Every Missed Child: Report of the Independent Monitoring Board of the Global Polio Eradication Initiative

"This is a programme that reaches into households bereft of any other healthcare; whose microplans map whole communities; whose communication and surveillance networks penetrate the most deprived populations..."

This fifth report from the May 15-17 2012 meeting of the Independent Monitoring Board (IMB) of the Global Polio Eradication Initiative (GPEI) sets forth a series of recommendations that affect primarily countries in Africa, Asia, and the Near East but have general public health relevance.

The report puts a finger on the pulse of the polio eradication effort, noting some clear successes. Polio is at its lowest level since records began. As of June 6 2012, there were 67 confirmed cases of polio in the world, as compared to a total of 650 cases worldwide in 2011. Polio is gone from India, and no cases of polio have been reported in Angola and the Democratic Republic of Congo (DRC) since the beginning of 2012. Chad has reported just three. However, 2.7 million children in the 6 persistently affected countries have never received even a single dose of polio vaccine. According to the IMF, this number "should be sending shock waves through the leadership of the Global Programme and through the political and public health leadership in each affected country."

In this report, the IMB highlights challenges for the GPEI:

• "The primary risk to the Programme is its precarious financial position."
• "The underpinning assumption of the polio eradication effort is that all countries in the world recognise that their collective will is necessary to gift to the world freedom from the scourge of polio. We do not see this 'global public good' philosophy driving the Programme. The participation in eradication as well as the donation of resources is uneven."
• "Consistently high quality vaccination and surveillance must be achieved everywhere. Islands of excellence are not enough."
• "Planning for the 'polio endgame' is in hand, but we are not convinced that the fundamental nature of what is required is fully understood by the Programme."
• "More innovative methods need to be used to extinguish the possibility of outbreaks in a more comprehensive way."
• "The Programme thinks and acts too much in isolation. Children missed by polio teams may be reached by other services. Stronger, more effective alliances can bring eradication closer."
• Remaining polio virus infection is confined not just to a few countries but to a small number of discrete locations within these countries. The IMB has called these "sanctuaries" for the polio virus. The report examines 10 such sanctuaries spread across the 6 remaining polio-affected countries. For example, in Afghanistan, "[c]ampaign awareness is considerably higher where Immunisation Communication Networks have been established. These are present in only a quarter of the 13 highest risk districts, and need to be expanded." And, in DRC, "'[r]eligious refusals' are still a significant problem. The IMB was pleased to hear the distinction made between 'hesitant refusals' and 'entrenched refusals'....Parents who 'hesitantly refuse' could, if successfully converted set off a domino effect in their communities, adding their own voices to the partners' communications drive."
• "The good progress in Angola, the Democratic Republic of Congo and Chad sits alongside the improvements in Pakistan's Programme where considerable challenges remain, but momentum is building. Elsewhere, the picture is less bright. Nigeria and Afghanistan are missing far too many children..."
• "The Programme has missed all but one of its 2010-12 Strategic Plan milestones. But in the last six months, its operation has strengthened considerably."

The IMB also makes several recommendations:

• An emergency meeting of the Global Polio Partners Group should be held to mobilise funding to re-instate cancelled campaigns.
• The Polio Oversight Board should review the effectiveness of the Programme; 10 transformative activities are set out, including: "Transformation 10: Parents' 'pull' for vaccine dominates over 'push'. There is an increased focus on social mobilisation, and a major surge in communications personnel, but there is as yet no step-change from 'push' to 'pull'."
• "A polio 'end-game and legacy' strategy should be urgently published for public and professional consultation."
• "A plan to integrate polio vaccination into the humanitarian response to the food crisis and conflict in West Africa should be rapidly formulated and implemented. Alliances with all possible programmes must be urgently explored, to make every contact count."
• "The presence of polio virus in environmental samples should trigger action equivalent to that of an outbreak response..."
• "Contingency plans should be drawn up now to activate the International Health Regulations to require travellers from polio-affected countries to carry a valid vaccination certificate; this measure should be implemented when just two affected countries remain."
• "The number of missed children...should henceforth be the predominant metric for the Programme; a sheet of paper with these three numbers should be placed on the desk of each of the Heads of the Spearheading Agencies at the beginning of each week. This action should commence immediately."