By Lois Privor-Dumm and Huma Khawar.
This article was originally published on Vaccineswork and is cross-posted here with permission.
Photo: UNICEF/PAK 2015/Asad Zaidi
In Nigeria and around the world, citizens, governments, doctors, and parents are fighting polio – and they’re winning. After nearly 30 years of polio eradication efforts, the end is in sight. In 1988, the year the World Health Assembly (WHA) resolved to eradicate polio, there were an estimated 350,000 polio cases globally; last year there were only 359, and this year cases so far are down by 75%.Misbau Lawan Didi leads a club he wants to eliminate. As president of the Polio Survivors Association, he is committed to not only end polio in Nigeria but to eradicate it from the planet. “We are determined,” he says, “to ensure that our members are no more.”
Polio has eluded us for decades. There have been plenty of starts and stops and lots of excitement about the polio eradication effort.
So what makes this time different?
Communities around the world are mobilizing, and momentum is building. Last month, one of the remaining three endemic countries, Nigeria, passed the one year mark without a single case of wild poliovirus. Once the final samples are tested and cleared, the World Health Organization should even be able to declare Nigeria a non-endemic country. Many thought it wouldn’t be done.
Now, Pakistan is embarking on one important step in its fight against polio and implementing the endgame strategy with introduction of the inactivated polio vaccine (IPV) across the country. It will take determination and sustained effort to ensure that it can be done – and with a decentralized health system, years of war, and continued threats against health workers, it will be no easy feat.
Step by step, progress is being made. We are on the brink of an unprecedented accomplishment. Yet, public health experts warn “the last mile” will be the hardest. Ending transmission of the virus in every country will take a focused effort and the use of every available tool against the disease. The Polio Eradication and Endgame Strategic Plan was developed to provide countries with a roadmap to help navigate this challenge. The plan calls on countries to make three important changes to their immunization efforts: 1) to introduce one dose of (IPV) into routine immunization schedules, 2) to strengthen routine immunization, and 3) to eventually withdraw oral polio vaccine (OPV).
The first phase of this plan, the introduction of IPV, is well underway. While there was initial concern over an accelerated timeline, communities and governments around the world have risen to the challenge. The introduction of IPV will be one of the fastest rollouts in history. Out of 126 oral polio vaccine (OPV) only using countries, 30 have now introduced. Today, on August 20th, Pakistan launches its nationwide rollout, which is no small feat. The significance of this rollout is monumental.
Photo: UNICEF/PAK 2015/Waseem Niaz
Introducing a new vaccine involves hundreds of technical and logistic details. There are budget considerations, procurement, storage and transport of vaccines, training of health workers, and communication with parents. Countries need to assess their systems and strengthen necessary components. In Nigeria, for example, communicating with the public was particularly important as skepticism about the polio vaccine halted past efforts. When Nigeria introduced the new polio vaccine in February of this year, community and religious leaders were active in the outreach to parents. In markets and in mosques, the public was told about the importance of immunization and using the IPV vaccine in the battle against polio. In February, when Nigeria became the first polio endemic country to introduce the vaccine, it was widely accepted by parents.
We are down to the last three polio endemic countries – Nigeria, Pakistan and Afghanistan – and now there is even greater hope. Last year, there were no new members of Nigeria’s Polio Survivors Association as the country did not have any cases of the disease. Work in Nigeria is far from over, but the effort is paying off: two more years without a reported case and Nigeria can be certified as polio free.
The same can be true in Pakistan and the other countries where communities are hard at work to protect their children and eradicate this virus. This time it really can be different. Pakistan, is your time now?
Lois Privor-Dumm is the Director of Policy Advocacy & Communication at IVAC at the Johns Hopkins Bloomberg School of Public Health. Huma Khawar is a freelance journalist and consultant based in Islamabad who works with stakeholders on the ground in Pakistan to advocate for new vaccines through the Vaccine Implementation Technical Advisory Consortium (VITAC), a project of the Gavi Alliance.
With the help of a long list of partners and supporters, IVAC has developed a portfolio of advocacy materials supporting IPV introduction, which can be found here. Inquiries can be directed to Lois Privor-Dumm at firstname.lastname@example.org.
Inactivated Polio Vaccine and Its Role in Eradication Plan
By Lois Privor-Dumm
It’s been just under a decade since the focus of my work shifted to resource-constrained countries. At the time, it seemed a far-off dream that so much progress could be made in protecting children from vaccine-preventable diseases. Eradication efforts had only ever succeeded against one disease – smallpox – and there were still many cases of polio in endemic countries (which at the time were Afghanistan, India, Nigeria, and Pakistan). Immunization was discussed, but never received the focus it does today. Now, on this World Polio Day, I reflect on where the world was and where it is today - closer than ever to reaching a goal of ending polio for good – AND doing it while strengthening immunization programs that have been all too weak in the past.
