WHAT'S NEW THIS THURSDAY: THREE ON POLIO

Monday, 10th of September 2012

• THREE ON POLIO

• THE FINAL PUSH FOR POLIO

The Lancet Infectious Diseases, Volume 12, Issue 8, Pages 591 - 592, August 2012

Original Text

Talha Burki

At first glance, efforts to eradicate poliomyelitis seem in excellent shape. “Epidemiologically, the picture has never looked better”, WHO's Oliver Rosenbauer told TLID. Only 88 cases have been reported in 2012, a favourable contrast with the 252 cases reported by same time last year. India has been free of poliomyelitis since January, 2011, which resolves any lingering questions about the technical feasibility of eradication. Of the three countries classified by WHO as having re-established transmission, Angola has not had a case since mid-2011; the Democratic Republic of the Congo has not had a case since December, 2011; and Chad has only had four cases thus far in 2012—the same period in 2011 had 82 cases.

Elsewhere, outside of the remaining three endemic countries—Afghanistan, Pakistan, and Nigeria—no cases of poliomyelitis have been reported. Moreover, Pakistan has registered a mere 22 cases this year; by this time in 2011, it had registered 58. Wild poliovirus type 2 was eradicated in 1999, and the introduction of monovalent vaccines in 2005, and bivalent vaccines in 2009, provided additional impetus to the global fight for eradication (the new vaccines are roughly three-times as effective as the trivalent vaccine). The strategic plan of the Global Polio Eradication Initiative for 2010—12 aims to cease transmission of the poliovirus by the end of this year. “It would be premature to entirely rule out achieving the end-2012 milestone”, noted the authors of Every Missed Child, a report released by the initiative's independent monitoring board.

Yet, when the World Health Assembly met in May, 2012, it adopted a resolution declaring “the completion of poliovirus eradication a programmatic emergency for global public health”. Meanwhile, experts—including the authors of the independent monitoring board report—routinely use the term crisis when describing the present state of eradication efforts. Why?

There are two key reasons. First, the massive funding gap. The polio campaign for 2012—13 needs a budget of US$2·2 billion, but current funding falls short by $945 million. Thus, 68 campaigns in 33 countries have had to be cancelled. If the money is not provided, 94 million children, mostly in west and central Africa, will not be immunised. In view of the virus's persistence in Nigeria, notes Every Missed Child, “the risk of an explosive return of polio in Nigeria and west Africa is ever-present and raises the chilling spectre of many deaths and a huge financial outlay to regain control”. The global financial benefit of polio eradication has been estimated at $40—50 billion.

The second issue is the absence of meaningful progress, particularly in endemic countries but also in African nations with re-established transmission. Cumulatively, these countries have an estimated 2·7 million children younger than 5 years who have not received even one dose of vaccine. Even more children have been insufficiently vaccinated. If not addressed, the consequences could be severe. “We're seeing all over the world a build up of young adults who were never exposed to poliovirus, because polio has been eradicated from their area and there have been declining vaccination coverage levels”, explains Rosenbauer. “If poliovirus gets in this group, there could be some really devastating outbreaks, far deadlier than we have seen in the past.” Mathematical modelling suggests the possibility of incidences of 200 000 cases per year within the next decade, wiping out nearly all the gains of the 24 years since the international community committed to eradication of polio.

In west Africa, for example, insecurity in Mali, the food crisis in the Sahel, and the onset of the rainy season means that population movement is greater than normal. Nigeria has already seen 52 cases this year; two-thirds of the global burden and a sharp increase compared with the same period in 2011. Couple this rise with the scaled-back vaccination campaigns in neighbouring countries and children in the region are particularly vulnerable. An immunisation campaign in the highest risk areas of Burkina Faso, Mali, and Niger was done earlier this month, but a more comprehensive endeavour would be preferable.

Fortunately, problems within the endemic countries should be resolvable. Crucially, polio is not evenly distributed across the three nations. In Afghanistan, it is concentrated in ten high-risk districts in the troubled southern provinces of Helmand and Kandahar. In Pakistan, the disease is concentrated in Gaddap in Karachi, Pishin district in Quetta, and the Federally Administered Tribal Areas bordering Afghanistan. In Nigeria, polio persists in four northern states.

