GPEI-‘Nothing is impossible’: gaining ground on polio in the Horn of Africa

Jean-Marc Olivé, Chairman of the Technical Advisory Group (TAG), addressing the participants. WHO/L.Dore

From the 27 – 29 November, the Technical Advisory Group (TAG) met in Nairobi to review the outbreak response in Somalia, Ethiopia and Kenya, and preparedness measures in Yemen, Uganda, Tanzania, Sudan, South Sudan and Djibouti in case of international spread.

Jean-Marc Olivé, Chairman of the TAG, spoke to WHO about the recommendations made to address the challenges faced by countries, his hopes for eradication and his life in the programme.

What are the main challenges faced by the countries of the Horn of Africa in the drive to stop the outbreaks?

The major challenges have been the same for a long time – like, the issue of inaccessibility due to conflict and humanitarian crises. If we cannot access populations then it is very difficult to cover them properly during vaccination campaigns and so it is hard to stop poliovirus transmission. This is not a programme-related issue, it is a political one. Until we have access, it will be very difficult to make it.

I have said it before and I will say it again: access is success.

I think the second challenge is – and this is one of the reasons why we still have the transmission of circulating vaccine-derived poliovirus in the Horn of Africa – is persistently low vaccination coverage. There are still remote areas, rural areas, heavily populated urban areas where routine immunization has really never been able to offer the same services and coverage as in more accessible areas with fewer challenges.

Since last TAG meeting in the Horn of Africa, what progress have you seen?

I have seen the capacity really building up in the Horn of Africa. The biggest shift is that we now have collected a lot of data about surveillance, about immunization coverage, vaccination campaigns, communications, and also data by the type of population we are reaching and not reaching. What is missing now, and what was the focus of this TAG, is to use this data to monitor progress and orient the programme toward those difficult areas. We have to use the data to tell us a story about what is happening and what to do next.

Jean-Marc Olivé vaccinating a child in Kandahar, Afghanistan. © WHO/Afghanistan

What were the most important recommendations made by the TAG this time around?

I think the most important is to follow the plan that has been set up for the three outbreak countries to interrupt transmission. Secondly, the countries that have not been yet infected by the virus should have a preparedness plan to ensure that if there are any problems they can move swiftly into action.

The Horn of Africa has seen several outbreaks in the past. What must be done to break the pattern and keep the region polio-free once and for all?

They have identified the problems. They just have to implement the solutions! We need to be sharing and analysing knowledge, information, and building capacity at the local level to ensure that we are on the right track to success.

I say to all the countries, go to the areas where you know you have problems and engage local communities and health authorities. Most of the issues can only be addressed at local levels by local people who understand the situation. Help them to do that, and monitor progress.

This is your thirteenth TAG; what have you learned about the process of international review?

First, you have to work as one team in support of National Teams, all agencies together. There cannot be any agency that claims, “This is us, we are doing that, this is WHO, this is UNICEF…”; this is the Global Polio Eradication Initiative, working together with all committed partners, using the competencies that each of them has. If you don’t address issues comprehensively as one, effective interventions are much more difficult to implement.

How long have you worked on polio eradication? What lessons have you learnt from this experience?

I was involved in the eradication of polio in the Americas. We started in 1985. We did it from A to Z in 9 years. We had very good leadership, commitment from the Government and partners, clear guidelines, very strong monitoring, and solid and reactive support to the field. Then we moved on into measles elimination with the same engagement – and the same results.

Because I have seen it happen, I know it is feasible. I think this is what keeps me so motivated. Polio eradication is a fantastic initiative. If we focus on weak and problematic areas within countries, if Governments and Partners continue to be engaged, we will make it. It’s going to be tough, mainly because of inaccessibility.

Is there anything else you want to add?

The people working in this programme, particularly local people working in the countries are amazing. They are the basis of any future public health intervention. In Pakistan and Afghanistan, woman are more and more playing an important role. This is an incredible advancement and an incredible contribution that was previously thought to be impossible.

But nothing is impossible – you just push, go slowly and constructively you will manage to gain ground over the virus.

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Participants of the Africa Regional Commission for the Certification of poliomyelitis eradication (ARCC) in Nairobi, Kenya, from 12-16 November 2018. WHO AFRO/2018

Efforts to end polio across the WHO African Region came under the microscope at a meeting of the Africa Regional Commission for the Certification of poliomyelitis eradication (ARCC) held in Nairobi, Kenya, from 12 – 16 November 2018.

