Feature

Q&A: ‘We still have work to do’ before eradicating polio

Photo of Apoorva Mallya
Apoorva Mallya

According to the Global Polio Eradication Initiative, only two countries still have circulation of wild poliovirus: Afghanistan and Pakistan.

Earlier this year, WHO’s Strategic Advisory Group of Experts on Immunizations estimated that Nigeria — along with the entire WHO Africa Region — would qualify to declare elimination status by the end of 2019. In fact, the country just marked 3 years without a case of wild poliovirus. Meanwhile, 58 cases of wild poliovirus type 1 (WPV1) have been reported in Pakistan so far this year, compared with 12 cases in 2018, according to the Global Polio Eradication Initiative. Additionally, the organization stated that 15 cases of WPV1 have been reported in Afghanistan this year.

Apoorva Mallya, a senior program officer on the polio team at the Gates Foundation, said in an interview that the effort to eradicate polio in both Pakistan and Afghanistan has been in progress for many years but “we still have work to do” to eradicate WPV in these areas.

Mallya spoke with Infectious Diseases in Children about the struggles and progress made in improving polio vaccination rates in endemic areas and how experts are adapting strategies to conflict zones. – by Katherine Bortz

 
Apoorva Mallya spoke with Infectious Diseases in Children about the struggles of eliminating polio from countries with actively circulating wild poliovirus.
Source: Adobe Stock

Q: What have been the main drivers of polio outbreaks in Afghanistan and Pakistan?

A: There are several drivers of the ongoing outbreaks we see in both countries. During polio campaigns, which are the primary way that we deliver vaccines to children, are simple house-to-house campaigns, whereby large groups of vaccinators knock on every door in a nation, region or province and try to deliver polio vaccines to every child aged younger than 5 years in each house. These are very difficult operations to set up and implement in places like Pakistan or Afghanistan with incredibly dense populations with different ethnicities, cultures, languages and complex geography.

At the most basic level, these campaigns are just not effective enough at the moment. They are not reaching high enough levels of operational quality to stop polio. To stop poliovirus in these environments where poliovirus thrives, you have to get very high levels of vaccination coverage in all areas, including the smaller, provincial and rural areas.

We have also had issues of communities questioning the need for repeated large-scale polio vaccination campaigns. Those reasons vary. We deliver polio vaccines over and over every couple of months to incredibly underserved communities. People in these areas may ask why we keep coming back with polio vaccines and not with other services.

Q: How has violence complicated polio vaccination efforts in countries where the disease remains endemic?

A: In Afghanistan in particular, there have been issues of insecurity where certain areas are more conflict-affected amidst ongoing complex geopolitical situations. It makes conducting these campaigns very difficult, and it’s tough with ongoing war to do something that requires teams of people going to each and every door. Also, there are other issues — from just getting agreement from all sides of the conflict to general chaos in a situation where people are moving around a lot and shifting locations, being forced to move out of homes and so forth.

Let’s not blame the conflict fully for the current situation, but it definitely has had its role. A good comparison is the census. The U.S. Census requires workers to go to every home, ask questions, get data together and be very detailed and thorough. That in itself is very complicated in the U.S. and requires thousands of workers in a very highly complex organization. Imagine that same scenario in a conflict zone, where you’re not sure who is in charge of a particular place, you’re not sure if it’s safe for your vaccination teams to go to a particular place on a particular day, you’re not sure if the community that you’re trying to reach has been displaced — that just adds to the complexity of an already complex program.

Q: Is Nigeria still on track to achieve this eradication status?

A: There are three types of poliovirus that have existed historically and circulated in affected humans: types 1, 2 and 3. We’ve gotten rid of type 2 and haven’t seen type 3 in many years. Really, it’s WPV1 we’re battling.

We have not seen this last strain of wild poliovirus in Nigeria since 2016. Given our level of ability to detect the virus circulating in any area, we feel pretty confident that we have gotten rid of it. We have not seen WPV in Africa for 3 years, which is an important sign of progress. Passing the 3-year mark means that the Africa Regional Certification Commission will now begin a rigorous process to confirm if Nigeria and the rest of Africa are in fact free of WPV1.

Q: What is the strategy for reversing recent setbacks in countries where polio is endemic ?

A: I think the strategy has several components to it. It’s really going to be up to the Global Polio Eradication Initiative partners to work with these governments to put in the appropriate strategies, the appropriate resources and the appropriate monitoring of that strategy to get the job done. That’s the overall philosophy: The partners work with the governments to do the right things.

