The Long Goodbye: Poliovirus Continues to Resist Extinction - Twenty-Third Report of the Independent Monitoring Board of the Global Polio Eradication Initiative

"That polio remains a public health emergency of international concern in 2024, the longest running ever, leads people to ask: When will it end? When will the job be finished? Why has it taken so long? These are the questions that haunt the Polio Programme."

The 23rd report from the Independent Monitoring Board (IMB), which provides independent assessments of the polio programme to help refine and improve the Global Polio Eradication Initiative (GPEI)'s work, presents an analysis of the status of eradication efforts and suggests actions to help accelerate progress toward interruption of wild poliovirus type 1 and to stop all outbreaks of circulating vaccine-derived polioviruses. It emerged from a joint meeting with the Polio Transition Monitoring Board (TIMB) in July 2024. This report deals only with the IMB's monitoring responsibilities; the TIMB will be producing its own report.

The IMB report notes the promising decline of types 1 and 2 variant poliovirus cases globally in the past year and the strong regional commitment to eradication throughout the Eastern Mediterranean Region. However, progress against variant poliovirus to date is extremely fragile and variable across geographies, and the recent rise in wild poliovirus detections in Pakistan and Afghanistan is of serious concern. The IMB also recognises the complex environments where the virus remains and the external factors impeding the GPEI's ability to consistently reach children in these places. For these reasons, the GPEI has decided to extend the timeline of certifying the eradication of wild polio to 2027 and certifying the elimination of type 2 variant polio to 2029.

The report offers details on: Polio Risk Management in Endemic Countries; Prospects for Stopping Polio in the Endemic Countries; Polio Impact and Vulnerabilities in Other Eastern Mediterranean Countries; Polio Risk Management in Africa; and Prospects for Stopping Polio in Africa. It also looks at global policy developments, noting here, in part the "growing worry that the GPEI might end its reign prematurely, leaving countries to deal with vaccine-derived polio without a strong coordinating entity. This scenario would pose a significant risk to the gains made in polio eradication and could lead to many new outbreaks." 

In reflecting on the analysis provided in the report, the IMB shares some communication-centred insights, such as the importance of gaining trust and support of communities. "Since it began its work 12 years ago, the IMB has continued to urge the Polio Programme to consider the feelings of communities and to recognise how easily negativity and hostility to the oral polio vaccine can develop. Engaging communities and understanding their perspectives is vital to the task of interrupting poliovirus transmission....Listening sympathetically and respectfully to the concerns of communities should be a fundamental value of the Polio Programme."

Specifically: "Fostering a climate where communities want the vaccine, fear the risks of polio to their children and value the protective effect of regular vaccination goes way beyond messaging. It is about proper strategic planning of communication, and building trust at a very local and personal level. This takes time, skill and constant listening to local voices."

Furthermore: "With high frequency, intensive vaccination campaigns, multiple knocks on the door can turn people against the programme. They do not know why repeated vaccination is necessary. They become suspicious of motives. They can become very negative and may hide their children or demand false finger marking. If the vaccinator is from the community, and is maybe even their neighbour, there is pressure to collude in deception. Vaccinators need support and training to equip them with the skills to handle such situations....The countries where polio activities are most intensive...contain some of the most conservative gender norms....Gender should be a mandatory and core part of the discussions on planning and delivery of the Polio Programme."

