The hour is getting late, warns global polio watchdog

Urges Pakistan, Afghanistan to move to higher level of joint working; calls for definitive

solutions and incisive action implemented with dynamism and speed


The hour is getting late, cautions the 13th report of the Independent Monitoring Board (IMB) of the Global Polio Eradication Initiative (GPEI), while underlining the need for Pakistan and Afghanistan “to acquire politically neutral help in moving to a higher level of joint working.” Although seen as one epidemiological block, the two countries are still well short of a seamless ‘one programme’ approach in planning polio immunization campaigns, surveillance, and social mobilization, the report warns, four months short of the December 2016 GEPI promise to interrupt polio transmission everywhere in the world.

“It is not a good sign, so close to the deadline, that the polio programmes in these two countries have not yet been able to reduce the number of reservoirs,” the report flags. In contrast to their counterparts in India and Nigeria, Pakistan still has four core reservoirs (KP, FATA, Sindh, Balochistan); and so does Afghanistan (Nangarhar, Kunar, Kandahar, Helmand).

Titled ‘Polio will not end everywhere until everywhere ends it,’ the report offers an independent assessment of the progress of the polio programme worldwide as the December 2016 goal for interruption of global poliovirus transmission inches closer. The IMB is quite clear that the polio programme has not yet reached peak performance, and terms this “disappointing.”

While reminding that it is no longer the low transmission season in Pakistan and Afghanistan; in fact, the high season is upon these countries’ programmes, the report highlights that the poliovirus reservoirs in the two countries are very closely intertwined. Three such mega-reservoirs are recognisable: Khyber-Peshawar corridor and Greater Nangarhar; Quetta Block and Greater Kandahar; and, Karachi.

The poliovirus has traditionally been a passenger within population flows back and forward across the borders between Pakistan and Afghanistan, and it has moved freely in and out of these big reservoirs of infection. “This continues to be the case. Some of this population movement is long established and predictable. Some is in response to conflict and changing political allegiances. Some is hidden from view. Poliovirus survives because children within these populations are not properly immunised,” the report highlights.

The IMB believes it is not just important to immunize children at border crossings, it is essential also to get to them in their communities, whether their residence is temporary or semi-permanent. It is most of all vital to understand why children are being missed and to close the gap decisively.

Against the backdrop of strengthening the polio programmes of Pakistan and Afghanistan, the report warns of “very serious weaknesses that are placing the entire endeavour in jeopardy,” and adds, “They are crying out for definitive solutions and incisive action, implemented with speed and dynamism.”

According to the report, the political leadership in northern Sindh, Pakistan,

is not fully engaged and aligned with the urgency of the situation; as a result, many observers believe that this could be the last place in the world where the poliovirus exists.

Similarly, the polio programme in the city and districts of Karachi is continuing to let the poliovirus slip out of its grasp; it made a slow start to the low season and there is a core group of families persistently refusing the vaccine. The polio programme in Karachi, the report states, needs to embrace the practices of programmatic excellence that have eliminated the poliovirus elsewhere. “Abrupt changes to crucial senior personnel have imposed unnecessary further difficulties, leaving a vacuum in vital leadership roles, and making an inexplicably friendly gesture to the poliovirus,” the report mentions.

While being extremely mindful of what still needs to be done, the IMB also highlights several “very substantial improvements” that have been achieved since its last meeting. The fact that the global footprint of the poliovirus is smallest in human history is a miracle itself. Moreover, the continent of Africa still has no polio endemic countries.

The polio programme in Pakistan finds a mention for “achieving a high level of performance overall,” and for having “transformed from its position three years ago.” While highlighting improvements achieved in key performance indicators, the report states that the 13 wild polioviruses detected in 2016 up until July represent a 59% reduction on the same period in 2015; the proportion of polio positive environmental samples was 10% for the first part of 2016 compared to 20% for the same period last year; the genetic diversity of viruses has narrowed; the quality of campaigns has remained above the target level of 90%; the number of zero dose Acute Flaccid Paralysis (AFP) children has continued to fall (2% in 2016 compared to 24% in 2016); the proportion of missed children has fallen from consistently above 10% in 2014 to less than 4% in 2016; and the work of the Pakistan military and more community-focused campaigns have improved the security surrounding programme delivery.

The IMB report also offers a discussion on implications of vaccine-derived poliovirus. As the polio programme seeks to end poliovirus transmission in the two remaining endemic countries, it cannot be certain that the end of transmission across the whole world will rapidly follow. One of the reasons for this is the emergence of vaccine-derived poliovirus in many places. These viruses are making multiple, rapier-like thrusts through the world’s polio defenses. This is most serious when such viruses begin their own chains of transmission.

Any use of the oral polio vaccine leads to the vaccine form of the virus being transmitted to close contacts. If these contacts are immune, then there is very limited further circulation of the virus. However, with more susceptible contacts, the virus can replicate and cause circulating vaccine-derived poliovirus capable of causing paralysis. Even the simple discovery of such a poliovirus (without evidence of transmission) must be taken very seriously, the report warns.

In disseminating one of its key messages, the IMB concludes: “One thing is inescapable: polio will not end everywhere until everywhere has ended it. The challenge for the polio programme now is to create an unrelenting focus on the smaller areas where the virus is still present, where children are being repeatedly missed where immunity levels are low, and where surveillance is weak.”

The report also reinstates the IMB’s Red List, which names countries vulnerable to polio outbreaks because of low immunity, weak surveillance or poor infrastructure, as a starting point for discussion.