The World Is Waiting: Nineteenth Report of the Independent Monitoring Board of the Global Polio Eradication Initiative

"Some communities have become so hostile to the Polio Programme, and so opposed to letting their children have the vaccine, that negative attitudes may have reached the point of no return....[T]he GPEI - from global to regional to national to local level - needs to adapt and do things differently."

As outlined in the last (18th) report by the Independent Monitoring Board (IMB) Report of the Global Polio Eradication Initiative (GPEI), clarity on the root causes of the slump in performance of the polio eradication effort during 2019 and the barriers facing the programme became blurred and distorted by the arrival of the COVID-19 pandemic. (See Related Summaries, below.) This 19th IMB report follows a series of videoconference meetings of the Board held November 17-19 2020 with the GPEI Strategy Committee, regional representatives, donors, wider polio partners, and the governments of the polio-endemic countries (Afghanistan and Pakistan). Participants took stock of the polio programme: after resumption of some polio eradication activities in the field, which had been paused due to COVID-19; as it is poised to introduce the novel oral polio vaccine type 2 (nOPV2) to combat the effects of vaccine-derived poliovirus (VDPV); as it revisits the factors that had made it a failing endeavour before COVID-19 emerged; as it puts in place measures to operate within the constraints imposed by the ongoing pandemic threat; and as it faces unprecedented financial pressures.

In the first session of the IMB meeting, the GPEI leadership began by outlining 3 main challenges the polio programme confronted at the end of 2020: (i) the perceived lack of full country ownership for the polio situation on the part of the endemic countries and some of the outbreak countries; (ii) the very low population immunity against type 2 poliovirus; this poses a high level of risk of the international spread of type 2 VDPV; and (iii) the COVID-19 pandemic, which has had various impacts on the polio programme (some positive - e.g., in some places, use of polio eradication resources for communications on COVID-19 may have softened populations' attitudes towards OPV. Another positive: the certification on August 25 of the African region as wild poliovirus (WPV)-free.) The report examines other issues at the global level, including how the programme is doing with "integration" (offering other health products or amenities valued by communities, not just immunisations), outbreaks and vaccine deployment, and the programme's gender strategy.

Next, the IMB shares data insights from, and looks at the situations in, Pakistan and in Afghanistan - both in the countries as a whole and in key provinces. For example, the IMB calls on the government of Pakistan's Khyber Pakhtunkhwa (KP) to "take concerted political, administrative and community-oriented actions to address long-standing programmatic weaknesses and vulnerabilities in the south of the province. This means providing essential public services and putting a stop to the activities of factions looking to use population access to polio vaccine as a bargaining tool. The social engagement of communities is vital. It is essential to involve locally respected community members, influencers, and tribal leaders, as well as political and government administrative leaders; they too must be mobilised. The programme will need to tailor the 'Pashtun strategy' to the local context." And, even in some accessible areas of Afghanistan, "refusals [of OPV] reflect the influence of the Taliban. They are not only banning campaigns in the areas that they control. They are also sending messages to their followers in big cities like Kandahar, Kabul, and Jalalabad to tell them not to accept vaccination until they have reached a deal in international negotiations. To address these challenges, the Ministry of Public Health recently designed the Afghanistan Health Transformation Program. This initiative is about broader health system strengthening measures, not just polio."

Based on a detailed analysis, the IMB presents recommendations, including the following examples:

• Sustain the momentum of resumed polio activities by ensuring that rigorous COVID-19 protective measures for health workers and communities are in place and by organising for polio and essential immunisation field staff to be vaccinated against COVID-19.
• Establish a public health emergency modus operandi for polio eradication by building upon, and learning the lessons from, the response to the COVID-19 emergency (e.g., "the speed, the flexibility, the incisive decision-making, the close working of national and subnational levels, the tight coordination, the rapid problem-solving, the placement of the best people in the most difficult places").
• "Reset" the Pakistan polio programme to strengthen its performance following the appointment of a new Special Assistant to the Prime Minister on Health, with a focus on strong national-provincial teamwork.
• Build on and extend the success of the Afghanistan polio programme's pilot scheme that gained access through locally based negotiations, whereby talks with community leaders, community elders, and anti-government elements (AGE) in some inaccessible areas have been effective (leading, for instance, to complete access in Uruzgan for a multi-antigen campaign).
• Ensure implementation in Pakistan's 40 super-high-risk union councils of the "polio sub-package" initiative, an integrated model, with specific focus on water, sanitation, and hygiene (WASH) interventions.
• Ensure that the communications strategy for the rollout of the nOPV2 is fully transparent, regularly assessed against actual experience of vaccine deployment, and adjusted accordingly - particularly in the context of any resistance to the COVID-19 vaccine.
• Establish a high-level commission to strategise about ridding the World Health Organization (WHO) Eastern Mediterranean region of polio.