All three countries have issued national emergency action plans, which aim to involve civil society as well as the public sector, much as India did. “The leadership at the top is engaged, in Pakistan in particular we've seen tremendous support from the government at the highest level”, notes Carol Pandak (Rotary International) however, the difficulty is in translating that support to the lower levels. Resistance to immunisation campaigns can be ameliorated by engagment with religious and community leaders—as UNICEF has done in Nigeria, and Rotary International did in India and is attempting in Pakistan. Even the decision by the Taleban to ban vaccinators from some parts of Pakistan need not be insurmountable. “We've been faced with these challenges before”, Pandak points out, “and with the right negotiation they can be overcome.”

Security issues—in Afghanistan, Pakistan, and Nigeria's Borno state—complicate matters. “In Afghanistan, the programme sometimes has to try to access kids during periods of deep instability”, explains Nicholas Grassly (Imperial College London, UK). “Those periods of access are quite variable and some years there will only be a limited amount of times that those kids are accessible.”

Nonetheless, Rosenbauer points out that accessibility is actually increasing in Afghanistan: by March, 2012, only 5% of children were inaccessible, compared with 30% at the beginning of 2011. Yet vaccine coverage in both Afghanistan and Pakistan has decreased over the past few years. “That tells us that the problems are probably more to do with management of the campaigns, operational issues and so forth.” It is a common theme. In Pakistan, for example, polio is concentrated within Pashto-speaking communities. Progress can be made by ensuring vaccinators are the same ethnic origin, speak the same language, and include women on their teams. The independent monitoring board's report praised Pakistan—which it had previously criticised for having a “deeply dysfunctional programme”—for its “revitalised energy and augmented national emergency plan fit for the purpose of stopping polio transmission”.

Experts agree that countries striving to eradicate polio should look to India for inspiration. The Indian Government offered strong support; migrant groups were identified and targeted with immunisation campaigns; large numbers of technical staff were trained and deployed (Nigeria has enacted a huge surge of technical staff—WHO alone has increased the number of its staff in the country from 744 to 2950—and the country has also started using global positioning system technology to help map communities); and an advanced surveillance system was established. “Afghanistan, Nigeria, and Pakistan have all put in place plans that can turn the situation around”, Rosenbauer says firmly. “But we're at crisis point until those plans are fully implemented, and we need funding, otherwise we will see the international spread of polio.”

• POLIO ENDGAME ISSUES

Excerpt below; full text is at http://www.who.int/bulletin/volumes/90/7/BLT.12.020712.pdf

WHO Director-General Dr Mar­garet Chan told the [World Health] Assembly that polio eradication was “at a tipping point be­tween success and failure,” highlighting the funding gap of US$ 945 million until the end of 2013 (against a US$ 2.19 billion budget for that period). This year alone, the cash shortage has led to a reduc­tion in mass vaccination activities in 24 high-risk countries, putting millions of children at risk.

The polio eradication endgame plan is to switch from the trivalent oral polio vaccine, currently the vaccine of choice in most countries, to two vaccines: a new bivalent oral polio vaccine for routine immunization backed up by judicious use of inactivated polio vaccine (IPV).

First used in Afghanistan in 2009, the bivalent oral polio vaccine is at least 30% more effective than the old trivalent oral polio vaccine against polioviruses types 1 and 3 and does not contain live type 2 poliovirus that caused most of the outbreaks of circulating vaccine-derived poliovirus since the first outbreak in Hispaniola.

Bivalent vaccines protect against two serotypes of a disease, trivalent vaccines against three. In the case of polio, although there are three types of the poliovirus, it is the type 2 compo­nent in the trivalent oral polio vaccine has caused more than 80% of cases of vaccine-derived polioviruses that have caused outbreaks and so removing the type 2 component from the vaccine is vital to success.

And that is where IPV comes in. IPV, which is administered through injection, provides immunity to all three types of poliovirus but, unlike the oral vaccine, does not cause vaccine-derived polio because the virus used in its manu­facture is dead.

Unlike the oral vaccine, however, IPV does not invoke intestinal immunity needed to stop transmission. So a child who receives only IPV won’t develop polio, but could excrete the virus per­petuating its circulation. That’s why a combination of both the bivalent oral vaccine and IPV is now necessary.

