments to focus on the importance of global health, and commit to fulfilling and maintaining the promise of a polio-free future.
28 May 2018, Geneva, Switzerland: ‘Eradicate first’ was the mantra at last week’s World Health Assembly (WHA). While holding detailed discussions to plan for a polio-free world, delegates emphasized the need to finish the job of eradication.
With wild poliovirus transmission levels lower than ever before, Ministers of Health and delegates reviewed progress being achieved through national emergency action plans in the remaining endemic countries. As at May 2018, only eight cases due to wild poliovirus had been reported globally, from just two countries: Afghanistan and Pakistan.
To prepare for a polio-free world, Member States adopted a landmark resolution on poliovirus containment. A limited number of facilities will retain poliovirus after eradication, to serve critical national and international functions such as the production of polio vaccine or research. It is crucial that these poliovirus materials are appropriately contained under strict biosafety and biosecurity handling and storage conditions, to ensure that virus is not released into the environment, either accidentally or intentionally, to again cause outbreaks of the disease in susceptible populations.
WHO and countries that are currently funded by the Global Polio Eradication Initiative (GPEI) face significant financial, human resource, and programmatic risks as a result of the scaling down of the GPEI budget (2017-2019) and its eventual closure. Hence, Member States requested the Director-General to develop a strategic action plan on polio transition that will mitigate these risks, as well as strengthen country health systems. Delegates considered the resulting 5-year strategic action plan on polio transition, which has 3 key objectives: (i) sustaining a polio-free world after eradication of polio virus; (ii) strengthening immunization systems, including surveillance for vaccine-preventable diseases; and (iii) strengthening emergency preparedness, detection and response capacity in countries to ensure full implementation of the International Health Regulations. The strategic action plan outlines how essential polio functions like surveillance, laboratory networks, and some core infrastructure can support the implementation of the Post Certification Strategy to sustain a polio-free world, and can be integrated into the immunization or health emergencies’ programme, or mainstreamed into national health systems. The plan provides detailed costing for the integration of essential polio functions into WHO’s Thirteenth General Programme of Work, and some financing options. The three polio-endemic countries (Afghanistan, Pakistan and Nigeria) and a few high-risk countries battling outbreaks have been excluded from transition planning until eradication. All other GPEI-funded countries are expected to plan for polio transition.
Member States expressed overwhelming commitment to fully implement and finance all strategies to secure a lasting polio-free world in the very near term. Rotary International, speaking on behalf of the GPEI, which includes WHO, Rotary, CDC, UNICEF and the Bill & Melinda Gates Foundation, offered an impassioned plea to the global community to eradicate a human disease for only the second time in history, and ensure that no child will ever again be paralysed by any form of poliovirus anywhere.
A unique group of people gathered last month in Sokoto state to commit to the twin goals of eradicating polio, and working to rapidly strengthen routine immunization. Bill Gates, and Africa’s richest man, Alhaji Aliko Dangote, joined traditional leaders from across northern Nigeria, Federal Ministry of Health officials, representatives from several State governments, and partners including UNICEF and WHO.
The two billionaires play a significant role in the fight to eliminate polio in Nigeria, where no wild virus has been detected since 2016. The Bill & Melinda Gates Foundation has committed US$1.6 billion in the country to date to fund pilot projects targeted at health care, agriculture and financial inclusion, a contribution which makes up their biggest investment in Africa. Aliko Dangote, who is Nigerian, has previously worked with Mr Gates to help interrupt transmission of the poliovirus in his country, and helps fund other health programmes as president of the Dangote Foundation.
During their visit, Mr Gates and Mr Dangote witnessed first-hand the progress Nigeria is making in polio eradication, routine immunization and primary health care provision.
At meetings held at the Sultan’s Palace and Governor’s House, Mr Gates highlighted the commitment of traditional leaders and reiterated the importance of engaging communities to reach every child with vaccines. Expressing his concern over the high infant mortality rate in Nigeria, he noted that vaccination is a cost effective way to save children’s lives.
