Highs and Lows in the Quest for Zero: Twenty-First Report of the Independent Monitoring Board of the Global Polio Eradication Initiative

"Political commitment, consensus, alignment, and coordination are essential for polio eradication to be successful but they are not enough alone."

This report on the (virtual) March 2022 Independent Monitoring Board (IMB) of the Global Polio Eradication Initiative (GPEI) meeting tells the story of polio eradication during 2022 so far. It examines the situation in Pakistan, where news of 2 wild poliovirus (WPV) cases after such a 14-month interval came in April 2022 as this report was being finalised. Now that the Taliban has taken power in Afghanistan, the report addresses the prospects for being able to vaccinate the large number of children that have been inaccessible in Afghanistan for several years. It also reviews the factors that have contributed to the outbreak of cases of vaccine-derived polio in Nigeria and what needs to be done to gain control.

In their presentations to the IMB, the GPEI leadership pointed to a number of key areas of progress - as well as reasons for concern - in the endemic countries (Pakistan and Afghanistan), in Nigeria, and in terms of multinational outbreaks of vaccine-derived poliovirus. In Afghanistan, the GPEI leadership explained to the IMB that they were maintaining intensive engagement with the Afghanistan health authorities about the balance between house-to-house and mosque-to-mosque modalities of campaign delivery. There have also been advocacy missions to seek the support of the Qatar Government. The IMB was told that there are concerns within the Taliban authorities about community attitudes. As there are very acute health needs, they argue that going house to house with vaccines when people do not have basic health services would not be good for their new government. Here are a few additional examples out of Pakistan:

• The GPEI leadership informed the IMB that, overall, there has been a consistent decrease in the number of chronic or persistent vaccination refusals in Pakistan. New social and behavioural change approaches have been piloted to really make sure communication is strengthened, particularly targeting hostility towards the vaccine and its avoidance and refusal.
• According to the 2021 Knowledge, Attitudes, Practices and Experiences (KAPE) survey conducted by GPEI partner the United Nations Children's Fund (UNICEF), people surveyed in Balochistan reported far lower rates of trust and willingness to vaccinate their children than those living in other Pakistan provinces. Very few respondents in Balochistan regarded religious leaders or traditional healers as being supportive of polio vaccination, and the majority believed that vaccinators were "outsiders". The UNICEF survey offers 4 recommendations to help improve perceptions of the Polio Programme and parents' willingness to vaccinate: (i) Reduce the frequency of campaigns. (ii) Meet caregivers' needs for other services. (iii) Eliminate coercive tactics. (iv) Increase awareness in local languages, and use visual methods to reach illiterate audiences.
• The provincial polio team in Sindh told the IMB about its microlevel planning based on profiling of vaccine refusals, establishing detailed language and cultural information, and investigating the reasons for the refusal. This analysis enables the teasing out of the reason for the refusal, whether it be a misconception about the vaccine, a religious belief, a fear of exposure to the risk of COVID-19, or a demand-based matter (e.g., resentment about lack of government provision of services or sanitary infrastructure). The provincial Polio Programme then chooses the appropriate person is to help engage with the family who are refusing. Among other activities: Parliamentarians are involved in inaugurating campaigns and helping to turn round refusals; there are alliance-building activities with the Pakistan Paediatric Associations; influencers' engagement has given good results, and this is now being further developed; the communications and operations teams have been integrated; in prioritising high-risk, mobile populations, there are communication tactics that aim to unpack the missed children data, sustain demand, and engage the most vulnerable through tailored strategies; there have been efforts to match the language profiles of vaccinators to local communities; and women's organisations have helped in developing the action plan for Urdu-speaking areas.
• Khyber Pakhtunkhwa (KP) province is the focus of the greatest concern globally and nationally. The IMB was told that some of the refusals in KP were strongly linked to protest about lack of public resources and infrastructure. The provincial government is trying to address this problem, in part through visits to these areas to listen to communities' concerns and to explain to them what the government is doing for the people. The IMB understands that there is very little deployment of female vaccinators in key areas of KP province. Male vaccination teams do not have the authority to enter the houses, so the children have to be brought outside, thus risking chronic omission of children from the vaccination rounds.

