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Polio Eradication & Endgame Midterm Review July 2015

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Executive Summary

The Global Polio Eradication Initiative (GPEI) leadership agreed at the time of the 2013–2018 Polio Eradication and Endgame Strategic Plan (PEESP) development that the programme would regularly assess progress, reflect on the lessons learned, plan for the risks ahead, and make needed adjustments to the activities and costs of the plan going forward. This midterm review (MTR) was conducted by a team from the GPEI partners under the guidance of the Strategy Committee (SC) from March-May 2015.

Achievements Since Start of PEESP

• Only one serotype of Wild poliovirus (WPV) remains: In September 2015, the Global Certification Committee (GCC) is expected to formally affirm that wild poliovirus type 2 (WPV2) circulation stopped globally more than 15 years ago and report its decision to the World Health Assembly (WHA) in May 2016. No WPV3 case has been reported since November 2012 anywhere in the world. Interruption of WPV3 would represent another historic milestone for the GPEI and would leave only WPV1 still circulating.

• Polio-free certification of SEARO: In March 2014, after three years of no cases in India, the World Health Organization (WHO) South East Asia Region (SEARO) was certified polio-free. Four of the six WHO regions are now certified and 80% of the world’s population lives in polio-free regions.

• End of all WPV outbreaks (Horn of Africa, Central Africa and Middle East): As a result of collaborative partnership efforts, all recent outbreaks stopped in mid-August 2014.

• Heightened global urgency and commitment to complete polio eradication: WHO’s Director-General declared the international spread of polio a Public Health Emergency of International Concern (PHEIC) and issued Temporary Recommendations under the International Health Regulations (IHR) to curtail the risk of international spread.

• Historic progress in Africa: No WPV cases have been reported in Africa since 11 August 2014 • Successful use of IPV in campaigns: The combined use of oral polio vaccine (OPV) and Inactivated Polio Vaccine (IPV) in areas with security challenges and in outbreak settings boosted immunity in critical geographies, such as Afghanistan, Kenya, Cameroon, Nigeria and Pakistan.

• Documentation of “Legacy in Action”: The polio Emergency Operations Centre (EOC) in Nigeria rapidly responded to the Ebola virus outbreak in Lagos and played a major role in preventing Ebola from spreading. More recently, GPEI infrastructure was leveraged for the Nepal earthquake response.
Challenges While the programme had many successes, both external and internal factors still stand in the way of reaching eradication goals.

External Factors:

• In 2013, growing conflict and insecurity played a major role in precipitating outbreaks in the Horn of Africa and the Middle East. Increased instability in parts of Pakistan also played a role in limiting access to children, allowing continued transmission. While insecurity was not the sole contributor to these outbreaks, the disruption of immunization activities led to areas of low population immunity and ongoing insecurity hampered outbreak response.

• The West Africa Ebola virus outbreak in 2014 diverted some of GPEI’s focus away from implementing the PEESP. As a consequence of the outbreak, supplementary immunization activities (SIAs) had to be suspended or postponed in Guinea, Liberia, Sierra Leone, Senegal and Mali. Substantial numbers of WHO and United Nations International Children’s Emergency Fund (UNICEF) polio staff in the region and from headquarters were deployed to assist in the outbreak response.

Internal Factors:

• Although national and even subnational AFP surveillance indicators are adequate in most countries, persistent pockets of suboptimal surveillance create a risk that polio cases will not be rapidly detected.

• The strategy of frequent SIAs has had an insufficient impact on stopping transmission in Pakistan and Afghanistan and resulted in worker fatigue, variable quality and insufficient time allocated to surveillance and planning. These factors, along with suboptimal management and accountability, likely contributed to the same groups of children being chronically missed.

• Multiple risks remain in preparation for the global introduction of IPV and the upcoming switch from trivalent OPV (tOPV) to bivalent OPV (bOPV), including tight IPV supply, persistent circulating vaccine-derived poliovirus (cVDPV) transmission in Nigeria and Pakistan and challenges to meet containment requirements.

• Despite the success of the 2013 Vaccine Summit, failure to operationalise pledges threatens to financially constrain the programme.

MTR Recommendations

The 2013–2018 PEESP was developed in 2012 with input from each GPEI partner agency, the Independent Monitoring Board (IMB), the Strategic Advisory Group of Experts on Immunization (SAGE), the donor community and other stakeholders through the Polio Partners Group (PPG), countries, and independent selected advisers. The review concluded that the PEESP still captures the key strategic elements required to reach polio eradication. While there are no significant gaps that require major changes, there is an urgent need to refocus priorities, strengthen implementation, and initiate new tactics. After careful consideration of the progress to date, lessons and risks, the SC identified 11 strategic adjustments that will address current challenges to ensure a polio-free world.