Mr Gates also talked about the need to plan for the future of a polio-free Nigeria. Looking to how the polio eradication infrastructure can be used to help meet other health needs, Mr Gates said that the strong existing polio infrastructure – including vaccine supply chains, disease surveillance, laboratory systems and social mobilization networks – can be used to develop and improve routine immunization coverage for other diseases.
“We can prevent millions of deaths through routine immunization,” Mr Gates said. “We will not relent in our commitment towards this.”
Mr Dangote further highlighted that the fight against polio requires commitment from all stakeholders.
Drawing attention to malnutrition as one of the biggest factors undermining Nigeria’s progress, Mr Dangote urged the government and partners to reach out to private sector companies and ask them to donate at minimum 1% of their profits to financing the health sector.
At the meeting, the governors of Bauchi, Borno, Kebbi, Kaduna, Kano, and Sokoto States signed extensions of their Memorandum of Understanding on routine immunization. In doing so they reaffirmed their commitment to maximizing immunization coverage in their respective states, helping to protect every child against polio and other vaccine-preventable diseases.
“When I received the confirmation of the first case of Lassa fever…nothing prepared me for the tasks ahead other than my work in polio eradication” – Mrs Faith Ireye, WHO State Coordinator in Edo state.
In the first two months of 2018, there were 110 deaths in Nigeria from suspected Lassa fever. Outbreak response, led by the Nigerian government and WHO, is focused on detecting every case, and tracing the virus wherever it is hiding.
Bolstering this effort are individuals with experience of guarding against a different disease – polio.
Ms Ireye, who has worked with the Global Polio Eradication Initiative for over ten years, is currently helping to coordinate the Lassa fever outbreak response in Edo State, one of the hardest hit by the outbreak.
“My experiences in polio eradication activities allowed me to immediately swing into action. So, when the [Lassa fever] outbreak was confirmed, I realized the need to use my expertise to serve communities at risk,” she says.
Part of her job is to help coordinate surveillance, specifically ensuring that everyone who has come into contact with someone with Lassa fever is found, and tested for the virus.
Her work is critical to help prevent further fever cases. Deputy Governor of Edo State, His Excellency Philip Shaibu said, “WHO…is one of the pillars that have helped lead surveillance in Edo state… In this particular outbreak, WHO was the first to draw attention to the fact that we need to galvanize resources from all partners, from other parts of the country, to ensure that things get done.”
The polio infrastructure
When outbreaks of other diseases happen, the knowledge and experience of polio personnel like Ms Ireye can make a significant difference to outbreak response. For example, polio workers were essential to containing the Ebola virus outbreak in 2014. For the Lassa fever response, 271 polio workers are involved in active case search, 235 in contact tracing, and 320 in community sensitization activities across the 18 at-risk states.
“The polio infrastructure was originally designed towards achieving the polio eradication goals,” said Dr Wondimagegnehu Alemu, WHO Country Representative to Nigeria. “Now polio infrastructure has expanded its support to broader disease surveillance strengthening, outbreak response and basic health care services including immunization.”
Other activities carried out by polio workers include data collation and analysis, and case reporting.
“The polio teams on ground in the states were crucial for mounting the initial response to the Lassa fever outbreak, and have continued to be WHO’s frontline technical support to the NCDC, States Ministry of Health and local government area teams,” Dr Emmanuel Musa, WHO Incident Manager for Lassa fever Management Team in Nigeria observed.
A legacy for posterity
Investments by donors and partners have gone far beyond polio eradication. Reflecting the positive impact that polio infrastructure and knowledge has had on other health priorities such as Lassa fever, WHO and other partners are currently supporting the development of a national transition plan. This will ensure that the investments that have brought the world to the brink of eradication are made available to support other national public health efforts, long after polio has been defeated.
