Independent Monitoring Board of the Global Polio Eradication Initiative: Tenth Report - October 2014

"It is clear that the level of political commitment, the extent of engagement of regional and local leaders, the quality of public health leadership and management, and the involvement of civil society are totally inadequate. Pakistan puts the entire global goal in jeopardy."

The above finding is one of those shared in the tenth report following from the eleventh meeting of the Independent Monitoring Board (IMB) of the Global Polio Eradication Initiative (GPEI), held in London, United Kingdom (UK), from September 30 to October 2 2014. The key message of the report: "Something big has to change in Pakistan....The programme will not achieve its end-2014 target of stopping global polio transmission. Faced with a missed target, not for the first time, there are signs that the [polio eradication] programme's leaders have shifted their sights to the ambition of seeing a polio-free Africa by the end of the year, or soon after....The IMB...believes that setting polio cases in Pakistan on a sharp downward trajectory should be pursued with equal tenacity to the laudable goal of seeing an end to polio in the entire continent of Africa."

The IMB notes that "the prospects for interrupting polio transmission have become entangled with Ebola in a number of ways that are very adverse. Firstly, many staff working in the polio programme have been transferred to Ebola duties....Secondly, supplementary rounds of polio vaccination in the Ebola-infected countries have been abandoned for the foreseeable future. Thirdly, in many Ebola-affected areas, polio surveillance has become impossible. Fourthly, Ebola has killed around 400 doctors and nurses...and an already poor health infrastructure has been further savagely degraded. Finally, Ebola-ravaged populations were already living in conditions of extreme poverty and the situation has become much worse, with attendant impact on sanitation."

Statistics about "polio's two breeding grounds" - Pakistan and Nigeria - are included. For instance, between July and September 2014, 8 times as many children were paralysed in Pakistan than everywhere else in the world put together. Communication lessons are outlined in terms of what could have been done differently - e.g., "Other countries have demonstrated that an effective programme to stop transmission of the polio virus requires a modern and effective leadership structure that galvanizes commitment, strategic focus and unity of purpose from national to regional to local level. This has been missing in Pakistan for nearly two years." In Afghanistan, all but one of the children paralysed by polio in 2014 to date were afflicted by the Pakistan polio virus.

To address the problem, the IMB recommends that the National Disaster Management Authority do "command and control", working with the military and with the provinces to address issues such as violent, deadly attacks against Pakistan's polio vaccinators.

Noting the "commendable progress" in Nigeria, where at the same time one year prior, the country had had 49 cases of polio compared to just 6 at the time of this writing, the IMB describes the importance of analysing campaign coverage at the Local Government Area (LGA) level. Having identified the problems, the Emergency Operations Centers (EOCs) have implemented solutions, such as intensified social mobilisation (if the problem is refusals). The "best hands" have been deployed to the areas where they are needed the most. That said, the IMB notes that "there are surveillance gaps. Social mobilisers and health camps have reached scale but not uniform quality. Rumours suggest that some are afraid to report cases of paralysis....Nigeria has not stopped polio transmission..., and it has not eradicated polio until it has kept the virus out for at least three years."

Concluding elements of the report explore what it will take to achieve a polio-free Africa, looking at countries beyond Nigeria. Communication challenges remain, e.g., "In Cameroon, the polio virus was missed for two years. Parents barely know about polio campaigns." The report also explores topics such as key strategic considerations in the effort to eradicate polio and provides recommendations and conclusions, such as: "This is the moment for transformative action, not iterative year-by-year improvement. The World Health Assembly has declared polio eradication a programmatic emergency for global public health. WHO [World Health Organization] has declared polio's spread a Public Health Emergency of International Concern. At the end of 2014, the programme will miss yet another target. It has to be the last time and the IMB's recommendations reflect this vital moment in history." One recommendation: "A special meeting of the Independent Monitoring Board in early 2015 with those who will lead the eradication of polio from Pakistan, at federal level, in each province and in FATA [Federally Administered Tribal Area of Pakistan]. It is to be hoped that the government of the United Arab Emirates might play an important part in such a meeting."