The New Normal: Finding the Path Back to Eradication in the Time of Coronavirus - Eighteenth Report of the Independent Monitoring Board of the Global Polio Eradication Initiative

"At this complex and difficult moment for the polio programme..., inspiration has come from the teamwork, the dissolution of silos, and the warm solidarity as everyone has come together to protect communities and save lives from the effects of the worst pandemic in a hundred years. Infused by that spirit, the polio programme must now put petty differences aside, think big ideas, turn towards the light and begin the fightback to earn the right to stand on the path to polio eradication once again."

The findings and necessary action to address the crisis in the polio programme that were identified by the 17th Independent Monitoring Board (IMB) report (see Related Summaries, below) were accepted by the Polio Oversight Board (POB) of the Global Polio Eradication Initiative (GPEI) and by the governments of the polio-endemic countries. However, within weeks, the COVID-19 emergency had surfaced, and resources were repurposed in the fight against the pandemic coronavirus. In this context, the 18th IMB Report follows videoconference meetings the IMB held with the GPEI Strategy Committee, donors, wider polio partners, and the governments of the polio-endemic countries on June 29-30 and July 1 2020. The discussions had to take account not only of the programmatic weaknesses and action needed to transform them before COVID-19 struck, but how to build the impact of COVID-19 into the GPEI's ongoing strategic approach to polio eradication. The conversations also had to explore whether the period of pause and reflection, imposed on the polio programme by COVID-19, had caused the leadership to think differently about the path to eradication.

In brief, when COVID-19 was declared a pandemic, the POB moved quickly to instruct that GPEI structures, people, and resources (e.g., communication systems) should be repurposed to help in the fight against the new disease. All vaccination rounds were stopped for several months before restarting in late July 2020. It was clear from the outset of the pandemic that many of the reservoirs of poliovirus were likely to be places where COVID-19 would hit communities hard. The polio programme knows these areas, regularly maps them, and maintains community engagement platforms within them. Those resources have been commandeered, prioritised, and integrated into the COVID-19 response.

At the time of this 18th IMB report, the polio programme was poised for resumption. The GPEI has set up a new committee to oversee this process, the GPEI Continuity Planning and Facilitation Group (PFG). The PFG will need to address the many issues outlined in the IMB report related to the restart. For example, it is difficult to predict how communities will react to resumed polio vaccination programmes in a period of continuing risks with COVID-19, especially in areas with high pre-existing oral polio vaccine (OPV) refusal levels, or in communities with deep-seated hostility to the polio programme. The IMB stresses that crafting good communication strategies, using trusted local vaccinators, and listening to community leaders and influencers will be vital. There will be challenges with keeping polio teams safe and - in general - with controlling, and dealing with, the further circulation of COVID-19 and its impact.

The report goes on to offer an overview of the global polio situation. Highlights include the fact that August 2020 is poised to be the time when the African Region could be certified wild poliovirus (WPV) free. However, the two final polio-endemic countries - Pakistan and Afghanistan - are beset by three epidemics at once: WPV, vaccine-derived poliovirus (VDPV), and pandemic coronavirus. The situation is examined in depth in the country sections later in the report but, in short, the IMB describes the polio situation in Pakistan as "very grave"; one concern is the scaling down of the Community Based Volunteer programme, whose workers (mostly women) were able to secure access even when there was violence and community mistrust. And in Afghanistan, even without the unanticipated addition of a COVID-19 pandemic, the complex geopolitical, cultural, environmental, and economic had seriously damaged prospects of early interruption of WPV transmission in the country.

In its 17th report, the IMB called for sweeping change and a new, dynamic, and comprehensive approach to communications. In its formal response to this IMB recommendation, the GPEI described the communication strategies developed in Pakistan and Afghanistan in response to that call. In brief:

• The Pakistan polio programme is addressing the IMB's concerns with an integrated communication strategy, which includes an alliance-building and community engagement component that focuses on building a cadre of polio champions in a systematic way. The objective is to empower the identified champions (medical, religious, traditional), provide them with appropriate training and tools, and integrate them into ongoing community engagement efforts and in social media as appropriate. It is believed that this will allow them to become a sustainable community engagement resource, interacting with communities to fully address their concerns and misconceptions. It is argued that this will help to create a community environment that is supportive of polio campaigns. This strategy is being finalised by the Pakistan polio team and its implementation will be monitored. Also, in light of the fragility of the trust between the polio programme and the Pashtun communities (brought into focus by events around misinformation spread via social media videos in April 2019), in Karachi, communication interventions specifically geared toward the Pashtun communities are being implemented. Examples include hiring Pashto-speaking frontline workers and conducting jirgas and focus group discussions in Pashtun communities.
• The Afghanistan polio programme has developed a new regional communication and community engagement plan for the south. It believes that this will engage key influencers in a more systematic way and ensure they receive appropriate training and tools to support their engagement. Also, Wakil-e-Guzars, who are influential figures in urban settings, are being engaged to mobilise communities in their areas. Follow-up strategies from a meeting with them are being developed. Some mullahs in the south and east regions of the country are engaged in "refusal conversion". Islamic Advisory Group focal persons in high-risk provinces are engaging with local religious influencers to obtain their support. They are also seeking support from the madrassas.