“We must carefully consider how we transition many of the polio workers and the polio infrastructure to help with managing other health needs,” Dr Alemu said. “Future funding and partnerships will be a key part of this work.”
For now, experienced polio personnel continue their work to end the Lassa fever outbreak. Thanks to them, and the support of governments, partners and donors, we are ending polio, and are also helping to strengthen other health interventions.
Support for immunization to the Federal Government of Nigeria through the World Health Organization is made possible by funding from the Bill & Melinda Gates Foundation (BMGF), the United Kingdom, the European Union (EU), Gavi, Global Affairs Canada (GAC), the Government of Germany, the Japan International Cooperation Agency (JICA), the Korea Foundation for International Healthcare (KOFIH), the Measles and Rubella Initiative (M&RI) through the United Nations Foundation (UNF), Rotary International, the United States Agency for International Development (USAID), the United States Centers for Disease Control and Prevention (CDC) and the World Bank.
Reducing polio cases by 99.9% globally is an incredible feat, achieved through innovative strategies and years of trial and error.
While the polio eradication programme is focused on getting to zero, now is the time to make sure everything we’ve learned isn’t lost and can be used to inform future global health programmes. Just as the polio eradication effort applied lessons learned from the successful smallpox campaign to its own work, the goal is for future health programmes to understand and build on the knowledge of the polio effort.
Under a new grant from the Bill & Melinda Gates Foundation, the Johns Hopkins Bloomberg School of Public Health (JHSPH) will be working to do exactly this.
JHSPH will partner with academic institutions from around the world to document lessons and develop graduate-level courses and hands-on training clinics for public health students and professionals, including an online open course available to the public and implementation courses for managers from other health programmes.
Under the leadership of Dr Olakunle Alonge, the team at JHSPH will collaborate with a global team from public health institutions in seven countries: Nigeria, India, Afghanistan, Ethiopia, the Democratic Republic of the Congo, Bangladesh and Indonesia. This will not only ensure a balanced and diverse perspective, but also enable the exchange of public health training strategies between the institutions.
To develop the content of each course, JHSPH will be identifying “change agents” at the local, national and global levels who have expertise in polio eradication that may not otherwise be captured. This unique global strategy promises to yield coursework that speaks to the issues faced by a broad range of global health programmes and actors.
“Without an active strategy to map, package and deliver the knowledge from the global polio eradication efforts to other programs and global health actors, I’m afraid that these knowledge assets may not find any useful purpose beyond the end of the polio campaign, which could come to an end within a few years,” said Alonge.
Alonge expects to glean lessons that will apply to immunization systems, public health emergency response, primary health care, disease eradication and infectious diseases—ensuring that the polio programme continues to positively impact global health for years to come.
The year’s end offers the chance to reflect on the polio programme’s milestones and challenges in 2017, and look ahead to what we can achieve in the coming year. 2017 saw the fewest wild polio cases in history — a total of 17 cases, or a 50% reduction from the year before—with these cases occurring in just two countries: Afghanistan and Pakistan. Yet the need to reach every last child is more important than ever, as demonstrated by surveillance gaps in Nigeria and outbreaks of vaccine-derived polio in Syria and the Democratic Republic of the Congo.
From programme strategies that helped protect progress and overcome obstacles, to commitments from donors and partners, 2017 demonstrated the resolve required to achieve a polio-free future. Accelerating progress in the new year and ending polio for good will require maintaining these political and financial commitments as well as building upon the programme’s efforts to find the virus wherever it exists.
Rooting out the virus
Throughout 2017, developments in disease surveillance – both in humans and in the environment – allowed the programme to better hone in on the virus and identify its remaining hiding places.
These innovations are building robust, sensitive surveillance networks around the world that pick up every trace of the virus and enable the programme to develop targeted immunisation responses before polio has the chance to paralyse children.