The rollout of IPV in the Philippines was marked by a ceremony attended by several health dignitaries including the Secretary of Health, Enrique Ona, the Undersecretary of Health, Jeanette Garin and the Assistant Secretary of Health Enrique Tayag among other high-ranking officials.
In 1988, when the Global Polio Eradication Initiative (GPEI) began, polio paralyzed more than 1,000 children worldwide every day. Today thanks to millions of volunteers more than 2.5 billion children have been immunized against polio. Global immunization campaigns have reduced polio by 99% worldwide. Eradication is within reach.
This year kicked off with a huge milestone, with India being declared polio-free in January, leaving just three countries with ongoing transmission. While Pakistan faces many challenges and has seen an increase in polio cases this year, Nigeria has had the fewest cases of wild poliovirus ever, with just six cases so far this year, and Afghanistan’s burden also remains low with just 12 cases this year.
Another important step forward was taken this year as countries began introducing inactivated poliovirus vaccine (IPV), an important milestone in the Polio Eradication and Endgame Strategic Plan, an ambitious but achievable plan endorsed by the World Health Assembly in 2013. The plan calls on countries to introduce at least one dose of IPV into routine immunization schedules and gradually withdraw all oral polio vaccines (OPV). Until now, OPV has been the primary tool in the global polio eradication effort, and has been instrumental to achieving the reach necessary to eliminate polio from all but three countries, and to reduce cases to a mere fraction of historic trends in Nigeria, Pakistan, and Afghanistan. However, new evidence now clearly demonstrates that adding one dose of IPV to multiple doses of OPV is the most effective method available to stop the virus and protect children.
The amazing part is that countries are introducing IPV along with other important new vaccines. In September, Nepal became the first country to introduce IPV with Gavi support. Gavi-supported rollouts will continue, as more than 90% of Gavi-eligible countries have applied for support. Next month, Nepal is also expected to introduce pneumococcal conjugate vaccine. Gone are the days when countries have to wait years between vaccine introductions. In fact, in 2014, five countries have introduced more than one vaccine already, and nearly 15 more multiple introductions are planned for next year, accelerating the path to reducing both child death and severe illness.
But it’s not only Gavi supported countries that are making strides. Middle-income countries, where most of the world’s poor reside, are also recognizing the importance of IPV and making the investment to introduce this and other new vaccines. Earlier this month, the Philippines became one of the first non-GAVI countries to start the transition from an all-OPV schedule to add one dose of IPV. The global rollout of IPV will continue across 126 countries through the end of 2015.
IVAC is proud to be part of the global efforts to help eradicate polio and support the introduction of new vaccines through targeted advocacy efforts in middle-income countries, helping to engage and sensitize civil society, and supporting communications activities of partners. It is a big job ahead, but with committed governments, partners and advocates, we now know it is possible. The hard part of our job as advocates is just beginning, but we look forward to more milestones in the fight against polio in the coming year, as the finish line gets closer.
Lois Privor-Dumm, MIBS, is Director of Policy, Advocacy & Communications
By Dr. Kate O’Brien
Today is a landmark day, one that many global health experts thought might not happen. Today marks three years since the last case of wild polio in India, the requirement to officially certify the country, and with it the WHO South-East Asia Region, polio-free. While the official declaration is not due until March when a WHO Regional Certification Committee reviews all the data, today is a day to celebrate and to be remembered in India and around the world for years to come.
Photo Credit: Rotary International
It is a day to congratulate India, but also the global community. It is a day that gives us all strengthened hope and confidence in achieving the goal of global polio eradication. In 1998, India had a high of nearly 2,000 cases of paralytic polio from the wild poliovirus, and as recently as 2009, it still was home to most of the world’s polio cases. By 2011, it had wiped out wild polio cases, and now it has maintained that status for three years. India’s large, dense, and often migratory population combined with poor sanitation conditions in parts of the country created some of the most difficult conditions throughout the world to control disease. However, with a depth of commitment from all levels of government and civil society and dedication of significant resources, India achieved this mammoth goal. It could not have been done without the work of millions of individuals, including the 2.3 million vaccinators, the thousands of clinicians and epidemiologists in more than 33,000 surveillance sites, the religious leaders and advocates committed to on-the-ground outreach, and the leaders across government and industry who together contributed nearly US$2 billion in funding.
Thanks to all of these individuals, India is now polio-free, and its triumph over polio is a massive public health achievement---one that will leave a lasting impact on children's health in India and around the world. It is also a testament to the power of immunizations, which have been saving lives in India and around the world for centuries.
