Ethical dilemmas in current planning for polio eradication

A qualitative exploration of the contributions of Polio Eradication Initiative to the Nigerian health system: policy implications for polio transition planning

BACKGROUND

The Nigerian health care system is weak due to lack of coordination, fragmentation of services by donor funding of vertical services, dearth and poor distribution of resources, and inadequate infrastructures. The Global Polio Eradication Initiative has supported the country's health system and provided strategies and skills which need to be documented for use by other health programs attempting disease control or eradication. This study, therefore, explored the contributions of the Polio Eradication Initiative (PEI) activities to the operations of other health programs within the Nigerian health system from the perspectives of frontline workers and managers.

METHODS

This cross-sectional qualitative study used key informant interviews (KIIs) and inductive thematic analysis. Twenty-nine KIIs were conducted with individuals who have been involved continuously in PEI activities for at least 12 months since the program's inception. This research was part of a more extensive study, the Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE), conducted in 2018. The KII tool focused on four major themes: work experience in other health programs, similarities and differences between polio programs and other health programs, contributions of polio programs, and missed opportunities for implementing polio lessons. All interviews were transcribed verbatim and analyzed using a thematic framework.

RESULTS

The implementation of the PEI has increased health promotion activities and coverage of maternal and child health interventions through the development of tangible and intangible resources, building the capacities of health workers and discovering innovations. The presence of a robust PEI program within a weakened health system of similar programs lacking such extensive support led to a shift in health workers' primary roles. This was perceived to reduce human resources efforts in rural areas with a limited workforce, and to affect other programs' service delivery.

CONCLUSION

The PEI has made a notable impact on the Nigerian health system. There should be hastened efforts to transition these resources from the PEI into other programs where there are missed opportunities and future control programs. The primary health care managers should continue integration efforts to ensure that programs leverage opportunities within successful programs to improve the health of the community members.

The effects of polio eradication efforts on health systems: a cross-country analysis using the Develop-Distort Dilemma

Vertical disease control programmes have enormous potential to benefit or weaken health systems, and it is critical to understand how programmes' design and implementation impact the health systems and communities in which they operate. We use the Develop-Distort Dilemma (DDD) framework to understand how the Global Polio Eradication Initiative (GPEI) distorted or developed local health systems. We include document review and 176 interviews with respondents at the global level and across seven focus countries (Afghanistan, Bangladesh, Democratic Republic of Congo, Ethiopia, India, Indonesia and Nigeria). We use DDD domains, contextual factors and transition planning to analyse interactions between the broader context, local health systems and the GPEI to identify changes. Our analysis confirms earlier research including improved health worker, laboratory and surveillance capacity, monitoring and accountability, and efforts to reach vulnerable populations, whereas distortions include shifting attention from routine health services and distorting local payment and incentives structures. New findings highlight how global-level governance structures evolved and affected national actors; issues of country ownership, including for data systems, where the polio programme is not indigenously financed; how expectations of success have affected implementation at programme and community level; and unresolved tensions around transition planning. The decoupling of polio eradication from routine immunization, in particular, plays an outsize role in these issues as it removed attention from system strengthening. In addition to drawing lessons from the GPEI experience for other efforts, we also reflect on the use of the DDD framework for assessing programmes and their system-level impacts. Future eradication efforts should be approached carefully, and new initiatives of any kind should leverage the existing health system while considering equity, inclusion and transition from the start.

