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GLOBAL POLIO ERADICATION INITIATIVE: 8TH MEETING OF THE INDEPENDENT MONITORING BOARD

Wednesday, 14th of August 2013

Global Polio Eradication Initiative: 8th meeting of the Independent Monitoring Board

 

The following summary is from the Weekly Epidemiological Record, www.who.int/wer  The full text of the IMB report is at

http://www.polioeradication.org/Portals/0/Document/Aboutus/Governance/IMB/8IMBMeeting/8IMB_Report_EN.pdf

 

The Independent Monitoring Board (IMB) was established in November 2010, at the request of the World Health Assembly, to monitor and guide the progress of

the Global Polio Eradication Initiative (GPEI). The goal of the GPEI programme is to interrupt polio transmission globally by the end of 2014.

 

The IMB held its 8th meeting on 7–9 May 2013 in London, United Kingdom. Following this meeting, the IMB issued its 7th report1 to the heads of WHO, the US Centers

for Disease Control and Prevention, UNICEF, Rotary International, the Bill & Melinda Gates Foundation’s Global Health Program and the governments of the

remaining 3 polio-endemic countries. This article summarizes the discussions and conclusions of the IMB.

 

The 8th meeting of the IMB was the first since the target for interrupting polio transmission by the end of 2012 (as stipulated in the GPEI 2010–2012 Strategic

Plan) was missed. It was also the first meeting since the tragic killings of polio workers in Pakistan and northern Nigeria. Their personal sacrifice in service to public

health will forever be recorded in the annals of polio eradication, and the greatest honour to them would be to rapidly achieve the goal of eradication.

 

The IMB considered that the missed target for interruption of transmission is not a reason for pessimism. The programme’s achievements in the last 3 years have been

formidable. After a decade-long plateau – there was no significant reduction in the number of wild polio virus cases between 2001 and 2010 – case numbers have

dropped substantially since 2010. In 2012 there were (i) 3 endemic countries (down from 4 in 2010); (ii) cases in just 2 other countries (down from 16 in 2010); and

(iii) 223 cases of paralytic polio due to wild polio virus, mainly in children (down from 1352 in 2010).

 

The latest data at the time of the IMB meeting recorded 26 cases of poliomyelitis due to wild polio virus in 2013, compared with 53 at the same point in time last year.

While this represents considerable progress, it also reflects the fact that the polio virus has not been eradicated.

 

In each of its previous reports, the IMB has set out a consistent analysis of the reasons why the programme is performing suboptimally. Major areas of dysfunction

identified included:

 

 failure to focus sufficiently intensively on why children were not being vaccinated;

 failure to ensure accountability;

 inability to transfer methods of programme excellence rapidly and reliably to areas where performance is mediocre or poor; and

 failure to put continuous quality improvement at the heart of the programme.

 

The programme has made major progress in dealing with these problems. A global emergency has been declared, and a rapid increase in staff numbers implemented.

Accountability has been strengthened in many

 

1 Independent Monitoring Board of the Global Polio Eradication Initiative. Seventh

report – May 2013. (Available at www.polioeradication.org/imb.aspx, accessed

June 2013.)

 

areas, and vaccinator pay and selection improved. There has been a sharper focus on finding missed children and on the key endemic areas (“sanctuaries”). These

changes, and many others, have enabled the programme to make substantial gains.

 

In the IMB’s 7th report, a “system map” for polio eradication was created. Some parts of this system have been designed and built over many years by the programme.

Others represent the complex natural environment in which the programme operates – with political, financial and security factors affecting its work in many ways.

 

In its previous 2 reports, the IMB strongly recommended the introduction of mandatory polio vaccination certification for people travelling out of endemic countries. The IMB continues to believe that this would powerfully underpin the eradication effort. It is one of a number of new actions that could help overcome the continuing survival of the polio virus.

 

The complexity of the system map is a stark reminder that each domain of activity – political, technical operations, security, financial, strategic – has an important

bearing on local communities where vaccination programmes succeed or fail. Moreover, the factors within these domains of the system map can interact with others

in ways that are not always possible to predict or control. It is also clear from the system map that the programme is only as strong as its weakest point and that the complex forces affecting communities cannot be completely controlled.

 

A regrettable challenge remains the very negative perception of the programme – and the polio vaccine in particular – in many of the places where the virus still

circulates. Many communities regard the vaccine as being imposed from the outside and do not understand the benefit that it brings. Parents ask, “Why so many

doses?”, and often receive unsatisfactory answers. When anti-programme campaigners recently produced a series of compact disks for dissemination in Nigeria,

they found a receptive audience, their messages spreading rapidly across the north of the country.

 

The IMB is deeply concerned at the programme’s weak grip on communications and social mobilization, activities that could not only counteract communities’

negativity but also generate more genuine demand. Within the programme, communication is, undeservedly, of much lower priority than vaccine delivery.

Communications expertise is sparse throughout. UNICEF, the lead agency for communications, is underpowered. Communications is everybody’s business and

should be more prominently at the heart of the programme’s concerns.

