The Path towards Polio Eradication over 40 Years of the Expanded Program on Immunization in the Americas

"The importance of EPI [Expanded Program on Immunization] teams working with professionals to develop a quality communications campaign and a well-informed media was one of the lessons learned..."

This article synthesises lessons learned from polio eradication in the Region of the Americas, including initial and more recent challenges and best practices, as well as particular factors surrounding attainment of this goal. Using documents, interviews, and country surveys, the authors describe and analyse the strategies developed and implemented during the 40 years of the Expanded Program on Immunization, or EPI (1977-2017). Some major milestones and challenges specifically covered are: the vaccine-derived poliovirus (VDPV) outbreak; the regional "mop-up operation"; poliovirus containment in essential facilities; the introduction of inactivated polio vaccine (IPV); the synchronised switch from trivalent to bivalent oral polio vaccine (OPV); and the countries' commitment to the cause.

Specifically, the report begins by looking at early signs that eradication was possible, sharing the experiences of Cuba and Brazil, for example. In the latter country, it is noted that among the factors in the reported incidence of polio dropping dramatically were: political commitment, the engagement of partners, and recruitment of nearly 300,000 volunteers, who vaccinated 20 million children in a single day. Other communication-related approaches were seen in Mexico, which implemented a strategy that mobilised the community through local health committees; these groups promoted vaccination to help improve coverage. These countries' strategies and successes, and in particular, the experience of Brazil, were noticed by the head of the Immunization Unit at the Pan American Health Organization (PAHO), who began to believe that a well-planned, disease-specific, Regional programme could eliminate polio from the Americas.

The report continues by explaining how the process of attempted eradication in the Americas gathered strength, guided by an Inter-agency Coordinating Committee (ICC) that was formed with participants from the Inter-American Development Bank, the United Nations Children's Fund (UNICEF), the United States Agency for International Development (USAID), Rotary International, and the Task Force for Child Survival, all of which endorsed and supported a Plan of Action. In addition to the regional-level ICC, many countries established national ICCs, which helped mobilise support and the commitment of all actors involved. As part of this coordination effort, the Plan of Action emphasised personnel training, so PAHO prepared manuals and materials and assisted countries with customising these to fit the local context.

The importance of this grounding in partnership was made evident in October 2000, when the Dominican Republic and Haiti reported two cases of acute flaccid paralysis (AFP). The VDPV outbreak brought to light the need for widespread public information and social mobilisation campaigns, which, as reported here, were key factors that contributed to achieving high coverage. The EPI teams worked with professionals to develop a communication campaign and to ensure that the media was informed. "These were key factors in getting the correct message to the public regarding the risks and the need to vaccinate, and for maintaining the public informed throughout the outbreak."

The report examines actions undertaken in the Americas to support the polio endgame plan. "[T]he greatest challenge and simultaneously the greatest potential looking ahead, is to garner the lessons learned, the capacity built, and the infrastructure and strategies in place from the polio eradication efforts, to strengthen the immunization programs and health systems as a whole. The Taylor Commission concluded that...the polio program in the Americas had ...substantially enhanced the health services' reputation and ties to local communities, broadened support for vaccination at every socioeconomic level, and provided a model for social mobilization and interagency cooperation for future health challenges." Box 3 on page 6 of the report lists essential components for a successful vaccine-preventable disease eradication and highlights from polio eradication in the Americas. Highlighted as factors that made it possible for the Americas to progress toward the goal of polio eradication include:

• the existence of a plan with well-defined strategies;
• a high level of political commitment among governments;
• the dedication, commitment, and hard work of thousands of health care workers;
• a high degree of community participation;
• the strong collaboration of various agencies and organisations; and
• the availability of well-managed resources under strong PAHO leadership.

The report concludes by suggesting that these lessons learned should be considered for future vaccine-preventable disease eradication efforts beyond the Americas.