Seven countries (Cameroon, Nigeria, Guinea-Bissau, the Central African Republic, South Sudan Equatorial Guinea and South Africa) made presentations to the ARCC on their efforts to eradicate polio, presenting evidence on their level of confidence that there is no wild polio in their borders, the strength of their surveillance systems, vaccination coverage, containment measures and outbreak preparedness. Kenya, the host country, alongside the Democratic Republic of the Congo and Namibia, presented updated reports on their efforts to maintain their wild poliovirus- free status.

Professor Rose Leke, Chair of the ARCC, speaking to the participants. WHO AFRO/2018

A total of 109 participants including partners of the Global Polio Eradication Initiative, non-governmental organisations and Health Ministries were in attendance to hear the reports.

The ARCC is an independent body appointed in 1998 by the WHO Regional Director for Africa to oversee the certification and containment processes in the region. It is the only body with the power to certify the Africa region free from wild polio. The African Regional Office and the Eastern Mediterranean Regional Office are the two WHO regions globally that remain to be certified free from wild poliovirus.

Professor Rose Leke, Chair of the ARCC, reflected on the importance of this meeting: “The rich, open and in-depth discussions held this week with each of the ten countries will allow these countries to strengthen ongoing efforts to further improve the quality of surveillance and routine immunization including in security compromised and hard to reach areas as well as in special populations such as nomads, refugees and internally displaced persons.”

Recommendations made

The ARCC, made up of 16 health experts, made recommendations to the ten countries. They noted with concern that outbreaks of circulating vaccine-derived poliovirus in the Democratic Republic of Congo, Kenya, Niger, Nigeria and Somalia were symptoms of low population immunity and varied quality vaccination campaigns. These countries were encouraged to conduct a high-quality outbreak response. Neighbouring countries were advised that they should assess the risk of spread or outbreaks within their borders. Low population immunity was identified as a significant concern, given the risk further emergences of vaccine-derived poliovirus strains.

Inaccessibility and insecurity were also flagged as a significant concern, with limits to the number of children who were being reached with polio vaccines and the coverage of surveillance efforts in affected areas. Countries were advised to scale up strategies that have proved in the past to be effective in the face of these challenges and to build relationships with civil society and humanitarian organisations who could provide immunization services.

Recommendations were made across the board to address chronic surveillance gaps, especially related to factors affecting the quality and transportation of stool samples reaching the laboratory for testing. The introduction of innovative technologies was commended, and a call was made for countries to expand their use, especially in inaccessible and hard-to-reach areas. Countries were also encouraged to accelerate their progress towards poliovirus containment.

In addition, all of the presenting countries received specific recommendations to support their efforts towards improving surveillance, immunization and containment in order to achieve a level that would give the ARCC the confidence needed to declare the region to have eradicated polio.

Dr Rudi Eggers, WHO Kenya Country Representative, said: “I commend all the countries on the efforts that have gone into achieving the results presented in their reports. It gives us hope that eradication is achievable in the midst of the unique challenges faced by all countries. We appeal to all the countries to fully implement all ARCC recommendations.”

Polio eradication efforts in Kenya

Dr Jackson Kioko, Director of Medical Services, the Kenyan Ministry of Health, said: “Kenya has worked hard to rid the country of wild poliovirus, and we will continue to do so until Africa and the world are certified polio-free.”

While Nigeria remains the only country in Africa to be endemic for wild poliovirus, responses are underway to stop outbreaks of circulating vaccine-derived poliovirus in the Democratic Republic of the Congo, Kenya, Niger and Somalia.

The circulating vaccine-derived poliovirus in Kenya was found in a sewage sample in Eastleigh, Nairobi, in March 2018, closely related to viruses found in Somalia. The Ministry Health, with the support of WHO, UNICEF and partners, has done several polio vaccination campaigns since then to ensure that every child’s immunity is fully built and no virus can infect them.

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“Ali was a humble, simple person. He had talent – real talent – in communicating the importance of vaccines to people in his community and around Somalia. He was seen by many as a hero.”

This is how Mahamud Shire, a long-time collaborator of the World Health Organization in Somalia, remembers the late Ali Maow Maalin.

Ali was the last person in the world to be infected with naturally occurring smallpox. After contracting the virus, he decided to devote his life to improving health through vaccination. He did so until his sudden passing in his home district of Merka on 22 July 2013. At the time, he was still serving with WHO as a district polio officer as part of the global polio eradication programme. He was 59 years old.

