Global Polio Eradication Initiative (GPEI)

OLAKUNLE ALONGE: In this lecture, we’re going to be talking about strategies for global health program implementation with insights from polio eradication. Now, the Global Polio Eradication Initiative, it’s really the largest of its kind in terms of global health programs in the world. And there’s quite a lot to learn from the Global Polio Eradication Initiative, in terms of the scope, in terms of the actors, in terms of the context, and the strategies. All of these lessons are applicable for other global programs and for health system strengthening activities throughout the world. And given the time for what the polio program had been, we’ve also seen a lot of dynamic changes in the context in which the polio program was implemented.

And these dynamic changes have also prescribed newer ways, innovative ways, for addressing challenges and strategies. And all of these really provide a very niche experience for other global health programs to learn from. So you can imagine that a program that has reached over 2 billion, at least there were over 2 billion doses of polio vaccination to over 2.5 billion children all around the world. And it has reached almost every nook and cranny of the world, really the present global program.

So indeed, the Global Polio Eradication Initiative do have a lot to offer practitioners, researchers, academics, and students of public health and other global programs broadly on what to do and what not to do in terms of coordination, organization, and planning and implementing strategies for achieving a global objective. The Global Polio Eradication Initiative was something that started far back in 1988, which was borne out of the effort and the need to eradicate polio, which is a debilitating paralytic disease from the face of the world. So back in 1988, some key stakeholders recognized that the benefit of vaccination was something that could in fact be a useful vehicle for eliminating polio throughout the world. And it did come together.

So obviously this collaboration required stakeholders working, which we’ll talk about in the short while, working at a global level, at the regional level, at the national level, and at subnational level. So we have actors working at different levels to coordinate efforts. And the effort was basically to target immunization and [INAUDIBLE] of diseases to children who were at risk of polio all across the world. So it crossed across boundaries, geographies, contexts, and different peoples and cultures. As I said, far back, about 30 years ago, in 1988, there was a lot of success in eradicating polio from North America and from the Philippines and in the [INAUDIBLE] region.

The [INAUDIBLE] region is the Pan-American region which basically is Latin America and South and Central America. So riding on the success, the world felt that it was indeed ready to not just only eliminate polio from some regions of the world, but in fact to completely eradicate it, that is to say to completely remove the chance of any child or any individual suffering polio to zero. And the world came together at the World Health Assembly on the [INAUDIBLE] of the World Health Organization involving stakeholders like the Rotary International or the UN agencies, and identifying eradication of polio from the world as a major goal.

So a target was set to eradicate, at least to eliminate, polio completely across the world by 2000. And the major activities were really around mass immunization with the polio vaccine, active surveillance for cases of market flux and policies. And these just were the two major prongs, which were later morphed into additional strategies which were to combat. But the idea was that there was political commitment. There was a lot of solidarity at the very global level. And there was an evidence-based intervention, which was a vaccine, some set of strategies which could be helpful to eliminate polio. With hindsight now, there’s been a lot of look back to really revisit that goal, so the goal to eradicate.

Eradication is a really very scientific term. And in the strictest definition, it actually should be distinguished from other kinds of efforts for reducing or combating mortality and morbidity due to infectious diseases. So the first that we should clarify is control. So when you say you’re going to control a disease, it’s really the effort to bring down the incidence or the prevalence of the disease to an acceptable level. So it’s a scenario where you have a disease still occurring in the environment. But the morbidity and the mortality resulting from the disease is really manageable. And for these, you really need to continue to maintain measures for controlling the disease.

So treatment, public control, and so on needs to be ongoing for you to achieve a control goal. With eradication, which was the goal that was set for polio in 1988, really requires a global extinction of the disease-causing agent. So not only are you going to control the disease, but you really want to completely remove the chance of transmission from one individual to another to complete zero. You want to eliminate the incidence of the disease to zero, that is to say that no individual, no person, really have the disease on the face of the Earth. So that was really what was the goal that was set for polio.

And to achieve this, obviously there’s a lot of resources that you have to think about and you have to figure out. But if the eradication goal is achieved, unlike control, you don’t anticipate to continue to put in prevention measures. So you can end your prevention measures permanently. So you would see that there’s really quite a lot of difference between aiming to control a disease or trying to eradicate a disease. And there is a [INAUDIBLE] variant of goal that you could have, which is to eliminate. Eliminate is similar to eradication. The only difference is really that you limit the effort to a specific geographical boundary.

So for instance, polio was initially eliminated from the United States of America, from South America, before the Global Polio Eradication Initiative were implemented. Eradication, on the other hand, is really elimination from across the globe, so across all geographies, across all boundaries, and so on. The question is, why was the goal for polio to eradicate and not control? It’s a debate that we keep having, even as of today, because many with hindsight, given the protectedness of trying to actually win the eradication goal, has really looked back and wondered whether eradication was indeed the right call as far back as in 1988. Well, just to say that there are classical characteristics or criteria that are useful for setting an eradication goal.

