IMB Imposes Urgent Deadlines to Jump-Start Needed Polio Program Improvements
September 7, 2016Global polio eradication’s Independent Monitoring Board (IMB) is pushing stringent deadlines for its latest recommendations hoping to generate the urgent program improvements necessary to stop wild poliovirus transmission by the end of the year. Meeting the end-2016 goal is necessary to ensure certification of eradication can occur in 2019, as currently targeted by the Global Polio Eradication Initiative (GPEI).
”…[T]he IMB is quite clear that the Polio Programme has not yet reached peak performance, and this is disappointing,” the panel said. “With six months to go, it must do so if the goal of ending polio transmission by the end of 2016 is to be realized.”
To foster a sense of immediacy, the eight-member panel-- formed to monitor progress toward the goal of global polio eradication-- set an end of September 2016 deadline for nine of 12 recommendations with the remaining to be completed this fall. Previous IMB recommendations generally have not highlighted particular deadlines, especially ones as tight as those included in this report. While the GPEI, which manages the polio program, is under no specific obligation to follow the IMB’s advice, officials take the recommendations seriously and attempt to comply when possible.
While there currently is a record low 25 cases of paralytic wild poliovirus reported globally as of September 7, the IMB noted with concern that the low season for transmission is over in the two remaining endemic countries, Afghanistan and Pakistan, and the high season looms. Further, it says, when India was still an endemic country it had only two polio reservoirs six months before it recorded its last case. By contrast, Afghanistan and Pakistan each still have four core reservoirs. Polio reservoirs are areas where wild poliovirus has been detected repeatedly. “It is not a good sign so close to the deadline, that the Polio Programmes in these two countries have not yet been able to reduce the number of reservoirs,” the report says.
The Polio Oversight Board, a panel comprised of the heads of the five organizations managing the GPEI-- the World Health Organization, UNICEF, the U.S. Centers for Disease Control and Prevention (CDC), Rotary International, and the Bill & Melinda Gates Foundation-- has endorsed a financing scenario that targeted 2016 for ending poliovirus transmission and 2019 for global certification of eradication. There is a three year lag between the last case and when certification can occur. For the program to achieve the goal, the IMB recommends that by end September 2016, the GPEI:
• Instate a high level leader to oversee cross border immunization efforts in Afghanistan and Pakistan;
• Appoint a senior female official to strengthen the role of female workers, especially in Afghanistan;
• Provide financial incentives to health workers to improve polio surveillance, and;
• Improve the political leadership of the polio program in Northern Sindh, Pakistan.
In specific recommendations to CDC, the IMB urges the agency to facilitate improved polio surveillance reporting and assessment in both Pakistan and Afghanistan with an action plan completed by the end of September.
The quality of polio surveillance is a strong theme in the report. While both immunization and surveillance are required for eradication, surveillance is “too often the poor relation—taken for granted and with not enough resources,” the IMB says. In particular, the IMB notes the importance of environmental surveillance, which can detect traces of poliovirus in sewage and therefore determine if the virus is still circulating silently. Only one in every 200 people who come into contact with poliovirus actually develops symptoms, meaning the virus can circulate undetected for months and even years.
Other IMB recommendations address improving understanding of social circumstances preventing vaccination, reviewing standards for outbreak response, and re-establishing a Red List of 32 countries that are vulnerable to polio transmission.
While cracking the whip on the program to urge quick improvements, the board also noted significant progress since its previous report, issued last October. It said, for example, that the virus is now contained in the smallest geographic area ever and that the Pakistan polio program has improved greatly. It noted that the establishment of a polio emergency operations center and personnel changes in Afghanistan have enhanced performance there, and that GPEI management is performing more effectively.
Overall, the IMB has in the last year urged the GPEI and especially country polio programs toward the excellent performance it says is necessary to achieve eradication. As it has been throughout the last decade and a half, progress toward eradication remains fragile and tenuous, particularly as the GPEI attempts to extinguish the virus in in some of the world’s most insecure environments. In fact, since the IMB’s July meeting, called to formulate the August report, Nigeria has reported three cases of wild poliovirus paralysis in violence-torn Borno state, a program setback the panel now is assessing. The outbreak proves once again that in addition to peak programmatic quality, the current geopolitical situation will require unprecedented collaboration between security personnel and public health experts for eradication to succeed.