The Final Phase of Polio Eradication and Endgame Strategies for the Post-Eradication Era

The authors of the more than 60 articles in this supplement to The Journal of Infectious Diseases reflect on the tools, tactics, and alliances that the Global Polio Eradication Initiative (GPEI) partners have undertaken as part of the effort to combat the international spread of wild polioviruses into previously polio-free countries from the period of 2003-2014.

Following an introductory section, the publication includes (click here to view the full table of contents):

1. "Acceleration of Eradication", which provides information on global progress toward interruption of wild poliovirus transmission and the role of the Independent Monitoring Board (IMB) of the GPEI in monitoring that progress.
2. "Regional and Country Experiences", which highlights, amongst other things, technical and programmatic innovations and challenges in the African region, the American region, the Eastern Mediterranean region, the European region, the Southeast Asia region, and the Western Pacific region. Sample communication-related insights, from a few of the articles in this section that are focused on polio eradication activities in one country, Nigeria, follow:
   • "Progress Toward Poliomyelitis Eradication in Nigeria", which includes a section on social mobilisation and advocacy, describing the role of a widely circulated, locally produced video that expressed concern about polio vaccine safety and efficacy, leading to considerable anti-polio vaccine sentiment in selected communities. To address these concerns, the programme intensified community and household engagement, with particular emphasis on traditional and religious leaders, to provide advocacy and pro-polio vaccine messages. In selected areas, the programme has also enlisted the support of local physicians (Doctors Against Polio) during supplementary immunisation activities (SIAs), given that they are respected in their communities, and has realigned volunteer community mobiliser networks (VCMs).
   • "An Assessment of the Reasons for Oral Poliovirus Vaccine Refusals in Northern Nigeria": "Caregivers refuse OPV [oral polio vaccine] largely because of poor polio risk perception and religious beliefs. Communication strategies should, therefore, aim to increase awareness of polio as a real health threat and educate communities about the safety of the vaccine. In addition, polio eradication partners should collaborate with other agencies and ministries to improve total primary healthcare packages to address identified unmet health and social needs."
   • "An Evaluation of Community Perspectives and Contributing Factors to Missed Children During an Oral Polio Vaccination Campaign - Katsina State, Nigeria": "To address the challenges of missing children during campaigns, we recommend that intra-campaign operational deficiencies should be addressed to ensure that all children are reached. For instance, improved social mobilization should provide communities with the exact dates when their community would be visited. Some of the ways preferred by respondents included announcements by town criers, as well as engaging traditional leaders (village and ward heads). Mosque announcements could be considered, where feasible. Secondly, all homes where a child was absent should be revisited by vaccination teams, ideally at a time when the child is expected to be at home. Alternatively, vaccinators should give a date when they will revisit homes so that parents can arrange for their kids to be present. The plan for revisiting households with missed children should be clearly outlined in microplans, and there should be enough vaccination teams to accomplish this goal. Third, in addition to visiting all homes, we advocate that more vaccination should occur in public places using special teams. Hopefully, this will capture children in playgrounds, farms, mosques, motor parks, and other public places."
   • "Outreach to Underserved Communities in Northern Nigeria, 2012-2013": "The initial outreach focused mostly on nomadic Fulani settlements. Future efforts should identify and conduct similar outreach activities among migrant fishermen, migrant farmers, and other underserved populations. We also observed the advantage of leveraging available local resources and derived robust operational support from the veterinary health workers. Because of their long-term well-established relationship with the nomads, veterinary health workers were trusted among the nomads, and they facilitated the community engagement meetings, assisted with the search for nomadic settlements, provided appropriate linkages with the nomadic populations, and assisted in vaccinating nomadic children. Finally, the community engagement meetings were one of the key thrusts of the outreach activities and afforded the community leaders an unprecedented opportunity to participate in the planning for polio SIAs. It is also serving as a platform for sustained involvement of these leaders in the planning and implementation of healthcare-related services in their settlements. Their awareness of available health services at the LGA [Local Government Association] level is expected to increase the community demand for these services."
   • "An Evaluation of Polio Supplemental Immunization Activities in Kano, Katsina, and Zamfara States, Nigeria: Lessons in Progress", which describes a research project that evaluated SIAs, including team performance, communications/mobilisation activities, and vaccine acceptance, in 3 high-risk states. Structured survey and observation instruments, document review, and stakeholder interviews were conducted, and included 1,697 households. Vaccine acceptance ranged from 87%-94%; among households rejecting polio vaccine, 38% of mothers sought measles vaccine for their children. Teams performed 4%-42% of assigned tasks. The researchers conclude that acceptance is high, but teams have a critical role in surmounting residual vaccine resistance.
   • "Using Geographic Information Systems to Track Polio Vaccination Team Performance: Pilot Project Report": "[W]e have demonstrated that GIS [geographic information system] data hold great potential to improve microplanning and evaluation of SIAs. Images showing GPS [global positioning system] tracks of vaccination teams have also proven to be a powerful advocacy tool when meeting with local officials, many of whom are keenly interested in seeing the activities of vaccination teams characterized visually and objectively."
   • "Improving Polio Vaccination Coverage in Nigeria Through the Use of Geographic Information System Technology": "Geographic information system (GIS)-based maps were created for 2238 wards in the 8 target states. The resulting microplans included all settlements and more-efficient team assignments, owing to the improved spatial reference. GPS tracking was conducted in 111 high-risk local government areas, resulting in improved team performance and the identification of missed/poorly covered settlements."
   • "Polio Eradication in Nigeria and the Role of the National Stop Transmission of Polio Program, 2012-2013", which describes, amongst other things, how N-STOP short-course training modules were adapted from the Centers for Disease Control and Prevention (CDC)-World Health Organization (WHO) STOP programme to include Nigeria-specific modules. The modules are based on adult learning principles and include participatory exercises, role-playing, and development of interpersonal communication skills. Content includes technical aspects of poliomyelitis, GPEI, and the Expanded Program on Immunization (EPI), as well as good management and problem-solving practices. In addition to this basic central training, N-STOP uses an applied periodicmodular training model to strengthen EPI at the district level in 100 LGAs.
3. "Epidemiologic, Virologic, and Environmental Surveillance", which explores the role of these tools for monitoring progress and understanding the dynamics of polio outbreaks.
4. "Risk Assessment, Mitigation, and Prevention", which describes the risks of vaccine-associated paralytic polio among healthy individuals and persons with primary immune deficiency disorders and the use of mathematical modeling to better define and manage population immunity and prevent poliovirus transmission.
5. "The Polio Endgame: Preparing for the Post-Eradication Era," which explores the rationale and evidence supporting the endgame and post-eradication vaccination policy changes, including introduction of inactivated polio vaccine (IPV), as well as the development and potential role of poliovirus antiviral agents and an update on poliovirus laboratory containment.
6. "Beyond Polio Eradication: Immunization and Health Systems and Legacy", which deals with what lies ahead, including how to use the knowledge, experience, lessons learned, and assets of the GPEI to forge stronger and more sustainable routine immunisation (RI) and primary healthcare systems going forward and, more generally, how best to apply the lessons learned and assets of GPEI to other global health priorities.