 

The IMB has drawn attention to this weakness for some time; it has not been addressed and is now a serious threat to eradication. In areas where communication

capability is strong the IMB sees:

 

 rapid rebuttal of unfounded and unscientific claims about the vaccine;

 engagement in dialogue with communities and local groups to achieve widespread community support, particularly with women’s groups and religious

leaders;

 education of and explanation to parents and communities, as well as to vaccinators themselves (so that they are able to answer all questions in an

informative and reassuring way);

 incorporation of polio vaccine delivery with other health and social benefits that communities value; and

 consistent and effective advocacy of the benefits of the vaccine.

 

However, this good practice is not being implemented at the the scale and with the energy and focus needed. The GPEI Strategic Plan states that “experience throughout

the GPEI has shown that polio virus circulation stands little chance of surviving in fully mobilized communities, even in the most difficult contexts”. The IMB

fully endorses this view and considers that the leaders of the programme need to make it a reality, which currently it is not.

 

If not successfully remedied, the current communications shortfall will become a grave impediment for the programme. However, if the challenge is seized and

managed with ambition, stronger communications have the potential to transform the programme’s progress.

 

If a billion-dollar-a-year emergency global health programme were newly established today, its management structure would not resemble that of the GPEI. It would

probably have a central secretariat authorized to provide a single source of clear and rapid leadership on behalf of the partners. Now is probably not the time for

a radical structural overhaul but the complex multipartner GPEI structure is creating serious problems that need to be addressed.

 

If major restructuring is deemed too disruptive at this stage of the programme, the global partners instead need to mitigate these current structural problems, which are a major impediment to progress. When the partners disagree on important issues, such as data sharing or the role of inactivated polio vaccine (IPV), the result is too often a protracted and circular debate that can last for years. This stagnation and maintenance of the status quo allows the virus to live on.

 

Similarly, GPEI core partners expend too much energy focused inwards, rather than being sharply responsive to what the polio-affected countries need from them as

a group.

 

The hindrance caused by intra-partnership disagreement is exemplified by the current stalemate on the utility of IPV in endemic countries. This idea has been discussed for more than 2 years. According to the endgame plan, IPV will be introduced in the 3 endemic countries (and 137 others) in 2015. Some partners favour earlier introduction to the endemic countries, believing IPV would help stop transmission. Discussion of this idea has been circular because there are no operational trial data to test the hypotheses advanced in support of, and against, the concept. A trial in Pakistan, planned for later this year, needs to provide definitive answers to all of the unresolved immunological, operational and communications questions so that the circular debate can be terminated. The programme needs to have a clear and evidence-based plan on this issue by the end of 2013.

 

Afghanistan is on the brink of stopping polio transmission but has been at this point for some time. The country needs a final major push to resolve the basic errors

still plaguing its vaccination campaigns. The ability to access “inaccessible” areas is a real strength but sizeable communities still need to be reached. From the top of

government downwards, the need to stop transmission by the end of 2014 must be more clearly expressed, and acted on, by all.

 

Nigeria’s programme has surged forward over the last year, in most areas and in many different ways. Nevertheless, progress in a number of Local Government

Areas is stagnant, presenting an ongoing impediment for the overall country programme. Insecurity is more significant than ever, and the programme’s approach to

address this challenge has not yet been optimized. Despite recent progress, Nigeria remains the country most in need of greater strategic focus on communications.

Pakistan transformed its programme in 2012. Heightened political commitment drove through a raft of programmatic improvements. These had real impact, significantly

reducing circulation of the virus. The country held elections in the days following the IMB meeting. Strong leadership of the programme from those coming into power will now be crucial. Interruption of transmission in Pakistan has never been simple or straightforward and recent events have increased the difficulties. Pakistan’s programme is strong but there needs to be recognition of the considerable challenges that lie ahead.

 

In all 3 endemic countries, there has been clear evidence of absolute commitment to eradicating polio from the highest political levels. Sustained high-level support in

each country will be crucial to stopping transmission. Cases of poliomyelitis in Somalia and Kenya, reported in the days since the IMB’s meeting, are deeply worrying,

and a reminder that no country is safe from polio until it has been eradicated from all countries worldwide.

 

The IMB judges that stopping polio transmission by the end of 2014 is a realistic goal provided there is clear understanding of what is required to attain it. Over

the last 2 years, all aspects of the programme have been vastly improved. Transmission can be stopped if the programme recognizes the absolute need to continually

improve, and does so effectively and as a matter of urgency.

 

The programme that finally stops transmission will not be the programme as it exists today, but one that has rapidly and purposefully evolved from it. It will be a

programme that truly puts communities at its centre, and that sees communications as being key to its success, rather than as a mitigating measure in a programme

driven by supply. It will be a programme that seizes the opportunity to tackle every weakness as it arises, continually scanning the polio eradication system

to turn every element in its favour.

 

The IMB will continue to provide a frank and independent assessment of the progress being made towards global interruption of polio transmission.

The next IMB meeting will be held in London, United Kingdom, on 1–3 October 2013.