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NINTH REPORT, GPEI INDEPENDENT MONITORING BOARD, EXEC SUMMARY AND RECOMMENDATIONS

Monday, 2nd of June 2014

INDEPENDENT MONITORING BOARD OF THE GLOBAL POLIO ERADICATION INITIATIVE

NINTH REPORT – MAY 2014

 

A STORY THAT STILL NEEDS AN ENDING

 

Excerpts below; full text, with figures, is at http://www.polioeradication.org/Portals/0/Document/Aboutus/Governance/IMB/10IMBMeeting/10IMB_Report_EN.pdf

 

 

EXECUTIVE SUMMARY

 

Eighteen months ago, as 2012 drew to a close, optimism was running high for the Global Polio Eradication

Initiative. Polio transmission in India had been interrupted. The three remaining endemic countries (Pakistan,

Nigeria, Afghanistan) had made significant programmatic improvements. Some believed that success was

imminent; that polio would soon be history.

 

Within a matter of months, this optimism quickly unwound:

 

•Targeted killing of polio vaccinators in Pakistan shocked the world and created major operational constraints.

 

•Polio virus entered Waziristan, a part of Pakistan in which polio vaccination had been – and remains – banned

by Taliban commanders.

 

•The national structure for managing polio eradication in Pakistan was dismantled at a time when it needed to

be strengthened.

 

•Nigerian security situation deteriorated. Here too, vaccinators tragically lost their lives and the program

operations were severely impaired.

 

•Nigeria polio virus was exported to southern Somalia, where it infected a population unprotected against polio

because of an al-Shabab ban on vaccination that remains in place.

 

•Pakistan polio virus spread to Syria, causing a major outbreak amidst the countrys civil war.

 

•Pakistan polio virus spread also to Israel, West Bank and Gaza, and Iraq, and Nigeria polio virus to Cameroon

and Equatorial Guinea – each outbreak over-stretching the global program resources and credibility.

 

In 2012, there were 223 polio cases in five countries. In 2013, there were 407 cases in eight countries.

During last year and the first few months of this year, much hard work has been undertaken by infected countries

and their global partners to try to reverse the negative eradication trend that became established in 2013:

 

•Nigeria has markedly improved vaccination coverage in many areas, most notably in Kano and in the highest-

risk Local Government Areas, and has been rewarded with a substantial decrease in polio transmission.

 

•Afghanistan has maintained strong performance and is on track to stop endemic transmission before the end

of 2014, although importation of Pakistan polio virus will continue to pose a threat.

 

•In Somalia, the program responded strongly to the outbreak of Nigeria polio virus and transmission has now

been substantially quelled as a result. Responding quickly to the IMB criticism in October 2013, the program

also strengthened its coordination across the Horn of Africa.

 

•In Pakistan, Peshawar and Karachi mounted innovative and determined campaigns to reach children with polio

vaccine in a manner that maximizes the safety of the polio vaccinators – bright spots in an otherwise gloomy program.

 

•When Pakistan polio virus was detected in Syria, novel challenges mixed with some controversy over the

programs approach in a complex conflict-affected environment. Despite this, in the IMBs view, the program

responded well – in Syria and across the region.

•The global community, recognising the importance of polio eradication, requested WHO to convene an

emergency committee under the International Health Regulations, as the IMB had recommended. On this

committees advice, WHO has recommended mandatory travel vaccination for residents and long-term visitors

travelling internationally from countries exporting polio (currently Pakistan, Cameroon, and Syria); but the

recommendation would also immediately apply to Nigeria or any other country in the event of a future export.

 

The global partnership has made considerable strides towards restoring the favourable position that the program

had created in 2012. However, the IMB cannot conclude that the grip on polio control, and the positive trajectory, is yet as strong as it needs to be. This is particularly because, with just seven months left until the end-2014 deadline of stopping polio transmission, Pakistan has little hope of meeting this deadline, and Nigeria, on account of the impending elections, is at real risk of losing the vital window of opportunity that its good work has pushed open:

 

•Pakistans situation is dire. Its program is years behind the other endemic countries. As currently constituted,

the setup of the Prime Ministers Polio Monitoring Cell only allows shadow-boxing against the polio virus. A

much stronger form of management and co-ordination is required. Currently Pakistan is firmly on track to be

the last polio-endemic country in the world. It is an indictment of this countrys program that even in the easier

eradication context of the low-season, it has had almost as many cases in the first four months of 2014 as in

the whole of 2012 – and nine times as many as in the same period last year. Whilst some progress has been

made in Peshawar, Karachi and Quetta, this is not sufficient to stop polio transmission. It is absolutely vital

that the Prime Minister and President urgently activate an emergency body with the resources, power and

capability to turn this desperate situation around.

