The Last, Best Chance for Global Polio Eradication?

After 25 years of remarkable achievements and sometimes harrowing setbacks, a successful conclusion to global polio eradication could finally be within reach. In late April, the Global Vaccine Summit in Abu Dhabi released the Global Polio Eradication Initiative (GPEI), a promising new six-year strategy to win the polio “endgame.”

While focusing on increasing vaccine use and highlighting the growing involvement of Islamic leaders in the eradication effort, the Summit also served as a fund-raising venue. Together, donor governments and philanthropists pledged $4 billion—nearly three quarters of the $5.5 billion needed to fully fund the strategic plan. New private donors included the Mexico-based Carlos Slim Foundation and the Alwaleed Bin Talal Foundation-Global, headquartered in Lebanon. Bill Gates, cochair of the Bill & Melinda Gates Foundation which pledged $1.8 billion, said other potential donors were reviewing the plan and that he expected additional commitments. He commented that “Based on what’s happened here today, the financing will not be the thing that stands in the way of us achieving the miracle of polio eradication.”

This unprecedented mobilization may spark the momentum to stamp out the disease once and for all. But, as with most things associated with this long campaign, the outcome is still uncertain and much hard work remains. Success will require a complicated global transition to a more expensive vaccine. In addition, uncertainty persists over how to deal with the continuing threat of targeted violence against polio vaccinators in unstable parts of northern Nigeria and Pakistan, while Afghanistan also could become more dangerous as coalition forces withdraw. It remains to be seen whether the initiative’s organizing partners -- the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), UNICEF, Rotary International, and the Gates Foundation -- have the leadership coherence to carry out such an ambitious plan. And how to win better prices and transparency in markets for polio vaccines has not yet been explained.

Spanning 2013-2018, the GPEI plan has four objectives: detecting and halting transmission of all poliovirus, strengthening routine immunization programs and withdrawal of the oral polio vaccine, successful containment of poliovirus used in laboratories and vaccine production, the certification of eradication, and planning a transition of the initiative’s infrastructure and resources to other global health programs.

The strategy is groundbreaking in several ways. First, it calls for a multiyear budget largely funded upfront, whereas the initiative had previously been paid for on a near-term basis. Having signed onto a 1988 commitment that originally was scheduled to conclude in 2000, the initiative’s long-term donors, including the United States, needed to know there was an end date and a credible plan for getting there. Outlining the steps needed to complete the job and attempting to get commitments in the bank at the beginning of the period will, it is hoped, lower the risk of interrupted funding in the future.

Secondly, the plan highlights the importance of routine immunization programs and links between them and polio campaigns which will pave the way for a global switch from the oral polio vaccine (OPV) to the injectable inactivated poliovirus vaccine (IPV). The plan includes specific commitments from the GPEI to improve vaccine coverage rates for childhood immunizations and contribute to better coordination between other vaccine programs and polio campaigns.

Experts are becoming aware that, although still rare, an increasing proportion of polio outbreaks is being caused in areas with low immunity by the live, weakened OPV. In fact, according to the most recently available draft of the strategic plan, “in 2012 more countries reported outbreaks caused by a circulating vaccine-derived poliovirus than due to a wild poliovirus.” This gives a greater sense of urgency to transitioning to the IPV, which is used in most industrialized countries and carries no risk of causing disease.

Still, the switch won’t be easy. OPV, currently used in routine immunization programs in more than 140 countries, is a fraction of the cost of the IPV. In addition, IPV must be administered by health workers trained to use sterile injection equipment and procedures. The GPEI is working to ensure an adequate vaccine supply, developing outreach campaigns that will explain the need for the change, and looking at ways to shape global markets to make the vaccine affordable.

The plan also addresses new and highly disturbing security threats to polio vaccinators. While the GPEI has historically been able to operate successfully in difficult environments, since late 2012, targeted attacks on vaccinators in Nigeria and Pakistan have killed two dozen local health workers and several security personnel according to CDC figures. The plan warns that “In 2013-2014 in all three remaining endemic countries [Afghanistan, Nigeria and Pakistan], complex security issues that the programme cannot control may delay expected progress in areas of persistent transmission.”

In Pakistan, the Taliban has banned vaccinations in North and South Waziristan, while withdrawal of coalition forces from Afghanistan will accelerate in 2013-2014, potentially causing further instability. As the strategy notes, “Pending elections in Afghanistan and Pakistan, and the potential for rising tensions, may complicate already difficult situations.”

The plan calls for operational adjustments in areas with security concerns, including lowering the public profile of vaccine campaigns and increasing flexibility in their timing and speed. It also calls for greater investments in political and security risk analysis, as well as improved coordination among civilian, health, and security services to better gauge and avoid threats to vaccinators.

The GPEI also is placing more emphasis on raising awareness about polio in communities, increasing the active engagement by religious leaders to encourage vaccine acceptance and exploring ways to expand the range of health services associated with polio campaigns. As the strategy notes, “Fatigue associated with campaigns and distrust for the program may be overcome if a larger set of health services are offered that deal with other acute needs (e.g. clean water).”

Speaking as part of a Global Vaccine Summit panel on polio eradication, Pakistan’s top polio eradication official Shahnaz Wazir Ali said that despite the violence in some areas, the program in many parts of the country “continues to produce good results.” Nonetheless, she said that Pakistan continued to address the potential for violence. She noted “We were not quite expecting the level of hostility and targeted attacks,” adding “It’s hard to predict when the next attack will take place or if it will take place.”

Muhammad Pate, minister of state for health in Nigeria, said polio eradication has an unprecedented political commitment at the national and regional levels and that security challenges have not stopped immunization efforts. He cautioned against “militarizing” the program, arguing that enhanced partnership between the international and national programs and local authorities and improved efforts in vaccine education will help address potential violence.

Success against polio in India, which saw its last case in January 2011 and a record low 223 wild virus paralytic polio cases globally in 2012, has created significant momentum toward completing eradication. The challenge remains difficult, but armed with the new strategy and adequate funding, the GPEI has many of the tools it needs to be successful.

Every effort should be made to capitalize on this promising moment. “With 223 cases …it’s time to strike,” said Walter Orenstein, associate director of the Emory Vaccine Center and a signatory to a scientific declaration in support of the strategic plan. “If we don’t, I think the opportunity to eradicate polio will slip by.”

Nellie Bristol is a fellow with the Global Health Policy Center at the Center for Strategic and International Studies (CSIS) in Washington, D.C. J. Stephen Morrison, senior vice president and director of the Global Health Policy Center at CSIS.

We would also like to highlight an important CSIS study, The U.S. Role in Global Polio Eradication, which analyzes the history of the U.S. contribution to the Global Polio Eradication Initiative; Nellie Bristol authored this work.

Commentary is produced by the Center for Strategic and International Studies (CSIS), a private, tax-exempt institution focusing on international public policy issues. Its research is nonpartisan and nonproprietary. CSIS does not take specific policy positions. Accordingly, all views, positions, and conclusions expressed in this publication should be understood to be solely those of the author(s).

© 2013 by the Center for Strategic and International Studies. All rights reserved.



Nellie Bristol
Senior Associate (Non-resident), Global Health Policy Center