Ambiguities and Certainties: Meeting the Diverse Expectations of Polio Transition

"In some polio-affected or polio-vulnerable countries, vaccination has begun to take a back seat, as political commitment has drained away into other priorities such as COVID-19 or malaria. Advocacy to governments, to keep up the pressure, is vitally important."

Polio transition is the process of repurposing and transferring the network and infrastructure developed by the polio programme to strengthen broader health priorities, especially essential immunisation and emergency preparedness and response, under the leadership of national authorities. The Transition Independent Monitoring Board (TIMB) was created in 2016 by the Global Polio Eradication Initiative (GPEI) to monitor and guide polio transition planning. Following the World Health Organization (WHO) taking over the leadership and management of polio transition planning from the GPEI, the TIMB was reconstituted. This, the sixth TIMB report, follows a meeting with stakeholders held in Geneva, Switzerland, April 27-28 2023.

The report outlines developments since the fifth report (see Related Summaries, below), noting that a case of wild poliovirus (WPV) in Malawi in 2021, followed by an outbreak in Mozambique in 2022, was a worrying and unwelcome surprise in the polio eradication journey. Following the huge multinational outbreaks of vaccine-derived poliovirus (VDPV) that began in 2020, with the epicentre in Nigeria, 4 out of the 6 WHO regions became infected. Four countries are now in the eye of the storm, accounting for 85% of all the active poliovirus emergences: Nigeria, Northern Yemen, south-central Somalia, and Democratic Republic of the Congo (DRC). TIMB stresses: "Polio outbreak preparedness is an integral part of broader epidemic disease outbreak preparedness."

With regard to the endemic countries, 6 cases of WPF have been recorded so far (as of July 11) in 2023, 5 of which were in Nangarhar, Afghanistan, and 1 of which was in south Khyber Pakhtunkhwa, Pakistan. Afghanistan is plagued by significant security risks, with the development of resistance movements and opposition to the Taliban authorities. The continuing restriction on house-to-house campaigns, largely in the south, with use, instead, of mosque-to-mosque and site-to-site vaccine delivery modalities, has produced a large immunity gap. An estimated half a million children have yet still to receive vaccination. In Pakistan, the polio eradication programme continues to receive a high level of political commitment, but there is political uncertainty looming, as well as conflict and civil unrest. There are more than 120 environmental surveillance sites across Afghanistan and Pakistan. Any detections trigger a very aggressive outbreak response.

As outlined in the report, the impact of the COVID-19 pandemic on essential immunisation programmes has been devastating. To cite only one example, research in West Africa has shown that communities were refusing oral polio vaccine (OPV) because they believed that it was a new COVID-19 vaccine. "Mistrust and misinformation about vaccines, and the polio vaccine in particular, is nothing new, but this comes at a critical time when the polio eradication programme needs to sustain communities' support for repeated visits and multiple doses of the vaccine."

In response, the United Nations Children's Fund (UNICEF), together with other key partners in global immunisation, has been leading the development of a strategy for catching up on missed children and restoring immunisation through an essential immunisation recovery plan. Around the time of the last IMB meeting, there was increased enthusiasm for integration, but integrated campaigns do not always work. For example, some attempts to combine delivery of different antigens with tetanus vaccination have met poor community acceptance. The position of inactivated polio vaccine (IPV) coverage, post-pandemic, is a key consideration and is mission-critical for securing a polio-free world.

The TIMB has argued consistently for a surveillance system to encompass all communicable diseases and pointed out that COVID-19 made a persuasive case for it that would surely be listened to at the highest political levels. Moreover, advances in genetic, digital, analytical, artificial intelligence (AI), and information and communication technology (ICT) make such a prospect a realistic goal. The report outlines recent steps forward in surveillance. Environmental surveillance and regular monitoring of staff are 2 ways to detect containment breaches. The central guidance requires countries to establish a body to regulate the process: a National Authority for Containment.

The report moves on to provide specific country progress reports. The reader learns, for example, that in South Sudan, "When GPEI funding eventually stops, indicators for polio, essential immunisation, outbreak response, and surveillance, are almost certain to weaken significantly. The risk of a polio outbreak will then be very high." And in Yemen, a VDPV type 2 outbreak began in November 2021, which has paralysed 228 children, nearly all in the north of the country. "No satisfactory outbreak response has been mounted because the GPEI has not been able to negotiate access with the Houthis."