The recommendations are categorized into three strategic areas (more detailed descriptions of the recommendations are included under section C of each objective):
Activities for interruption 1. Recommendation: Increase surveillance capacity and quality Example actions include rapid finalization of the global surveillance plan, increased investment to implement recommendations from previous surveillance reviews ensuring sufficient qualified staff in high-risk areas, and full implementation of the environmental surveillance (ES) expansion plan.

2. Recommendation: Improve SIA quality with a focus on missed children and intensified social mobilization SIA strategies should be reoriented to focus on chronically missed children and other vulnerable subpopulations with targeted use of the most effective SIA strategies. The programme also needs to develop consensus criteria with countries for rational frequency, vaccine selection and scope of SIAs.

3. Recommendation: Increase global and national capacity for outbreak preparation and aggressive response to cVDPV and WPV Future actions for endemic and high-risk countries include development of national rapid response plans, strengthening of accountability, identification and training of national rapid response teams and regular review of the SIA schedule along with intensified monitoring of SIA quality. For post-outbreak countries, follow-up is needed on implementation of risk–reduction recommendations.

7. Recommendation: Rapidly accelerate support for GAPIII implementation National government regulatory agencies and vaccine manufacturers must significantly accelerate their activities to meet the timelines in the revised Global Action Plan (GAPIII). Within the next six months, the GPEI, principally WHO, should assist by organising regional GAPIII implementation/certification workshops, developing specifications for containment certifications and training rosters of experts to carry out facility visits for verification of GAPIII compliance.

Activities for OPV withdrawal

5. Recommendation: Prioritise strategic IPV use The Immunization Management Group (IMG) and the Emergency Operations Management Group (EOMG) are working together to mitigate the impact of IPV shortage. Given this reality, the programme should review and update existing guidelines, provide clear decision-making criteria on when and how much IPV to use in campaigns, determine how many doses will be set aside to address new cVDPVs and ensure compliance with these decisions.

6. Recommendation: Focus on tOPV to bOPV contingency planning

The IMG has initiated contingency planning for a worst case scenario of delaying the switch in the case of unsuccessful cVDPV2 eradication. In the next six months, the programme should accelerate and increase the breadth of its contingency planning in order to address any residual cVDPV2 risk and determine next steps for vulnerable countries that may not have introduced IPV due to supply constraints.

Enabling activities

4. Recommendation: Strengthen collaboration and joint accountability between polio and broader RI community GPEI has so far set its own expectations for how it contributes to routine immunization (RI), often measured through the amount of polio worker time spent on non-polio activities. Greater clarity is needed from the Global Vaccine Action Plan (GVAP) partners regarding GPEI’s specific role in enhancing RI prior to eradication and the GVAP’s role in leveraging polio assets post-eradication.

8. Recommendation: Strengthen management capacity and accountability The programme should strengthen performance management systems in endemic, outbreak and high-risk geographies. The programme should ensure sub-national ownership of the polio eradication activities especially for managing front line workers (FLWs). Likewise, it should ensure strong training, supervision, and prompt payment is provided to FLWs

9. Recommendation: Increase advocacy at sub-national levels and improve communication with external and internal stakeholders The programme should develop and operationalise national and local advocacy plans that strengthen national commitment to polio eradication and allocation of domestic resources in endemic, outbreak and high-risk geographies.

10. Recommendation: Increase data standardization, monitoring capacity and analysis
It needs to ensure robust global, national and sub-national level data analysis, wide spread sharing of results, and increased capacity at various levels to support real-time, data-informed decision making.

11. Recommendation: Update resource mobilization and allocation strategy
It should fully implement Polio Oversight Board (POB) commitment to transparency in use of resources and increased communication with donors to build trust in the programme and encourage donors to provide more flexibility and predictability in funding to respond to evolving needs.

While not specifically highlighted as one of the strategic recommendations, the programme will continue to look for innovative tools and methods to achieve programme goals such as reaching missed children, implementing more costeffective surveillance, and developing cVDPV and vaccine-associated paralytic polio (VAPP) mitigation strategies. As these innovations roll out, their impact will be assessed to determine which should be scaled-up and in what order.

To facilitate strategic and financial planning, the review also identified multiple possible endgame scenarios outlined in the finance section of the report. The programme will assess the progress of WPV interruption in the remaining endemic countries and other programme goals between now and the September 2015 POB meetings and select the most likely scenario at the time. Key stakeholders (e.g., IMB, PPG) will continue to be engaged throughout the process.

The SC recognises the need to develop an execution plan to ensure these recommendations are implemented and monitored. The SC will review these recommendations, provide guidance and discuss tactical options with the Management Groups who will need to develop and implement the execution of these plans.