The IMB report offers 17 recommended actions. In brief:

 

1. Broaden the focus from what the GPEI has designated as the "consequential geographies" (countries and areas) so as to systematically take action to raise the immunity levels in the surrounding countries and areas.
2. Urgently reboot the Nigeria Polio Programme, which is "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."
3. Carry out an in-depth analysis of the reasons the Polio Programme in Pakistan has not yet interrupted transmission of wild poliovirus, and conduct rigorous monitoring of the programme performance in real time, with rapid course corrections as soon as plans are going off track.
4. Remove the fear factor from polio team culture in Pakistan. At key moments, when it seemed that stopping poliovirus circulation was imminent, the pressure was felt all the way down through the management structure to the frontline. There, it generated fear; staff dared not report bad news to their bosses, created false data returns, and engaged in fake finger marking. The Pakistan provincial chief secretaries should cultivate an open, learning, non-hierarchical team structure.
5. Create a more participative approach to deciding on vaccination campaign frequency in polio-endemic areas of Afghanistan and Pakistan. The emphasis should be on seeking, and giving more weight to, the views of frontline teams. The aim should be to create more time and space between rounds for active, quality improvement work.
6. Address the lack of adequate polio vaccination coverage in the southern Afghanistan city of Kandahar, immediately moving to house-to-house polio campaign modality for the whole country.
7. Strengthen communication and social mobilisation in Afghanistan and Africa in light of:
    
   • The change in policy to adopt house-to-house polio vaccination campaigns in most parts of Afghanistan (it is important to ensure that the rationale for the change in policy is clearly communicated to the population, as it may seem counterintuitive to them) and 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 leadership of the Afghanistan Polio Programme should work with UNICEF and civil society organisations (CSOs) to follow through with communication and social mobilisation activities to address suboptimal vaccination uptake, and the government should establish how many of their workers are rejecting the vaccine and why, and ensure that leaders publicly vaccinate their children.
   • The growing concern in the Africa region 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 UNICEF leading, should make a rapid appraisal of the scale and nature of the problem of vaccine refusal in Africa, and work with the WHO regional office, country and subnational leadership, and CSOs to mount a large-scale coordinated social mobilisation response.
8. Expand the female public health workforce. When parents have doubts, reassurance can be given mother-to-mother. Women have access to the inside of houses that male vaccinators do not, and they are generally trusted. With proper training opportunities created, their skill base is easily broadened. A full-scale, coordinated initiative should be taken by the national and provincial governments in Afghanistan and Pakistan to build a female public health workforce. 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.
9. Mount a true emergency response for vaccine-derived poliovirus. The regional polio team should provide a public-facing report frankly explaining the reasons for each suboptimal 2024 outbreak response. This report should then be used to define measurable, ambitious, achievable timeline targets for detection; confirmation; zero, first, and second vaccine responses; and measures of the effectiveness of these responses.
10. Fast-track new methods for detection and differentiation of polioviruses. At least two specific areas require urgent attention: timeliness of transport of specimens in Democratic Republic of the Congo and elsewhere, and roll-out of direct detection laboratory methods. Ambitious, achievable targets should be set and met.
11. Enhance integrated delivery systems. The development of better integration of polio with other programmes must be grounded in country realities. Integrated service-delivery models have been particularly helpful in areas where there is extreme poverty and community hostility to the oral polio vaccine. UNICEF has been a strong force in these forms of integration that embed the 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 health, nutrition, and the water and sanitation programme. The key partners for integration (WHO, UNICEF, and Gavi) should urgently design and implement an approach to ensuring that their in-country teams miss no opportunity to take a combined approach to boosting polio immunity in the places where this is most necessary.
12. Move toward greater integration of CSOs' work. 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.
13. Manage performance of inactivated polio vaccine coverage. About 39 countries in the world have yet to introduce two doses of inactivated polio vaccine. The GPEI, working with Gavi and the Essential Programme on Immunization, should actively manage the increased uptake of inactivated polio vaccine coverage, ensuring that it goes preferentially to the areas with the lowest levels of immunity and most zero-dose children.
14. Establish a polio subcommittee for the WHO Regional Committee for Africa.
15. 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.
16. Speed up funding flows and vaccine supplies for outbreaks, and strip out bureaucracy that is slowing effective action.
17. Close important gaps in surveillance quality. The GPEI should work with countries to rapidly review practice for identifying acute flaccid paralysis in city hospitals. It 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.