The Drum Beat 841: Polio's Persistence: What Health Communicators Can Learn from the Eradication Effort

• 1. Foster a deep system understanding of the Pakistan polio programme - In 2024, wild poliovirus (WPV) surged back into the seemingly cleared historical polio reservoirs. It is necessary to carry out an in-depth analysis of the reasons the polio programme in Pakistan has not yet interrupted WPV transmission. Relatedly, the IMB recommends changing the management culture in the programme, removing the fear factor from the polio team. The pressure to reach the endgame is felt all the way down through the management structure to the frontline, leading staff to not report bad news to their bosses, to create false data returns, and to engage in fake finger marking. There is a need for fresh thinking, continued strong commitment and innovation, and an open, learning, non-hierarchical team structure.
  * Relevant CI summary:
  How to Eradicate Polio in Pakistan: Insights from Community Health Workers
  by Marium A. Sultan, Svea Closser, Arman Majidulla, et al. 
• From 2020-2022, a human-centred design ideas competition sought to listen to the people who know the polio programme best: frontline workers (FLWs) in 18 super-high-risk union councils in Pakistan. Ideas of 171 FLW teams on how to eradicate polio fell into 4 main categories, one of which is improving human resources (HR) processes and workplace dynamics. For example, multiple teams suggested that FLWs should have regular private meetings with external monitors, leadership, and/or HR where workers could discuss workplace issues confidentially and transparently and then come up with solutions. Other teams proposed that group discussions take place where FLWs openly share common issues and potential solutions. One team envisioned a hotline staffed by women where FLWs could report workplace issues without facing repercussions. [Aug 2023] 
   
• See also:
  Eradicating Polio in Pakistan: A Systematic Review of Programs and Policies
   
• 2. Address the lack of adequate polio vaccination coverage in the southern Afghanistan city of Kandahar - The notable programmatic weakness is the failure to initiate the house-to-house modality (vs. site-to-site or mosque-to-mosque) in Kandahar City, believed to be because of the administration's concerns about covert surveillance activities. The IMB recommends immediately moving to house-to-house polio campaign modality for the whole country.
  * Relevant CI summary:
  Progress in Access and Oral Polio Vaccine Coverage Among Children Aged <5 Years in Polio Campaigns After the Political Change in Afghanistan
  by Wrishmeen Sabawoon, Shion Seino, Bakht Mohmmad Pason, et al.
• In Afghanistan, armed conflict has resulted in the underimmunisation of the population in certain areas and children's inaccessibility during polio vaccination campaigns. This study describes progress in access to children under 5, OPV coverage among children under 5 in nationwide polio campaigns, and polio surveillance performance indicators after the Islamic Republic of Afghanistan collapsed to Taliban forces in August 2021. June 2022's house-to-house OPV coverage was 34.2% higher than non–house-to-house modalities. As suggested here, advocacy efforts should be intensified to persuade Taliban representatives to continue to allow house-to-house visits throughout Afghanistan. [Apr 2024] 
   
• 3. Strengthen communication and social mobilisation in Afghanistan - It is important to ensure that the rationale for the change in policy to adopt house-to-house polio vaccination campaigns in most parts of the country is clearly communicated to the population, as it may seem counterintuitive to them. There is also strong anecdotal evidence from multiple sources in some areas that government workers are refusing the vaccine for their own children, which may prompt more families to follow their lead. The government should establish how many of their workers are rejecting the vaccine and why and should ensure leaders publicly vaccinate their children.
  * Relevant CI summary:
  Report on the Meeting of the Technical Advisory Group (TAG) on Poliomyelitis Eradication in Afghanistan
  This report outlines the strong national and regional social and behaviour change communication plans and multiple activities implemented, leading to increasing use of data to demonstrate impact, despite some loss of the local programme capacity in 2021. For example, the programme has adopted approaches to address chronically missed children and refusals, including extensive vaccination of children in transit to cover high-risk mobile populations, creating a supportive environment by strategic mass media interventions. The programme has also strengthened advocacy, with a focus on gender, by partnering with local influencers with tribal, religious, and political affiliations, as well as community-based and non-governmental organisations in high-risk union councils. With these key strategies, since March 2022, the national trends of missed children and still refusals improved. [Oct 2022] 
   