However, there are communication-related challenges related to vaccine policy (the report explains that there are now five polio vaccines to potentially deploy - alone or in combination). The risk communication dimension is further complicated by the need to deal with communities' fears of polio programmes being run while COVID-19 is still active. The GPEI told the IMB that a "crisis communications" perspective is being built in to responses, and preparations are being made to respond to negative social media messages. While the IMB welcomes the amount of work the GPEI is putting into its communications strategy for new vaccine introduction, the group stresses that it will be important to have modern communications specialists involved at strategic level, reliable sources of advice on cultural knowledge and beliefs, and strong feedback loops prepared to "speak truth to power" when things go wrong.

Following a section of the report sharing data insights, the report offers overall recommendations including, in brief:

• In Nigeria, the GPEI spearheading partners, the federal and state governments, donor countries, and the Aliko Dangote Foundation should meet urgently to formulate a funding strategy.
• In Afghanistan, a carefully designed, quality-controlled, rigorously evaluated pilot programme of non-governmental organisation (NGO)-delivered polio vaccination should be introduced, with technical support, mentoring, and monitoring from the United Nations agencies and the Emergency Operations Centres (EOCs), which should be independently overseen, and open, high-level discussions should be held with the World Bank to add a polio incentive to the Sehatmandi scheme (a 3-year project administered by the World Bank through the Afghanistan Reconstruction Trust Fund, which aims to increase the utilisation and quality of health services).
• In Pakistan:
  • The federal government should use its full political influence and oversight to ensure all-party and institutional support for polio eradication at each governance level in the country; it should institute regular meetings of the National Strategic Advisory Group for Polio Eradication and Immunisation in Pakistan, as was intended when it was established in 2019.
  • The federal government and provincial administrations, working together, should build a strong political relationship with representatives of the Pashtun communities in the country.
  • A new, carefully chosen national polio leadership team should be appointed, particularly in light of the additional pressures of the coronavirus pandemic.
  • The GPEI leadership and the Pakistan polio programme should be prepared to adapt the Community Based Volunteer programme, which continues to have major potential to increase vaccine coverage.
• Targeted action to improve community infrastructure and quality of life through water, sanitation, hygiene, and basic service provision that was agreed as policy in 2018 should be implemented urgently in multiply-deprived and alienated communities in Afghanistan and Pakistan.
• All in-country polio programmes should be designed to work with other teams to deliver vaccination for polio as part of other essential services (especially immunisation); the precise model of integration should be tailored to match local circumstances and community preferences. Programmes should also seek to meet communities' wider and basic needs (related to water, sanitation, soap, or other amenities that communities value).
• In the COVID-19 context, the GPEI should work with the leadership of the country polio programmes to produce, and regularly update, comprehensive plans to deliver safe and effective polio vaccination campaigns; also, they should create a decision-making framework to guide national and local teams on how to make rapid judgements on the extent to which polio staff should be repurposed again in the event of second and third waves of COVID-19 or pockets of resurgence.
• In a resumed programme of polio vaccination during COVID-19, specialists in infection prevention and control and in supply logistics should be appointed to each national and regional EOC.
• The GPEI should designate a Global Director of Polio Vaccine Implementation and a small support team for a one-year period. Work will focus on: introducing the new novel monovalent OPV type 2; making decisions and choices on which vaccine to use, including during outbreaks; keeping abreast of availability of vaccine stocks; supplying vaccines rapidly over a wide range of geographies; tracking progress; gathering real-time soft intelligence on problems; monitoring impact and adverse reactions; and handling both public and internal communications.

In the concluding section of the report, the IMB offers the warning that "The Polio Programme is in dire straits....The opportunity of COVID-19 to finally determine innovative and integrated delivery strategies provides a lifeline for polio eradication. The risk of a Polio Programme going back into the field tired and half-hearted about needing new ideas could be the death knell of the programme....The Polio Programme can continue to chip away at community engagement, using the same old methods, but if it cannot deliver something that looks fundamentally different then it will not get over the finishing line of polio eradication."