In the framework of IsAG studies on health cooperation in Africa, Giuliano Luongo – Director of the “Africa and Latin America” Research Programme at IsAG – interviewed Mrs. Sona Bari – External Relations Officer at the Global Polio Eradication Initiative, World Health Organization (WHO-OMS) – regarding the latest important goal reached in the fight against Poliomyelitis.
Giuliano Luongo: On September 25, 2015, the World Health Organization declared that Poliomyelitis is no longer endemic in Nigeria. Why is this such an important milestone in the global fight against this disease?
Sona Bari: Polio is one of the few diseases which can be eradicated. In 1988, when the global effort to eradicate polio was launched, nearly 1,000 children were paralyzed worldwide every day. Since then, thanks to the millions of health workers who reached children with vaccine, country after country has stopped polio. By 2014, 359 children were paralyzed in the entire year in only a few countries. Nigeria was considered one of the hardest places to reach every last child with vaccine, and their achievement is another encouraging step towards showing that we can eradicate polio and reach even the most vulnerable, under-served communities with health care. Nigeria is the last country in Africa to stop polio, and this starts the countdown for the entire region to be certified polio-free in 2017. Now only two endemic countries remain: Afghanistan and Pakistan.
GL: Which are the main instruments put into place to reach this goal? Furthermore, with the current situation, how can be prevented the return of the illness?
S. Bari: Polio eradication rests on two pillars: surveillance, to know where the virus is, and vaccination, to protect every child. The Global Polio Eradication Initiative – a partnership of national governments, WHO, Rotary International, the US Centers for Disease Control and Prevention and UNICEF – has put in place a worldwide surveillance system to detect any case of polio. This system has been fundamental to our progress so far. Surveillance is also one of the keys to preventing any return of the disease, by detecting the virus quickly, countries can respond rapidly. The second pillar is vaccination. Countries have routine immunization systems which are strong or weak depending on the country; where they are weak, they are complemented by vaccination campaigns. Together, routine immunization and campaigns keep up the immunity of a community. When a poliovirus arrives, it then finds an inhospitable environment and no unvaccinated children to infect. This is how the disease has been stopped everywhere except the remaining endemic countries. And this is how every country needs to continue to protect its children, through high immunity.
Around these two pillars, the Global Polio Eradication Initiative has built an environment to strengthen both. This includes research into new vaccines and better combinations of vaccines, community-based surveillance and vaccination, creative tactics to reach children in insecure settings, ways to engage communities and build trust, and sound political and financial support.
GL: Next to constraints strictly related to budget, which are the main hurdles to the fight to endemic diseases – and to health cooperation in general – in developing or least developed countries?
S. Bari: You rightly point out budget as a constraint, and you are equally correct that it is not the only constraint. Countries may lack infrastructure or have weak infrastructure that allows health service delivery – roads, refrigeration, means of transport, laboratories, storage facilities. They may struggle with human resource capacity – trained medical personnel, vaccinators, recorders, social mobilizers. They also have to work in settings without strong regulatory capacity – drugs regulations, standards of care. The vaccination community, often under the aegis of a country’s Expanded Programme on Immunization, has invested in filling these gaps, and polio eradication efforts have been directly involved in building capacity at the health worker level, at the planning and management level, and in surveillance, storage and delivery capacity. What enables all this is the political commitment from a country’s leadership, which is independent of its financial status. Countries with weak health systems and poor in financial resources have stopped polio with this political and community will.
GL: Did the prevention activity in Nigeria show specific challenges to face, especially thinking about the recent security- and terrorism-related problems?
S. Bari: Nigeria faces a complex set of security challenges and still managed to stop polio. While each conflict is unique, polio has been stopped in many conflict settings, from El Salvador to the Democratic Republic of the Congo. Nigeria developed its own creative ways of dealing with the situation. These ranged from the social and political – the sustained work of groups like the Governors’ Forum and Traditional and Religious Leaders’ Forum – to the operational – conducting rapid vaccination campaigns as soon as an area becomes safe or vaccinating children as their families leave an area of insecurity. We have learned a lot from Nigeria in terms of how to adapt to security challenges especially in today’s complex conflicts.
GL: Now Polio remains endemic only in Pakistan and in Afghanistan: which are the most recent progresses made by prevention activities in these countries?
S. Bari: These two countries are really one epidemiological block and what we consider a shared reservoir of poliovirus. So first and foremost, they are concentrating on their shared border and on harmonizing and strengthening their cross-border collaboration. Both countries have tweaked their surveillance programmes to make sure no virus goes undetected. Surveillance systems are being strengthened through the engagement of more private clinics, traditional healers and pharmacies, making it more likely that all cases of polio will be reported. The testing of sewage is also being expanded.
Afghanistan’s polio eradication effort is viewed positively by different actors in the conflict, and the programme continues to negotiate access to vaccinate children in all areas. The country is focusing on reaching children who miss vaccination, whether because they are in remote locations, whether vaccination teams are not operating well, or because of insecurity. Some steps already underway include improved mapping of households so that they can be better served by health workers, to improve strategies for revisiting households where children were missed, to assess and strengthen polio vaccination teams. These teams are tailored to the local environment: some are made up of community members who live and work within their community; others are posted at transit points like bus stations to make sure children on the move are vaccinated; still others ensure that children crossing the border are given vaccine.
Recent progress in Pakistan includes: Almost half a million children who were previously missed have been reached, due to gradual improvements in programme quality and access since late 2014. More than 200,000 motivated frontline health workers have been selected from their local communities, and trained to reach children and build trust. Innovations such as the engagement of female community volunteers to deliver vaccines in high security threat areas, health camps to reach children with vaccines and other health services and better data collection on missed children have helped to improve the programme in the last six months. Health camps have reached almost 350,000 people in the high risk areas with additional health services alongside polio vaccines. All this work is coordinated by a strong, functional Emergency Operations Centre is working at the national level to ensure coordination and accountability.