Isaac Ghinai from UCL Medical School and the London School of Hygiene and Tropical Medicine recently worked with WHO on Polio Eradication. Followig this work, the Assistant Director General for Polio, Emergencies and Country Collaboration Bruce Aylward and Isaac have written an article on polio eradication aimed at medical students interested in global health.
Working in East Africa in 2008 I met George, a boy who couldn’t walk to school or play football with his friends because his left leg was paralysed.
Poliomyelitis is a debilitating disease caused by the ancient poliovirus a highly infectious virus which usually affects children under five. Though most of those infected show no symptoms, once in every 200 children the virus destroys motor neurons leading to irreversible paralysis, usually of one leg. George was lucky - if the paralysis had spread to the nerve which innervates the diaphragm death could result.
In 1988 poliovirus killed or paralysed around 1000 children every day across 125 countries. The World Health Assembly resolved to eradicate polio forever and formed a public-private partnership called the Global Polio Eradication Initiative (GPEI). After 23 years of effort, the GPEI has achieved phenomenal success in nearing its captivating goal: just over 600 children like George were paralysed in 2011 and polio remains endemic in only three countries – Afghanistan, Nigeria and Pakistan. The world is more than 99% of the way to complete eradication
Such progress has not been easy. The GPEI has immunised over 2.5 billion children through the unprecedented collaboration of more than 20 million volunteers and an investment of more than US$8 billion. The GPEI has also driven innovation in other areas by developing an impressive global laboratory network used in diagnosing a range of diseases and revitalising routine immunisation. The challenge now is to integrate this infrastructure into sustainable, nationally owned health systems. With studiesestimating the economic savings from polio eradication between US$40 billion–50 billion between 1988 and 2035, the GPEI has become the largest public health initiative in history with some of the highest economic and humanitarian stakes.
However, these successes have been tempered. Annual polio cases are not dropping as fast as hoped, and polio-free countries have occasionally experienced surprising and devastating outbreaks or re-established transmission. 2011 exacerbated some of these challenges – polio resurged in parts of Africa and China reported its first cases in 15 years. Transmission continues unabated in areas of Pakistan and Nigeria still has all three types of polio circulating, including vaccine-derived type 2 poliovirus“back from the dead” after the wild type was eradicated in 1999.
A number of other difficulties presented themselves:a “deadly” funding shortfall of over US$500 million; waning political will; continuing service delivery challenges and gaps in surveillance quality; risks associated with a live vaccine.
Whilst the last year has undoubtedly been a challenging one for the GPEI, there has also been some remarkable progress. India, often considered the most challenging terrain, has recently been removed from the list of endemic countries for the first time. With a huge birth cohort each year and difficult-to-reach populations in an environment where traditional vaccines proved less efficient than predicted India deserves congratulations on interrupting a chain of polio transmission that has lasted millennia. On top of this, epidemics in Angola and DRC appear to be slowing, and outbreaks in West Africa were successfully controlled.
Though the original target for completing eradication was 2000, the latest strategic plan from the GPEI aims for end 2012. A panel of independent public health experts (the IMB), however, believe that “polio simply will not be eradicated unless it receives a higher priority”. They believe eradication must be completed soon“or risk widespread resurgence of a disabling and fatal disease” and lose the hard-won trust of public health workers and sceptical communities world-over.
Thus the public health, moral and economic cases for eradication remain compelling, and there are encouraging signs that the tools may be materializing to finish the job. The Executive Board of the WHO recently declared ongoing polio transmission a ‘programmatic emergency’ for global public health necessitating stronger international action plans and accountability – whilst the US Centres for Disease Control moved all polio activities into a war-room style operations centre with state-of-the-art facilities. Despite clear funding pressures during economic upheaval, the GPEI reduced its funding gap over the last year: David Cameron, doubling UK support for polio eradication, said "it is never the wrong time to do the right thing."
And 2012 is the right time. Polio is cornered. Political commitment is growing, and the GPEI has the proven track-record of technical success to match this. If the political will, funding and expertise can be sustained over this critical juncture there is a real possibility that wild poliovirus type 3 (WPV3) – with cases at an all-time low – may be eradicated this year, followed soon by the final strain, WPV1.
An integral part of this will be a surge in support at the field level. The GPEI is therefore seeking highly motivated people for short-term placements on the ground to help Stop Transmission Of Polio (STOP). STOP teams have already made a huge difference to the landscape of eradication and given hundreds of young health professionals a chance to play their part in an historic public health achievement. To join the 20 million-strong team of volunteers as a STOP-er, visit www.cdc.gov.
Petitions encouraging governments to maintain their commitments to polio eradication were instrumental in securing such strategic gains, and if you would like to get involved further resources can be found on www.theendofpolio.com/ and www.polioeradication.org.
2012 represents a real chance for us, the young medical community, to ensure that, unlike George, every child everywhere is free from polio forever – it’s now a global priority, and it should be our priority.
 Duintjer Tebbens, R. et al. 2010. ‘Economic analysis of the global polio eradication initiative.’ Vaccine: 29(334–343).