NAIROBI — During a year with few public health victories, the African region celebrated a major one this week — the declaration that wild polio had been eradicated from the continent. And lessons learned from the successes around polio vaccination campaigns can help guide other health interventions, including the COVID-19 response.
Polio is a highly infectious viral disease that can cause paralysis and death, primarily spread through exposure to feces. There is no cure for the disease, but it is vaccine preventable. It’s only the second virus to be eradicated from Africa, following the elimination of smallpox.
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“It is a vivid reminder that vaccines work and that the collective actions of communities, governments, and partners can bring about tremendous changes,” said Dr. Matshidiso Moeti, World Health Organization regional director for Africa, during a virtual event of the declaration held Tuesday.
Since 1996, almost 9 billion polio vaccines have been delivered in Africa. Some 220 million children are vaccinated multiple times each year through the efforts of 2 million volunteers. These vaccinations have averted 1.8 million cases of wild polio and saved 180,000 lives.
The achievement is decades in the making. In 1988, the World Health Assembly endorsed a resolution to eradicate polio globally. In its wake, the Global Polio Eradication Initiative was launched — a public-private partnership led by national governments, WHO, Rotary International, the U.S. Centers for Disease Control and Prevention, UNICEF, Bill & Melinda Gates Foundation, and Gavi, the Vaccine Alliance.
Then, in 1996, African heads of states signed a commitment to end polio in Africa. That year, wild poliovirus paralyzed over 75,000 children across Africa. Nelson Mandela, with Rotary International, launched the Kick Polio Out of Africa Campaign.
In 1998, the Africa Regional Certification Commission for Polio Eradication was established.
There has not been a case of wild poliovirus on the African continent since 2016. The last four cases were reported in Borno State, Nigeria, where the presence of terrorist organization Boko Haram prevented health workers from immunizing children.
Money has been poured into winning the fight against polio, but those gains are now in a precarious position.
The victory was a collective effort of frontline health workers, communities, national governments, donors, and NGOS, according to partners. Thousands of frontline workers have worked to access children in Africa’s cities, as well as in remote communities, using cars, motorcycles, canoes, and helicopters to transport vaccines.
Health workers have inspected health facilities for cases of children with paralysis, sampled sewage to see if the virus is present, and trained communities to be on alert.
New technologies were also deployed in the fight. This included the AVADAR mobile phone application that allows trained community workers to report possible polio cases, said Dr. Christopher Elias, president of the global development division at the Gates Foundation, during the event. Previously, many health workers were using hand-drawn maps to identify settlements as part of their immunization campaigns. Now, with geographic information systems technology, health workers can reach children with more detailed maps, he said.
Some polio workers even lost their lives in the line of duty. In 2013, gunmen in northern Nigeria killed nine polio workers, in an environment where some Muslim leaders said polio vaccinations were a conspiracy against Muslim children.
“As long as polio persists anywhere, it's a threat everywhere.”— Dr. Tedros Adhanom Ghebreyesus, director-general, WHO
“It took tremendous effort over many years,” said Holger Knaack, president of Rotary International, during the event.
The last countries where wild poliovirus is still regularly spreading are Afghanistan and Pakistan.
In Pakistan, vaccine campaign disruption because of the COVID-19 pandemic led to the disease expanding and appearing in parts of the country that previously did not have cases of polio.
The pandemic has also disrupted polio vaccination campaigns across Africa, as well as surveillance and outbreak response activities, said Professor Rose Gana Fomban Leke, chairperson of Africa Regional Certification Commission for Polio Eradication, during the event.
“As long as polio persists anywhere, it's a threat everywhere,” said Dr. Tedros Adhanom Ghebreyesus, WHO director-general, during the event, noting the virus could be reintroduced to the continent. This includes maintaining high-quality surveillance systems and increasing immunization coverage.
And while wild poliovirus was eradicated on the continent, there are still cases of vaccine-derived polio cases. This can happen when a child who received the oral polio vaccine, which contains a weakened virus, spreads the virus to the surrounding environment. This occurs in severely underimmunized populations with poor sanitation.
Sixteen African countries are still experiencing outbreaks of circulating vaccine-derived poliovirus because of low immunization coverage, resistance to vaccines, and challenges in accessing communities.
This can also increase general skepticism around vaccinations — when people are told that a polio outbreak is caused by a vaccine, Dr. Samuel Usman, from Catholic Relief Services, who is the Nigeria director for CORE Group Partners Project, told Devex.
One of the problems with announcing the end of wild polio in Africa, is that some groups are winding down their funding on polio vaccination efforts, Usman said.
“That’s one of the drawbacks of the announcement,” he said. “People are fatigued. They’ve been doing these polio efforts for years.”
Applying these lessons to COVID-19
These networks, expertise and infrastructure built around the polio campaigns have contributed to a stronger public health system across the continent.
“The Global Polio Eradication Initiative has helped to deliver vitamin A, bed nets, and deworming tablets and support for outbreaks including Ebola,” Tedros said.
These same systems are now helping in the COVID-19 response, including surveillance, contact tracing, risk communication, data management, reporting, preparedness, and coordination, he said. The polio laboratory network, with 16 labs in 15 countries, is dedicating half of its capacity to testing for COVID-19.
Many of the lessons learned from fighting polio can also be used in tackling the COVID-19 pandemic, particularly when future vaccines are found and rolled out in communities, Usman said.
One of the key lessons that polio professionals have learned is that bundling messaging and health services is effective. With polio efforts, community volunteers have gone house-to-house to raise awareness about the importance of children taking the oral polio vaccine and now they are adding in messaging about preventing the spread of COVID-19, such as the need to social distance and regularly wash your hands.
Another lesson learned is that it is critical to involve religious leaders.
Most of the polio cases in Nigeria had been in the northern part of the country, where Islamic culture dictates that women can’t take a child to a health facility without the consent of her husband, said Usman. Health care providers worked with religious leaders to encourage men to give their wives open-ended verbal permissions to attend health facilities when needed, allowing them to vaccinate their children.
Religious ceremonies themselves can be an in-road to communities to improve health care. The CORE Group Partners Project carried out a vaccination intervention program during Ramadan: first, mapping the homes of families that had not vaccinated their children, then working with nearby mosques to train leaders on the importance of vaccination.
During the Iftar breaking of the fast, the polio program gave out food to the heads of those households and talked to them about the importance of vaccination. Some 96% of the families that were targeted had their kids vaccinated following this intervention, according to Usman.
The project has also tapped technology to counter anti-vaccination messaging — something that may be critical once a COVID-19 vaccine is released.
After anti-vaccination messages gained traction through bluetooth — which allows people to share messages if they are in close proximity to one another, even if they can’t afford internet credit — the program rolled out its own countermessaging on the importance of polio vaccinations.
They’ve also worked in insecure areas using local armed vigilante groups to administer polio vaccines, Usman said.
“I think the lessons we’ve learned in polio can improve any health system,” he said.
Update, Aug. 28, 2020: This article has been updated to reflect that Dr. Samuel Usman, from Catholic Relief Services, is the Nigeria director for CORE Group Partners Project.
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