A erradicação da poliomielite em quatro tempos

O objetivo deste artigo é rever o “estado da arte” dos avanços, obstáculos e estratégias para atingir a erradicação global da pólio. As ações de controle da poliomielite iniciaram na década de 1960 com o advento das duas vacinas antipoliomielíticas, a vacina oral da pólio (VOP) e a vacina inativada da pólio (VIP). No período de 1985 a 2020, são implementadas estratégias para atingir a meta de erradicação do poliovírus selvagem (WPV). Após o sucesso da interrupção da transmissão autóctone do WPV na região da Américas, foi lançada a meta da erradicação global. Descrevemos o processo de erradicação em quatro tempos: (1) O advento das vacinas VIP e VOP iniciou a era do controle da poliomielite; (2) A utilização massiva e simultânea da VOP teve impacto significativo sobre a transmissão do poliovírus selvagem no final da década de 1970 no Brasil; (3) Políticas públicas (nacionais e internacionais) decidem pela erradicação da transmissão autóctone do poliovírus selvagem nas Américas e definem as estratégias epidemiológicas para interromper a transmissão; e (4) A implantação das estratégias de erradicação interrompeu a transmissão autóctone do WPV em quase todas as regiões do mundo, exceto no Paquistão e Afeganistão, onde, em 2020, cadeias de transmissão do WPV1 desafiam as estratégias de contenção do vírus. Por outro lado, a persistência e a disseminação da circulação do poliovírus derivado da VOP, em países com baixa cobertura vacinal, somadas às dificuldades para substituir a VOP pela VIP constituem, atualmente, os obstáculos para a erradicação a curto prazo. Finalmente, discutimos as estratégias para superar os obstáculos e os desafios na era pós-erradicação.

The contribution of the polio eradication initiative on the operations and outcomes of non-polio public health programs: a survey of programs in the African region

Introduction

The effect of the Global polio eradication initiative (PEI) on public health programs beyond polio is widely debated. PEI contribution to other health programs has been assessed from the perspective of polio-funded personnel, which may introduce bias as PEI staff are probably more likely to show that they have benefited of other programs. We set out to identify and document how public health programs have benefited from the public health capacity that was provided at the country level as part of the PEI program in a systematic and standardized manner.

Methods

Between July and November 2017, we conducted a mixed-methods cross-sectional study, which combined two methods: a multi-country quantitative survey and a qualitative study. We created a self-administered electronic multi-lingual questionnaire in English, French and Portuguese. The qualitative study, which followed an interim analysis of the quantitative survey, comprised interviews with national and subnational level staff in a few countries.

Results

A total of 127 public health workers from 43 of the 47 countries in the African WHO Region responded online. Most of the respondents 56/127 (42.7%) belonged to the immunization sector and 51/127 (38.9%) belonged to the emergencies and outbreaks sector. Respondents who identified themselves with the immunization (50/64 (78%)) and maternal health program (64/82 (78%)) reported the highest level of greatly benefiting from PEI resources. A total of 78/103 (76%) respondents rated PEI's contribution data management system to their program very high and high. Of the 127 respondents, the majority 91 (71.6%) reported that the withdrawal of PEI resources would result in a weakening of surveillance for other diseases; 88 (62.9%) reported that there would be inadequate resources to carry out planned activities and 80 (62.9%) reported that there would be poor logistics and transport for implementation of activities. Cameroon, DRC, Nigeria and Uganda participated in the qualitative study. Each country had between 7-8 key informants from the national and sub-national level for a total of 31 key informants. Polio funds and other PEI resources have supported various activities in the ministries of health of the four countries especially IDSR, data management, laboratories and development of the public health workforce. Respondents believed that the infrastructure and processes that PEI has created need to be maintained, along with the workforce and they believed that this was an essential role of their governments with support from the partners.

Conclusion

There is a high awareness of the PEI program in all the countries and at all levels which should be leveraged into improving other child survival activities for example routine immunizations. Future large-scale programs of this nature should be designed to benefit other public health programs beyond the specific program. The public health workforce, surveillance development, data management and laboratory strengthening that have been developed by PEI need to be maintained.

National responses to global health targets: exploring policy transfer in the context of the UNAIDS '90-90-90' treatment targets in Ghana and Uganda