2018 marks five years since Ali’s passing. This article is being published to commemorate his life and achievements.

Smallpox

Ali Maow Maalin was born in 1954 and worked as a hospital cook. Aged 23, he contracted the smallpox virus.

Although he had previously worked as a vaccinator in the smallpox eradication programme, he himself had not been vaccinated. Fearing the needle, he had avoided the shot by holding his arm when vaccinators came to visit, pretending he had already been inoculated.

“I was scared of being vaccinated then. It looked like the shot hurt,” Ali would later recall when asked why he wasn’t immune on the day the smallpox virus caught up with him.

A man carrying two smallpox-infected children from a nomad encampment had been driving all day, looking for the local isolation camp. Taking wrong turn after another, he finally decided to stop and ask for directions. He did so at the hospital where Ali worked.

“Ali didn’t think about it twice – he jumped in the van and immediately offered to accompany the driver,”
Mahamud tells us. The driver then asked Ali if he had been vaccinated, but Ali simply said: “Don’t worry about that. Let’s go.”

It only took 15 minutes for Ali to contract the virus. Luckily, the form he caught was the less virulent one – variola minor – although still potentially lethal.

Nine days later, Ali started feeling sick.

Making history

Ali’s infection did not lead to a new outbreak. This was primarily because once the hospital where he worked found out he was sick, he was told to stay home. In the meantime, the hospital stopped accepting patients while everyone inside was being vaccinated and quarantined.

A 2011 WHO publication reports how a special team set out to vaccinate everyone in the 50 houses around Maalin’s home. Over the course of two weeks, a total of 54 777 people were vaccinated.

Effectively isolated, the virus didn’t spread. Smallpox was officially declared eradicated in 1979.

This was the first time in history that a major disease had been completely destroyed by human endeavour.

Document declaring the eradication of smallpox. Geneva, 9 December 1979. © WHO Archives

After sickness – a lifelong commitment to polio eradication

After recovering, Ali decided to commit his life to the eradication of another major disease: polio.

Beginning his new role as a vaccinator, he was determined that his own encounter with smallpox would serve as a powerful reminder of why immunization is so important.

“When I meet parents who refuse to give their children the polio vaccine, I tell them my story,” said Ali in 2006. “I tell them how important these [polio] vaccines are. I tell them not to do something foolish like me.”

When we spoke with Mahamud Shire, Ali’s friend and collaborator, we got the unequivocal impression that everyone who crossed paths with Ali, in one way or another, simply liked him.

“He was this really happy person – happy that he was the last case of smallpox still alive, happy that he now had the chance to do his part for his community,” Mahamud says.

Mahamud, who first met Ali in 1977, says Ali’s methods were very successful.

“The way he communicated the importance of vaccination to people – his entire approach – was very effective,” Mahamud says. “He would tell people, ‘I’m vaccinated, and I’ll never get sick’.”

Getting the job done

His work, together with that of his WHO colleagues and peers, helped crush Somalia’s polio outbreak in 2005, protecting children from the paralyzing virus.

When Ali suddenly passed away in July 2013, he was still working with WHO through the Global Polio Eradication Initiative, trying to fulfill his quest.

We have never been so close to the final eradication of polio as we are today. When smallpox was eradicated, there were a total of about 52 000 cases each year of wild polio virus. In 2017, only 22 cases of wild poliovirus were reported worldwide.

Now, as with smallpox, the final steps are the most challenging. To eradicate the virus, we must reach every last child with vaccines. We must maintain political and civil society commitment, continue filling immunization gaps, and strengthen disease surveillance in difficult settings.

Ali’s work in communities across Somalia is a reflection of WHO and partner’s long-standing commitment to increasing access to vaccines – everywhere.

One of Ali’s most famous quotes, the one most often used to capture his energy, enthusiasm and firm commitment, is one that puts smallpox and polio one next to the other.

“Somalia was the last country with smallpox. I wanted to help ensure that we would not be the last place with polio too.”

Young girls outside their home during vaccination activities in Punjab province, Pakistan. © WHO EMRO

World leaders gathered in Charlevoix, Canada last week to discuss the most critical issues facing the planet today, including their reaffirmed commitment to a polio-free world.

