Lancet Editorial – Polio eradication: where are we now?

The Lancet  
Oct 26, 2013  Volume 382  Number 9902  p1381 – 1458

Polio eradication: where are we now?
The Lancet
[Full Text]

On Oct 17, WHO received reports of a cluster of acute cases of flaccid paralysis in Syria. Initial results showed two suspected cases of poliomyelitis, indicating the first apparent outbreak of polio in 14 years in the country. Syria is now considered at high risk for polio and other vaccine-preventable diseases, and this suspected outbreak raises the alarm that the country’s health crisis has deepened further. With the appalling conflict in Syria continuing to damage the health system infrastructure needed for polio eradication, as well as other health services, this new suspected outbreak is a reminder that political determinants of health underscore the success or failure of eliminating this disease once and for all.

Beyond Syria, polio campaigns in Pakistan have been damaged by repeated violent attacks and killings of polio workers, lack of public confidence in vaccines because of the false characterisation of vaccination as a plot to sterilise Muslims, and publicly boycotted polio immunisation by the Taliban. Worryingly, the situation in North Waziristan Federally Administered Tribal Areas—where polio vaccines are strictly blocked—is becoming increasingly severe, with the largest number of children being paralysed by poliomyelitis in all of Asia.    Compared with this time last year, Pakistan has made little progress with almost identical numbers of polio cases. Clearly, attacks on health workers are unacceptable, and those who engage in them must face prosecution. Furthermore, the reasons why the general community might be suspicious of vaccination should be addressed. While health education is an important part of promoting vaccine uptake, the mistrust of authority that fuels anti-vaccination conspiracy theories must also be examined. The latest sociological and psychological research as to how and why people come to hold such beliefs, as well as the specific cultural milieu in which vaccination programmes operate, should be taken into consideration.

Poliomyelitis also re-emerged in the Horn of Africa this May, with 174 cases in Somalia, 14 in Kenya, six in Ethiopia, and three in South Sudan according to the most recent reports. In Somalia, many polio cases are in areas south of Mogadishu where Al-Shabaab operates. The group refused to admit supplies of polio vaccine and launched a propaganda campaign in areas it controls, spreading falsehoods about the vaccine to scare off parents. Furthermore, Somalia has been so dangerous for health workers that Médecins Sans Frontières pulled out of the country in August of this year, ending an involvement of 22 years.

Continued virus transmission in endemic countries, and the outbreaks of polio in the Horn of Africa and Syria, are pertinent reminders that the most difficult challenges for global polio eradication are the political determinants of health such as weak health systems, public mistrust, political instability, and conflict—rather than medical barriers.

With regard to the technical dimension of ending polio, global eradication efforts led by WHO, UNICEF, and the Rotary Foundation have made remarkable progress. Poliomyelitis cases have been reduced by more than 99% and there are only three remaining polio-endemic countries—Afghanistan, Nigeria, and Pakistan. In 2013, the number of polio cases from the three endemic countries—99 in total—is 40% lower than in 2012. To further strengthen the efforts, the Global Polio Eradication Initiative (GPEI) launched the new Eradication & Endgame Strategic Plan 2013—18 in May, with a detailed budget and a new deadline for polio eradication set for 2018.      The plan has four simultaneous objectives: detection and interruption of wild poliovirus, strengthening of routine immunisation and withdrawal of the oral polio vaccine (OPV), containment of all virus samples and certification of interruption of transmission, and legacy planning to benefit other health and development initiatives. Notably, the most ambitious vaccine introduction plan in history has been initiated, which aims to introduce inactivated polio vaccines (IPV) by the end of 2015 in 124 countries to replace OPV and eliminate the rare risk of vaccine-derived cases of polio. In June of this year, the GAVI board agreed to provide financial support and play a lead role in introduction of IPV.

Technical improvements are insufficient, however, unless the political context, which has been paid little attention, is tackled more seriously. World Polio Day on Oct 24 is a reminder of the importance of global polio eradication. To end poliomyelitis at this stage, strong political will from international partners and governments to address the political determinants of disease eradication more vigorously and urgently is key.