Crossing the finish line

The war against polio has been a series of successes and setbacks  - and it isn’t over yet. GPEI’s Oliver Rosenbauer on the bid to relegate polio to the history books

As recently as 1988, polio was on the march in more than 125 countries, paralysing tens of thousands of children a year. Thanks to a sustained global campaign, just 27 cases of polio have been reported this year – but the final push to eradicate polio is proving the hardest. Oliver Rosenbauer, spokesperson for the Global Polio Eradication Initiative (GPEI), a public-private partnership led by national governments and spearheaded by the World Health Organisation, outlines the scale of the challenge ahead.

How close are we to achieving a polio-free world?

We’ve never been closer. Just three countries still have wild poliovirus transmission – Pakistan, Afghanistan and Nigeria – and in all, the virus is increasingly geographically restricted. In Pakistan, 20 years ago, there were 35,000 children paralysed by polio across the country each year. This year, there have been 14 cases. By any other public health measure, the campaign against polio has been a huge success. But it is an eradication effort, and there is no room for error, so we have to get to zero.

Can you give an idea of the scale of the campaign to date?

It is perhaps the largest international healthcare effort in history. The campaign to eradicate polio began with Rotary International in 1988, at a time when there were more than 350,000 cases of polio a year, and 125 endemic countries. Since then, and with the launch of the GPEI, more than 2.5 billion children have been immunised and the polio caseload has fallen by 99.9 per cent. There is a network of 20 million volunteers, and a vast network of disease surveillance, which every year investigates more than 100,000 acute flaccid paralysis cases to verify that they are not caused by polio. As a result of these efforts, 16 million cases of paralysis have been averted, and 1.5 million lives have been saved. It is hard to understate the tremendous global effort that has got us to the threshold of being polio-free.

"Polio now is a disease of the world's most marginalised, poorest communities"What more will it take to eradicate the virus?

At a basic level, it is simple: if you vaccinate enough children with sufficient doses of polio vaccine, the virus will be eradicated. The challenge is when you miss children, or you don’t reach all children, everywhere, consistently. And in areas of instability, or insecurity, where populations are on the move, and there is a suboptimal health infrastructure, where there isn’t a stable cold chain supply, it’s very challenging.

Polio now is a disease of the world's most marginalised, poorest communities. These are areas without clean water supplies, with open sewage systems, poor sanitation infrastructure and malnourished children, who may need extra doses of the vaccine. The lesson from Nigeria is that if you fail to vaccinate in any - even small - area of the country, or if coverage is not high enough, polio will rebound. If you don’t eradicate the disease in reservoir areas, the fire will keep spreading.

After two years in which Nigeria appeared polio-free, the country has seen new cases this year. How significant a setback is this?

We knew there were immunity and surveillance gaps in Borno and northeastern Nigeria, so this [the outbreak] confirmed our suspicions. This is a region affected by a much broader humanitarian emergency. There are 7 million people on the move, who don’t have access to healthcare, nutrition, shelter – polio in that context is the least of their concerns. For us, it is a challenging task because many areas are inaccessible, and upwards of 500,000 people. But we are conducting vaccination rounds – we aim to target 41 million children in five rounds – and we hope as access improves, we can continue our response.

What is the risk of polio resurfacing elsewhere if vaccinate rates fall?

In 2003, and 2004, a small area of northern Nigeria stopped immunising against polio because there were rumours that the vaccine was laced with anti-fertility agents. That 12-month lull resulted in the virus spreading to 20 countries around the world, including as far away as Indonesia. Containing the outbreak cost half a billion dollars. There are economic and public health consequences if you stop vaccinating.

Most people infected with poliovirus don’t know they have it. Just 1 in 200 infections lead to paralysis. In other cases, people can be secreting the virus over six to eight weeks, as they travel. So when you identify a case, you have to assume you have 199 other infections: the horse is out of the barn. Polio will always spread. It will always find unvaccinated children. If coverage falls, in 10 years, we could see 200,000 cases a year again. The stakes are high.

"India showed that if we fail to eradicate polio, it will be because of political and societal reasons"To what degree was India being declared polio-free a gamechanging moment?

The polio campaign was built on gamechanging moments. The first was courtesy of Rotary International, which founded the campaign. They brought $350m to the table, a huge amount of money in 1988, and tremendous links to politicians and communities worldwide. Then there was the development of the monovalent vaccine in 2005, and the bivalent vaccine in 2009. These were key moments.

But India proved it [eradicating polio] could be done. India was the most challenging place to wipe out polio, and the strategies trailblazed there are of huge help today in Pakistan and Nigeria. Previously, the approach had been ‘one-size-fits-all’ mass immunisation days, and we’d reach 80 per cent of children and hope it was enough. It wasn’t good enough for India, so they zeroed in. They discovered the virus was circulating in specific communities and children, namely Muslim populations in western Uttar Pradesh. They engaged Muslim leaders and parents in those communities, and created a new strategy to target these children. It was the first time we’d seen this sort of bespoke approach. Now it is the standard in Pakistan.

The second thing India did was show mobile population groups could sustain transmission. In northern India, at any given time, 7 million people are on the move – a country the size of Switzerland. India led vaccination rounds at border crossings and, using community-based teams, overcame this challenge.

Ultimately, India showed that if we fail to eradicate polio, it will be because of political and societal reasons; it won’t be because we don’t have the technical tools.

What will be the payoff of eradicating polio?

No child will ever again be paralysed by polio. That is the primary benefit. And we will have safeguarded a global investment of more than $10bn so far. It makes economic sense to finish the job. We know that a polio-free world, because of the savings associated avoiding disability, loss of economic productivity, rehabilitation – will result in savings of $50bn. That’s $50bn in funding that can be applied to other public health initiatives. From a humanitarian perspective, from a health economic perspective, polio eradication is our best buy.

What more can people do to aid the campaign?

Success is within our grasp. We need to be fully funded – of the $7bn we need, we have yet to raise $1.3bn – and we need the eradication plans in place in Afghanistan, in Pakistan and in Nigeria to be fully implemented, which requires political will. If we have the funding and the implementation, polio is going to disappear very, very rapidly - and the consequences of failure are just too big. There have been 27 cases of polio globally this year, but if we fail to halt polio, it could be 200,000 children a year. We need to finish this job.