The Road to Zero Polio in Africa: Africa Regional Polio Eradication Action Plan 2024/2025

"Stopping all circulating variant poliovirus transmission and preventing the emergence of new poliovirus outbreaks requires a redefined plan..."

This African Regional Polio Eradication Action Plan for 2024/2025 charts a new course of action by outlining the goals, objectives, and core principles required to stop all poliovirus transmission in Africa. The plan mirrors the eradication goals of the Global Polio Eradication Initiative (GPEI) and outlines strategic objectives and key actions that the World Health Organization (WHO) African Region will take to achieve two primary goals: (i) to permanently interrupt wild poliovirus type 1 (WPV1) transmission in endemic countries and (ii) to stop the transmission of circulating variant poliovirus and prevent outbreaks in non-endemic countries. The 2024/2025 plan is based on a review of the progress, risks, and challenges experienced by the polio response in the African Region. 

As explained in the document, the 2024/2025 plan "represents a shift in approach by tackling all poliomyelitis (polio) transmission, including circulating variant poliovirus outbreaks, as if the reported cases or isolates were wild poliovirus (WPV). Rather than adhering to the previously prescribed response of two campaign rounds, this action plan details a more aggressive approach, whereby polio-affected countries determine campaigns of between three and five rounds based on their risk and population immunity."

The goals of this plan are pursued through four main objectives:
 

• Intensify outbreak response;
• Improve timeliness of detection;
• Expedite progress through integration; and
• Create urgency through advocacy.

To achieve these objectives the plan outlines nine core principles as a framework to guide its efforts in achieving zero polio, as well as 10 priority areas. The nine core principles are as follows:
 

1. Ensure a realistic response plan by anticipating real-world challenges, such as delays or inaccessibility. There is no room for wishful thinking.
2. Proactively adjust response plans by conducting regular regional and/or subregional risk assessments. Outbreak zones should include relevant geographies beyond national boundaries.
3. Minimise scoping errors (according to geography and/or age groups) by using all available data.
4. Focus on immunity gaps when planning a response of between two and five rounds, depending on transmission scale, ongoing risk, and prior population immunity. For new outbreaks and in geographies of very high programmatic risk, a minimum of three rounds and a maximum of five rounds will be planned.
5. Implement special interventions - including fractional doses of inactivated polio vaccine (fIPV), in-between rounds activities, essential immunisation interventions, extended transit vaccinations, and health camps - in high-risk areas that are hard to reach and that host displaced populations or nomadic communities.
6. To overcome vaccine hesitancy, continuously review and innovate new approaches to community engagement and social mobilisation.
7. Use field-level outbreak response assessments (OBRAs), led by competent leadership, to periodically assess progress and propose additional actions.
8. Integrate programme delivery whenever and wherever it does not compromise the speed or quality of response, and foster integration with other antigens and other health interventions.
9. Maintain response posture at least until six months have passed since the last detection. 
    

The ten priority areas outlined in the report are meant to reflect the determination of managers of the programme to increase its capacity and leverage its strengths to fulfil its mission. These priority areas fall within the four main objectives. Priority areas with the strongest communication components are: 
 

• Devise new communication strategies to overcome vaccine hesitancy in high-risk populations.
• Integrate programme delivery whenever and wherever it does not compromise speed and quality of response, and foster integration with other antigens and other health interventions.
• Intensify advocacy efforts to engage leaders and donors to renew their commitments to eradicating polio in all its forms.

The plan defines six zones based on similar epidemiological characteristics and risks, with a timeline for attaining the goals of the plan phased across epidemiological zones. Based on a risk assessment, WHO AFRO grouped countries into five risk categories. Countries at very high risk (Chad, Democratic Republic of the Congo, Madagascar, Mozambique, Niger, and Nigeria) and at high risk (Algeria, Angola, Benin, Burkina Faso, Cameroon, Central African Republic, Côte d’Ivoire, Ethiopia, Kenya, Malawi, Mali, and Zambia) of circulating variant poliovirus spread will be considered priority countries for resource allocation.