The year also came with new challenges, including outbreaks of circulating vaccine-derived polio in Syria and the Democratic Republic of the Congo, where conflict has ravaged the health infrastructure. In these communities, and others where polio still exists, difficult terrain, conflict and highly mobile populations can all stand as hurdles to vaccinating children. Yet the polio programme continues to find new and effective ways of delivering vaccines.
For example, in Afghanistan, a collaboration with a mobile circus is sharing important messages about polio vaccination with hard-to-reach populations, including those living in camps for internally displaced persons. In Pakistan, campaigns based at border crossings and train stations vaccinated children on the move who might otherwise have been missed by traditional methods. And in Syria, dedicated workers are delivering vaccines at transit points and registration centres for internally displaced persons. Thanks to these strategies, more than 255,000 children have been vaccinated in Deir Ez-Zor, 140,000 were reached in Raqqa and the programme continues to work to reach every child.
The mobile circus passed on vital health care and social messages, encouraging full immunization of every child. UNICEF Afghanistan / Ashley Graham
Renewed commitment to end the disease
Complementing these programmatic innovations were political and financial commitments that highlighted polio eradication as a priority for global health leaders. These included:
Next year, country programmes will need to continue working to ramp up surveillance, particularly in Nigeria, and reach children everywhere with vaccines. Cross-border coordination between Pakistan and Afghanistan, which has already had a huge impact in reducing cases, will continue to be critically important to stopping transmission.
At the same time, the global community is beginning to solidify plans for keeping the world polio-free once eradication is achieved. Countries are developing strategies for transitioning the infrastructure and tools that they currently use to fight polio. And the GPEI is working with global stakeholders and partners to develop the Polio Post-Certification Strategy, which will define the activities needed to keep polio from returning after the virus is eradicated.
If the remaining endemic countries continue to do all that they can to stop the virus, and if the global community continues to meet the level of political and financial commitment needed to make and keep children everywhere polio-free, 2018 will bring the world’s best opportunity yet to end the disease.
At a meeting of the Group of 7 on 5-6 November 2017 in Milan, Ministers of Health reiterated the importance of sustaining commitment to polio eradication as part of their broader commitment to strengthen health systems. They also recognized… “the importance of continuing our efforts to succeed and keep the world sustainably polio‐free, and, of the opportunity to leverage and transition polio assets and resources that have generated major and broader health benefits, including strengthened health systems.”
At the meeting, entitled “United towards Global Health: common strategies for common challenges”, Ministers discussed key global health challenges guided by the G7 Taormina Leaders’ Communiqué. Their statement on polio was aligned with previous G7 and G20 commitments and with the Sustainable Development Goals.
The attention given to polio eradication by the Ministers forms an integral part of their broader commitment to … “the importance of strengthening health systems through each country’s path towards Universal Health Coverage, leaving no one behind, and of preventing health systems from collapsing during humanitarian and public health emergencies and effectively mitigating health crises”.
Under Japanese and Italian Presidencies in 2016 and 2017, the importance of the global effort to eradicate polio and the opportunity to transition polio-funded assets for Universal Health Coverage and Global Health Security after eradication have been highlighted several times. Such high-level political support for the initiative is critical to maintain the momentum needed for success.
In 2018, Canada, a longstanding GPEI donor, will hold the Presidency of the G7, 16 years after it placed polio eradication on the agenda of the G7 for the first time.
Young mothers waiting to vaccinate their children receive information on exclusive breastfeeding from a polio-funded Volunteer Community Mobilizer. @ UNICEF/R. Curtis
“Are you watching me?” “Yes, ma’am.”
“Are you seeing me?” “Yes ma’am.”
Along two rows of benches under the awning of the Chikun Primary Health Centre in northern Nigeria’s Kaduna State, about 50 young mothers sit still, their babies swaying on their laps. All eyes are fixed on Lidia, the assured polio social mobilizer who is not delivering polio vaccine, but showing the women how to correctly breastfeed.
