Recent Findings From an Evaluation of the CORE Group Polio Project_Perry_5.11.11

Global Polio Eradication Initiative: Current Status

Henry PerrySenior Associate, Johns Hopkins Department of International Health

11 May 2011

Global Polio Eradication Initiative

Current Status of Polio Eradication

• In 1998, 350,000 children paralyzed annually by polio• Number of cases in 2010 reduced by 99.996% since 1998 (1,291

cases)• Number of cases to date (May 4) globally: 123 (vs 115 through April,

2010) • 10 billion doses of vaccine dispensed and $8.2 billion spent• Poliovirus still endemic in four countries (transmission never

interrupted):– Afghanistan– India– Nigeria– Pakistan

• Countries with re-established transmission(active and persistent poliovirus transmission of more than 12 months following an importation)

AngolaChadDemocratic Republic of the CongoSudan (suspected)

Countries with imported poliovirus are experiencing ongoing outbreaks following an importation:

• Congo• Kazakhstan• Liberia• Mali• Mauritania• Nepal• Niger

• Russian Federation• Senegal• Sierra Leone• Tajikstan• Turkmenistan• Uganda

Challenges

• Uneven vaccination coverage (and pockets of un-immunized children)

• Viral mutations (causing transmission and disease in the live vaccine virus itself)

• Variable vaccine effectiveness (less effective in India, where AFP is also higher and where 83% of children who developed polio had received three doses of OPV)

Challenges (cont.)

• Prominent opposition/skepticism by DA Henderson (head of WHO Smallpox Eradication program and former Dean of the School of Public Health at Johns Hopkins)

• Community “resistance” and “campaign fatigue”

• Re-introduction of new cases in countries where transmission had been stopped – accounted for 82% of cases in 2010

Key Features of Poliomyelitis

• Transmitted mostly through fecal-oral route• Three serotypes (1, 2 and 3) and a separate vaccine

exists for each, type 2 eliminated from the wild in 1999• Most cases asymptomatic, only 1% produce paralysis• One paralytic case of polio corresponds to several

hundred cases in the community• Surveillance for acute flaccid paralysis is key to identify

new cases of polio (there is “normally” 1 case of AFP each year for every 100,000 children 0-14 years of age caused by non-polio viruses)

Bill Gates

• “Vaccines are the best investments we can make in global health”

• Polio eradication now a top priority for the Gates Foundation

• “If we don’t do it now, the task will be nearly impossible”

• “Success will lead to great benefits for global health”• $10 billion committed by the Gates Foundation for

the next decade for polio eradication

Issues

• How to increase local investment/ accountability for the PEI

• How to use the PEI to reinforce the existing health system “infrastructure” (especially for routine immunization) instead of weakening it

• How to overcome local resentment among alienated groups

• “We need to involved grassroots people from around the world in this final push for polio eradication”

• Charles McCormick, President and CEO of Save the Children: “We’re focusing on CHWs, not on a single disease – but it is a tough sell”

Health Hum Rights. 2009;11(1):87-92.

Understanding Social Resistance

Resentment against focus and energy on polio, which is not a local priority, while other priorities for which governments should be giving attention – such as food and primary health care – are not being attended to– One case in which polio campaign went on in Nigeria

while a measles epidemic (in which thousands of children died) was neglected

– “… the apparent incongruity between the impoverished state of the primary health care system and the well-funded polio eradication campaign”

Health Hum Rights. 2009;11(1):87-92.

(cont.)

“Some people have never even seen polio but yet they keep giving us medicine for it. If you look around it is hard to find 2 or 3 people with polio but it is easy to go to the hospital and find 50 people sick with no money to buy the medicine they need to be treated with. Help them instead, but No! You find a small baby who is well and drop medicine in his mouth, for free!”

Health Hum Rights. 2009;11(1):87-92.

“There are problems concerning healthcare, housing, hunger, unemployment that bother people. With all these problems, they now say that they want to help us with polio. My people will never be able to understand this.”

Health Hum Rights. 2009;11(1):87-92.

New Tools in the Armamentarium

• Focus on newly developed bivalent (instead of trivalent) polio vaccine – more potent, and wild poliovirus type 2 appears to have been eradicated

• Focus on prevention of diarrheal diseases in hard-core areas (by promoting handwashing, zinc supplementation, hygiene education, etc.) to improve effectiveness of polio vaccine

Reasons for Recent Reversal by DA Henderson

• Stronger independent scientific monitoring and technical director

• Vast financial commitment of Gates Foundation (and Bill Gates’ willingness to go meet with heads of state) and his statement that it is “the number 1 priority of the Gates Foundation)

• Gates support for further research on oral vaccine (to reduce chance of mutation into a virulent form) and make it heat stable

Status in CORE Group Polio Project Countries

• Angola – 2 polio cases confirmed in 2011 so far (and 1 by this date in 2010)

• Ethiopia – No cases identified so far in 2011, in 2010, or 2009 (last case in the spring of 2008)

• India – No cases identified in Uttar Pradesh so far in 2011 (but 1 case from West Bengal), and 19 identified by this date in 2010

Key Strategy – Reaching the “Hard to Reach”

Global Eradication Initiative, Strategic Plan 2010-2012

Role of NGOs“NGOs play key roles in advocacy and programme implementation, including by training volunteers and health workers, transporting vaccines and equipment, monitoring the quality of the cold chain, implementing communication and social mobilization activities and improving SIA quality. The NGO umbrella organization CORE, for example, through the efforts of many of its members, builds partnerships with governments and the communities they serve, supporting SIAs, assisting with AFP surveillance, and monitoring the immunization status of children. Country programmes will be encouraged to approach and engage other networks of NGOs, community-based organizations and private voluntary organizations, to assist with SIA planning and implementation as appropriate.”

Global Eradication Initiative, Strategic Plan 2010-2012, p. 56

Conclusion

The CORE Group Polio Project is well-positioned to play an increasingly greater role in the Global Polio Eradication Initiative