THE ART OF SURVIVAL: THE POLIO VIRUS CONTINUES TO EXPLOIT HUMAN FRAILTIES
Our last report followed an in-depth field review of the remaining polio endemic countries. We commissioned and coordinated this important piece of work. Its findings together with the subsequent IMB report led to a searching analysis and the identification of profound reasons for concern about the state of polio eradication at the end of 2018.
One of the underlying messages of these reviews was that the Polio Programme in Afghanistan and Pakistan was not in as strong a position as the epidemiological situation suggested. The public-facing polio narrative and advocacy message was of “nearly there,” “one final push,” and “polio at an historical low.” The deep analysis from the field review and the IMB’s deliberations found:
• Widespread hostility to, and rejection of, the oral polio vaccine in many deprived communities;
• A weak emergency culture not commensurate with the present stage of the eradication process;
• Oppressive top-down demands stifling local creativity and ingenuity and creating a climate of fear at the frontline;
• The top performing staff not being identified or sent to the most difficult places;
• Action to raise essential immunisation levels unconvincing and inadequate;
• A programme inundated with excessive amounts of data and weak in using insights to improve quality;
• Levels of missed children in Afghanistan very high and rising fast;
• Widespread environmental samples and community mistrust in the Pakistan Programme were not being given proper attention;
• Wild poliovirus circulation in Nigeria could not be ruled out until the security situation improves and surveillance is conducted in inaccessible areas.
Tellingly, even in July and August 2018, no one in middle management and frontline roles in the Polio Programme, who spoke on condition of anonymity to the Review Team or IMB, subscribed to an optimistic view. Most did not see the interruption of wild poliovirus transmission as imminent or even inevitable.
The fighting talk was at the more senior leadership levels of the Polio Programme. Below that, in the engine room of the GPEI, there was an air of despondency, fatigue, and uncertainty. We commented on this in our last report.
At that time, in 2018, one member of staff told us that below the surface of the reassurances being given by senior leadership to the IMB lay a “powder keg” of risks and programmatic weaknesses ready to explode.
This situational analysis and the resulting recommendations in the 16th IMB report left the GPEI with a great deal of work to do, some covering very difficult implementation ground that had never been touched before.
The GPEI’s planned response was still warm from the printing press when a horror story began to unfold in Pakistan and Afghanistan as the country teams and their United Nations agency partners completely lost control of the polio eradication process.
It is important to make clear that the resurgence of polio is not some sort of biological mystery. It should not have happened. It need not have happened. It is a source of public embarrassment for the GPEI and the two countries’ governments.
It is no exaggeration to describe it as a crisis. Even worse, looking more widely at the current state of polio eradication, the crisis has three peaks: the first is the level of wild polioviruses in Pakistan; the second is the way that the escalating restrictions in access in Afghanistan have created a huge immunity gap; and the third peak is the widespread occurrence of vaccine-derived polioviruses.
Vaccine-derived poliovirus is moving across Africa, with vaccine-derived Type 2 poliovirus spreading uncontrolled in West Africa, bursting geographical boundaries and raising fundamental questions and challenges for the whole eradication process. It is already endemic in the Democratic Republic of Congo, with outbreaks there for more than a year. Other countries that have had Type 2 vaccine-derived polio cases this year include Angola, Benin, Central African Republic, Chad, China, Ethiopia, Ghana, Niger, Nigeria, Phillipines, Somalia, Togo and Zambia (data as of 29 October 2019). Vaccine-derived Type 1 cases have also occurred in Myanmar in 2019.
These polioviruses are causing paralysis, blurring the distinction between wild and vaccine-derived forms of the disease and their impact on populations, and creating challenges and confusion in immunisation programmes. Health Ministers from Pakistan, Afghanistan and Nigeria led delegations to the October 2019 IMB meeting and made full situation reports as well as outlining their current and future plans. There was then extensive questioning and discussion between each country delegation and the IMB privately.
Following this, they were joined in a larger meeting by the GPEI leadership, country and regional representatives of WHO and UNICEF, donor countries, expert committee chairs and wider polio partners. These discussions with the countries were open, searching, intensive and commensurate with the seriousness of the polio situation.
The IMB also led a series of thematic discussions on: the outbreaks of vaccinederived poliovirus; vaccine refusals; bans; multiply-deprived communities; and new thinking.
In this, our 17th report, we will try to make sense of the present situation and offer further advice and recommendations building on our prior report.