Global health organizations frequently set disease-specific targets with the goal of eliciting adoption at the national-level; consideration of the influence of target setting on national policies, programme and health budgets is of benefit to those setting targets and those intended to respond. In 2014, the Joint United Nations Programme on HIV/AIDS set 'ambitious' treatment targets for country adoption: 90% of HIV-positive persons should know their status; 90% of those on treatment; 90% of those achieving viral suppression. Using case studies from Ghana and Uganda, we explore how the target and its associated policy content have been adopted at the national level. That is whether adoption is in rhetoric only or supported by programme, policy or budgetary changes. We review 23 (14 from Ghana, 9 from Uganda) national policy, operational and strategic documents for the HIV response and assess commitments to '90-90-90'. In-person semi-structured interviews were conducted with purposively sampled key informants (17 in Ghana, 20 in Uganda) involved in programme-planning and resource allocation within HIV to gain insight into factors facilitating adoption of 90-90-90. Interviews were transcribed and analysed thematically, inductively and deductively, guided by pre-existing policy theories, including Dolowitz and Marsh's policy transfer framework to describe features of the transfer and the Global Health Advocacy and Policy Project framework to explain observations. Regardless of notable resource constraints, transfer of the 90-90-90 targets was evident beyond rhetoric with substantial shifts in policy and programme activities. In both countries, there was evidence of attempts to minimize resource constraints by seeking programme efficiencies, prioritization of programme activities and devising domestic financing mechanisms; however, significant resource gaps persist. An effective health network, comprised of global and local actors, mediated the adoption and adaptation, facilitating a shift in the HIV programme from 'business as usual' to approaches targeting geographies and populations.

Impact of an Intervention to Use a Measles, Rubella, and Polio Mass Vaccination Campaign to Strengthen Routine Immunization Services in Nepal

Background

The potential to strengthen routine immunization (RI) services through supplementary immunization activities (SIAs) is an important benefit of global measles and rubella elimination and polio eradication strategies. However, little evidence exists on how best to use SIAs to strengthen RI. As part the 2012 Nepal measles-rubella and polio SIA, we developed an intervention package designed to improve RI processes and evaluated its effect on specific RI process measures.

Methods

The intervention package was incorporated into existing SIA activities and materials to improve healthcare providers' RI knowledge and practices throughout Nepal. In 1 region (Central Region) we surveyed the same 100 randomly selected health facilities before and after the SIA and evaluated the following RI process measures: vaccine safety, RI planning, RI service delivery, vaccine supply chain, and RI data recording practices. Data collection included observations of vaccination sessions, interviews with the primary healthcare provider who administered vaccines at each facility, and administrative record reviews. Pair-matched analytical methods were used to determine whether statistically significant changes in the selected RI process measures occurred over time.

Results

After the SIA, significant positive changes were measured in healthcare provider knowledge of adverse events following immunization (11% increase), availability of RI microplans (+17%) and maps (+12%), and awareness of how long a reconstituted measles vial can be used before it must be discarded (+14%). For the SIA, 42% of providers created an SIA high-risk villages list, and >50% incorporated this information into RI outreach session site planning. Significant negative changes occurred in correct knowledge of measles vaccination contraindications (-11%), correct definition for a measles outbreak (-21%), and how to treat a child with a severe adverse event following immunization (-10%). Twenty percent of providers reported cancelling ≥1 RI sessions during the SIA. Many RI process measures were at high proportions (>90%) before the SIA and remained high afterward, including proper vaccine administration techniques, proper vaccine waste management, and availability of vaccine carriers and vaccine registers.

Conclusions

Focusing on activities that are easily linked between SIAs and RI services, such as using SIA high-risk village list to strengthen RI microplanning and examining ways to minimize the impact of an SIA on RI session scheduling, should be prioritized when implementing SIAs.

Polio infrastructure strengthened disease outbreak preparedness and response in the WHO African Region

INTRODUCTION

The continuous deployments of polio resources, infrastructures and systems for responding to other disease outbreaks in many African countries has led to a number of lessons considered as best practice that need to be documented for strengthening preparedness and response activities in future outbreaks.

METHODS

We reviewed and documented the influence of polio best practices in outbreak preparedness and response in Angola, Nigeria and Ethiopia. Data from relevant programmes of the WHO African Region were also analyzed to demonstrate clearly the relative contributions of PEI resources and infrastructure to effective disease outbreak preparedness and response.