Now, in terms of actually doing the right things, that is a process that’s being undertaken right now. Essentially, we need to understand why house-to-house campaigns are not working, why hesitancy toward the programs exists, how conflict impacts us and understand what can be done to improve these things.

For example, getting polio vaccine experts from within the country or outside of the country right in the field to help people on the ground manage and run polio programs is one thing that you can imagine a strategy would entail.

Other strategies include increasing our monitoring of how campaigns are being implemented. For example, whenever we do a campaign, we want to measure the percentage of kids we actually reached. Having a really excellent monitoring system could show us where the pockets of kids we missed are located. That’s where we really need to focus our energy and attention so we can use additional resources, maybe go and visit those places and try to understand the drawbacks of the operations in those places.

There will also be strategies for conflict areas. These are things like setting up transit teams. People are moving around, coming in and out of these areas, and we can have vaccination teams ready to vaccinate kids stationed at main transit routes such as bus terminals, highways or trains. It’s about getting creative and finding alternative approaches when the conflict affects your primary approach for vaccination campaigns.

Q: What is needed to improve vaccine uptake among families included in these strategies?

A: We’ve learned that we need to understand communities and address community resistance to vaccination. That includes sending people to talk to the communities and understand what the drivers of any resistance are. We need to explain to people what the rationale of polio vaccination is in general and the house-to-house campaign strategy that we’ve specifically adopted.

Then, we just need to be able to meet their needs. If they are raising concerns specifically about the vaccine or generally about the services they’re receiving, we need to be able to respond to those and meet their needs. Maybe it’s providing other vaccines to them. Maybe it’s connecting them to other government services. Maybe it’s better explaining why polio vaccines are very effective and needed for all kids. It could be a variety of approaches, but they need to include listening — getting on the ground and listening to mothers and communities in general and why there are any hesitations about getting the polio vaccine.

References:

Global Polio Eradication Initiative. Where we work: Afghanistan. http://polioeradication.org/where-we-work/afghanistan/. Accessed August 4, 2019.

Global Polio Eradication Initiative. Where we work: Pakistan. http://polioeradication.org/where-we-work/pakistan/. Accessed August 4, 2019.

Global Polio Eradication Initiative. Where we work: Nigeria. http://polioeradication.org/where-we-work/nigeria/. Accessed August 4, 2019.

Disclosure: Mallya reports no relevant financial disclosures.

Photo of Apoorva Mallya
Apoorva Mallya

According to the Global Polio Eradication Initiative, only two countries still have circulation of wild poliovirus: Afghanistan and Pakistan.

Earlier this year, WHO’s Strategic Advisory Group of Experts on Immunizations estimated that Nigeria — along with the entire WHO Africa Region — would qualify to declare elimination status by the end of 2019. In fact, the country just marked 3 years without a case of wild poliovirus. Meanwhile, 58 cases of wild poliovirus type 1 (WPV1) have been reported in Pakistan so far this year, compared with 12 cases in 2018, according to the Global Polio Eradication Initiative. Additionally, the organization stated that 15 cases of WPV1 have been reported in Afghanistan this year.

Apoorva Mallya, a senior program officer on the polio team at the Gates Foundation, said in an interview that the effort to eradicate polio in both Pakistan and Afghanistan has been in progress for many years but “we still have work to do” to eradicate WPV in these areas.

Mallya spoke with Infectious Diseases in Children about the struggles and progress made in improving polio vaccination rates in endemic areas and how experts are adapting strategies to conflict zones. – by Katherine Bortz

 
Apoorva Mallya spoke with Infectious Diseases in Children about the struggles of eliminating polio from countries with actively circulating wild poliovirus.
Source: Adobe Stock

Q: What have been the main drivers of polio outbreaks in Afghanistan and Pakistan?

A: There are several drivers of the ongoing outbreaks we see in both countries. During polio campaigns, which are the primary way that we deliver vaccines to children, are simple house-to-house campaigns, whereby large groups of vaccinators knock on every door in a nation, region or province and try to deliver polio vaccines to every child aged younger than 5 years in each house. These are very difficult operations to set up and implement in places like Pakistan or Afghanistan with incredibly dense populations with different ethnicities, cultures, languages and complex geography.

At the most basic level, these campaigns are just not effective enough at the moment. They are not reaching high enough levels of operational quality to stop polio. To stop poliovirus in these environments where poliovirus thrives, you have to get very high levels of vaccination coverage in all areas, including the smaller, provincial and rural areas.

We have also had issues of communities questioning the need for repeated large-scale polio vaccination campaigns. Those reasons vary. We deliver polio vaccines over and over every couple of months to incredibly underserved communities. People in these areas may ask why we keep coming back with polio vaccines and not with other services.

