REPORT OF INDEPENDENT MONITORING BOARD, GLOBAL POLIO ERADICATION INITIATIVE

Wednesday, 20th of July 2011

The Independent Monitoring Board of the Global Polio Eradication Initiative, chaired by Sir Liam Donaldson, has issued the report of its most recent meeting, recently concluded in London. Full text is available at http://www.polioeradication.org/Portals/0/Document/Aboutus/Governance/IMB/3rdIMBMeeting/IMB.Report.July.pdf
Below, I reproduce the executive summary and recommendations.

Good reading.

Bob Davis

EXECUTIVE SUMMARY

1. Our first report, in April 2011, took a broad, frank look at the task of interrupting polio transmission– its historical context, the factors critical to success, the key remaining countries. The Global Polio Eradication Initiative (GPEI) achieved a 99% reduction in polio cases worldwide between 1988 (the year of the GPEI’s founding) and 2000, but this was followed by a decade of ‘stalemate’ with no further headway being made. Evidently, eradicating the final 1% of polio is the greatest challenge yet. Nothing short of excellence will complete this task.

2. By our current assessment, the GPEI is not on track to interrupt polio transmission by the end of 2012 because:

• The programme is performing poorly in controlling polio in countries with re-established transmission (DR Congo, Chad and Angola)

• The programme is weak in anticipating and preventing outbreaks in high-risk countries

previously free of polio; 14 such countries have suffered outbreaks since the beginning of 2010

• The polio numbers in Pakistan are going in the wrong direction: the number of cases this year has doubled compared to the same period in 2010

• The urgency and power of the response of the programme to the situations in Chad and DR Congo has not been commensurate with the serious problems of capacity, capability and quality control on the ground in these countries

• There are too many examples of failure to ensure consistently high quality of vaccine campaigns and surveillance in key areas

3. If the question is asked: “What will be done differently next month to completely transform progress against the stubborn persistence of active polio?” there is no convincing answer. More of the same will not deliver the polio eradication goal.

4. But polio eradication is still possible, in the near term, if there is enhanced political commitment, secure funding, strengthened technical capacity, and if the concerns below can be swiftly tackled.

5. This report identifies key areas of immediate risk. Listing these, we ask the GPEI to ensure that it has a clear plan to deal urgently with each.

6. We highlight areas of inconsistency, dysfunction and weakness in the programme, and provide recommendations to break through these.

7. We raise key long-term issues relating to serious resource shortfalls and the need for a clear polio endgame plan.

8. We update our assessment of the global milestones (see next page) and of progress in each of the seven countries with persistent transmission:

• India has made strong progress and is on track to interrupt transmission this year.

• Afghanistan is making good progress, but has not yet sufficiently overcome its access challenges.

• Recent national elections set back Nigeria’s strong progress, which now needs to be resurrected.

• High-level commitment is evident in Pakistan, but the country needs to get to grips with serious local level performance issues.

• We welcome the additional technical support being afforded to Chad, where the situation is alarming. The surge teams of WHO and UNICEF need to become swiftly functional.

• We are deeply concerned by DR Congo, where visible commitment of the President is much needed.

• Angola is making good progress but needs to retain its focus on the province of Luanda.

9. Our view remains that stopping polio transmission needs to be treated as a global health emergency. Failure would allow this vicious disease to resurge. We will continue to provide a frank and independent assessment of the progress being made. Our next meeting will be held in London on 28-30 September 2011.

RECOMMENDATIONS

On the basis of our preceding analysis,

1. We recommend that the heads of the spearheading partner agencies ensure that a clear plan is in place to address each of the seven key risks that we have highlighted

2. We recommend the creation of twinning mechanisms, through which a country explicitly commits technical expertise and financial assistance in support of a named polio-affected country. Such arrangements should be agreed at ministerial level. The country with polio should retain primary control over what technical assistance it requests. We recommend that the GPEI seek to establish at least two such

arrangements urgently, such that the agreements and the technical assistance are in place within the next three months.

