Closing in on Zero: Adapting to Complexity and Risk on the Path to End Polio - Twenty-Second Report of the Independent Monitoring Board of the Global Polio Eradication Initiative

"Community acceptance of the oral polio vaccine is a critical concern, and trained personnel are needed to ensure effective communication strategies."

The Polio Eradication Strategy 2022-2026, Delivering on a Promise set 2023 as a target year to interrupt all remaining type 1 wild poliovirus (WPV) transmission (Goal One) and circulating type 2 vaccine-derived poliovirus transmission, or cVDPV (Goal Two), with the aim of reaching eradication by 2026. This Independent Monitoring Board (IMB) report, which is part of its normal cycle of independent assessments of the Global Polio Eradication Initiative (GPEI), provides a mid-term review of that strategy. Readers of this 22nd IMB report may find value in the the 6th Polio Transition Independent Monitoring Board (TIMB), available at Related Summaries, below, if they wish to understand the roles that polio transition is playing in helping to achieve the interruption of poliovirus transmission.

As the report outlines, at its July 2023 meeting, the IMB was involved in wide-ranging discussions with the GPEI leadership, delegations from the key affected countries, donors, and wider polio partners. In brief, the IMB notes the encouraging restriction of WPV1 transmission in the two remaining endemic countries, Afghanistan and Pakistan, and acknowledges the continuous work to reach every child with polio vaccines and the political commitment to maintaining the progress that has been made (e.g., the pivotal role played by Pakistan's provincial Chief Secretaries). For instance, in Pakistan, the most recent focus has been on the 69 most at-risk councils in south Khyber Pakhtunkhwa (KP), where detections are still occurring in the context of severe insecurity and large numbers of boycotts (over 200) of the polio programme in response to unmet wider demands by communities and interest groups. (" Too many communities see polio vaccination as something being imposed upon them, rather than a service provided for their benefit. It therefore carries massive bargaining power in the eyes of key communities and interest groups.") In response, language-matched vaccination teams are being deployed to enhance community engagement, particularly in the Pashtun population. Integration of polio vaccination with broader healthcare provision is underway. Overall, in this province, community-based approaches are being increasingly used to encourage local leaders to support the polio programme and its aims.

However, data analysed by the Technical Advisory Group highlighted an adverse trend in south KP, whereby over 60% of refusals are attributed to missed visits to households or incomplete vaccination within the visited households. Other assessments put the proportion closer to 75% to 80% of children being missed by polio vaccination teams. The reasons cited are wide-ranging and encompass insecurity, boycotts, clustering of refusals, and frontline teams missing houses or children within houses. Real and present dangers of violence and refusal surround these teams, compounded by misinformation about, and mistrust of, vaccination campaigns. Insecurity has led to loss of campaign quality, including instances of the fake finger marking of children. These difficulties have persisted across the last 10 rounds of vaccination, pointing to systemic management weaknesses that the IMB says must be addressed urgently. "Achieving sustainable solutions requires an astute understanding of local dynamics and often involves delicate negotiations and engagements at various community levels."

Likewise, Afghanistan is still not free of conflict, with an armed threat to Taliban and civilian targets coming mainly from an Islamic State affiliate, ISIS Khorasan (ISIS-K). Staff delivering polio activities have been targeted in the past, and there are still risks that this could happen again. The de facto authorities have continued to impose severe restrictions on women, affecting their freedom of movement, access to education, and participation in the workforce. ("Despite some in positions of authority in Afghanistan acknowledging the power of female vaccinators to establish trust with parents, their level of participation is still low.") In June 2023, scheduled polio vaccination campaigns in the east (home to Nangarhar province, which is the place where all polio cases were reported in 2023) were shelved, for unclear political reasons. The polio programme was challenged, at the July 2023 IMB meeting, to explain to donors why their large past investments in communication and social mobilisation activities had led to a situation in Afghanistan where 27,000 missed children in the east region could not be reached.

During the COVID-19 pandemic, the GPEI suspended over 60 polio campaigns, leading inevitably to an increase in cases of type 2 VDPV and outbreaks of type 1 VDPV. The GPEI leadership acknowledges the challenges countries face in implementing effective outbreak responses. There is an increasing concentration of VDPVs in a small number of "consequential geographies", which is where the polio programme is focusing much of its attention and concern. They are: the eastern part of the Democratic Republic of the Congo, northwestern Nigeria, south-central Somalia, and northern Yemen. The GPEI leadership told the IMB about the complex context in each of these four areas (e.g., the strong anti-vaccine stance of the Houthis in Yemen). The IMB report also explores issues that have arisen due to the introduction of the novel oral polio vaccine type 2, which did not succeed in eradicating VDPV within 6 months, as hoped, but did have a major effect on attitudes in polio-affected countries. In short, the IMB stresses that the vaccination strategy alone is insufficient to stop transmission in the most consequential geographies and those suffering from repeated importations, usually from their immediate neighbours. These areas have very high rates of zero-dose children. Per the IMB, a multisectoral collaboration involving health agencies, the government, and local stakeholders is required to address challenges relating to complex humanitarian emergencies, malnutrition, major security threats, and persistent barriers to access.

Based on this analysis, the IMB's mid-term review deems:

• Goal One - to interrupt WPV transmission globally by the end of 2023 - is off track, with a very high probability that it will be missed. In the IMB's view, attention should now be turned to ensuring that the gains that moved the polio programme quite close to achieving its first strategic goal on WPV are not lost and are built on very quickly. The goal of interrupting WPV transmission in Pakistan and Afghanistan in 2024 "is possible but not a shoo-in". Notably, once WPV in Afghanistan has been interrupted, "the country will need substantial funding to secure its polio legacy and contribute to a polio-free world with no resurgence of polio."
• Goal Two will be missed. Per the IMB: "The GPEI's approach to vaccine-derived poliovirus has been a turbulent journey marred by rigid attitudes, missed opportunities, lack of foresight, and an inability to adapt swiftly to evolving circumstances....The world is now in a situation where vaccine-derived polioviruses are paralysing nearly 50 times more children than wild polioviruses....The IMB still hears vaccine-derived poliovirus being described as a 'fake virus'. The IMB repeats: every case is a failure."

The report concludes with 18 recommended actions, including this one: "The Polio Programme, the Essential Immunisation Programme, and Gavi should open up and act on the many opportunities to run more vaccination initiatives that build in polio. This is one important way to realise the benefits of integrated and mixed methods thinking. It needs more creativity and better inter-programme communication and is an opportunistic way of working that, over the years at IMB meetings, has been described as 'low-hanging fruit'."