RESULTS

Polio resources including, human, financial, and logistic, tool and strategies have tremendously contributed to responding to diseases outbreaks across the African region. In Angola, Nigeria and Ethiopia, many disease epidemics including Marburg Hemorrhagic fever, Dengue fever, Ebola Virus Diseases (EVD), Measles, Anthrax and Shigella have been controlled using existing polio Eradication Initiatives resources. Polio staffs are usually deployed in occasions to supports outbreak response activities (coordination, surveillance, contact tracing, case investigation, finance, data management, etc.). Polio logistics such vehicles, laboratories were also used in the response activities to other infectious diseases. Many polio tools including micro planning, dashboard, guidelines, SOPs on preparedness and response have also benefited to other epidemic-prone diseases. The Countries' preparedness and response plan to WPV importation as well as the Polio Emergency Operation Center models were successfully used to develop, strengthen and respond to many other diseases outbreak with the implication of partners and the strong leadership and ownership of governments. This review has important implications for WHO/AFRO initiative to strengthening and improving disease outbreak preparedness and responses in the African Region in respect to the international health regulations core capacities.

The impact of polio eradication on routine immunization and primary health care: a mixed-methods study

Background. After 2 decades of focused efforts to eradicate polio, the impact of eradication activities on health systems continues to be controversial. This study evaluated the impact of polio eradication activities on routine immunization (RI) and primary healthcare (PHC).

Methods. Quantitative analysis assessed the effects of polio eradication campaigns on RI and maternal healthcare coverage. A systematic qualitative analysis in 7 countries in South Asia and sub-Saharan Africa assessed impacts of polio eradication activities on key health system functions, using data from interviews, participant observation, and document review.

Results. Our quantitative analysis did not find compelling evidence of widespread and significant effects of polio eradication campaigns, either positive or negative, on measures of RI and maternal healthcare. Our qualitative analysis revealed context-specific positive impacts of polio eradication activities in many of our case studies, particularly disease surveillance and cold chain strengthening. These impacts were dependent on the initiative of policy makers. Negative impacts, including service interruption and public dissatisfaction, were observed primarily in districts with many campaigns per year.

Conclusions. Polio eradication activities can provide support for RI and PHC, but many opportunities to do so remain missed. Increased commitment to scaling up best practices could lead to significant positive impacts.

Economic considerations for the eradication endgame

An infectious disease will be eradicated only if it is eliminated everywhere, including in the hardest-to-reach, most vaccine-wary communities. If eradication is successful, it promises a dividend in the form of avoided infections and vaccinations. However, success is never certain unless and until eradication is achieved, and claiming the dividend means bearing the possibly great risk of re-emergence. Economic analysis of eradication evaluates these risks and rewards relative to the alternative of 'optimal control', and also exposes the incentives for achieving and capitalizing on eradication. Eradication is a 'game', because some countries may be willing to eliminate the disease within their borders only if assured that all others will eliminate the disease within their borders. International financing is also a game, because each country would rather free ride than contribute. Finally, for diseases such as polio, capitalizing on eradication is a game, for should any country continue to vaccinate in the post-eradication era using the live-attenuated polio vaccine, the countries that stop vaccinating will be exposed to the risk of vaccine-derived polioviruses. In the framework developed in this paper, eradication is a seductive goal, its attainment fraught with peril.

Methods for evaluating the impact of vertical programs on health systems: protocol for a study on the impact of the global polio eradication initiative on strengthening routine immunization and primary health care

Background

The impact of vertical programs on health systems is a much-debated topic, and more evidence on this complex relationship is needed. This article describes a research protocol developed to assess the relationship between the Global Polio Eradication Initiative, routine immunization, and primary health care in multiple settings.

Methods/Design

This protocol was designed as a combination of quantitative and qualitative research methods, making use of comparative ethnographies. The study evaluates the impact of the Global Polio Eradication Initiative on routine immunization and primary health care by: (a) combining quantitative and qualitative work into one coherent study design; (b) using purposively selected qualitative case studies to systematically evaluate the impact of key contextual variables; and (c) making extensive use of the method of participant observation to create comparative ethnographies of the impact of a single vertical program administered in varied contexts.

Discussion

The study design has four major benefits: (1) the careful selection of a range of qualitative case studies allowed for systematic comparison; (2) the use of participant observation yielded important insights on how policy is put into practice; (3) results from our quantitative analysis could be explained by results from qualitative work; and (4) this research protocol can inform the creation of actionable recommendations. Here, recommendations for how to overcome potential challenges in carrying out such research are presented. This study illustrates the utility of mixed-methods research designs in which qualitative data are not just used to embellish quantitative results, but are an integral component of the analysis.