“IPV would serve as a kind of in­surance policy by boosting children’s immunity to type 2 and would have the added advantage of also boosting types 1 and 3 immunity and, thereby, ac­celerating the removal of those last wild polioviruses,” says WHO’s Roland Sutter, coordinator of the Research and Product Development Team of the Global Polio Eradication Initiative.

This two-prong strategy, involving the bivalent oral polio vaccine and IPV, Aylward and Sutter believe, will succeed in eliminating the main risk due to the type 2 virus. After the eradication of all remaining strains of wild poliovirus transmission, countries could stop using the bivalent oral polio vaccine, eliminat­ing any residual remaining risks associ­ated with the type 1 and 3 components contained in that vaccine.

The chief hurdle to this plan is cost. At a minimum of US$ 3 a dose, IPV is far too costly for the low-income countries that might need it most. So the fear when developing the plan was that, in the unlikely event that a type 2 vaccine-derived poliovirus did emerge during or immediately after the switch, children with immunity only to types 1 and 3 wouldn’t be protected as countries would not be able to afford IPV.

The challenge, then, was to find a way to use IPV in a significantly less expensive but yet sufficiently effective way. And Aylward knew that wouldn’t be easy. “If you’re a manufacturer, there isn’t a great incentive to find ways to make your product more cheaply available,” he says. “We sometimes had to push hard.”

Eventually, in 2010, WHO experts collaborated with researchers in Cuba and Oman, among other countries, to look at four possible scenarios to reduce the cost of IPV use: reducing the number of doses, using a fractional (1/5th) dose, increasing the interval between doses and producing the vaccine in resource-limited settings. “All of this work was driven by a developing country need for a cheap solution to this circulating vaccine-derived poliovirus problem”, says Aylward, “and the really exciting thing is that most of this research took place in developing countries.”

Moreover, he says, the results were far better than expected. “Will one-fifth of a dose work?” he says. “Yes, just as well as a full dose for boosting. Will two doses work as well as four doses? Yes, if you give them four months apart. Can you make an affordable IPV product in a low-income country? Well, it turns out you probably can. These were all big surprises for many working in im­munization.”

“What we need now is for manufac­turers to agree to produce intra-dermal fractional dose IPV, and for licensing bodies to rapidly examine whether this potential solution can undergo fast-track licensing – given the strong public health imperative – so that we have it within a year,” says Aylward. But for all of the promising data, that has yet to happen.

“The A380 is on the runway, but we haven’t gotten it up in the air yet. And that requires a lot of people cooperating.”

• REACHING EVERY CHILD: COMMUNICATION FOR POLIO ERADICATION INDIA

Author: Ellyn W. Ogden, Rina Dey

Affiliation:United States Agency for International Development (Ogden); CORE Group Polio Project India (Dey)

Publication Date: March 29, 2011

Summary: 

"Every aspect of polio eradication has a communication component: Campaigns, surveillance, advocacy and fundraising, new vaccine introduction and certification..."

Ellyn Ogden Polio Presentation

This presentation from a meeting hosted by The Communication Initiative on March 29 2011 ("Social and Behavioural Change Research Results: Strategic Implications") in Geneva, Switzerland explores the evolution of polio communication in north India. The United States Agency for International Development (USAID) funds polio communication because, as described here, it: is critical for success, improves quality, is cost-effective, increases local capacity, and sparks civil society and community participation, which has many beneficial spin-offs.

Opening slides provide context in the form of graphs and charts illustrating the polio situation in India from the late 1980s through to 2010/2011. Historical details are provided to give context for these figures; for example, in 1995, the polio eradication programme was launched in a campaign mode with two National Immunization Days (booth-based), and in 1999, a house-to-house (following booth day) strategy was introduced. In 2001, community resistance grew in Western Uttar Pradesh (UP); Muslim mothers reported the highest rates of hearing rumours/concerns about the oral polio vaccine (OPV) - e.g., some believed that polio immunisation would lead to impotency or was part of a family planning programme. In response, in 2002, a communication response was initiated. The United Nations Children's Fund (UNICEF) and CORE deployed hundreds of volunteers from schools, nursing schools, and non-governmental organisations (NGOs) in high-risk areas of UP to tackle resistance to OPV. Then, in 2003, a mass media campaign was launched involving India's "most popular superstars." Also that year, a unifying look was developed for all of the campaign's communications (in Hindi/Urdu); reportedly, these products were extensively pre-tested and focused on notifying people of the date(s) of the next supplementary immunisation activities (SIAs). From 2003-2006, UNICEF and CORE set up a system whereby community mobilisation coordinators (CMCs) were deployed based on epidemiological and operational criteria to ensure that polio communication reached communities most at risk. This involved training community mobilisers in interpersonal communication (IPC) skills to carry out both one-on-one interactions and group meetings.

