Summary of the 22nd report of the Independent Monitoring Board (IMB) for Global Polio Eradication Initiatives (GPEI)

Wrishmeen Sabawoon, M.D., Ph.D., Senior Advisor Liaison

This report summarizes the IMB 2023 report entitled “Closing in on Zero: Adapting to Complexity and Risks on the Path to End Polio” and its implications for Japanese stakeholders. It reviews polio endemic (Afghanistan and Pakistan) and polio outbreak countries situations and concludes whether the GPEI 2022-2026 strategy will achieve its goals(the interruption of both wild poliovirus (WPV) and vaccine-derived polioviruses (VDPV)) by the end of 2023.   

 Goal 1 of GPEI 2022-2026 strategy: Interruption of WPV by the end of 2023: In spite of recent significant progress toward polio eradication, the IMB judges that the progress toward the first strategic goal is off track with a very high probability that it will be missed. This is because the complexity of the continuing barriers to interrupting wild poliovirus transmission in endemic countries is too great to be resolved in a short period, explained as follows:

Pakistan:

• Pakistan succeeded in eliminating and clearing key reservoirs of poliovirus (e.g. Karachi and Quetta) in the past years. However, looking at Pakistan's current context, the interruption of WPV by the end of 2023 is formidable. There have been few political shifts in the past few years and there will be a national election at the end/or early 2024, which comes with the potential of losing political commitment to polio. The security situations in Khyber Pakhtunkhwa and Balochistan provinces deteriorated, resulting in a fearful environment for operations in some areas. Moreover, the Mehsud Belt of South Waziristan, a wide area containing some of the high-risk districts for polio, is inaccessible. In Balochistan, near the border of Iran, external monitors cannot monitor polio campaigns. There are also areas in Balochistan, where a few of the planned campaigns were done. These political and security situations are less likely to be resolved in a short time.

• In addition to access and political issues, other challenges include low routine immunization coverage, poor sanitation, polio campaign quality (missed houses by vaccination team), refusal and mistrust of vaccination campaign (e.g., fake finger marking), and a boycott of the polio vaccine (e.g., 218 in January 2023) due to the community and interest groups' unmet wider demands also exist.

• The program staff has concerns about the risk of reestablished transmission of WPV1 in the Quetta Block, one of the traditional reservoirs in the country.

• There are various health issues and different demands of the community, and there is still a lack of critical mass of integrated service methods in polio-endemic areas.

Afghanistan:

• As of July 31, 2023, the poliovirus has not been detected for more than 18 months in 30 out of 34 provinces in Afghanistan. In spite of improved access to children in polio campaigns, there is an immunity gap in the eastern region. Moreover, there is a risk of re-establishment of WPV transmission in Kandahar, one of the three traditional reservoirs, where a positive environmental sample was reported in May 2023. It poses major risks to both Afghanistan and Pakistan.

• The key challenge for polio in the country is humanitarian crises affecting 28.3 million people amid mid-2023 due to decades of conflict, insecurity (occasional ISIS Khorasan suicidal attacks), natural disasters (e.g., drought), and political upheaval; poverty, economic contractions with a drastic reduction of international aid, freezing of assets, and millions of malnourished children throughout the country are also factors to consider.

• The second challenge is the implementation of a site-to-site campaign instead of a house-to-house (H2H) one, especially in the southern region, making more children susceptible to getting polio. There is a cluster of 27,000 refusals scattered in the eastern endemic provinces. These refusals are three categories of people, 1) refugees from the Bajawar and Swat districts of Pakistan, 2) refusal due to religious grounds, and 3) governmental authorities not allowing vaccinators to enter their areas.

• The third challenge is the poor routine immunization program, which is a health system component dependent on donors’ grants. The funds to the health system, especially the hospital sector, have dwindled, making it difficult to own a strong routine immunization program required for maintaining polio-free status.

• The women are allowed to work in the polio campaign, though their participation is low. Women are the best human source that can help in the conversion of vaccine refusal in the country.

• There is poor sanitation throughout the country, especially in the polio-endemic eastern region. 

Goal 2 of GPEI 2022-2026 strategy: Interruption of VDPV by the end of 2023. The cumulative number of cases of polio due to types 1 and 2 vaccine-derived poliovirus shortly after the IMB meeting (25 July 2023) was 192. By the same period in the previous three years, it was 391(2022), 327 (2021), and 495 (2020). The majority of the cVDPV cases are reported from a small number of “consequential geographies”, including the eastern part of the Demographic Republic of Congo, western Nigeria, south-central Somalia, and northern Yemen. Nigeria is responsible for the infection of 23 countries and the DRC for another five or six countries. In each of the four consequential geographies, a range of deep-seated contributory factors are fueling transmission, including inaccessibility, lack of security, political instability, and logistical complexity. Despite the reduction in cases, the IMB judges that the target will be missed.

Its main reasons are the poor performance of routine immunization programs in the outbreak countries, poor surveillance systems, and the shortage of financial resources to improve their health systems and conduct preventive polio campaigns. The health systems in the cVDPV-affected countries have challenges in the timely and effective implementation of the outbreak response. Moreover, in accordance with the Global Polio Surveillance Action Plan 2022-2024, it sets a target of 35 days for the notification of the poliovirus detection. However, only two countries(Afghanistan and Pakistan) have met that target.

 In summary, despite a significant reduction in the number of WPV and cVDPV cases, the GPEI 2022-2026 strategy is less likely to achieve the interruption goals by the end of 2023 due to security, access issues, operational issues, and financial challenges. Donor countries, polio-endemic and outbreak countries, and polio partners should have a long-term commitment to eradicate polio. The donor countries and GPEI partners need to provide financial resources for health system strengthening, boosting of surveillance, and integration of services in polio-affected countries.