By the end of 2014, significant progress had been made towards each of the Endgame Plan’s four objectives; the world has never been in a better position to eradicate polio.
As the GPEI enters 2015, efforts are being intensified to build on this progress and stop polio once and for all.
Capitalizing on progress in Nigeria, against outbreaks in central Africa and the Horn of Africa, and against two out of three strains of wild poliovirus
In Nigeria, no new cases due to wild poliovirus (WPV) occurred from July 2014 to the end of the year as a result of the improved quality of immunization campaigns. Subnational surveillance gaps in some areas remain, however, and the country continues to be affected by a persistent circulating vaccinederived poliovirus type 2 (cVDPV2) outbreak.
The second half of 2014 also saw the two-year mark of the most recent case of WPV3, which was last detected globally in November 2012, in Nigeria. This allows cautious optimism that this strain may have been eradicated. It would be a historic milestone for the GPEI and would leave only one wild serotype – wild poliovirus type 1 (WPV1) – in circulation (WPV2 has not been detected anywhere since 1999).
In the second half of 2014, the outbreaks in the Horn of Africa, central Africa and the Middle East that spanned 2013 and the first half of 2014 were brought to the verge of being stopped.
Thanks to regionally-coordinated outbreak responses in all three regions, one case was reported in this six-month period, in Somalia on 24 August. No case has been reported from any of the outbreaks since then. Risks remain across all three outbreak zones, however, such as residual surveillance gaps, which could hide undetected transmission, so none of the outbreaks has been considered closed. At the same time, the Middle East is considered at high risk of renewed reinfection, given the intense virus transmission in Pakistan and further deterioration of immunization systems in the Syrian Arab Republic and Iraq due to the conflict and security situation.
To minimize the risks of the renewed international spread of WPV, the International Health Regulations Emergency Committee reiterated its conclusion for the third time in November 2014 that the current situation regarding international spread remains a PHEIC and underlined its Temporary
Recommendations for the vaccination of international travellers from polio-infected countries.
Preparing the world for the phased removal of oral polio vaccines In October 2014, the SAGE reviewed global readiness for the planned phased removal of OPVs, beginning with a switch from trivalent OPV to bivalent OPV in April 2016. This readiness includes the introduction of IPV into all countries that currently use only OPV by end-2015, to continue to provide protection against all strains following the planned switch in 2016.
Reviewing all evidence, the SAGE concluded that preparations for the switch are on track and urged countries to further intensify efforts.
A critical factor to assure a successful switch will be the containment of type 2 polioviruses in laboratories, as well as certification that WPV2, last detected in 1999, has indeed been globally eradicated. In late 2014, a new and updated global containment action plan was endorsed by the SAGE and progress towards WPV2 verification continued.The trigger for the global, phased withdrawal of OPVs will be to ensure that all persistent cVDPV2 outbreaks are fully stopped. At the end of 2014, persistent cVDPV2s endured in Nigeria and Pakistan.
Ensuring the legacy of polio eradication
In late 2014, work continued to ensure that the legacy of polio eradication can be secured, in other words that the investments made in the GPEI will continue to benefit other development goals in the long term through the documentation and transition of knowledge, lessons and assets.
Ongoing consultations with Member States, major partners and stakeholders, as well as detailed pilot evaluations, reinforced the conclusions of the regional committees in 2013 that legacy planning should benefit existing health priorities and be driven by countries.
Its success will require establishing a formal process in all countries where substantial assets for polio eradication were financed through external resources.
In 2015, finalization of the Global Legacy Framework will ensure that the essential functions of the GPEI’s programme of work will be transitioned to other priorities. The Democratic Republic of the Congo India, Nepal and Nigeria have initially been selected for focused legacy transition planning support in 2015, with other countries with significant polio resources to be prioritized.
The final battleground: stopping transmission of poliovirus in Afghanistan and Pakistan In 2014, Pakistan accounted for 85% of all WPV cases worldwide and, in the second half of 2014, it was the only country that continued to export the poliovirus internationally. This intense virus transmission across the country is now the greatest epidemiological risk to achieving a polio-free world, as too many children remain under-immunized (due to a number of factors, including operational challenges, insecurity, targeted attacks on health workers and hampered access). Mass population movements from previously inaccessible areas present both a risk and an opportunity. The risk is that the poliovirus continues to be exported from these areas, but the opportunity is that, for the first time in more than two years, populations can be reached at transit points as they move out of these areas.
Recognizing the risks Pakistan poses to the global effort, end-2014 saw a build-up in government commitments at all levels. Following initial strategic planning, an emergency meeting convened the political leadership from the high-risk provinces and districts to prepare a robust “low-season emergency plan” with consensus from all key levels. This low-season plan focuses on overcoming clearly identified, area-specific challenges in the early part of 2015 (the low season for polio transmission).
The plan has all the necessary elements in place to rapidly eradicate polio; its success, however, hinges on its full implementation at all levels.
To facilitate implementation, a national task force reporting directly to the prime minister’s office has been established, a cabinet committee on security for immunization has been formed, and close collaboration is being fostered to secure the assistance of the army and the Ministry of the Interior for polio eradication.
Emergency operations centres established at the federal and provincial levels will oversee implementation, assure real-time monitoring and guide corrective actions as necessary.
In neighbouring Afghanistan, efforts focused on holding ground against the poliovirus in the face of importations from Pakistan. While the bulk of WPV cases is linked to cross-border transmission with neighbouring Pakistan, residual endemic poliovirus circulation persists and access challenges remain in some areas.