3. We recommend that the GPEI spearheading partners and country programmes mandate that all sections of AFP (i.e. possible polio) case investigation forms must be completed in full, notably the social data sections. Any forms in which information is missing should be returned to the individual who filed them to be completed.

4. We recommend that Rotary International pilots the use of a short team-based checklist by vaccination teams at the start and finish of each vaccination day. The items on the checklist should reflect the accepted best practices that are taught to teams.

The day’s work should not start or finish until the team has talked through the checklist, and committed to each of its items.

5. We recommend that UNICEF pilots and rapidly implements a simple tool that field staff can use in immunisation debrief sessions to identify, record, and locally disseminate effective micro-innovations.

We recommend that UNICEF establishes an expectation that this tool will be used after each immunisation round, and that very brief reports are compiled globally and shared rapidly.

6. We recommend that UNICEF creates or commissions textual and audiovisual materials (including short films) that use case studies to communicate the power of micro-innovations, and empower vaccinators and social mobilisers to be creative in tackling the challenges that they meet. These videos should be widely distributed

for viewing at vaccination team training days. The GPEI may wish to use this opportunity to communicate other key messages, such as the global view of polio eradication and the vital role of front-line workers.

7. We recommend that, at its next meeting, SAGE examines the potential for a combined IPV/OPV approach to be used in appropriate settings

8. We recommend that the spearheading partners identify leading disability advocates and explore their interest in learning more about polio eradication, with a potential view to advocating for enhanced financial and political support.

9. We recommend that the spearheading partners formally explore with GAVI whether a portion of its recent large funding package could be allocated to activities that further the goals of both GAVI and of the GPEI

10. We recommend that Pakistan, Afghanistan, DR Congo, Chad and Angola each establish a system with the same four key elements as the Abuja Commitments, to enhance and track the commitment of the key individuals at state/province and local level.

11. We recommend that each of the seven countries with established transmission should set out a timeline of milestones en route to interrupting transmission.

18. We recommend that the spearheading partners secure the engagement of the President of DR Congo as the leader of this country’s emergency actions to interrupt polio transmission

19. We recommend that DR Congo, with CDC and WHO, amend the Major Process Indicator for end-2011 that is based on vaccination, to reflect the need for good coverage across the recently affected areas

20. We recommend that within the next month each state of India completes its risk analysis to identify areas and populations at high risk of importation and spread of polio, setting out a clear plan to address the vulnerabilities identified

21. We recommend that the Indian national programme critically updates its own view of risk in light of the state analyses, to discover whether any areas need further intervention

22. We recommend that Nigeria works with CDC and WHO to agree and introduce an additional Major Process Indicator, based on independent monitoring data, for end-2011

12. We recommend that the GPEI’s endgame plan should incorporate a phase-by-phase plan to optimise the GPEI’s public health and health service delivery legacy. This should list out the benefits that are achievable and define how each can be reached, setting clear objectives, milestones and indicators. We recommend that the GPEI

identifies a named individual or group who has clear authority to lead this part of the work. This might involve recruitment. It could alternatively involve identifying existing capability elsewhere within WHO or UNICEF. Such an arrangement would allow the core current teams to concentrate on completing the eradication of polio, whilst

ensuring that the broader focus is also given the attention that it needs.

And from earlier in the report,

13. We recommend that WHO appoint, at the earliest, an epidemiologist on a long-term contract to support the Angolan national government

14. We recommend that the heads of WHO, CDC and UNICEF pay personal attention to ensuring that arrangements are in place to enable their agencies’ new teams in Chad to begin functioning effectively at the soonest possible time

15. We recommend that Chad’s emergency action plan is reviewed to (i) establish a clearer priority focus in the areas identified as being high risk, (ii) establish performance indicators that can be monitored as the technical teams increase in size

16. We recommend that the Chad programme incorporates collaborative working with the animal health sector in order to enhance vaccination amongst remote and difficult-to-reach populations.

17. We ask to receive fortnightly updates on the implementation of Chad’s emergency plan, with a particular focus on progress made in establishing a functional WHO/CDC/UNICEF team.