• 4. Recognise and value the role of women as a mainstay of the public health workforce - Women have access to the inside of houses when male vaccinators do not, and they are generally trusted. When parents have doubts, reassurance can be given mother-to-mother. A full-scale, coordinated initiative should be taken by the national and provincial governments in Afghanistan and Pakistan to build this workforce by maximising recruitment and building skills. Priority should be given to working with tribal, religious, and community leaders in the most socially and religiously conservative areas of the endemic countries. (Similar action should be taken in parts of Africa where such conditions also prevail - for example, in places where female vaccinators are not allowed to work without a male (preferably a family member) accompanying them.)
  * Relevant CI summary:
  The Central Role of Women in Polio Vaccine Acceptance Among the Pashtun in Pakistan
  by Zainab Khawaja and Adnan A. Khan 
• Despite forming only a part of Pakistan's population, Pashtun households contribute the biggest number of polio cases to the country's caseload. Pashtuns are a nomadic, pastoral, Eastern Iranic ethnic group primarily residing in northwestern Pakistan and southern and eastern Afghanistan. This chapter explores the intersection of gender norms and power relations with cultural norms, the marginalised social location of Pashtuns, geographic location, and age through the lens of polio vaccination. The one norm that is never violated is that women talk to women; a male health worker visiting a household is unacceptable. The researchers argue that "polio campaigns in Pakistan would benefit from conceiving a more central role for mothers and other women caregivers. Polio (or other vaccination) teams must understand the nature of women's agency and internalize its implications for campaigns and communication in their work." [Aug 2024] 
   
• 5. Create a more participative approach to deciding on vaccination campaign frequency in polio-endemic areas of Afghanistan and Pakistan - Ensuring the right campaign frequency and intensity is important. For example, multiple knocks on the door can turn people against the programme and lead them to hide their children or demand false finger marking. The aim should be to create more time and space between rounds for active, quality improvement work. The emphasis should be on seeking, and giving more weight to, the views of frontline teams.
  * Relevant CI summary:
  Understanding High-Priority Populations: Learning Brief 3
  A rapid desk review of key documentation between 2014 and 2020 identified a series of shared issues in Pakistan's South Khyber Pakhtunkhwa (KP), Peshawar, Quetta Block, and Karachi - e.g., annoyance with campaign frequency and demoralised and overworked FLWs. Areas deemed critical for engaging high-priority populations included, e.g., the use of FLWs as "problem solvers" and the role of key provincial- and district-level actors in setting the right "tone". [Feb 2021] 
   
• See also:
  * 30 Years of Polio Campaigns in Ethiopia, India and Nigeria: The Impacts of Campaign Design on Vaccine Hesitancy and Health Worker Motivation 
  * Fatigue and Fear with Shifting Polio Eradication Strategies in India: A Study of Social Resistance to Vaccination
   
• 6. Enhance integrated delivery systems - Integration involves embedding polio vaccination activities within a programme of practical health benefits that are valued by families. For example, in Afghanistan, interventions have included health camps, polio "pluses", and nutrition and water and sanitation programmes. Integrated service-delivery models have been particularly helpful in areas where there is extreme poverty and community hostility to OPV. Integration must be grounded in country realities.
  * Relevant CI summary:
  A Holistic Strategy of Mother and Child Health Care to Improve the Coverage of Routine and Polio Immunization in Pakistan: Results from a Demonstration Project
  by Muhammad Atif Habib, Sajid Bashir Soofi, Zamir Hussain, et al. 
• This study assesses the impact of an integrated strategy implemented between 2014 and 2016 to enhance community engagement and maternal and child health (MCH) immunisation campaigns in 146 high-risk union councils of 10 polio-endemic districts in Baluchistan, Pakistan. The evaluation demonstrated a substantial increase in the coverage of routine immunisation along with polio vaccines: "Despite uncertain security conditions, population restrictions, and vaccine hesitancy, the favorable combined impact of community mobilization, and delivery of MNCH and immunization services through temporary MCH-focused health camps during SIAs [supplementary immunisation activities] was evident. Furthermore, this intervention was effective in increasing vaccine coverage and considered feasible and acceptable by the community." [Jan 2024] 
   

• To access the full IMB report, see this CI summary: The Long Goodbye: Poliovirus Continues to Resist Extinction - Twenty-Third Report of the Independent Monitoring Board of the Global Polio Eradication Initiative