India has achieved a laudable reduction in global child deaths in recent years, and vaccines have been one of the most effective interventions in this effort. Not only have vaccines prevented deaths, but they’ve also helped children stay healthy and averted crippling social and economic costs to families and society. Beyond polio, India’s other great achievements related to vaccines are highlighted in this infographic.
Vaccines clearly work and they clearly work in India. As coverage levels increase and new vaccines are introduced into its Universal Immunization Programme, disease reduction will amplify, and children will lead healthier, longer lives. These inspiring efforts should be applauded along with India’s polio achievement.
India’s achievements should also inspire the global community to rededicate our efforts to ensure every child around the world is protected from preventable diseases. We have a unique window of opportunity to change history by eliminating polio from the three remaining countries where transmission has not yet been stopped – Pakistan, Afghanistan, and Nigeria – and maintaining disease control in other countries where elimination is fragile and polio threatens to return. With much learned from India’s success, communities, countries and the global community have a strong, actionable plan to achieve a polio-free world by 2018.
Ending polio everywhere, forever, is a critical step toward improving the lives of the world’s most vulnerable children. As India has clearly shown, polio eradication can lead the way for other child health initiatives, by strengthening surveillance systems, building networks of trained community health workers, and engaging leaders from across diverse disciplines. The job is not yet done; India and other countries around the world will need to sustain and continue to build on the progress to date while planning for the next step of introducing at least one dose of inactivated polio vaccine.
The remaining polio-endemic countries should have a deep sense of hope, bolstered by the accomplishments and lessons learned in India, that this goal is at their fingertips. The scientific, public health, communication, and organizational tools are in place. With the right political will, polio will be wiped out; there will remain substantial and at times unanticipated challenges to match the accomplishment of India in the remaining countries, but these are surmountable. There is a lot to be optimistic about. India has demonstrated to the world what is possible when the community in all its dimensions – local and global, political and religious, scientific and lay – has a common commitment. We call on all partners to continue without wavering the march toward worldwide polio eradication and in so doing achieve the purest measure of health equity.
Kate O’Brien, MD, MPH, is Executive Director of IVAC. A pediatric infectious disease physician, epidemiologist, and vaccinologist, she previously served as Deputy Director of IVAC. She also serves as Associate Director of the Center for American Indian Health.
By Dr. Kate O’Brien
This week scientists came together to declare that we will eradicate polio in 5 years. It’s an achievable goal, and admittedly an aspirational one. But, if we as a global community leverage proven strategies and follow through on commitments made, it will be met. It is amazing to think that this goal, which just two decades ago seemed impossible to many, is now firmly in our sights. It also gives me confidence that we can reach other goals, such as reducing preventable childhood deaths to a degree that any such death is seen as a shocking, rare event rather than predictable and intractable. This challenge, which the global health community laid out in last year’s Promise Renewed initiative may seem daunting, given that despite recent declines, 6.9 million children died in 2011. However, when you consider that worldwide polio cases have dropped by 99% since the Global Polio Eradication Initiative began in 1988, it is clear these problems are surmountable. Like polio eradication, we need a concrete approach to tackling the leading child killers, and we made a big step forward with today’s launch of the Integrated Global Action Plan for Prevention and Control of Pneumonia and Diarrhoea (GAPPD). Released by WHO and UNICEF, GAPPD clearly outlines the steps we must take to eliminate the two leading killers of young children in 20 years.
The Integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD)
Most of my professional life has been spent assessing and applying interventions to reduce pneumonia and diarrhea, both in the United States among American Indian communities and around the world in the communities where most child deaths still occur. I’ve seen the burden of these diseases in the numbers we calculate and on the faces of the patients I’ve treated. I’ve also seen that we have the tools we need to stop children from dying or suffering from severe pneumonia and diarrhea. When I worked in Haiti, the ward was full of children, over a third of whom would die in those beds. Nearly all of the illnesses these children had were fully preventable, mostly through the use of vaccines but also through other simple, sensible interventions. The interventions we have work, and the task we have is to figure out how to use them most effectively, to know if what we are doing is working, and to make adjustments in optimizing their impact. This feedback loop can only be put in place when we can measure the impact of what we’re doing. We may not be able to measure with absolute precision, but with enough precision to know if our time and treasure is being wisely spent.
We know what we need to do to tackle pneumonia and diarrhea, and establishing clear evidence on the burden of disease and on interventions that work creates the platform from which we can prioritize our efforts. A new series published in the Lancet today in conjunction with GAPPD provides updated evidence on this front. One of the papers, led by faculty in our Department of International Health at Johns Hopkins provides updated mortality estimates for pneumonia and diarrhea – together responsible for more than 2 million child deaths in 2011.