The plans for 2024/2025 are outlined in the document according to the four overall objectives. For the purposes of this summary, only examples of strategies and plans with a strong communication component will be highlighted in brief here.

Objective 1. Intensify Outbreak Response - This objective will be achieved through four sub-objectives: improving campaign quality; optimising vaccine management; increasing vaccine acceptance through community engagement; and strengthening preparedness and capacity-building. Context-adapted community engagement in outbreak and at-risk countries is seen as important to generating vaccine demand and essential for ensuring quality campaign coverage. In light of past challenges - which include persistently high rates of refusals in some countries; limited social mobilisation training, deployment, and supervision during supplementary immunisation activities (SIAs); and the fact that microplanning has often lacked social and behavioural change (SBC) analyses such as social mapping and team movement plans - the 2024/2025 plan outlines specific objectives for increasing vaccine acceptance through community engagement. Plans include, for example:
 

• Improving vaccine acceptance by training programme staff and frontline workers in SBC; supporting countries to develop SBC between rounds; prioritising pre-campaign outreach to community leaders and local influencers; and assessing the impact of strategies through systematic data use and analysis.
• Ensuring one process for vaccine management in SIAs by identifying barriers through rapid analysis of supply and demand for immunisation; developing integrated packages of tailored SBC activities; conducting an external review on communication; and developing a comprehensive plan for SBC activities, focusing on cross-border issues.
• Improving communication in/around SIAs by updating microplans with social maps, team movement plans, and other key social mobilisation elements; and continuing to provide technical assistance to countries for preparing and monitoring outbreak response.
• Engaging at the highest level to maintain momentum by rebuilding and sustaining advocacy with decision-makers and political, community, and religious leaders; and advocating with humanitarian partners to increase investments.

Objective 2: Improve Timeliness of Detection - Besides improving monitoring and surveillance, one of the sub-objectives is to improve data and information management. Here, the plan stresses the need to continue to explore new ways to address gender barriers to vaccination through: a data collection framework that captures and disaggregates data by sex and age for campaign coverage, missed and zero-dose children, acute flaccid paralysis (AFP) cases, and stool sample adequacy; dashboards that support analysis of all age and sex-disaggregated data by in-country rapid response teams; and reporting that ensures that gender-specific nuances are considered and communicated to stakeholders.

Objective 3: Expedite through Integration - The GPEI strategy emphasises the need for an integrated service delivery approach that combines polio vaccination with other essential immunisation and health services to optimise outcomes and reach a broader population group. The programme aims to expedite progress through: (i) integrated campaigns; and (ii) activities related to immunisation system strengthening. To expedite progress through integrated systems strengthening, the 2024/2025 plan highlights the need to ensure strong coordination with in-country Expanded Programme on Immunization (EPI) and essential immunisation partners to identify zero-dose and under-immunised communities in polio-priority geographies. It also stresses the importance of increasing access to and utilisation of essential immunisation services by integrating operational microplans, enhancing supportive supervision and monitoring outreach activities, harmonising social mobilisation, and using new technology (such as mobile money and geographic information systems, or GIS) to support operations where necessary.

Objective 4: Create Urgency through Advocacy - The GPEI Polio Eradication Strategy identifies the need for strong political will and national prioritisation of resources created through effective advocacy. In order to intensify advocacy efforts and reach out to and engage leaders and donors to renew their commitments to eradicate polio in Africa, a regional polio advocacy framework was developed. The framework (available in the annex) emphasises the importance of context-sensitive communication, adaptive strategies, and collaboration among the stakeholders. It identifies proactive and reactive approaches/potential proposed activities for advocacy for priority countries, outlining the need (e.g., identify country-specific advocacy needs and plans), the country, the audience (e.g., ministers of health), the ask, the messenger, and the opportunity (when and where).   

The final two sections of the plan look at coordination, management, oversight, and resource requirements.