• 7. Urgently reboot the Nigeria Polio Programme - Described by the IMB as "now dysfunctional at all levels and in key areas of activity", the Nigeria programme has a sizeable workforce, but more attention needs to be given to staff quality and experience. "If there is no emergency mindset, nothing will change."
  * Relevant CI summary:
  Exploring the Landscape of Routine Immunization in Nigeria: A Scoping Review of Barriers and Facilitators
  by Yahaya Mohammed, Heidi W. Reynolds, Hyelshilni Waziri, et al. 
• Nigeria holds a large share of burden of zero-dose and under-immunised children, with an estimated over 2.1 million based on 2023 estimates. Furthermore, there are significant regional inequalities that are exacerbated by parental hesitancy and resistance, primarily fuelled by rumours about vaccine safety and reinforced by religious and cultural considerations. This scoping review systematically maps and summarises existing literature on the barriers and facilitators of immunisation in Nigeria, focusing on regional inequalities. One suggestion: Develop comprehensive solutions to health-system-related barriers, spanning from targeted training programmes to alleviate communication gaps among healthcare providers to strategic workforce planning initiatives aimed at mitigating staffing shortages. [Sep 2024] 
   
• 8. Strengthen communication and social mobilisation in Africa - There is growing concern about persistently high refusal rates due to mistrust of the authorities, false rumours, religious orthodoxy, and negative information and adverse advice about polio vaccination being disseminated in communities. The GPEI, with the United Nations Children's Fund (UNICEF) leading, should make a rapid appraisal of the scale and nature of the problem of vaccine refusal in Africa and work with the World Health Organization (WHO) regional office, country and subnational leadership, and civil society organisations (CSOs) to mount a large-scale coordinated social mobilisation response.
  * Relevant CI summary:
  Factors Influencing Community Engagement during Guinea Worm and Polio Eradication Endgames in Chad: Recommendations for "Last Mile" Programming
  by Maryann G. Delea, Lalique Browne, Severin Kaji, et al. 
• Poor community engagement in the context of eradication programmes can lead to misconceptions and noncompliance that set back hard-fought progress. This paper shares the result of qualitative operational research conducted in a district of Chad co-endemic for both Guinea worm disease and circulating vaccine-derived poliovirus (cVDPV) to reveal factors influencing community engagement behaviour in the context of eradication-related programming. For example, one facilitator: "Inviting village chiefs and administrative authorities together with the population for social mobilization events related to an initiative is viewed as synonymous with credibility." The need to address context-specific barriers affecting community engagement and to involve and empower community members in the planning and implementation of programme activities within the context of eradication and health programmes is a salient theme. [Jul 2024] 
   
• See also:
  Sustaining the Gains of Polio Eradication: Addressing Vaccine Refusals in Northeast Nigeria [Presentation from the Sharing Learning from Polio SBC Side Event at the 2022 SBCC Summit]
   
• 9. Address weaknesses in surveillance - Better surveillance will be needed in places where vaccine-derived polioviruses may emerge or be hard to detect. Furthermore, the IMB believes there is a systemic weakness in surveillance within the big cities in Africa (and in Pakistan as well). The GPEI should take action to raise awareness, issue guidance, and ensure that the authorities in every hospital give freedom of access to polio surveillance officers. It should also assess and correct weaknesses of digital surveillance systems that give misleading geolocation data, thereby impairing accurate tracking of the poliovirus.
  * Relevant CI summary:
  The Evolution, Facilitators, Barriers, and Additional Activities of Acute Flaccid Paralysis Surveillance Platform in Polio Eradication Programme Bangladesh: A Mixed-method Study
  by Humayra Binte Anwar, Yameen Mazumder, Sanjana Nujhat, et al. 
• Conducted by the Synthesis and Translation of Research and Innovations from Polio Eradication project, this study outlines acute flaccid paralysis (AFP) surveillance evolution in Bangladesh, its success and challenging factors, and its potential to facilitate other health goals. Due to effective AFP surveillance, Bangladesh detected 18 imported cases of WPV1 in 2006 from western Uttar Pradesh, India, and contained the outbreak. The surveillance reportedly contributed to the decrease in poliomyelitis cases and in attaining polio-free status for Bangladesh in 2000. Examples of factors driving the success of AFP surveillance: multi-sectoral collaboration, support, and activities; social environments; and high political commitment. [Jun 2024] 
   

• To access the full IMB report, see this CI summary: The Long Goodbye: Poliovirus Continues to Resist Extinction - Twenty-Third Report of the Independent Monitoring Board of the Global Polio Eradication Initiative

