The Last Mile in Polio Eradication: Program Challenges and Perseverance

As the Global Polio Eradication Initiative (GPEI) strategizes towards the final steps of eradication, routine immunization schedules evolve, and high-quality vaccination campaigns and surveillance systems remain essential. New tools are consistently being developed, such as the novel oral poliovirus vaccine to combat outbreaks more sustainably, as well as non-infectiously manufactured vaccines such as virus-like particle vaccines to eliminate the risk of resurgence of polio on the eve of a polio-free world. As the GPEI inches towards eradication, re-strategizing in the face of evolving challenges and preparing for unknown risks in the post-certification era are critical.

Lessons learned from the polio eradication initiative in the Democratic Republic of Congo and Ethiopia: analysis of implementation barriers and strategies

BACKGROUND

Since its inception in 1988, the Global Polio Eradication Initiative (GPEI) has partnered with 200 countries to vaccinate over 2.5 billion children against poliomyelitis. The polio eradication approach has adapted to emerging challenges and diverse contexts. Knowledge assets gained from these experiences can inform implementation of future health programs, but only if efforts are made to systematically map barriers, identify strategies to overcome them, identify unintended consequences, and compare experiences across country contexts.

METHODS

A sequential explanatory mixed methods design, including an online survey followed by key informant interviews (KIIs), was utilized to map tacit knowledge derived from the polio eradication experience from 1988 to 2019. The survey and KIIs were conducted between September 2018 and March 2019. A cross-case comparison was conducted of two study countries, the Democratic Republic of Congo (DRC) and Ethiopia, which fit similar epidemiological profiles for polio. The variables of interest (implementation barriers, strategies, unintended consequences) were compared for consistencies and inconsistencies within and across the two country cases.

RESULTS

Surveys were conducted with 499 and 101 respondents, followed by 23 and 30 KIIs in the DRC and Ethiopia, respectively. Common implementation barriers included accessibility issues caused by political insecurity, population movement, and geography; gaps in human resources, supply chain, finance and governance; and community hesitancy. Strategies for addressing these barriers included adapting service delivery approaches, investing in health systems capacity, establishing mechanisms for planning and accountability, and social mobilization. These investments improved system infrastructure and service delivery; however, resources were often focused on the polio program rather than strengthening routine services, causing community mistrust and limiting sustainability.

CONCLUSIONS

The polio program investments in the DRC and Ethiopia facilitated program implementation despite environmental, system, and community-level barriers. There were, however, missed opportunities for integration. Remaining pockets of low immunization coverage and gaps in surveillance must be addressed in order to prevent importation of wild poliovirus and minimize circulating vaccine-derived poliovirus. Studying these implementation processes is critical for informing future health programs, including identifying implementation tools, strategies, and principles which can be adopted from polio eradication to ensure health service delivery among hard-to-reach populations. Future disease control or eradication programs should also consider strategies which reduce parallel structures and define a clear transition strategy to limit long-term external dependency.

Synthesis and translation of research and innovations from polio eradication (STRIPE): initial findings from a global mixed methods study

BACKGROUND

Lessons from polio eradication efforts and the Global Polio Eradication Initiative (GPEI) are useful for improving health service delivery and outcomes globally. The Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) is a multi-phase project which aims to map, package and disseminate knowledge from polio eradication initiatives as academic and training programs. This paper discusses initial findings from the knowledge mapping around polio eradication activities across a multi-country context.

METHODS

The knowledge mapping phase (January 2018 - December 2019) encompassed four research activities (scoping review, survey, key informant interviews (KIIs), health system analyses). This paper utilized a sequential mixed method design combining data from the survey and KIIs. The survey included individuals involved in polio eradication between 1988 and 2019, and described the contexts, implementation strategies, intended and unintended outcomes of polio eradication activities across levels. KIIs were conducted among a nested sample in seven countries (Afghanistan, Bangladesh, the Democratic Republic of Congo, Ethiopia, India, Indonesia, Nigeria) and at the global level to further explore these domains.

RESULTS

The survey generated 3955 unique responses, mainly sub-national actors representing experience in over 74 countries; 194 KIIs were conducted. External factors including social, political, and economic factors were the most frequently cited barriers to eradication, followed by the process of implementing activities, including program execution, planning, monitoring, and stakeholder engagement. Key informants described common strategies for addressing these barriers, e.g. generating political will, engaging communities, capacity-building in planning and measurement, and adapting delivery strategies. The polio program positively affected health systems by investing in system structures and governance, however, long-term effects have been mixed as some countries have struggled to institutionalize program assets.

CONCLUSION

Understanding the implementing context is critical for identifying threats and opportunities to global health programs. Common implementation strategies emerged across countries; however, these strategies were only effective where organizational and individual capacity were sufficient, and where strategies were appropriately tailored to the sociopolitical context. To maximize gains, readiness assessments at different levels should predate future global health programs and initiatives should consider system integration earlier to ensure program institutionalization and minimize system distortions.