Implementing Integrated Disease Surveillance and Response: Four African countries' experience, 1998-2005

The Integrated Disease Surveillance and Response (IDSR) strategy was developed by the Africa Regional Office (AFRO) of the World Health Organisation (WHO) and proposed for adoption by member states in 1998. The goal was to build WHO/AFRO countries' capacity to detect, report and effectively respond to priority infectious diseases. This evaluation focuses on the outcomes in four countries that implemented this strategy. Major successes included: integration of the surveillance function of most of the categorical disease control programmes; implementation of standard surveillance, laboratory and response guidelines; improved timeliness and completeness of surveillance data and increased national-level review and use of surveillance data for response. The most challenging aspects were: strengthening laboratory networks; providing regular feedback and supervision on surveillance and response activities; routine monitoring of IDSR activities and extending the strategy to sub-national levels.

Political epidemiology: strengthening socio-political analysis for mass immunisation - lessons from the smallpox and polio programmes

Control and reduction of infectious diseases is a key to attaining the Millennium Development Goals. An important element of this work is the successful immunisation, especially in resource-poor countries. Mass immunisation, most intensively in the case of eradication, depends on a combination of reliable demand (e.g. public willingness to comply with the vaccine protocol) and effective supply (e.g. robust, generally state-led, vaccine delivery). This balance of compliance and enforceability is, quintessentially, socio-political in nature - conditioned by popular perceptions of disease and risk, wider conditions of economic development and poverty, technical aspects of vaccine delivery, and the prevailing international norms regarding power relations between states and peoples. In the past 100 years, three out of six disease eradication programmes have failed. The explanations for failure have focused on biotechnical and managerial or financial issues. Less attention is paid to socio-political aspects. Yet socio-political explanations are key. Eradication is neither inherently prone to failure, nor necessarily doomed in the case of polio. However, eradication, and similar mass immunisation initiatives, which fail to address social and political realities of intervention may be. A comparison of the smallpox and polio eradication programmes illustrates the importance of disease-specific socio-political analysis in programme conceptualisation, design, and management.

The impact of integrating the elimination programme for lymphatic filariasis into primary health care in the Dominican Republic

Integration of disease-specific programmes into existing health care delivery systems is a challenge for many countries, made more salient as the scope and scale of disease-specific programmes increases. This paper reports on the programmatic outcomes of 2 years of integrating the lymphatic filariasis (LF) elimination programme into primary health care (PHC) in the Dominican Republic during a period of national health care reform and decentralization. Data were collected retrospectively from community volunteers, PHC staff and LF programme staff using a mix of quantitative and qualitative methods. Benefits of integration for LF elimination included increasing the extent of the geographic coverage of mass drug administration (MDA) and a 21% increase in municipalities achieving the MDA target coverage rate of 80%. Benefits which accrued to PHC included improved information systems and strengthened relationships between the health services and the community. This study also identified challenges to implementing integration and the solutions found. These include the importance of focusing on the professional development of disease-specific program staff as their roles change, strengthening specific weakness in the general health system and finding alternative solutions where these are not easily solved, actively engaging senior management at an early stage, continually evaluating the impact of integration and not pushing integration for the sake of integration.

Global public health mandates in a diverse world: the polio eradication initiative and the expanded programme on immunization in sub-Saharan Africa and South Asia

BACKGROUND

The circulation of wild poliovirus is expected to cease soon due to the success of the global polio eradication initiative. Thereafter, intensified polio eradication efforts such as National Immunisation Days (NIDs) will most likely be discontinued. As a consequence, the expanded programme on immunization (EPI) will no longer enjoy extra inputs from the polio eradication initiative. We investigated whether today's EPIs are ensuring universal and equitable vaccine coverage; and whether the removal of extra inputs associated with the implementation of NIDs is likely to affect EPI coverage and equity.

METHODS

Using data from Demographic and Health Surveys conducted in 15 countries of South Asia and Africa during 1990-2001, we examined absolute levels of EPI coverage; changes in EPI coverage after the introduction of NIDs; and relative coverage according to urban versus rural residence, higher versus lower education of mothers, and wealthiest vs. poorest population segment.