PAGE BREAK

Q: How has violence complicated polio vaccination efforts in countries where the disease remains endemic?

A: In Afghanistan in particular, there have been issues of insecurity where certain areas are more conflict-affected amidst ongoing complex geopolitical situations. It makes conducting these campaigns very difficult, and it’s tough with ongoing war to do something that requires teams of people going to each and every door. Also, there are other issues — from just getting agreement from all sides of the conflict to general chaos in a situation where people are moving around a lot and shifting locations, being forced to move out of homes and so forth.

Let’s not blame the conflict fully for the current situation, but it definitely has had its role. A good comparison is the census. The U.S. Census requires workers to go to every home, ask questions, get data together and be very detailed and thorough. That in itself is very complicated in the U.S. and requires thousands of workers in a very highly complex organization. Imagine that same scenario in a conflict zone, where you’re not sure who is in charge of a particular place, you’re not sure if it’s safe for your vaccination teams to go to a particular place on a particular day, you’re not sure if the community that you’re trying to reach has been displaced — that just adds to the complexity of an already complex program.

Q: Is Nigeria still on track to achieve this eradication status?

A: There are three types of poliovirus that have existed historically and circulated in affected humans: types 1, 2 and 3. We’ve gotten rid of type 2 and haven’t seen type 3 in many years. Really, it’s WPV1 we’re battling.

We have not seen this last strain of wild poliovirus in Nigeria since 2016. Given our level of ability to detect the virus circulating in any area, we feel pretty confident that we have gotten rid of it. We have not seen WPV in Africa for 3 years, which is an important sign of progress. Passing the 3-year mark means that the Africa Regional Certification Commission will now begin a rigorous process to confirm if Nigeria and the rest of Africa are in fact free of WPV1.

PAGE BREAK

Q: What is the strategy for reversing recent setbacks in countries where polio is endemic ?

A: I think the strategy has several components to it. It’s really going to be up to the Global Polio Eradication Initiative partners to work with these governments to put in the appropriate strategies, the appropriate resources and the appropriate monitoring of that strategy to get the job done. That’s the overall philosophy: The partners work with the governments to do the right things.

Now, in terms of actually doing the right things, that is a process that’s being undertaken right now. Essentially, we need to understand why house-to-house campaigns are not working, why hesitancy toward the programs exists, how conflict impacts us and understand what can be done to improve these things.

For example, getting polio vaccine experts from within the country or outside of the country right in the field to help people on the ground manage and run polio programs is one thing that you can imagine a strategy would entail.

Other strategies include increasing our monitoring of how campaigns are being implemented. For example, whenever we do a campaign, we want to measure the percentage of kids we actually reached. Having a really excellent monitoring system could show us where the pockets of kids we missed are located. That’s where we really need to focus our energy and attention so we can use additional resources, maybe go and visit those places and try to understand the drawbacks of the operations in those places.

There will also be strategies for conflict areas. These are things like setting up transit teams. People are moving around, coming in and out of these areas, and we can have vaccination teams ready to vaccinate kids stationed at main transit routes such as bus terminals, highways or trains. It’s about getting creative and finding alternative approaches when the conflict affects your primary approach for vaccination campaigns.

Q: What is needed to improve vaccine uptake among families included in these strategies?

A: We’ve learned that we need to understand communities and address community resistance to vaccination. That includes sending people to talk to the communities and understand what the drivers of any resistance are. We need to explain to people what the rationale of polio vaccination is in general and the house-to-house campaign strategy that we’ve specifically adopted.

Then, we just need to be able to meet their needs. If they are raising concerns specifically about the vaccine or generally about the services they’re receiving, we need to be able to respond to those and meet their needs. Maybe it’s providing other vaccines to them. Maybe it’s connecting them to other government services. Maybe it’s better explaining why polio vaccines are very effective and needed for all kids. It could be a variety of approaches, but they need to include listening — getting on the ground and listening to mothers and communities in general and why there are any hesitations about getting the polio vaccine.

References:

Global Polio Eradication Initiative. Where we work: Afghanistan. http://polioeradication.org/where-we-work/afghanistan/. Accessed August 4, 2019.

Global Polio Eradication Initiative. Where we work: Pakistan. http://polioeradication.org/where-we-work/pakistan/. Accessed August 4, 2019.

Global Polio Eradication Initiative. Where we work: Nigeria. http://polioeradication.org/where-we-work/nigeria/. Accessed August 4, 2019.

Disclosure: Mallya reports no relevant financial disclosures.