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Posted by Chris Millard on Nov 02, 2015 at 01:27 pm

On September 28, 2015, the CSIS Global Health Policy Center hosted a major international conference on global polio eradication, bringing together top experts from around the world to discuss key remaining challenges to eradicating the paralytic disease. The conference came in the wake of three major developments sure to shape the direction of the global initiative for years to come: the World Health Organization (WHO) officially removing Nigeria from the polio-endemic list; the Global Commission for the Certification of the Eradication of Poliomyelitis (GCC) formally declaring type-2 wild poliovirus (WPV2) eradicated; and the Polio Oversight Board (POB) announcing that the Global Polio Eradication Initiative’s (GPEI) original 2018 eradication goal would not be reached, and instead calling for a new target end date of 2019 at the additional cost of US$1.5 billion.

This mixed result of programmatic triumphs and continued challenges underpinned conversations throughout the day. Panelists argued that the world is closer than ever to achieving eradication due to a broad range of collective efforts from across the entire initiative, including from donors, partners, front line vaccinators, and community health workers, as well as from the cleverly written and hard hitting reports by the Independent Monitoring Board. However, speakers also cautioned that reaching zero is by no means inevitable. In addition to ensuring continued financial and political support for global eradication following the POB’s announcement, long-term success will ultimately depend on how well stakeholders can navigate three major tests: legacy planning, the impending polio vaccine switch, and vaccinating in conflict settings.

Legacy Planning: Transitioning Polio Program Assets

Conference panelists explored what is rapidly becoming a more urgent priority in polio eradication: ensuring the thoughtful transition of public health assets developed by the polio program to other global health priorities, a concept referred to as polio legacy planning. Since the formation of the GPEI in 1988, the global community has invested billions of dollars into eradication efforts worldwide. This has included training millions of vaccinators, community mobilizers, and volunteers, increasing surveillance capacities to identify previously missed and hard-to-reach communities, constructing regional laboratory networks, and establishing emergency operations centers (EOCs) to rapidly respond to infectious disease outbreaks. As more countries achieve polio-free certification, the question becomes what to do with this unprecedented investment in global health capacities.

The GPEI addresses this topic in its Polio Eradication and Endgame Strategic Plan 2013-2018 (PEESP), calling for the strategic transition of polio assets to address other global health priorities once poliovirus transmission has been interrupted and national immunization systems strengthened. Illustrating the utility of polio assets in broader disease control efforts, Dr. Andrew Etsano—Incident Manager at the National Polio Operations Center in Abuja, Nigeria—chronicled how members of the polio EOC team in Abuja were deployed to Lagos in 2014 to help stem the rapidly worsening Ebola outbreak. If not for existing polio-financed staff and facilities in Abuja, Dr. Etsano argued, a catastrophic, continent-wide Ebola outbreak could have been an all too likely scenario.

Yet even with such demonstrated successes, questions remain as to how investments are to be maintained moving forward. The new 2019 target eradication end date and accompanying financial scenario raises concerns over donor fatigue for the decades-old initiative. Dr. Thomas Frieden—Director of the U.S. Centers for Disease Control and Prevention—spoke to this challenge in his keynote address. He argued that sustained financial and programmatic commitment from governments and donors will be paramount in ensuring eradication is successful and fostering the transition of polio assets to other global health priorities. By identifying concrete cases of successful repurposing of polio assets—as in the case of the Nigerian EOC—and beginning the gradual yet deliberate financial transition of assets to country ownership, such sustained political commitment will be aided greatly.

The Polio Vaccine Switch

The next topic discussed was the impending global polio vaccine switch. Dr. Heidi Larson—senior lecturer at the London School of Hygiene & Tropical Medicine—framed the complexity of this discussion well, stating that by using, “the term ‘switch’… it sounds like it’s a quick thing, like the flick of a switch. But actually [the vaccine switch] is about changing the electrical system in the house… to make it possible for the light to go on when you flick the switch.”

In light of the recent confirmation of type-2 wild poliovirus (WPV2) eradication, the global community is pressing forward with an ambitious vaccine switch involving the synchronized phase-out of trivalent oral polio vaccine (tOPV) for bivalent oral polio vaccine (bOPV)—which lacks the weakened WPV2-associated polio strain—as well as the addition of inactivated polio vaccine (IPV) to routine immunization programs.

This is necessitated by the rare yet real occurrence of circulating vaccine derived poliovirus (cVDPV), outbreaks of paralytic disease caused by the weakened live virus found in OPV. IPV—a killed virus vaccine—carries no risk of vaccine-related paralysis. Consequently, the GPEI’s strategic plan calls for the eventual global withdraw of all OPVs and their replacement with IPV. The first step of this phase-out is eliminating the type-2 OPV strain, which causes over 90% of annual cVDPV outbreaks worldwide. The GPEI is urging countries to make the switch to bOPV—which lacks the type-2 OPV strain—while introducing at least one dose of IPV into their national routine immunization programs as a means to maintain global immunity against all three polio strains.