One obviously are the biological considerations with respect to having an effective intervention, in this case a vaccine, that is available to interrupt the transmission of the disease-causing agent. And then there’s also the [INAUDIBLE] consideration, where you could really see clear clinical manifestation of the disease such that you can readily recognize, identify cases under surveillance measures in place which are more specific and sensitive to identify the disease. And then it’s important that for any disease for which eradication will be the goal, that humans are essential for the life cycle of the disease-causing agent. Phased in another way, humans should be their own [INAUDIBLE] of war.

So once you eliminate the disease-causing agent from among human populations, you do not anticipate that the disease will continue to replicate in the environment or amplify in the environment for any reason. So these are all biological considerations that you need to consider to set an eradication goal. But beyond biology, there are also the social and political criteria. I mean, the notion that if you’re going to achieve a scale within the country and the world, there has to be political commitment from leaders. It has to be seen as a socially ideal objective. It has to be acceptable to the different cultures and contexts under which you might have to walk.

And again, there’s also the economic consideration in terms of the cost that it would take to achieve such global collaboration, vis-a-vis the cost of just trying to control the disease. This in fact really speaks to a lot of debate in our case. So given all of this criteria, do we think that eradication should have been the goal for polio from the onset? And these are some of the critical lessons that we are hoping, or by the costs of these costs since, you will be able to understand how goal setting, agenda setting kind of influences implementation and success of global programs.

We know for a fact that of all the criteria that I listed, back then in 1988 our understanding of the biology of polio was not as it is right now. So as of today, we know that it’s in fact possible for polio to amplify in the environment, which if we knew back in 1988, maybe perhaps we wouldn’t have actually think the eradication goal. So just to say that that’s your food for thought.

One of the major lessons to learn from polio and from many global programs is really first around how you set a global agenda and how you use all of the information that you have at your disposal to set the appropriate agenda or the appropriate goal for the global effort. For polio, the effort was really spearheaded by a global coalition of international organizations and agencies, led chiefly by the World Health Organization and the Rotary International, the United States Center for Disease Control and Prevention. The United Nations [INAUDIBLE] emergency funds. And later on the Bill and Melinda Gates Foundation joined the key partners.

And more recently, in 2019, [INAUDIBLE] 20, the Gavi, that is the Global Vaccine Alliance, joined the [INAUDIBLE] coalition, as well. So these six partners currently lead the effort to set agenda, to implement activities, to track progress for the Global Polio Eradication Initiative. And then you can understand that bringing different entities with their different organizational behaviors and incentives really also portends a major challenge for global health. And again, this is another aspect of the polio program that other global health initiatives can learn from. Understanding the incentives of different agencies, aligning the incentives to achieve the common goal– we can learn from the polio program in terms of how this was achieved for polio and for the Global Polio Eradication Initiative today.

And we can also learn from some of the pitfalls and the challenges that was experienced earlier on in terms of integrating these different agencies together, working together, setting the clear set of [INAUDIBLE] principles, and so on. So again, there’s a lot to unpack. And these are steps that any global health initiative will have to undergo. So for any global initiative, either it is to address a pandemic like the COVID-19 or try to address an infectious disease like malaria, a goal will have to be set. And you have to think critically about how the goal is set. And the coalition of stakeholders will have to be involved in setting the goal.

And you have to think about how those coalitions will work together and the principles that will guide them and how their different expertises and the spheres of responsibilities will be defined. And looking back to over 30 years of the polio program, we can learn a lot from what was done right in the Global Polio Eradication Initiative and what could have done better with regards to these different aspects. Now, just to describe that indeed the polio program has been a huge success without a doubt, if we look at the metrics of the cases of polio that we have seen over the years, on this slide, we’re seeing the map of the incidence of polio in 1988.

So as of 1988– 350,000 cases of polio across the globe. And the map shows where these cases where concentrated. So as in 1988, we have most of the cases in Africa, which is shaded red or which is in a darker shade, and also in Asia. And then to some extent there were cases in Europe, particularly in Spain and France. And there were also some cases in South America, in Brazil, and in other parts of North America, particularly Mexico. So we see that this was truly a global disease as of the onset of the Global Polio Eradication Initiative. And by 2008, that is just in a span of 10, 20 years, the cases were reduced to about 8,500 cases globally.

So that in itself, it’s a huge success. That is in the first 20 years of the initiative, the cases of polio were reduced by over 90%, which is tremendous. And you can begin to understand the amount of effort and coordination that would have taken place at the global level, at the regional level, at the national level, and the subnational level, and the different actors and strategies and activities to achieve that goal. So by 2008, we had polio limited to largely part of Central and West Africa and to the India subcontinent and also including Pakistan and Afghanistan in Asia.