Lidia is a grandmother, a one-time community midwife now employed with Nigeria’s polio eradication programme as a UNICEF-supported Volunteer Community Mobilizer (VCM). During the monthly polio vaccination campaigns, she goes house to house with the vaccination team, opening doors through her trusted relationship with the mothers, tackling refusals where they occur and tracking any children missed in the campaigns through her field book containing the names and ages of all children in her area. But it is between campaigns where Lidia’s full worth is realized.
Trust
Helen Jatau, a supervisor in this Local Government Area, supervises 50 VCMs and five first-level supervisors. She is convinced the health care polio frontline workers provide between campaigns provides benefits beyond the surface value – it establishes trust. “When we bring different things to the mothers, it helps the community live better and even accept us more, because we are giving more than just polio vaccines.”
Between polio vaccination campaigns, mobilizers like Lidia track pregnant women and ensure the mothers undertake four Ante-Natal Care visits, including immunization against tetanus. They advise mothers-to-be to give birth at the government health facility, provide them with the first dose of oral polio vaccine, facilitate birth registration and connect them to the routine immunization system. In houses and at monthly community meetings, the mobilizers also provide information on exclusive breastfeeding, hand washing, the benefits of Insecticide Treated Bed Nets, Routine Immunization and the polio vaccination campaign.
Ante-Natal Care
VCM Charity Ogwuche stands before the mothers at the health centre and peels over the pages of a colourful flip book. “Breastmilk builds the soldiers inside your child,” she shouts. “It will save you money. You don’t need to find food for your child to eat. You don’t need to find water: 80% of breastmilk is water. It will protect your child.”
Adiza, a young mother holding her first child, Musa, carries a routine immunization card including messaging on breast feeding and birth registration. “Aminatu talked to me about antenatal care. She asked me to get the tetanus shot, and today she has brought me here to receive routine immunization for my baby. I am really grateful. If she wasn’t here I wouldn’t be here. I wouldn’t know about it. She is the only one who tells me about this.”
Charity is proud of her work. “The women are so familiar with me, it makes me happy. They call me Aunty. I provide most of the health information for them. Really there is no other in our community. They are very young mothers and they need me.”
Birth registration
Aminatu Zubairu, in her trademark blue VCM shawl, displays the birth registration cards she will carry back to mothers in her village. @ UNICEF/R.Curtis
Every Tuesday is birth registration day. Once, hardly a soul turned up to register their newborns, but today, a long line of VCMs are standing clutching handfuls of registration forms, waiting to register the newborns within their catchment area.
Aminatu Zubairu, wrapped in the trademark blue hijab of the VCM, explains how all social mobilizers must come from their own community, and how that familiarity breeds the trust that has enabled her to register hundreds of children in her area. “I go to their houses and ask if they had the birth registration. If they say no I take all the information. Now I will register them and get the certificate of birth and carry it to their house to give back to them. In a month I can do 50 of these. This year there are plenty of newborns.”
Danboyi Juma, the district’s Birth Registration Officer, believes birth registrations have increased by 95% since VCMs assumed responsibility for the service. “They are helping us so much because they go house to house,” he says. “They have increased the number of birth registrations in this area by so much – oh, that’s sure.”
Routine Immunization
Jamila and her baby Arjera, who was vaccinated for the first time, following the persistent efforts of her VCM Rashida Murtala. @ UNICEF/R.Curtis
Despite stifling heat, on this Tuesday, there are more than 50 mothers and several fathers sitting on benches, waiting for their turn to have their babies vaccinated. More than 80% of them carry the cardboard cards given to them by VCMs to remind them their baby is scheduled for routine immunization.
Jamila, a young mother wrapped in a white shawl around her orange head-dress, is bringing her six-month-old baby Arjera to be vaccinated for the first time. Her VCM, Rashida Murtala, badgered her for months before Jamila finally accepted.
“Oh, she refused and refused,” Rashida says. “She’s fed up with me visiting. I went to see her today and finally she followed me. I’m happy to see her here.”