 

•Though Nigeria has reduced viral circulation to a new historic low, the country is in danger of failing to

capitalize on this unprecedented opportunity to stop polio transmission once and for all. Its progress over

recent months has been impressive, but the strain of forthcoming elections is already showing. The crisis

of the kidnapped schoolchildren in Borno has heightened tension and danger in a key polio-affected area,

strained relationships between national and local structures and unleashed hostility to government amongst

communities and families. IMB sources are expressing the fear that “the wheels are at risk of coming off” the

Nigeria program. The Nigeria program has many dedicated and talented leaders and front-line workers. It is

vital that they recognize the need to re-double their efforts, and see that complacency is like a wolf waiting

outside the door, just waiting for an opportunity to devour the fruits of their labours so far. Success this time

would be wonderful for the country. It would be the key to establishing a polio-free Africa. Nigeria desperately

needs to avert the major risk that it now faces of history repeating itself, and of Nigeria becoming the nearly-

nation of polio eradication.

 

Globally, the flurry of outbreaks in 2013 has continued to menace 2014. Outbreak prevention and response

remain an inappropriately undervalued part of the polio eradication effort:

 

•The Middle East outbreak response has been strong, and must remain so.

 

•Polio transmission in Israel appears to have come to a stop without causing any paralysis, but surveillance

through the high season is required to confirm this absolutely.

 

•The Horn of Africa outbreak response is now in reasonable shape but is far from a done deal, with particular

vulnerability in Somalia (where half a million children remain unvaccinated), Ethiopia (where the Somali region

is of particular concern) and South Sudan (where surveillance gaps and vaccination deficits are potently mixed

with armed conflict and extensive migration)

 

•In Central Africa, the Cameroon response to polio importation was worryingly slow and major weaknesses

remain. The IMB is concerned and baffled by the global programs failure to replicate its model from the Horn

of Africa and the Middle East – it is only now, seven months on, mounting a proper multi-country response in

Central Africa. The program needs to ensure that this mistake does not hurt Central Africa, and learn from it so

that all future outbreaks are met with a consistent, best-practice response.

 

•Given that the program has been running for 26 years, its approach to preventing outbreaks seems

rudimentary. Robust plans are needed to deal with any major immunity gap and risk. Many countries are not

being given clear advice about how to close their immunity gap. The “Red List” now identifies the countries at

greatest risk, but work to reduce their risk is slow and unsophisticated. The program must create a dedicated

core of staff to rapidly improve its expertise in outbreak prevention. The current approach relies on multi-

tasking by the very people who are concentrating on countries already infected. This is not in keeping with a

21st Century response to an emergency.

 

The final section of this report examines areas of cross-cutting importance across the global program. Some clear programmatic improvements have been achieved in these areas since the IMB first started emphasizing their importance, but problems remain:

 

•Vaccinators must be able to answer parental questions effectively and persuasively, in ways that generate

trust. This means that first-class selection and training of vaccinators is crucial.

 

•Current program metrics do not make it easy to discern the contribution that social mobilisers are making, or to

judge the quality of their work. Metrics that better enable this need to be developed and deployed.

 

•More engaged debate is needed between those who see potential for social mobilization to contribute to

solving the programs remaining challenges, and those who are skeptical about this. Improved engagement

of this kind would help better integrate and target the use of social mobilization techniques, and build more

common ground between the believers and the skeptics.

 

•Insecurity has become a major and complex obstacle to eradication, and the program is changing to reflect

this. The IMBs keen interest is in the extent to which partners are coordinating, in the speed of their work, and

in their ability to draw upon the necessary expertise. Coordination, in particular, needs further attention.

 

•Key program funders still feel that they are not getting the information that they need, and some of the

longest-standing partners of the program are on the verge of disillusionment.

 

Finally, the Polio Oversight Board has commissioned a review of the programs management, on the IMBs

recommendation. This has the potential to transform the way the program operates, and must be allowed to do

so. We offer comments and a recommendation to assist this.