A Collaborative Initiative to Strengthen Sustainable Public Health Capacity for Polio Eradication and Routine Immunization Activities in the Eastern Mediterranean Region

The many challenges in the Eastern Mediterranean region put the involved countries at risk of polio transmission and affect their ability to meet progress targets in eliminating vaccine-preventable diseases. The Global Health Development (GHD) and Eastern Mediterranean Public Health Network (EMPHNET) are working together on the project "Strengthening sustainable public health capacity in the Eastern Mediterranean region for polio eradication and routine immunization activities" with an overall goal of improving routine immunization, eradicating poliovirus, and controlling/eliminating or eradicating other vaccine-preventable diseases in the Eastern Mediterranean region. The aim of this manuscript is to describe the project and the achievements of GHD/EMPHNET over the last 3 years (2016-2018) to build effective surveillance and immunization systems in the Eastern Mediterranean region through the development of a sustainable and competent public health system to eradicate polio and control/eliminate vaccine-preventable diseases. This project assists the targeted Eastern Mediterranean region countries to build effective surveillance and immunization systems in an effort to expand their capacities to eradicate polio and control/eliminate other vaccine-preventable diseases. The project is streamlined with the Global Polio Eradication Initiative, the Centers for Disease Control and Prevention's Strategic Framework for Global Immunization 2016-2020, and the Polio Eradication and Endgame Strategic Plan 2013-2018. The project also supports the Global Health Security Agenda by focusing on efforts to accelerate progress toward a world safe and secure from infectious disease threats. Project activities were designed to respond to countries' needs and assist them in building their institutional and workforce capacity to effectively plan, implement, and evaluate activities to eradicate polio and strengthen routine immunization activities. The project activities covered a set of areas including surveillance of acute flaccid paralysis and other vaccine-preventable diseases, family and community engagement, workforce capacity building, improvement of data quality, management and use of information systems, use of polio assets to control/eliminate other vaccine-preventable diseases, support of countries to develop national strategies, piloting of innovative initiatives, program evaluation and accountability, and immunization strengthening. The project adopts the Global Polio Eradication Initiative strategies for assisting countries to strengthen routine immunization services, maintain highly sensitive acute flaccid paralysis surveillance, and sustain polio eradication functions.

Low Rates of Poliovirus Antibodies in Primary Immunodeficiency Patients on Regular Intravenous Immunoglobulin Treatment

PURPOSE

Poliovirus has been nearly eliminated as part of a world-wide effort to immunize and contain circulating wild-type polio. Nevertheless, poliovirus has been detected in water supplies and represents a threat to patients with humoral immunodeficiencies where infection can be fatal. To define the risk, we analyzed antibodies to poliovirus 1, 2, and 3 in serum samples collected over a year from patients with primary immunodeficiency diseases (PID) on regular intravenous immunoglobulin (IVIG) replacement.

METHODS

Twenty-one patients on regular IVIG replacement therapy were evaluated: Twelve patients with common variable immune deficiency (CVID), six with X-linked agammaglobulinemia (XLA), and three with hyper IgM syndrome (HIGM). Over 1 year, four blood samples were collected from each of these patients immediately before immunoglobulin infusion. One sample of IVIG administered to each patient in the month before blood collection was also evaluated. Poliovirus antibodies were quantified by seroneutralization assay.

RESULTS

All IVIG samples had detectable antibodies to the three poliovirus serotypes. Despite that, only 52.4, 61.9, and 19.0% of patients showed protective antibody titers for poliovirus 1, 2, and 3, respectively. Only two patients (9.5%) had protective antibodies for the three poliovirus serotypes on all samples. Most patients were therefore susceptible to all three poliovirus serotypes.

CONCLUSIONS

This study demonstrates the need for ongoing vigilance regarding exposure of patients with PID to poliovirus in the community.

National, Regional and Global Certification Bodies for Polio Eradication: A Framework for Verifying Measles Elimination

The Global Certification Commission (GCC), Regional Certification Commissions (RCCs), and National Certification Committees (NCCs) provide a framework of independent bodies to assist the Global Polio Eradication Initiative (GPEI) in certifying and maintaining polio eradication in a standardized, ongoing, and credible manner. Their members meet regularly to comprehensively review population immunity, surveillance, laboratory, and other data to assess polio status in the country (NCC), World Health Organization (WHO) region (RCC), or globally (GCC). These highly visible bodies provide a framework to be replicated to independently verify measles and rubella elimination in the regions and globally.

The contribution of the polio eradication initiative to narrowing the gaps in the health workforce in the African Region

INTRODUCTION

The Global Polio Eradication Initiative (GPEI) massively invested to overcome the crippling disease in countries of the WHO African Region. In the context of economic crisis, almost all countries in the Region lack an adequate health workforce. Large amounts were invested by GPEI in human resources. This paper shows how the human resources funded by polio contributed to narrowing the gaps in health workforce and helped strengthening and supporting other priority health programmes in Angola, Chad, DRC, Nigeria, Tanzania, and Togo.

METHODS

The health workforce strengthening methods used in the five different countries included the following: policy development and strategic planning, microplanning, capacity building of public health and community workers, implementation and services, monitoring and evaluation, advocacy and social mobilization, and programme review.

RESULTS

Staff funded by polio helped with achieving good coverage in vitamin A and insecticide-treated mosquito nets (Angola, Chad); improvement of EPI and integrated disease surveillance indicators, improved quality of data (all five countries), administrative support, smooth introduction of new vaccines, increased case detection, and early isolation of patients suffering from the Guinea worm (Chad); reduction of cholera, extension of directly observed TB short course treatment (Democratic Republic of Congo); significant staff performance improvement (Nigeria).

DISCUSSION

GPEI investment achieved far beyond its primary goal, and contributed to narrowing the gaps in the health workforce in countries of the African Region, as demonstrated by the best practice documentation exercise. We recommend that expertise and experience of polio funded staff should be leveraged to strengthen, expand and support other public health programmes.