As explained by Michel Zaffran—Coordinator for the WHO’s Expanded Program on Immunization—the logistical challenges surrounding the switch are unprecedented. The move requires 126 countries to introduce IPV to their routine immunization services, preferably before the OPV switch occurs in April, 2016. In addition, 155 countries that now use OPV in their immunization system will be required to switch from the trivalent to the bivalent version during a two-week window. At the same time, all OPV containing the type-2 component must be contained or destroyed. “It’s a massive undertaking,” Zaffran noted.

But he also added that country commitment to the switch is high. Funding has been made available to low-income countries to aid implementation of the switch and ensure adequate monitoring of the process. Additionally, Zaffran noted, the countries at highest risk of experiencing problems with the switch are also the countries that have the highest amounts of polio-funded staff, who will be heavily involved in conducting and monitoring the switch and are most capable of responding to glitches that may arise during implementation. Furthermore, as noted by Dr. Stephen Sosler—Technical Immunization Advisor for Gavi, the Vaccine Alliance—critical technical and financial assistance is being provided by international organizations. Gavi, for example, is expediting financing for IPV introduction to 73 of the world’s poorest countries. Such assistance will be critical to ensuring a successful vaccine switch and preventing potential type-2 polio outbreaks during the two-week transition window.

Polio Vaccine Delivery in Conflict Settings

Finally, panelists explored how security threats—particularly in Afghanistan and Pakistan, the last remaining polio-endemic countries—pose serious operational challenges to fully interrupting transmission of the virus. Dr. Hamid Jafari—Director of Polio Operations and Research at the WHO—succinctly described the challenges that have emerged in recent years. Whereas the global polio eradication program has developed the expertise to navigate traditional conflicts between two clearly identified warring factions, today’s security environment poses a much greater test. The program now must navigate the dual challenges of not clearly defined armed groups—who often ignore international humanitarian laws and intentionally target health care workers—and larger geopolitical forces that threaten to undermine the program’s operational integrity—as was the case with the CIA’s fake vaccine campaign in Pakistan that resulted in mistrust of vaccinators and high vaccination refusal rates.

Yet, Dr. Jafari said there shouldn’t be “an acceptance… that because people are fighting, we’re going to ignore women and children in that area until the war stops. What we’ve learned is that with innovation, with strategic approaches, you can do very solid public health programming in very insecure environments.” By adopting new strategies to health delivery, the program has learned in recent years how to operate more effectively in chaotic, security-compromised environments. Such strategies involve understanding the nuanced, local drivers of insecurity, having a strong coordination between program planning and security analysis, and maintaining operational flexibility and resilience in the face of rapidly evolving security environments.

Dr. Elias Durry—Senior Emergency Advisor on Polio for EMRO at the WHO—further elaborated on this subject, stressing the utmost importance of community engagement in achieving polio eradication in conflict zones. To be successful, health care workers must effectively communicate with and integrate into local communities to ensure continued trust and support. As an example, Dr. Durry said that in Karachi, health care workers must operate in a space that even police officers will not enter. Only through engagement of traditional leaders, community elders, and other local individuals of importance can vaccinators have access to children that otherwise would be missed.

Looking Ahead

As conversations throughout the day highlighted, achieving global polio eradication is within the world’s reach. Yet the path to attaining that elusive goal remains littered with potential downfalls. Challenges such as legacy planning, the upcoming vaccine switch, and polio immunization delivery in security-compromised regions all carry the potential to delay or derail global eradication efforts. Yet perhaps the greatest challenge the international community must now face is maintaining the necessary financial and political support to tackle these issues in light of the POB’s newly announced one-year programmatic extension and its accompanying $1.5 billion price tag.

The extension could prove to be problematic for two reasons. In the immediate sense, it means that donors—who have already invested nearly $12 billion into eradication efforts since the GPEI’s inception in 1988—will be expected to open their wallets yet again to cover the program’s cost overruns. Yet perhaps more significant than the immediate financial implications are the potential longer-term political ramifications. If donors view the extension as an emerging trend rather than a one-time speed bump, political support for the program could begin to waiver and threaten the ultimate success of the entire global eradication initiative. Such a scenario could be all too likely if Pakistan and Afghanistan fail to interrupt transmission of poliovirus by the end of 2016—an assumption upon which the one-year extension is predicated.

Avoiding this erosion of political and financial support and ensuring that a multi-year program extension does not occur will require stringent and frequent assessment of the initiative, lending additional importance to the evaluative work conducted by the Independent Monitoring Board. Such independent oversight and unfiltered critiques will be vital to ensuring that major programmatic milestones are reached on time, including the polio vaccine switch in April 2016, interruption of wild poliovirus in Afghanistan and Pakistan by the end of 2016, and the projected polio-free certification dates for the WHO AFRO and EMRO regions in 2017 and 2019, respectively. Only through such efforts can the international community successfully navigate the precarious road ahead and close the book on polio once and for all.