 

In 1988 (26 years ago now) every country in the world resolved to eradicate polio. Most managed to do so by

the year 2000. For the last 14 years, we have been witnessing the excruciatingly long tail of completing global

eradication. The “last 1%”, a phrase that only three years ago was an inspiring rallying call to finish the job, is

becoming an open goal for eye-rolling cynics. Every additional polio year costs lives and money, saps morale,

puts future donations at risk and holds the public health world back from making further health gains. The goal

of stopping global polio transmission has been serially missed. The deadline year of 2000 came and went; so did

2004; and so too did 2012.

 

As the end-2014 deadline fast approaches, Nigeria and Pakistan are both at risk of failing to stop transmission in

time (with Pakistans risk extreme). There is a significant risk of one or more of the current outbreaks becoming

prolonged. There is serious risk of failure to anticipate and prevent an outbreak elsewhere. Given these factors,

the IMBs considered analysis is that the latest strategic plan goal of interrupting transmission by the end of 2014

stands at extreme risk.

 

The World Health Assembly has rightly declared polio eradication a programmatic emergency for global public

health. WHO has rightly called the spread of polio a public health emergency of international concern. There

is every reason why polio must be eradicated – and fast. Failure to do so is inexcusable. This last 1% cannot

be allowed to drag on any longer. The program is failing children and families in the poorest parts of the world.

These broken promises mean that every child paralysed in 2015 will be a child grossly let down, their paralysis an avoidable catastrophe.

 

All eyes must now be focused on minimising the number of such avoidable catastrophes – on ensuring that

Nigeria succeeds in 2014; on Pakistan rebuilding a program that can succeed soon after; and on preventing and

responding to outbreaks with consistency and vigour.

 

The IMB makes 11 recommendations:

 

1.We recommend the establishment of an Emergency Operations Center (EOC) in Pakistan, which builds

upon Pakistans recent experiences in responding to natural disasters and other countries experiences in

emergency polio response. Top-level civil servants, senior representatives of national, regional and local

government, religious leaders as well as military leaders should be a key part of this process. We urge that

this new body be fully operational by 1 July 2014.

 

2.We recommend that the heads of the Global Polio Eradication Initiative core partner agencies meet urgently

with the President and Prime Minister of Pakistan to support their essential leadership of the Pakistan polio

eradication program, and to offer every possible assistance in establishing the new EOC as a strong national

body with the power, resources and capacity to drive transformative action.

 

3.We recommend that the President of Nigeria galvanizes action to gain the pledge of all national, state and

local candidates in the forthcoming election, together with traditional and religious leaders, to protect the

polio eradication program from disruption and politicization, returning it to its humanitarian role in saving the

lives of Nigerian children.

 

4.We recommend that the Polio Oversight Board ensures that the promised Central Africa outbreak coordinator

is installed by 1 July 2014, resourced appropriately, and that the Board formally investigates why the

programs response in Central Africa has been much weaker than in the Horn of Africa or in the Middle East.

 

5.We recommend that a new, dedicated team be established at global level to focus on outbreak response, its

first job being to substantially strengthen the outbreak response Standard Operating Procedures to ensure

that future responses will be consistently excellent.

 

6.We recommend that a dedicated team be established at global level to rapidly improve the programs

approach to outbreak prevention in the Red List countries and beyond. Scenarios and exercises should form

a key part of its activities.

 

7.We recommend that the core partners meet in person to agree upon a way to address the three improvement

aims for securing communities greater trust, based on the analysis of social mobilisation in our report.

 

8.We recommend that WHO relax its grip on the training of vaccinators and their supervisors, allowing UNICEF,

CDC and other partners to contribute, particularly to enhance the interpersonal communication skills of

vaccinators

 

9.We recommend that Pakistan and Nigeria take urgent steps to license additional oral polio vaccines so that

they can be used within the next six months, in order to create greater flexibility in global vaccine supply.

 

10.We recommend that current concerns and unease about the transparency and communication of the polio

eradication budget are properly and openly addressed. This might best be achieved by a frank discussion at

the Polio Oversight Board.

 

11.We recommend, in relation to the management review that is underway, that the Polio Oversight Board

appoints an advisory panel of four seasoned executives and management experts, who have experience

of running or advising some of the most complex enterprises in the world, to help shape the management

consultants analysis and recommendations before they are finalized for the Polio Oversight Board.