Polio Eradication’s Biggest Threats: Insecurity and Complacency
August 30, 2016The recently discovered wild poliovirus outbreak in Nigeria shows the wisdom of waiting three years after the last polio case before a region is certified as polio free, but also points to the difficulties in resisting complacency during that period. Just past the two-year anniversary marking Nigeria’s last case of polio, the World Health Organization (WHO) announced two new paralytic polio cases in Borno state, a part of the country wracked with Boko Haram-instigated violence. Officials cite insecurity as a primary contributor to the outbreak since ongoing violence limits the actions of both polio vaccinators and disease surveillance staff. Terrorism also precipitates population movements as people attempt to flee, making it more difficult for vaccinators to track who has been immunized.
But there is another obstacle as well. While generally the WHO and others have praised Nigeria’s recent successes in reducing polio cases, some warned that it would be difficult to maintain political momentum and resource mobilization for a disease seen as on the wane. Those concerns may have been borne out with the recent cases.
Eradication standards developed by WHO require that a region be without a polio case for at least three years before it can be officially certified as polio free. During the period between the last case and certification, immunization drives must continue and surveillance should intensify rather than relax to ensure all cases are caught. John Vertefeuille, U.S. Centers for Disease Control and Prevention’s (CDC) polio eradication branch chief, said the Borno cases are a reminder for the entire program of the importance of stepping up surveillance activities in this critical period in the eradication effort. This year so far shows the lowest number of annual wild poliovirus cases ever, at 21 as of August 24, 2016. Nonetheless, the program’s ultimate success rides on finding and extinguishing every case of the disease worldwide and surveillance indicators are not being met in some places, including in half of the African countries examined in a recent report.
In Nigeria, some say attention to the disease has decreased and the quality of polio program activities diminished, especially in security-compromised areas. The Independent Monitoring Board of the Global Polio Eradication Initiative said prophetically in its most recent report, based on a meeting held before the new cases were announced, that the program was showing signs of flagging. “Of caregivers in Borno, less than half see the need to give polio drops to their child ‘every time,’” the report says, adding that 500,000 children in the state still are inaccessible to vaccinators because of insecurity. “All this should send a shiver down the spine of anyone in Nigeria who has been thinking, ‘almost there,’” the report adds.
In addition to concerns about programmatic intensity, insecurity remains a major hurdle to polio eradication, and not just in Nigeria. The last three countries with wild poliovirus circulation, Afghanistan, Pakistan, and Nigeria, all confront violence on a daily basis. While India was considered one of the most complex and difficult countries for polio vaccinators, it did not face the same security issues as the other countries and was able to eliminate the disease, a feat that was certified by WHO in March 2015. The government’s vigilance against poliovirus reimportation helped ensure it remained polio free.
In Nigeria and other countries, the polio program addresses insecurity through a range of tactics. In one, vaccinators take advantage of lulls in violence to quickly enter a previously inaccessible area and conduct brief polio vaccination campaigns. This approach requires the polio program to remain in constant communication with security personnel who are able to read evolving security situations in particular areas. In another approach, the polio program ensures heightened polio immunity in populations surrounding inaccessible areas. It also establishes vaccination posts on roadways traveled by people moving away from violence.
But ensuring vaccines are reaching populations on the move has proven a particular difficulty for the program. In the situation in Nigeria, people may flee into surrounding countries and take the virus with them. As a result, the response to the current outbreak is targeting not just Nigeria, but other countries in the Lake Chad region including Niger, Cameroon, Central African Republic, and Chad.
The scope of the job is enormous. A recent report from UNICEF indicates that 2.6 million people in the Lake Chad basin have been displaced by Boko Haram and another 2.2 million, including more than one million children, are thought to be trapped in areas under the control of the extremist group. While Nigerian President Muhammadu Buhari has made polio eradication a priority and pledged to curb terrorism, his country is beset by a series of crises ranging from attacks on oil production to increasing violence that will continue to challenge not only the government, but the polio program as well.
As the GPEI supports the Nigerian government in the outbreak response, U.S. participation will be critical. The U.S. Agency for International Development (USAID), an important long-term contributor to polio eradication, has released an extra $1.5 million to help with the response in addition to the $7 million a year it devotes to Nigeria’s polio efforts. CDC, one of the five international partners leading global polio eradication, supports $19 million in Nigerian polio programming and staff. Nigeria was the first location for CDC’s successful National Stop Transmission of Polio (NSTOP) program, which has trained 237 country staff in enhanced polio and routine immunization skills. Continuing all of these activities will be essential as Nigeria tackles not only the recent outbreak, but also gets itself back on track to polio elimination.
Since WHO certifies disease on a regional level, the Borno outbreak resets the clock and all of Africa will now have to wait at least an additional three years to receive polio-free status. While the cases are a setback, the Nigerian government and international supporters are responding quickly and aggressively. Nonetheless, the situation shines a spotlight on two of the biggest threats to global polio eradication: insecurity and complacency. While the former is less in the hands in the polio program, the latter is firmly in its purview. Country health and political leaders cannot afford to relax their attention not only until their country is certified as polio-free, but until the disease has been eliminated throughout the world. Toward that end, the polio program needs to devise more effective communications that, while celebrating eradication milestones, impress upon both leaders and populations at large that their own children are not safe from the disease until all children are safe from the disease.