The Current Polio Program

SVEA CLOSSER: Now let’s talk about where the polio program is today or at least when this lecture was recorded in 2020. First, between the years 2000 and 2010, there were major increases in routine immunization coverage across the world, a result of renewed attention to routine immunization through initiatives such as Gavi. Still, routine immunization was not high everywhere, particularly in polio endemic areas of Afghanistan, Pakistan, and Nigeria. Routine immunization coverage was low. So what this map shows is there’s still some pockets in South Asia and sub-Saharan Africa in 2010 that have less than 60% reaching immunization coverage. The same regions in South Asia and sub-Saharan Africa still stubbornly had polio cases.

In 2010, there were still polio in Nigeria, Afghanistan, Pakistan, and India. It’s those same regions that, while they had made big improvements in routine immunization, still didn’t have full coverage. In part in recognition of this, Gavi or the vaccine alliance, which is responsible for routine immunization, was added as a partner to polio eradication in 2019. This was a big, big move for polio eradication because, in practice, despite stated commitments, polio eradicators and those championing routine immunization, although one would think that their goals were quite similar, have actually sometimes been at odds.

In the 1990s, for example, part of the reason that polio eradication got off to a very slow start was because many in the World Health Organization were still skeptical of eradication as a strategy and of polio eradication in particular. On the other side, polio eradication officials have sometimes seen support for broader health goals, even the relatively narrow goal of promoting more routine immunization as a distraction from the single-minded focus needed to eradicate a disease. In the early 2000s, for example, many, though certainly not all polio eradication officials, were wary of Gavi. They viewed Gavi as a potential threat, a competitor for attention and funding.

A global level policymakers said, quote, “The Independent Monitoring Board made a recommendation back, and I believe it was 2014, that Gavi should be made a sixth spearheading partner of GPEI. And at that point in time, they decided not to invite Gavi to be a member of polio eradication, but there have been increasing calls for this to happen”, end quote. And it was shortly after this interview that Gavi was added as a partner. Given the different mandates of Gavi and the Global Polio Eradication Initiative– one aims to eradicate a disease, the other aims to increase routine immunization– it’s not yet clear how the addition of Gavi will affect the shared decision making within polio eradication.

So this map shows one way of thinking about the situation of the Polio Eradication Initiative in 2020. This is the optimistic view. It shows you that there’s only two countries in the world that still have wild polio cases– Pakistan and Afghanistan. This map shows a different and less optimistic version of the story. There’s a new problem– big outbreaks of vaccine-derived polio, the orange dots on this map. As you can see, countries across sub-Saharan Africa, South Asia, and even East Asia have been infected with vaccine-derived polio. We’ll dig into that in more detail elsewhere in this course. But the short version is that vaccine-derived polio functions almost exactly the same way as wild polio.

It’s preventable with adequate vaccination, and you need more vaccination campaigns in order to stop it. In addition, there’s an emerging problem in that COVID put vaccination campaigns on hold across much of the world. As this lecture is being recorded in August 2020, polio cases has risen across the world. So it’s been a very long road since that last case of polio was found in the Americas in 1991. It’s been much more difficult and much more expensive than anyone dreamed. But along the way, a new model for collaboration in public health was born. This model now seems common. These sorts of partnerships all built on the polio model are everywhere. But polio was the first.

And its trajectory gives us some idea both of the promise and the challenges of this model.