RESULTS

Polio and non-polio antigen coverage increased in seven countries during the study period. Substantial inequalities in coverage of non-polio antigens persist, however, translating into inequities in the risk of contracting vaccine preventable diseases. In some African countries, routine EPI coverage and/or equity declined during the study period. In these countries, any positive effect of NIDs on the EPI coverage must have been small, relative to the negative effects of declining economies or deteriorating health systems. In Nigeria, Zimbabwe, Kenya and Malawi, even polio coverage declined, in spite of the introduction of NIDs.

CONCLUSION

As additional inputs associated with polio eradication will cease, routine EPI services need to be strengthened substantially in order to maintain levels of population immunity against polio and to improve social equity in the coverage of non-polio EPI antigens. Our findings imply that this aim will require additional inputs, particularly in African countries.

Shifts in global immunisation goals (1984–2004): unfinished agendas and mixed results

The turn of the millennium has been marked by a large-scale mobilisation of resources for immunisation programmes in developing countries. The resources have been generated by public and private sector parties collaborating in the Global Alliance for Vaccines and Immunization (GAVI). GAVI was formed in response to deteriorating immunisation coverage rates occurring in the late 1990s. GAVI is the latest in a line of vaccine initiatives, which have operated over the past 20 years. This article reviews the five most important global immunisation initiatives that have taken place over those past 20 years. It analyses their origins, shifts in global immunisation goals, identifies key actors, assesses the initiatives' capacity to mobilise resources and increase immunisation coverage, and points to possible unintended effects of the initiatives. The study argues that shifts in global immunisation goals lead to fragmentation in the implementation of vaccine programmes at the local level in developing countries. It also suggests that global actors involved in the formulation of these initiatives appear to miss opportunities to build on past experiences and fail to learn from previous mistakes. This raises questions about the initiatives' sustainability and relevance to the overall objective of preventing vaccine-preventable deaths.

The impact of the national polio immunization campaign on levels and equity in immunization coverage: evidence from rural North India

Few studies have investigated the impact of immunization campaigns conducted under the global polio eradication program on sustainability of polio vaccination coverage, on coverage of non-polio vaccines (administered under Expanded Program on Immunization (EPI)), and on changes in social inequities in immunization coverage. This study proposes to fill the gaps in the evidence by investigating the impact of a polio immunization campaign launched in India in 1995. The study uses a before-and-after study design using representative samples from rural areas of four North Indian states. The National Family Health Survey I (NFHS I) and NFHS II, conducted in 1992-93 and 1998-99 respectively, were used as pre- and post-intervention data. Using pooled data from both the surveys, multivariate logistic regression models with interaction terms were used to investigate the changes in social inequities. During the study period, a greater increase was observed in the coverage of first dose of polio compared to three doses of polio. Moderate improvements in at least one dose of non-polio EPI vaccinations, and no improvements in complete immunization against non-polio EPI diseases were observed. The polio campaign was successful, to some extent, in reducing gender-, caste- and wealth-based inequities, but had no impact on religion- or residence-based inequities. Social inequities in non-polio EPI vaccinations did not reduce during the study period. Significant dropouts between first and third dose of polio raise concerns of sustainability of immunization coverage under a campaign approach. Similarly, little evidence to support synergy between polio campaign and non-polio EPI vaccinations raises questions about the effects of polio campaign on routine health system's functions. However, moderate success of the polio campaign in reducing social inequities in polio coverage may offer valuable insights into the routine health systems for addressing persistent social inequities in access to health care.

Global health goals: lessons from the worldwide effort to eradicate poliomyelitis

The Global Polio Eradication Initiative was launched in 1988. Assessment of the politics, production, financing, and economics of this international effort has suggested six lessons that might be pertinent to the pursuit of other global health goals. First, such goals should be based on technically sound strategies with proven operational feasibility in a large geographical area. Second, before launching an initiative, an informed collective decision must be negotiated and agreed in an appropriate international forum to keep to a minimum long-term risks in financing and implementation. Third, if substantial community engagement is envisaged, efficient deployment of sufficient resources at that level necessitates a defined, time-limited input by the community within a properly managed partnership. Fourth, although the so-called fair-share concept is arguably the best way to finance such goals, its limitations must be recognised early and alternative strategies developed for settings where it does not work. Fifth, international health goals must be designed and pursued within existing health systems if they are to secure and sustain broad support. Finally, countries, regions, or populations most likely to delay the achievement of a global health goal should be identified at the outset to ensure provision of sufficient resources and attention. The greatest threats to poliomyelitis eradication are a financing gap of US 210 million dollars and difficulties in strategy implementation in at most five countries.

