Polio Panel Warns Against Program Complacency
June 6, 2015
While polio eradication efforts currently are showing hopeful successes, the Independent Monitoring Board (IMB) of the Global Polio Eradication Initiative (GPEI) warned in its May 2015 report that sufficient funding and attention should be guaranteed to guard against backsliding. The initiative has thought it was nearing the end before, only to be afflicted with disease outbreaks that set it back, sometimes for years. A clear directive to move forward aggressively is warranted to avoid undue complacency.
“The current sense of optimism has some real basis to it,” the IMB wrote. “But the sense of optimism is also highly dangerous. The two-steps-forward-one-step-back history of the programme teaches hard lessons about assuming that plain sailing is ahead.”
To ensure the program continues to enhance its effectiveness, the IMB is recommending that the GPEI fund consultants for country-level emergency operations centers and for global program management to focus on quality improvement. Further, it recommends that GPEI’s international partners, including the World Health Organization, UNICEF, Rotary International, the U.S. Centers for Disease Control and Prevention, and the Bill & Melinda Gates Foundation, plan and respond in accordance with current eradication needs and not based on the funding available. If more resources are needed, the groups and other supporters should seek to raise it. In addition, the board calls for convening an “urgent global polio summit” to address the issue of persistently missed children. The summit would be charged with producing a plan that would reduce by 50 percent within six months the number of children chronically missed in polio vaccination drives.
In recent successes, the initiative is cautiously looking at what may be the end of polio in Africa, with the last cases reported in Nigeria and Somalia over the summer of 2014 (although official polio-free certification does not occur for three years after the last case). In addition, there has been a remarkable turnaround in Pakistan which last year produced 85 percent of the wild polio cases in the world, for a total of 306. As of May 27, Pakistan has had 23 reported cases versus 67 at the same time last year. The improvement is being attributed in part to Pakistani military operations that have allowed polio vaccinators to reach children who had been largely inaccessible. The IMB also cites program improvements in Pakistan including the establishment of emergency operations centers to better coordinate and oversee polio vaccination drives.
Pakistan’s Focal Person on Polio Eradication, Senator Ayesha Raza Farooq, told the World Health Assembly (WHA) in May that her country has made a “major turnaround” in polio elimination in the last seven months. She noted that in addition to reporting fewer polio cases this year, the virus increasingly is disappearing from environmental samples. She said the country’s program is focusing on ways to reach missed children including by improving communications with families to address vaccine refusals. It also has increased the number of female health workers and instituted “health camps” that offer services in addition to polio vaccination. Farooq said Pakistan is fully committed to polio eradication, adding that national health leaders are “cognizant of our obligation to our own children” but also those beyond their borders.
National health leaders at the Assembly received warmly Pakistan’s positive news. While most countries have been polio free for some time, remaining reservoirs of the disease anywhere in the world require continued vigilance everywhere. After so many years with polio eradication at the forefront, many countries are anxious to see the disease come to an end.
While praising Pakistan’s efforts, WHA delegates said they remain concerned about the potential for outbreaks in insecure areas and conflict zones. The delegate from China, for example, called for increased financial and technical support for high-risk areas grappling with war, conflict, and terrorism. Several other countries, including Iraq and Ethiopia said special efforts must be made to ensure vaccination of refugees and other displaced persons.
While its previous report took Pakistan to task for its large number of cases, the May 2015 IMB report expressed concern about Afghanistan’s program. “Afghanistan is failing to get to grips with the same programmatic problems that it has suffered for years,” the report says. “Frustratingly close to the finish line, Afghanistan’s polio programme has hit a wall.” Further, the report notes, while major outbreaks in Africa and Middle East in 2013 appear to be over, many areas remain at high risk. The board cites Yemen, Somalia, Syria, Iraq, Libya, Ukraine, and even Nepal as particular worries.
With multiple challenges still ahead for the GPEI, the IMB recommendations make sense. Nonetheless, a call for additional funding may be difficult to follow through on. Donors already have been supporting the program long past the initial target dates for eradication and many contributed what they thought was their final installments when the GPEI announced its Polio Eradication and Endgame Strategic Plan 2013-2018 in April 2013. Yet, the program still faces a $451 million shortfall for the strategy itself and faced unexpected outbreaks in 2013 in the Horn of Africa and the Middle East. The IMB is right to call on program partners to press for what they need particularly as insecurity and conflict complicate vaccination efforts, but program managers should ensure they are as transparent as possible about how the money will be used. In addition, while it may seem odd to call for substantial reforms when the program again appears to be close to achieving eradication, management of the awkward public/private partnership has long been an issue. Excellence will be required for the GPEI to reach the final goal and it should not stop looking now for ways to improve.
The recommendation for a summit on reaching missed children could have impacts beyond polio eradication. Children who are eluding polio vaccinators likely are bypassed by other health services as well. The summit could develop a global strategy for ensuring all children have access to health care, drawing on successful innovations from the polio program and others. The strategy could be tailored by countries for their own use and employed by other health initiatives.
While the polio program is experiencing a much-needed positive trend after several years of disheartening setbacks, remaining challenges to eradication dictate that the GPEI move forward with creativity and unrelenting determination. The IMB predicts the program has several complex outbreaks ahead and it must be prepared to deal with them, in addition to continuing to improve general polio immunity. The U.S. government, as a top supporter of polio eradication, needs to be fully engaged for the duration of the effort. Disease eradication is not an easy task and the last mile is the most difficult. As the IMB noted, “There will be some temptation to coast, to think that it is now just a matter of time. The rocky road to eradication does not allow for coasting.”