Jamila smiles. “She has been disturbing me every day that I have to take this child to the health centre. I know she’s right, so today I followed her.”
Priscilla Francis, the Routine Immunization provider who vaccinates young Arjera, believes VCMs are key to strong vaccination coverage in Chikun district. “There is much improvement in attendance since the VCMs started. They are well trained. They do a good job of informing mothers to come. If we lost them we would lose our clients – no doubt. When they come we tell them to come back, but no one else is going to their house to bring them.”
Hassana Ibrahim, a Volunteer Ward Supervisor, knows her mobilizers are important. “I have 10 VCMs, five in this ward. Non-compliance used to be a big problem but not now. Now with the routine immunization, the community sees they are providing a package of health care and now people comply with the polio vaccination.”
Naming ceremonies
New mother Naima with newly named Jibrin and her friends and family was happy to welcome her VCM to immunize children at her son’s naming ceremony: “She is my friend.” @ UNICEF/R.Curtis
Following the routine immunization session, the VCMs fan out to attend the naming ceremonies of newborns in their catchment area. Naming ceremonies provide an important opportunity to vaccinate lots of children, as family gathers around to celebrate. On average, they attend 10 naming ceremonies a month. Today we visit Naima, the young mother of a 7-day-old boy, who as per tradition has just been named Jibrin by his grandfather. Naima is surrounded by her sisters, family and village friends, who cook and eat with them, and their 68 children under five. Within minutes, the VCM has walked among them all, vaccinating them as they sit waiting with their mouths open to the sky like little birds.
Naima is happy to see her trusted VCM, and encourages her to vaccinate the children. “I know her well,” she says. “She taught me to go for ante-natal care, to deliver at the hospital and to go for immunization. She is the only health care worker who comes. We are from the same community. She is my friend.”
At the 70th World Health Assembly in Geneva, global health leaders have reiterated their commitment to polio eradication, discussing progress made and challenges ahead and emphasising the critical need for effective transition planning for the post-polio era.
Member States spoke of the continuing steady progress towards eradication, and the importance of supporting the remaining endemic countries in finishing the job. With only 37 cases in three countries in 2016, achieving eradication is closer than ever before.
Delegates from Afghanistan, Pakistan, and Nigeria, the last three endemic countries, outlined their key strategies for ending transmission as a matter of priority. The Pakistani delegate underscored the need for continued support from the global community: “Last miles are difficult, but we need to stay the course and reach a significant public health landmark of our time.”
Michel Zaffran, Director of Polio Eradication at WHO, spoke of the impressive decline in cases, achieved through the commitment of Member States, and stressed the critical need to continue to support the endemic countries in their efforts to stop the virus.
“We stand on the brink of making history, but progress is fragile… We cannot lower our guard. We must redouble our efforts to support Nigeria, Pakistan and Afghanistan to implement their national emergency action plans, and ensure they have the resources to do so.”
Member States also addressed the challenge of the scale down of the polio programme as eradication comes closer, including the potential impact on achieving and sustaining a polio-free world, on health programmes and systems currently supported by polio assets, and on WHO itself. They welcomed existing efforts to plan for the post-polio world, and stressed the importance of careful, considered, and strategic approaches to the transition of polio assets, requesting the WHO Director-General to prepare a detailed transition action plan.
Many delegates expressed concern about the ongoing shortage of inactivated polio vaccine, and noted the need to implement containment measures to ensure the safe and secure storage and handling of materials containing polioviruses, and destroy unneeded materials.
Rotary International reaffirmed the commitment of their 1.2 million volunteers to the global polio eradication effort, and expressed cautious optimism about the low levels of transmission in 2017. The Rotarian speaker called for the support of all countries to achieve eradication. “The support of every country is needed now more than ever. Passive support is not enough; we will not succeed without political and financial commitment… Let’s make history and end polio together.”