Immunization campaigns and political agendas: retrospective from Ecuador and El Salvador

Since the mid-1980s international donors have promoted vertical, campaign-based strategies to help improve immunization coverage in poor countries. National immunization days (NIDs) are currently in vogue and are prominent in the worldwide polio eradication efforts. In spite of their widespread use, campaigns that include NIDs have not been well evaluated for their effects on coverage, reduction in vaccine-preventable diseases, or effects on the health system. An assessment of the results of two such campaigns implemented in Ecuador and El Salvador shows limited impact on short-term coverage and questionable effects on long-term coverage and disease incidence. Although NIDs may have substantial short-term political benefits, the vertical approach can undermine provision of routine services by ministries of health and may be counterproductive in the long-term.

Reasons for non-vaccination during national immunization days: a case study in Istanbul, Turkey

OBJECTIVE

The member states of the 41st World Health Assembly agreed to aim for the global eradication of polio by the year 2000. Turkey adopted this goal and made substantial progress. In this report, we present the results of a coverage and risk factor survey conducted to evaluate vaccine delivery during the 1999 national immunization days (NIDs) in a large district of Istanbul, Turkey. This study provides important information regarding risk factors and reasons for non-vaccination during the NIDs, defines rumours about the NIDs, and provides estimates of vaccination coverage.

SETTING AND PARTICIPANTS

A survey was conducted 3-10 days after the second round of 1999 NIDs using the standard expanded programme on immunization cluster survey method, for each of 10 health centre areas in Umraniye. In total, 2102 children were included in the analysis.

RESULTS

The vaccination coverage rate was 82.2%. Logistic regression analysis showed increased risk of non-vaccination in people who did not know the purpose of the NIDs, who had not had contact with a mobile vaccination team, who were unvaccinated in the first round of 1999 NIDs and who lived in the area of the Central Health Centre. Use of primary-level state healthcare facilities for routine childhood immunizations, and living in the area of the Adem Yavuz Health Centre had significant positive effects on vaccination.

CONCLUSIONS

To achieve better results, better publicity of national campaigns using mass media, and improved use of mobile teams, are necessary.

Polio eradication initiative in Africa: influence on other infectious disease surveillance development

BACKGROUND

The World Health Organization (WHO) and partners are collaborating to eradicate poliomyelitis. To monitor progress, countries perform surveillance for acute flaccid paralysis (AFP). The WHO African Regional Office (WHO-AFRO) and the U.S Centers for Disease Control and Prevention are also involved in strengthening infectious disease surveillance and response in Africa. We assessed whether polio-eradication initiative resources are used in the surveillance for and response to other infectious diseases in Africa.

METHODS

During October 1999-March 2000, we developed and administered a survey questionnaire to at least one key informant from the 38 countries that regularly report on polio activities to WHO. The key informants included WHO-AFRO staff assigned to the countries and Ministry of Health personnel.

RESULTS

We obtained responses from 32 (84%) of the 38 countries. Thirty-one (97%) of the 32 countries had designated surveillance officers for AFP surveillance, and 25 (78%) used the AFP resources for the surveillance and response to other infectious diseases. In 28 (87%) countries, AFP program staff combined detection for AFP and other infectious diseases. Fourteen countries (44%) had used the AFP laboratory specimen transportation system to transport specimens to confirm other infectious disease outbreaks. The majority of the countries that performed AFP surveillance adequately (i.e., non polio AFP rate = 1/100,000 children aged <15 years) in 1999 had added 1-5 diseases to their AFP surveillance program.

CONCLUSIONS

Despite concerns regarding the targeted nature of AFP surveillance, it is partially integrated into existing surveillance and response systems in multiple African countries. Resources provided for polio eradication should be used to improve surveillance for and response to other priority infectious diseases in Africa.