The final communique of the 44^th G7 summit on 8-9 June 2018 highlighted global health as part of the foundation for investing in growth that works for all: “To support growth and equal participation that benefits everyone, and ensure our citizens lead healthy and productive lives, we commit to supporting strong, sustainable health systems that promote access to quality and affordable healthcare.” As part of this commitment, the communique refers to the important tasks of achieving the goal of polio eradication and ensuring a smooth post-eradication transition as key global priorities. World leaders stated: “We reconfirm our resolve to work with partners to eradicate polio and effectively manage the post-polio transition.”

The communique also stressed the importance of preparing for health emergencies and strengthening the implementation of the International Health Regulations. As emphasized in the 13th General Programme of Work of the World Health Organization, which was approved by the World Health Assembly in May 2018, the GPEI has “helped to strengthen health systems, and these wider gains must be maintained as the polio programme is being ramped down.” The programme has extensive experience in disease surveillance and quality laboratory networks, outbreak response, disease prevention through vaccination, and inter-country collaboration – all necessary components of emergency preparedness. As planning continues for the post-eradication era, it remains a priority that the infrastructure, data and tools built up over the past 30 years be transitioned effectively to support resilient health systems and public health infrastructure in the future.

Canada, the host of this year’s G7, continued in the footprints of its predecessors and maintained attention on health – as the country has throughout its G7 presidencies. Canada has been a longtime supporter of the Global Polio Eradication Initiative and plays an active role in keeping polio on the global agenda. In 2002, then-Prime Minister Jean Chrétien gathered his counterparts from the G8 in Kananaskis, Canada to pledge to provide sufficient resources for polio elimination in Africa – the first time polio was included in the communique. Since then, G7 countries have provided significant political and financial support for the global polio programme, and have repeatedly expressed commitment to polio eradication. Most recently, leaders’ statements at the 2016 G7 Summit and at a 2017 Group of 7 Health Ministers meeting included commitments to polio eradication. G7 leadership on the issue was expanded to the G20 in 2017. Polio was mentioned at both the G20 leaders’ summit and the first-ever G20 Health Ministers’ meeting, which recognized the historic opportunity that exists to end polio for good and the important role played by polio-funded assets in achieving broader health goals.

The communique also emphasized the need to advance gender equality and women’s empowerment. The polio programme recognizes women’s critical contributions to eradication and is constantly working to recruit more women to work as frontline workers in polio endemic countries. In Afghanistan, the polio programme accounts for one of the largest female workforces in the country. On a global level, the GPEI is working to analyze sex-disaggregated data to track progress towards eradication, echoing the communique in affirming women and girls as powerful agents of change.

The 2018 G20 Buenos Aires summit in November is next on the world stage, providing an additional opportunity for governments to focus on the importance of global health, and commit to fulfilling and maintaining the promise of a polio-free future.

The poliovirus takes a beating at WHA 2018. © Sini Ramo/WHO

28 May 2018, Geneva, Switzerland: ‘Eradicate first’ was the mantra at last week’s World Health Assembly (WHA). While holding detailed discussions to plan for a polio-free world, delegates emphasized the need to finish the job of eradication.

With wild poliovirus transmission levels lower than ever before, Ministers of Health and delegates reviewed progress being achieved through national emergency action plans in the remaining endemic countries. As at May 2018, only eight cases due to wild poliovirus had been reported globally, from just two countries: Afghanistan and Pakistan.

To prepare for a polio-free world, Member States adopted a landmark resolution on poliovirus containment. A limited number of facilities will retain poliovirus after eradication, to serve critical national and international functions such as the production of polio vaccine or research. It is crucial that these poliovirus materials are appropriately contained under strict biosafety and biosecurity handling and storage conditions, to ensure that virus is not released into the environment, either accidentally or intentionally, to again cause outbreaks of the disease in susceptible populations.

WHO and countries that are currently funded by the Global Polio Eradication Initiative (GPEI) face significant financial, human resource, and programmatic risks as a result of the scaling down of the GPEI budget (2017-2019) and its eventual closure. Hence, Member States requested the Director-General to develop a strategic action plan on polio transition that will mitigate these risks, as well as strengthen country health systems. Delegates considered the resulting 5-year strategic action plan on polio transition, which has 3 key objectives: (i) sustaining a polio-free world after eradication of polio virus; (ii) strengthening immunization systems, including surveillance for vaccine-preventable diseases; and (iii) strengthening emergency preparedness, detection and response capacity in countries to ensure full implementation of the International Health Regulations. The strategic action plan outlines how essential polio functions like surveillance, laboratory networks, and some core infrastructure can support the implementation of the Post Certification Strategy to sustain a polio-free world, and can be integrated into the immunization or health emergencies’ programme, or mainstreamed into national health systems. The plan provides detailed costing for the integration of essential polio functions into WHO’s Thirteenth General Programme of Work, and some financing options. The three polio-endemic countries (Afghanistan, Pakistan and Nigeria) and a few high-risk countries battling outbreaks have been excluded from transition planning until eradication. All other GPEI-funded countries are expected to plan for polio transition.