We also have a clear understanding of which interventions work, and we know that many of them overlap. As my colleague Bob Black pointed out in the Lancet series launch, while diarrhea and pneumonia have very different symptoms and causes, several risk factors for the two diseases are the same, including under-nutrition, suboptimal breastfeeding, and zinc deficiency, meaning that they can be effectively prevented and treated as part of a coordinated program. We also know that vaccination campaigns will play an important role. A second paper in the Lancet evaluated 15 key interventions using the Lives Saved Tool. It found that nearly one third of severe diarrhea episodes could be prevented by widespread vaccination against rotavirus and cholera, while up to two thirds of pneumonia deaths could be prevented by implementation of pneumococcal and Haemophilus influenzae type b vaccines. With ambitious scale-up – 80% coverage or more – the authors estimated all 15 interventions could effectively eliminate (95% prevented) diarrheal deaths and prevent around two-thirds of pneumonia deaths by 2025. All this at a total cost of just USD6.7 billion.
GAPPD and the Lancet series reflect years of work toward a consensus among all stakeholders that we must target our efforts on proven interventions, and we must work together in an integrated way. Many of the interventions for childhood diseases overlap, and can be delivered more efficiently if all parties work together. This integration will not only result in better care for each child, it is also crucial in resource-poor settings, where countries simply cannot afford to maintain siloed efforts and where partnering countries and organizations are increasingly demanding more impact for their investments.
We have the evidence, and our marching orders are clear. With polio eradication beckoning our efforts, it is the time to leverage this energy, know-how, and confidence by fulfilling our promises and advocating for all stakeholders – donors, governments, civil society, and other leaders – to fulfill theirs. We can all take inspiration and insight from polio eradication efforts and make the end of preventable pneumonia and diarrhea deaths a reality.
Kate O’Brien, MD, MPH is Acting Executive Director of IVAC. A pediatric infectious disease physician, epidemiologist, and vaccinologist, she previously served as Deputy Director of IVAC. She also serves as Associate Director of the Center for American Indian Health.
By Lois Privor-Dumm
This is a moment we have been cautiously optimistic about. Was today going to finally be the day? Friday the 13th is not an unlucky day this year – it is the day that India has gone one year without a single new case of poliovirus! Every time I look out the window as I’m driving around India, I witness the all-too-common sight of someone suffering the debilitating effects of the disease. That image is a reminder about how horrible this disease is and that polio’s impact is not just on the individual, but a whole nation.
A man who contracted polio walks on crutches in the village of Kosi, 113 miles from Patna, India. Photo by Altaf Qadri / AP.
The efforts to stop this disease in India have been dramatic and it has been a roller coaster with significant ups and downs. After 741 new cases in 2009, there were only 42 in 2010 – the country was almost there. And then in 2011, there was just a single new case in 18-month old named Rukhsar from West Bengal. It was a heartbreaking occurrence, but efforts persevered.
I am struck by the level of effort committed to this goal: government, civil society and international organizations including WHO, the National Polio Surveillance Project (NPSP) based in Delhi, UNICEF, CDC and Rotary are all laser-focused on making sure that kids even in the hardest to reach places were immunized. The Bill & Melinda Gates Foundation is also instrumental in these efforts. It was no easy feat, as we’ve seen in other polio-endemic countries including Nigeria, Pakistan and Afghanistan. India was considered one of the toughest countries to tackle, making this effort all the more impressive.
|History of Polio Case Numbers in India|
The infrastructure requires an enormous amount of coordination with stakeholders who were not part of the government or its partners. Civil society, including community and religious leaders, NGOs and others all needed to be engaged. The outcome of polio eradication efforts is not just the achievement of interrupting transmission, but the commitment that is gained by those involved in disease prevention efforts. I don’t work directly on polio, but I recognize the benefits of building an understanding of the value of vaccines, creating a system that can handle the supply chain, monitoring and evaluation and constant communication. On a recent GAVI consultation visit to India, I was very happy to hear that the discussion was about how we can leverage the infrastructure created by the polio efforts.
It is important that we learn the lessons from polio and leverage the best practices, not only in India, but in other large countries like Nigeria, where stopping Polio is also within reach. One of the biggest lessons is that there are a lot of stakeholders that contribute to a successful vaccine program – it takes a village. The government plays a big role, but it is the community, that will directly determine success.
Building an understanding of what can be achieved, and helping to implement the strategies that can lead to that success, are ways that the IVAC team is privileged make contributions. We are all working towards the goal of improved health for people in countries like India and Nigeria. Today’s milestone inspires others to act in ways that can help not only polio eradication efforts, but disease prevention and control efforts more broadly. One year without a new case of polio in India is an important milestone, but as we continue to make great strides around the world, our best years are ahead of us.
Lois Privor-Dumm is the Director of Alliances and Information at IVAC.