• 10. Manage performance of inactivated polio vaccine (IPV) coverage - About 39 countries in the world have yet to introduce 2 doses of IPV. The GPEI, working with Gavi and the Essential Programme on Immunization, should actively manage the increased uptake of IPV coverage, ensuring that it goes preferentially to the areas with the lowest levels of immunity and highest number of zero-dose children.
  * Relevant CI summary:
  Use of a Fractional Dose of Inactivated Polio Vaccine (fIPV) to Increase IPV Coverage among Children under 5 Years of Age in Somalia
  by Khaliif Nouh, Abdirizak Haga, Kyandindi Sumaili, et al. 
• There have been no WPV cases seen in Somalia since August 2014. However, in 2017, there was a surge in the number of cases of cVDPV2, even with different intervention responses using monovalent OPV type 2. This study assessed the use of fractional IPV (fIPV) in campaigns held in 5 districts in 2021. Participants described their experiences with the implementation of the fIPV pilot as a fast and child-friendly delivery strategy. One respondent said, "the training given to all supervisors, vaccinators, and social mobilizers, and different methods of advocacy and social mobilizations had played an important role in the success of the pilot." [Mar 2024] 
   
• 11. Move toward greater integration of the work of CSOs - CSOs play a vital role in ensuring that polio-essential functions are delivered in difficult-to-access and conflict-affected areas. They build trust in communities when governments and official agencies are not respected or trusted. The GPEI should meet urgently with the CSOs and the sovereign polio donors to agree ways to maximise the skills and experience of these organisations to contribute to achieving the polio goals, both short- and longer-term.
  * Relevant CI summary:
  Revisiting the Role of Civil Society in Responses to Infectious Disease Outbreaks: A Proposed Framework and Lessons from a COVID-19 Vaccine Equity Coalition in Uganda
  by Azfar D Hossain, Mastulah Nakalule, Shreenithi Venkataraman, et al. 
• CSOs - a diverse set of non-governmental, advocacy, and community-based groups - have historically played a role in advancing health equity. However, CSOs are often overlooked by traditional public health institutions during responses to infectious disease outbreaks. In September 2021, this group of authors formed the Vaccine Advocacy Accelerator-Uganda (VAX-Uganda), which is a coalition of CSOs, health workers, and academics working to increase access to and uptake of COVID-19 vaccination throughout Uganda, where, at the time, less than 1% of the population had completed a primary vaccination series. Members of the coalition and other partner CSOs have supported equitable access to vaccinations in three key, replicable ways: community mobilisation and empowerment, service delivery, and advocacy. Lessons learned from VAX-Uganda that may help to create more genuine outbreak-focused partnerships are shared. [Jun 2023] 
   
• See also:
  Leveraging CSO Contributions to Advance Polio Transition and Integration Efforts in the African Region
   
• 12. Introduce modern management, accountability, and quality improvement - "The IMB has said many times that 'all polio is local'. Management at the lowest administrative level is as important as management at the top." The IMB recommends that the polio programme review, refresh, and improve the indicators tracked, disseminated, and used for programme management and quality improvement to make them simple, meaningful, and useful.
  * Relevant CI summary:
  Quality Improvement Interventions Targeting Immunization Data from Urban Lower-level Private-for-profit Health Service Providers in Kampala Capital City: Processes and Implementation Experiences
  by Eric Ssegujja, Paul Kiggundu, Yahayah Kayemba, et al. 
• This paper documents the implementation processes and experiences of piloting a co-created intervention whose aim was to contribute to improvements in the accuracy and timeliness of immunisation service data among lower-level private-for-profit immunisation service providers in Kampala Capital City Authority, Uganda. Through a theory-driven design with the COM-B as the guiding model, the behavioural change intervention functions targeted to cause the desired change leading to improvements in data quality among private providers were: (i) targeted training, (ii) modelling through continuous quality improvement, (iii) persuasion through onsite mentorships and enhanced monitoring and support supervision, (iv) coercion through onsite spot checks, enforced supply of vaccines upon data accountability, and enforced timely submission of data, and (v) environmental restructuring through support that ensured availability of data tools and vaccines. [Jun 2024] 
   

• To access the full IMB report, see this CI summary: The Long Goodbye: Poliovirus Continues to Resist Extinction - Twenty-Third Report of the Independent Monitoring Board of the Global Polio Eradication Initiative

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