Member States expressed overwhelming commitment to fully implement and finance all strategies to secure a lasting polio-free world in the very near term. Rotary International, speaking on behalf of the GPEI, which includes WHO, Rotary, CDC, UNICEF and the Bill & Melinda Gates Foundation, offered an impassioned plea to the global community to eradicate a human disease for only the second time in history, and ensure that no child will ever again be paralysed by any form of poliovirus anywhere.

© Sweden National Authority for Containment

A vaccine manufacturer in Stockholm has taken the first step towards becoming a certified Poliovirus Essential Facility (PEF), leading the charge in global efforts to safely and securely contain type-2 poliovirus. This facility has been awarded a Certificate of Participation co-signed by the National Authority for Containment (NAC) in Sweden and the Global Commission for the Certification of Poliomyelitis Eradication (GCC). The Certificate is the first of its kind to be issued, indicating formal engagement in the global containment certification process.

Wild poliovirus type-2 was declared eradicated by the GCC in September 2015, however, there is risk of the virus resurging. Following the removal of the type-2 component from oral polio vaccine (OPV) and the discontinuation of type-2 containing OPV from routine use in April 2016, countries around the world have been asked to safely and securely destroy their type-2 polio samples. As a further precaution, countries continue to immunize against type 2 polioviruses with inactivated polio vaccine. For facilities needing to retain the virus for vaccine production or for critical research, stringent containment measures need to be followed. The first step is getting a Certificate of Participation.

Handling of infectious virus. © Sweden National Authority for Containment

“We are pleased to see Sweden leading the way in demonstrating conforming with the processes to minimize the risk of releasing type-2 poliovirus into the environment. Participation in the Containment Certification Scheme shows that both the facility and the host country are serious about taking on and implementing the safeguard measures necessary to become a PEF,” said Prof. David Salisbury, Chair of the GCC and of the Commission’s European regional body.

“Handling and storing an eradicated pathogen is a risk and responsibility – a leak or breach could have devastating consequences,” said Michel Zaffran, Director of Polio Eradication at the World Health Organization. “We commend Sweden for its commitment towards ensuring safety standards are met and protocols are in place to help minimize risk, and for paving the road for the containment certification process,” he said.

“The issuance of a Certification of Participation formally engages a designated PEF in the containment process. Provided that the facility meets the requirements outlined in Global Action Plan III for the containment of polioviruses (GAPIII) within given time frames, it can then progress to achieving an Interim Certificate of Containment and finally, a full Certificate of Containment to become an accredited PEF,” said Prof. Salisbury. “Countries planning to retain type-2 poliovirus will need to establish their NACs as soon as possible, and by no later than the end of 2018. The GCC urges all countries that plan to have PEFs to get the ball rolling in this process,” he said.

Since April 2016, most facilities around the world have opted to destroy their type-2 poliovirus materials rather than contain them. Twenty-nine countries, however, plan to continue to handle and store their materials in 92 designated PEFs.

WHO will propose a resolution for consideration by the World Health Assembly in May to seek international consensus on accelerating containment efforts globally.

To supplement Global Action Plan III for the containment of polioviruses, WHO has published guidance for non-polio facilities to help them identify, destroy, or safely and securely handle and store sample collections potentially infectious for poliovirus.

Dr Mark Pallansch from CDC explains what the guidance means for facilities worldwide.

Poliovirus potentially infectious materials (PIM) include fecal, nasopharyngeal, or sewage samples collected in a time and place where wild polioviruses/vaccine-derived polioviruses (WPV/VDPV), or OPV-derived viruses were circulating or oral polio vaccines (OPV/Sabin) were in use. Non-polio research facilities with a high probability of storing such materials include those working with rotavirus or other enteric agents, hepatitis viruses, influenza/respiratory viruses, and measles virus. Other facilities could include those conducting nutrition research or environmental facilities.