Analysis of the situation, as provided in section 4 of the report, surfaces the following themes:

• Collective responsibility and collective understanding - A clear consensus emerged during the April 2023 TIMB meeting that the current concepts and descriptors underpinning polio transition are no longer fit for purpose. In short, going forward, the key idea is that countries will have full ownership of, and accountability for, each of the component programmes that have been involved in polio transition planning: essential immunisation, integrated surveillance, health emergencies, and poliovirus containment. The countries will use former GPEI assets and other infrastructure to deliver them.
• Stronger global management, coordination, and inclusivity - Countries have told the TIMB that their work is made more difficult by weak or inconsistent interagency coordination. "The global governance architecture needs to be harnessed to drive forward polio transition to successful end-points; actions must include: clarifying and strengthening partners' existing roles and relationships towards more cohesive collaboration; bringing in new partners who may have found the intense polio branding off-putting; and working out how best to coordinate partners' multifaceted interests in a way that is most helpful to countries trying to achieve their goals." One specific suggestion is to consistently engage with civil society organisations (CSOs). "They are closer to the people, they understand the local communities and their often complex physical, social and economic environments....Often, they are better able to work in insecure areas. Civil society could be given a much greater role, extended responsibilities, and more resources."
• Funding, donors, and the budgetary cliff - The need for a simple understanding and explanation of the various funding streams that countries have available to them was raised repeatedly by participants in the April 2023 TIMB meeting. There were also calls for greater clarity on what the budget horizon looks like.
• Implications of the GPEI letting go - The GPEI's goals and responsibilities are set out in Polio Eradication Strategy 2022-2026: Delivering on a Promise. On the one hand, talk of "multiple roles in implementing integration", "political advocacy linked to broader health priorities", and "pandemic response" suggest an expanding role. On the other hand, the strategy document states, "The GPEI partnership will dissolve at certification" [in 2026]. Per the TIMB: "This wording does not give a very inspiring impression of the value of partnership for the future work required to get to a polio-free world. While this is not exactly mixed messages, it shows again the weak coordination and communication when the need is for stepwise, rather than sudden, actions when it comes to changes in the continuity of any aspect of polio programmatic responsibilities or funding flows."
• The vital role of strong, integrated surveillance - The greatest challenges to maintaining high-quality surveillance are in the increasing number, frequency, and intensity of armed conflicts and insecure areas within countries. Particularly driven by the barriers to access, by insecurity, and by population resistance, community-based surveillance was developed in (what were then called) the Federally Administered Tribal Areas of Pakistan, in northern Nigeria, and in other insecure polio-vulnerable parts of the world. In some parts of the world, technology has been used to assist surveillance, but in Afghanistan and Pakistan, it has been much more difficult to do so because of mistrust of the technology's purpose. However, there is no doubt about the major benefits from the use of electronic data tools for data collection.
• Countries: safe stewardship of a precious asset - A deeper approach to polio transition involves understanding the fine detail of each of the countries' individual contexts, which often involve adverse and increasingly complex operating environments. "If all the partners and donors on the ground in a country were involved in a discussion about all relevant plans, helped to put them together, agreed what activities were necessary for good implementation and who is going to do what, the polio transition process would be much improved."
• Containment: the potential Achilles' hell of successful transition to a polio-free world - "This is ongoing work that needs collaboration between the polio containment group, the WHO Laboratory Biosafety Team, researchers, and others involved in the production and distribution of polio vaccines. Promoting new technologies will create concern and may affect the market overall. WHO's remedy to risk mitigation will firstly be to keep the communication and opportunities for involvement in the production of new types of vaccines open to all potential suppliers."

Following a section on data insights, the report concludes with a section outlining remaining questions, challenges, and opportunities going forward. "In all the TIMB's meetings, discussions, and private conversations, one issue attracted a level of concern above any other. That was accountability. There is a broad consensus that without clear accountability for implementation (including coordination of all stakeholders, [etc.])[,] polio transition will falter or even fail. This would put at risk the achievement of a polio-free world."

Finally, the report concludes with 10 action recommendations. For example: WHO should lead work on producing a formal workforce plan that would set standards for the levels and skill mix of the workforce needed to deliver public health functions, including those necessary to secure and maintain a polio-free world. The plan should address training needs, including leadership training, and have a plan to deliver them.