Reactive vaccination in Sokoto Photo: WHO AFRO
In early May 2017, polio programme staff from across Nigeria joined efforts to combat a meningitis outbreak in Sokoto, providing support and expertise in outbreak response to help Sokoto State in controlling the outbreak.
Almost 200 WHO polio officers worked with state and national government agencies and other partners to plan and implement a state-wide vaccination campaign aimed at reaching almost 800 000 young people at risk of contracting the disease.
With considerable experience in delivering large-scale vaccination campaigns, polio staff played an important role in the planning, coordination and delivery of the meningitis response. Almost thirty years of fighting polio has equipped GPEI with valuable expertise in outbreak response that can be applied beyond the polio programme.
Working as part of a national support team, they supported the campaign in a number of areas, including the development of a detailed campaign strategy, coordination and logistics, planning, coordination and supervision of trainings, and vaccine management activities.
The broader benefits of the polio programme
This support for meningitis outbreak response is but one example of how the infrastructure and expertise of the Global Polio Eradication Initiative (GPEI) is helping to achieve positive health outcomes beyond polio eradication and can offer significant benefits for broader health efforts. In Nigeria alone, polio staff and infrastructure have contributed to multiple outbreak response and vaccination activities, including the response to Ebola and large-scale measles vaccination campaigns.
Polio-funded workers at country level spend on average 50% of their time supporting non-polio activities, including routine immunization, maternal and child health programmes, humanitarian emergencies and disease outbreak, and sanitation and hygiene programmes.
Skills and infrastructure of the programme in areas like healthcare delivery, disease surveillance and outbreak preparedness and response can be successfully applied to non-polio health priorities and programmes.
Planning for the future
While we remain focused on ending polio for good, GPEI is also beginning to plan for a world after polio – looking at how we can maintain some of this infrastructure, knowledge and expertise once the programme comes to an end. In 16 countries, including Nigeria, with the highest levels of GPEI-funded staff and infrastructure, GPEI partners are supporting national governments and other health partners to plan for the transition some of these critical assets in to existing health systems and initiatives, so they can continue to contribute to positive health outcomes around the world.
G20 Health Ministers’ meeting in Berlin, Copyright: BMG/photothek/Inga Kjer
20 May 2017, Berlin, Germany – The first-ever G20 Health Ministers’ meeting has issued a declaration on global health, including recognition of the historic opportunity that exists to contribute to global polio eradication, and the important role played by polio-funded assets in achieving broader health goals. The declaration also called for the timely and effective application of these assets to other programmes once eradication is achieved, to help countries maintain their ability to meet their obligations under the International Health Regulations (2005).
This is the first time that public health has been included on the G20 agenda, in recognition that health security contributes to socio-economic stability and sustainable development. The inclusion of polio in the inaugural Health Ministers’ declaration is symbolic of the global effort to stop polio and how close we are to achieving our historic goal, as well as the contribution the programme makes towards many other areas of public health.
This declaration comes ahead of discussions on the status of global polio eradication efforts, and polio transition planning at the World Health Assembly later in the month.
The G20’s acknowledgement of polio eradication and transition planning efforts comes off the back of sustained political commitment and financial support from the governments of the three remaining polio-endemic countries – Nigeria, Afghanistan and Pakistan – as well as the long-term commitment and support of G20 members Australia, Canada, the European Union, France, Germany, India, Indonesia, Japan, Republic of Korea, Russia, Kingdom of Saudi Arabia, Turkey, the United Kingdom, and the United States of America.
G7 leaders meet later this month in Italy. In 2016, in continuation of the G7 Ise-Shima Summit, the Ministers of Health and high representatives of the G7 “reaffirmed [their] commitment to achieve polio eradication… and recognize the significant contribution that the polio-related assets, resources and infrastructure will have on strengthening health systems and advancing universal health coverage.”