Amongst the impact data provided from this component of polio communication in north India:

The percentage of parents in UP who recalled social communication public service announcements (PSAs), August 2006, was 51% (compared to 20% who recalled immunisation PSAs, 20% who recalled HIV/AIDS PSAs, 16% who recalled family planning PSAs, 5% who recalled general health PSAs, 5% who recalled education/literacy PSAs, and so on).

Slide 24 shows that CMC areas reported higher booth coverage as compared to non-CMC areas (Jan 2005-Feb 2006). There were also fewer missed children in CMC areas (in UP, Feb 2005-July 2006).

In 2006, the underserved strategy began with the deployment of underserved coordinators to: foster intensive engagement with Muslim leaders in priority districts in UP, Bihar, and West Bengal; identify local influencers, students, and Imams who can work with the teams to influence family decisions; secure positive fatwas and local information, education, and communication (IEC) materials; and create caste-specific influencers and materials. Evidence of impact: 9 million people were exposed to polio messages during religious congregations in 2010, compared to 5 million in 2009.

In response to data indicating that Wild Polio Virus (WPV) in the UP was up in 2009 (with 75% of cases below 2 years of age), CMCs began visiting each pregnant woman followed by congratulation card at birth. CMCs, to this day, still track polio immunisation status of children under the age of 5. They use mapping and registers, and also provide the immunisation status of each child to vaccination teams.

Another challenge for polio communication is people on the move: migrants. Strategies have included waterproof boards/hoarding, posters for brick kilns and construction sites, and transit teams - all with the message of: wherever you go, make sure your child receives OPV. More than 4,000 barbers, shopkeepers, etc. were engaged as informers to reach migrant groups. CMCs also conduct IPC sessions with migrant families to stress the importance of polio and routine immunisation (RI). Based on findings that RI status in UP was low due to some mothers' beliefs, CMCs focused more on importance of RI during IPC sessions and mother meetings, using pictorial IEC materials. Also, special RI sessions and health camps were organised.

2010 saw a revised communication package. One slide here shows the main sources of information on Polio from a 2010 knowledge, attitudes, and practices (KAP) survey; one finding was that 50% of people reported seeing polio posters or banners prior to the immunisation round. A key strategy outlined here is that posters/banners can be used for more than date announcements; they can include behaviour change messages (e.g., give your child OPV every time it is offered until s/he is 5 years old). Acknowledging the need to proactively engage the media with positive news, the polio programme in north India has sensitised over 400 journalists on polio messages in UP and Bihar, trained 100 TV and radio producers and broadcasters across India, and developed a media kit. Results: Bihar and UP have interrupted transmission of both WPV1 and WPV3 from the majority of districts, and the 107 block plan has been developed to overcome the remaining challenges in the blocks of UP and Bihar that are at the epicentre of the virus. This communication Package for the 107 involves establishing the link between polio and hygiene.

Amongst the lessons learned:

Capacity building - Skills need to start at the beginning with good social mapping, understanding the local operating environment, and cover the range of communication needs (IPC, IEC, mass media). Increased use of role play and participatory techniques have helped internalise skills. IEC/tools development/job aids have evolved for general and specific issues, are increasingly integrated, and are being used strategically

Advocacy dominated the first few years, but wasn't enough over a long period; political advocacy becomes very important.

Monitoring and evaluation (M&E) - Messages needed to evolve based on data. Indicators are needed at all levels to track process and impact. Independent monitoring is essential for validation; external reviews are important for validating progress and identifying gaps. Peer review journals are important for disseminating results.