Unsettled World Creates New Challenges for Polio Eradication--IMB

Stopping all polio transmission by the end of 2016 will require enhanced security for immunization campaigns and devising ways to vaccinate children in increasingly complicated settings, the Independent Monitoring Board (IMB) of the Global Polio Eradication initiative argues in its October report. Fluctuating security situations along with growing displaced populations create a heightened risk of outbreaks, not just in the Middle East, but in parts of Europe as well since refugees sometimes skirt designated camps and avoid registration in attempts to resettle. In addition, once functioning health systems in places like Syria and Ukraine are faltering, creating other points of public health fragility, the board says.

The IMB’s concerns reflect the potential for broader public health degradation in the Middle East and Europe as global disorder intensifies. Officials will be forced to rethink health approaches as systems failures once confined to areas of conflict spill over to neighboring states and beyond. The chaos appears set to continue for the foreseeable future and is likely to add to rolls of unimmunized children. The IMB estimates there are already 6.6 million children worldwide who have never received a dose of polio vaccine.

To try to come to grips with the challenge, the IMB recommends that the GPEI conduct a more detailed risk assessment related to polio immunity in migrant and refugee communities from the Middle East and consider additional immunization activities in Jordan, Lebanon, and Turkey in addition to migratory routes into Europe, if findings dictate. In addition, it recommends that Middle Eastern countries with refugees from Syria advertise free vaccination for children without requiring official registration or identity checks. Attention and resources devoted to polio eradication in these areas could also aid provision of additional immunizations and help monitor for other health concerns.

Overall, significant progress toward eradication has been made in the last year and the number of wild poliovirus cases globally so far in 2015 is at a historically low 56. But insecurity and difficulties in ensuring vaccination in large mobile populations threatens progress in some regions and is hindering efforts to immunize children in the remaining two polio endemic countries, Pakistan and Afghanistan. 

To improve security, the IMB recommends that the GPEI institute a new “Golden Rule”: fully integrating vaccination plans with matching security plans involving relevant district and local officials in every security compromised area.

“In each of the endemic countries, those recently endemic and those where outbreaks have occurred, there is a common theme: areas of insecurity, and the disruption to infrastructure, access and government attention that this brings,” the board notes. “In several areas, due to continued geopolitical and local events, the situation on the ground may get worse in the months ahead.” It cites in particular temporary access bans in the southern provinces of Afghanistan causing vaccine disruptions. It says the situation may only get worse with the fragmentation of opposition groups in the area.

While coordinating polio activities with security personnel has become an unfortunate imperative in some places, it is not an easy task. A polio vaccination campaign performed this month in Pakistan was postponed twice because of a lack available police. The campaign finally went forward November 9, aimed at immunizing more than one million children in Sindh, but was still 500 officers short of the 3,200 expected.

Beyond the formidable challenges of global conflict and insecurity, the IMB also offered specific recommendations to individual countries:

• While praising it for reducing the number of inaccessible children from more than 500,000 in 2013 to 35,000 this year, the Board urges Pakistan to move more quickly to close remaining immunity gaps. “Pakistan still has widespread virus, “ the panel notes. “It is not in as strong a position as Nigeria was in less than a year before that country interrupted transmission; in Nigeria, the virus really was down to the final reservoirs only.” The IMB urges improvements in immunization activities and performance monitoring, and increased focus on immunizing children who are persistently missed by the program. Further, it calls for increased intensity of effort in Peshawar from which large populations frequently migrate to the country’s Federally Administered Tribal Areas and to Afghanistan, creating a “conveyor belt” of polio transmission. The panel recommends that GPEI international partners help Afghanistan and Pakistan establish a joint executive and planning body to coordinate cross-border polio prevention and control.

• The Afghanistan polio program was judged, for the second IMB report in a row, to be the worst performer. The panel cited weak social mobilization and vaccination team performance along with security-related inaccessibility. The IMB urged urgent establishment of an Emergency Operations Center in Afghanistan along with a redesigned leadership structure that improves accountability and coordination and provides the program with a new sense of direction.

• Nigeria, removed from the list of polio endemic countries this fall, faces continued challenges as it transforms its polio program from one aimed at stopping transmission to a focus on remaining polio free. Among IMB recommendations related to this task is instigating new social mobilization and communications campaigns to alert parents and health professionals that polio vaccination is still necessary.

The last few months have seen remarkable successes in the eradication effort, including Nigeria’s accomplishments and breakthroughs in immunization reach in Pakistan. Nonetheless, daunting challenges remain and are likely to spread and intensify as the Middle Eastern humanitarian crisis deepens. The board is urging continued innovations and a striving for excellence to ensure the last difficult steps to eradication are pursued with sufficient vigor and focus. “As the finishing line draws tantalizingly nearer, the potential cost of any mistake is magnified,” the panel warns. It continues: “Any misalignment of inefficient use of resources, any acceptance of substandard performance, any lapse of leadership attention or organizational concentration could set the programme back a year.”

The global community, including the United States, has a key role to play in helping countries stay focused on eradication despite multiple competing and urgent priorities. It should provide sufficient support for security operations in addition to vaccination resources and also help countries grapple with daunting cross-border and regional issues. A focus on polio eradication can help keep a spotlight on other immunization deficiencies during this turbulent, uncertain time when public health is increasingly imperiled by violence and chaos.