For over 25 years, the Global Polio Eradication Initiative (GPEI) has mobilized and trained millions of volunteers and health workers; reached remote and underserved households; mapped and brought health interventions to chronically neglected communities; and established standardized, real-time global surveillance and response capacity.
Going further
The knowledge, skills and infrastructure built to end polio are already helping to make dramatic progress on improving children’s health – not only reducing the number of children paralyzed by polio by over 99%, but also decreasing the number dying from other preventable diseases in countries with strong polio eradication infrastructure.
To find out more about how the polio eradication infrastructure is expanding the reach of health services, improving disease surveillance and building health worker capacity, read this factsheet which highlights just some of the broader health benefits enabled by the investments made to end this disease.
Securing these broader benefits for the future
Polio eradication will be one of the greatest public health victories of our lifetime. We need to plan now to ensure that the world will stay polio-free and that the lessons, resources and infrastructure, which are already benefitting children beyond this one disease, continue to help children for generations to come.
To make the most of this opportunity, it is crucial that governments, civil society, Ministries of Health, and donors transition some of the polio infrastructure to sustain a polio-free world and to help meet other health needs, particularly in places with weak health infrastructure. By identifying the overlap between what the polio program has to offer and country-level priorities for strengthening health systems, we can make a lasting difference to health beyond polio. We can strengthen the foundations of health by reusing the building blocks of polio eradication.
By beginning to plan now, we can keep the world polio-free and ensure that the investments made in ending polio have a broad and lasting impact on children’s health and development, long after polio is gone.
Last week, global political commitment to eradicating polio was affirmed at the World Health Assembly (WHA) in Geneva. During the polio agenda item, member states discussed progress made in the last year and the remaining hurdles that stand in the way of polio eradication.
In her opening address to the WHA, Dr Margaret Chan, Director General of WHO, said polio eradication has never been so close to the finish line. “During the short span of 2 weeks in April, 155 countries successfully switched from trivalent to bivalent oral polio vaccine, marking the largest coordinated vaccine withdrawal in history. I thank you and your country teams for this marvellous feat,” she said.
Member states reviewed the latest global epidemiology, noting the strong progress made across Africa with no case of wild poliovirus in approaching two years. Delegates from Afghanistan and Pakistan, the final remaining polio endemic countries, outlined the steps they are taking to ensure that transmission is interrupted as a matter of urgency. With fewer missed children than ever before and just 74 cases across the two in 2015, achieving eradication has never appeared to be such an achievable target.
Many member states spoke to reaffirm their commitments to fulfilling the objectives of the resolution passed at the last WHA to commit to ending polio once and for all. Michel Zaffran, Director of Polio Eradication at WHO, stated that strong progress had been made against all four objectives of the Polio Eradication and Endgame Strategic Plan.
Delegates also commended the historic achievement of the switch, warning that shortages of the inactivated polio vaccine and potential outbreaks of type 2 vaccine-derived polioviruses would be some of the major challenges of the coming year. They also expressed appreciation for the global contingency plans put in place to adequately manage the risks associated with the supply shortage, notably the availability of the stockpile of monovalent oral polio vaccine type 2.
Gavi, the Vaccine Alliance, supported the interjections of several member states highlighting the importance of ramping up transition planning in countries to prepare for the end of the polio infrastructure after eradication. “To be sustainable, the decision on which polio assets to sustain must be fully led and driven by countries themselves, based on national ownership, national plans and investments,” said the Gavi spokesperson.
Rotary international spoke to affirm that their 1.2 million volunteers worldwide remain fully committed to polio eradication. “We have three key challenges remaining,” said the Rotarian speaker. “First, we have to interrupt polio in Pakistan and Afghanistan. Second, we must avoid complacency. An additional US $1.5 billion is needed through 2019 to sustain high levels of immunity, repeatedly reaching more than 400,000,000 children in up to 60 countries and carrying out high quality surveillance to protect progress. Finally we must fully leverage the physical and intellectual assets of polio eradication so that they can benefit broader public health priorities.”