And the map that you see here shows the different types of polio viruses that were caused in the cases in the areas that I just described. The wild polio virus type 1, which is shaded in red, is concentrated more to Nigeria and to Pakistan and India and some part of Afghanistan. And then we have the type 3, which is more concentrated to India and Nigeria, as well as [INAUDIBLE] country Chad to Nigeria. And then you have places where you have both type 1 and type 3, which was mainly in India back in 2008. So again, this map just shows you how much success we were able to achieve.

I mean, when I say “we,” I mean global coalition and every actor working together in just the space of 20 years. And there’s a lot of lessons to learn from what were the facilitators to this success, what were the barriers to this success, how were the barriers addressed, and what were the key implementation strategies that were used to address these barriers and so on and so forth. And all of these lessons really provide a rich knowledge assets for other global health programs and for health system strengthening. And then by 2018, the cases were further reduced to just about 150 cases. So again, it really shows to you how much success that we had achieved.

And most of the cases were largely cases from circulating vaccine than wild polio viruses. If you listen to the lecture on the polio basics, we explain this to some extent. And the wild type of the polio viruses are only endemic to Afghanistan and to Pakistan as of 2018. Now, this indeed is success. But you can see that it took 20 years to reduce the cases from 350,000 to about 8,500 cases. And then it took another 10 years to reduce it from 8,500 cases to about 150 cases. And that really shows to you the challenges of really achieving an eradication effort, particularly with what we call the last mile.

So it’s more difficult to overcome the last mile than when you start. So last mile really describes special populations, challenging contexts and scenarios. So while it might be easier to deploy vaccination or [INAUDIBLE] to a widespread geographical area, there are some key world populations that are hard to reach for some reason, either politically, socially, culturally, or areas where you have insecurity. And this portends a major challenge to any global eradication initiative or to any global health program, in fact.

And there’s a lot of lessons that we can learn from the polio program from an implementation perspective on how to reach this last mile and how to think about addressing what I call weaklings in terms of context and settings that facilitate eradication initiatives. Nigeria is a special case which I would like to highlight in this slide again to show what success you can achieve with a concerted effort. Nigeria was one of the few countries that, until recently, was endemic for polio.

And it had all of those challenges that I mentioned earlier on, including having an insecurity conflict affecting some areas, issues with social contexts and cultural barriers which led to refusals of vaccines in some areas, then widespread inequality in terms of health outcomes and health services, and so on. But Nigeria was able to overcome all of these challenges. And by 2015, it was actually removed from countries for which polio was endemic. And since more than three years now, there has been no cases of wild polio virus detected in Nigeria. And just recently documentations were received from Nigeria by the African Regional Certification Commission. And the country and the rest of the African region is on track to be certified as polio-free.

So this really demonstrates that, yes, there are challenges to achieving global eradication goals, to achieving elimination, particularly in some hard-to-reach populations and some [INAUDIBLE]. But you can overcome these challenges. And the polio program provides lessons on how to do this. And these lessons are relevant for the global health initiative for health system strengthening more broadly. For Nigeria as the point in case, we know that, indeed, political commitment and leadership was really crucial for overcoming the different implementation challenges. And we know that this political commitment and leadership facilitated efforts to reach hard-to-reach populations and to support mass immunization and [INAUDIBLE] and laboratory sciences and for a coordinated effort to ensuring that every child receives the polio vaccine.

And again, this speaks to different strategies and different levels that strategies can operate to. In Nigeria, some of the strategies are operated through political commitments, through leadership, and so on. And these are some of the lessons that polio has to offer other global health initiatives. So what determines alliances? How do you trust that this alliance is into commitment at national levels? For instance, in a place like Nigeria, how does that translate to effective implementation of strategies at subnational levels? How do you coordinate efforts? And how do you overcome bias? How do you overcome cultural biases and limitation and so on? Again, this, yes, is not unique to polio. It’s something that is relevant for the health initiative, as well.

So in Nigeria, it’s really a huge success story. And we’ll discuss more in the course of this course series of how places like Nigeria and other countries overcame all of their challenges to achieve elimination of the polio virus and is contributing towards the global eradication goal. So we’re going to take a pause here just to reflect, again, what I’ve discussed in the last couple of minutes, is really to introduce the Global Polio Eradication Initiative to you to kind of give an idea of the direction of success that has been achieved in the last couple of years and to also clarify what have been actors and what are the main issues around setting the goal of forming coalitions and around how to monitor progress over time and how those dynamic changes can actually reveal challenges in achieving a global eradication effort.

So in the next couple of slides, I’m going to be talking about the fundamental approach that we’ll be using to synthesize and to inform on the lessons from the polio program in a way that it can be generalizable to other initiatives. So basically we’ll be talking about how the Global Polio Eradication Initiative provides a rich source of knowledge for teaching implementation science. If we think about it, most of the activities of polio involves implementation. And the science around implementation is really generalizable to other initiatives.