The Final Stages of the Global Eradication of Poliomyelitis

This paper explores the challenges encountered by the Global Polio Eradication Initiative (GPEI) in eradicating the last 1% of wild-virus transmission worldwide - especially within the remaining endemic countries: Pakistan, Afghanistan, India, and Nigeria.

In documenting the role of research in the GPEI's response to these challenges, some communication-related insights emerge - particularly within the section of the report that focuses on challenges to the eradication of wild-type poliovirus (WPV) in the area of vaccination coverage.

In Nigeria and Pakistan in particular, as reported here, there has been weak management and oversight of the programme at the local level. This has limited the performance and monitoring of supplementary immunisation activities (SIAs). Poor management leads to vaccination teams that are incapable of delivering oral polio vaccine (OPV) to enough of the population. For example, "teams in some parts of Pakistan have included only temporarily employed staff with insufficient local knowledge and no appropriate language skills, or they have lacked female members thereby limiting access to households when the men are absent....In addition, SIA implementation and monitoring rely on accurate maps and census data ('microplans'), which can be a major challenge, particularly for poorly managed programmes with insufficient technical support. Difficulties with programme management typically occur where political support is lacking, and this has been most notable at the provincial and district level in large federated republics such as Nigeria, India and Pakistan."

As the author explains, resistance to immunisation and lack of demand for OPV in some populations has also been a challenge. The most notable and well-cited example is the polio vaccine boycott that occurred in some states of northern Nigeria in 2003, following rumours that the vaccine contained sterilising compounds. "Of course, the interpretation of why some parents refuse vaccination must be taken not just in the social and political context, but also in the context of the quality of the vaccination programme. A poorly managed programme with inappropriate vaccination teams can lead to refusals and 'absent' children."

It is noted that the GPEI has responded to the challenges that limit vaccination coverage during SIAs and continue to innovate in this area. For example, the GPEI has undertaken "dedicated advocacy work at all levels, particularly through the support of Rotary International and UNICEF [United Nations Children's Fund]. Rotary International has engaged heads of state and political bodies including the African Union, Organization of the Islamic Conference, the Commonwealth and G8....As a result, support for the GPEI at the highest political levels has been extraordinary. At the local level, religious and political leaders have been engaged by the GPEI and attitudes to vaccination have become positive where once they were negative. For example, in tribal areas of northern Pakistan previously resistant to vaccination, Islamic scholars and leaders have issued fatwas in favour of vaccination with OPV. Advocacy at the local level occurs within a broader framework of mass communication and social mobilization led by UNICEF. These efforts have proved critical in recent years to the successes of the GPEI. It has been estimated that in endemic regions where communication has been included as a key component of immunization strengthening, vaccination coverage has increased by an absolute 12-20% compared with baseline..."

This paper details the fact that, shortly after the year 2000, it was apparent that more had to be done to reach inaccessible children. So, the GPEI introduced house-to-house visits by vaccination teams and booth activities in a systematic way into SIAs. Extensive efforts to map and vaccinate migratory populations involved in temporary or seasonal employment are now in place in remaining endemic regions. For example, in India, 162,000 migratory sites such as brick kilns and construction sites were mapped, and 4.2 million children under 5 years old identified at these sites. Access to children in countries affected by conflict has been achieved through negotiated ceasefires and strengthened community involvement. However, access can be infrequent and conflict in these areas remains a major challenge to the GPEI.

Also noted here, efforts to improve SIA coverage have been linked to routine immunisation (RI) strengthening. "As a 'vertical' programme, the GPEI has been criticized for its failure to invest more in improving underlying immunization and health services. However, the strong community involvement in polio eradication and the mobilization of resources from governments offer many opportunities for strengthening routine immunization....GPEI staff are regularly involved in activities unrelated to polio...."

The author concludes that the continued commitment of the global health community will hopefully make it possible to accomplish the so-called endgame strategy: to take the world from low incidence of polio to no incidence.