Impact of targeted programs on health systems: a case study of the polio eradication initiative

The results of 2 large field studies on the impact of the polio eradication initiative on health systems and 3 supplementary reports were presented at a December 1999 meeting convened by the World Health Organization. All of these studies concluded that positive synergies exist between polio eradication and health systems but that these synergies have not been vigorously exploited. The eradication of polio has probably improved health systems worldwide by broadening distribution of vitamin A supplements, improving cooperation among enterovirus laboratories, and facilitating linkages between health workers and their communities. The results of these studies also show that eliminating polio did not cause a diminution of funding for immunization against other illnesses. Relatively little is known about the opportunity costs of polio eradication. Improved planning in disease eradication initiatives can minimize disruptions in the delivery of other services. Future initiatives should include indicators and baseline data for monitoring effects on health systems development.

Eradication of vaccine-preventable diseases

Eradication is the permanent reduction to zero of the worldwide incidence of infection caused by a specific agent as a result of deliberate efforts; intervention measures are no longer needed. To date, the only infectious disease that has been eradicated is smallpox. Poliomyelitis is targeted for eradication by the year 2000, and the eradication initiative is well under way, with the Western Hemisphere certified as being polio-free and more than one year having passed since polio cases occurred in the Western Pacific Region of the World Health Organization. A review of the technical feasibility of eradicating other diseases preventable by vaccines currently licensed for civilian use in the United States indicates that measles, hepatitis B, mumps, rubella, and possibly disease caused by Haemophilus influenzae type b are potential candidates. From a practical point of view, measles seems most likely to be the next target. Global capacity to undertake eradication is limited, and care must be taken to ensure that a potential measles eradication effort does not impede achievement of polio eradication. Even in the absence of eradication, major improvements in control are both feasible and necessary with existing vaccines. New and improved vaccines may give further possibilities of eradication in the future. Eradication represents the ultimate in sustainability and social justice.

A model to estimate the potential economic benefits of measles eradication for the United States

Measles incidence is at a nadir in many parts of the world due to vaccination efforts. Although the technical feasibility of eradication has been acknowledged, financial and political commitment need to be concomitantly identified on the national and global level. We demonstrate the potential value of measles eradication by identifying the potential cost-savings to one country resulting from measles eradication. For the US, measles eradication would save $45 million annually. If achieved by the year 2010, the US would save $500 million to $4.1 billion depending on the year of elimination, post-eradication schedule and discount rate. Intensification of measles control efforts in the US beyond current levels would have minimal marginal benefits on disease burden reduction. Allocation of resources to achieve global measles eradication is the next level of efficiency which would provide substantial savings. Countries may adapt this model to estimate their savings for consideration of the required political and financial contribution towards a global measles eradication program.

Impact of anti-vaccine movements on pertussis control: the untold story

To assess the impact of anti-vaccine movements that targeted pertussis whole-cell vaccines, we compared pertussis incidence in countries where high coverage with diphtheria-tetanus-pertussis vaccines (DTP) was maintained (Hungary, the former East Germany, Poland, and the USA) with countries where immunisation was disrupted by anti-vaccine movements (Sweden, Japan, UK, The Russian Federation, Ireland, Italy, the former West Germany, and Australia). Pertussis incidence was 10 to 100 times lower in countries where high vaccine coverage was maintained than in countries where immunisation programs were compromised by anti-vaccine movements. Comparisons of neighbouring countries with high and low vaccine coverage further underscore the efficacy of these vaccines. Given the safety and cost-effectiveness of whole-cell pertussis vaccines, our study shows that, far from being obsolete, these vaccines continue to have an important role in global immunisation.

Disease eradication and health systems development

This article provides a framework for the design of future eradication programmes so that the greatest benefit accrues to health systems development from the implementation of such programmes. The framework focuses on weak and fragile health systems and assumes that eradication leads to the cessation of the intervention required to eradicate the disease. Five major components of health systems are identified and key elements which are of particular relevance to eradication initiatives are defined. The dearth of documentation which can provide "lessons learned" in this area is illustrated with a brief review of the literature. Opportunities and threats, which can be addressed during the design of eradication programmes, are described and a number of recommendations are outlined. It is emphasized that this framework pertains to eradication programmes but may be useful in attempts to coordinate vertical and horizontal disease control activities for maximum mutual benefits.