In its update on progress with its gender equality strategy (see Related Summaries, below), the GPEI leadership concentrated on gender mainstreaming, which is the process of assessing gender implications for all affected people within any planned action. In recognition of the fact that gender is a powerful determinant of health, the Polio Programme's systematic approach will work to address gender-related barriers to vaccination while increasing women's meaningful participation in decision-making and leadership roles, in demand creation, and in health service delivery. The Polio Programme has 4 specific areas of focus: (i) country support for gender strategy setting and planning; (ii) data for action; (iii) gender parity and human resources; and (iv) the prevention of sexual exploitation, abuse, and harassment, as well as policies and practices for safeguarding, protecting, and supporting polio workers and communities. The IMB was told that many initiatives applying the gender equality strategy are planned and being taken.

In subsequent sections of the report, the IMB discusses the main issues that arise from the progress reports and insights gained. Brief highlights include:

• Pakistan: In the weeks after the IMB meeting, the national political context changed dramatically. If the new government does not ensure continuity of approach and puts in place measures that do not replicate the key features of the previous arrangements, polio is likely to make a return on a larger scale. As the IMB report was being finalised, the GPEI reported that 2 new cases of type 1 WPV had been detected in North Waziristan in the KP province.
• Afghanistan: The Taliban initially showed no interest in talking about specific programmes, but it is encouraging that, during 2022, core organisational components for managing the Polio Programme have been re-established. At the time of the IMB meeting, of the 1.5 million children not reached in recent campaigns, about 1.3 million were in the 2 most epidemiologically significant regions, the east and the south. The inability to perform house-to-house vaccination campaigns everywhere in Afghanistan (vs. mosque to mosque) is the single biggest obstacle to success in the country.
• Nigeria: "A GPEI analysis found that, if all risks of vaccine-derived poliovirus had been completely eliminated in 2015 in northern Nigeria, outbreaks in 19 other countries would probably not have occurred. The IMB had repeatedly urged the Nigeria Polio Programme to avoid complacency and, particularly, to develop strong resilience. This advice was not heeded....IMB sources report that, in Kano state, a polio hotspot, mobilisation efforts to persuade people to vaccinate are much more limited than at the height of the action to eliminate wild poliovirus, when there was messaging featuring multiple languages, on all radio stations....Nigeria's essential immunisation performance is well below what would be expected for a country that had eradicated wild poliovirus and was building resilience on the journey to a polio-free world."
• Outbreak countries: "The sense of urgency for getting the job done on polio seems to have vanished among competing priorities, especially to get rates of COVID-19 vaccination up. Communities do not always see the polio vaccine as a priority...[T]he GPEI leadership told the IMB that it is trying to take a longer-term advocacy approach with countries to prevent outbreaks as well as respond to them. This will include engagement with external stakeholders. A GPEI advocacy group is working on a more comprehensive plan to ensure that it is engaged with the key influencers for specific countries."

The report also highlights the unexpected discovery of a case of WPV in Malawi. The war in Ukraine, a polio-vulnerable country, came after the IMB meeting, as did the occurrence of a case of vaccine-derived poliovirus type 3 in Israel.

Following data insights, the IMB report offers 10 recommendations, including:

• For Pakistan, example: "that the new Prime Minister of Pakistan gives his strong and public commitment to, and directly involves himself in, finishing polio eradication in this endemic country and that he works to maintain and sustain a political consensus to this end. It is also recommended that continuity of polio leadership is maintained, together with the collegiate style of working that has enabled federal and provincial programmes to share information, learn from each other's experience and plan and prioritise action together."
• For Afghanistan, example: "that the new Afghanistan administration and the GPEI...resolve to work jointly and supportively to launch a new and comprehensive programme to bring the polio vaccine to every house in the country before polio takes hold again..."
• For Nigeria, example: "[that] high-level advocacy action from the GPEI leadership and Nigeria senior public health officials [aim] to maintain full political attention and engagement, specifically in the context of forthcoming elections."
• In outbreak countries, example: "that reactive and outbreak response activities, as well as preventive vaccination activities, are implemented in a multiantigen format where possible, signalling the importance to communities that polio immunisation is a mainstream children's health necessity and not some sort of West-driven special project."

In conclusion: "A key learning point in the last two years is that the global Polio Programme cannot allow the quality of its operation to slide in countries that have the potential to become a major source of spread of polioviruses, either wild or vaccine-derived."