Michel Zaffran reflects on polio lessons and the job ahead

MANILA — Michel Zaffran is stepping down as director of the World Health Organization’s polio eradication program by the end of 2020, having reached the organization’s retirement age. But the French national is spending his last few months in office with his hands full.

In a conversation with Devex, Zaffran, who has led the organization’s polio program for the past five years, said there is ongoing work to make a novel oral polio vaccine available by fall. The vaccine will be used to respond to the outbreak of circulating vaccine-derived poliovirus type 2, replacing the monovalent type 2 oral polio vaccine currently in use. The goal is to make it available under emergency-use listing initially and supply the vaccine for free to countries experiencing outbreaks of vaccine-derived poliovirus type 2, such as Sudan.

But care will be taken to ensure no concomitant use of the new and old vaccines to avoid any misunderstandings of the impact of each vaccine.

“And then eventually, when we are reassured that the vaccine works well after its initial use in, I would say, half a dozen countries, then we'll be able to supply to any country that requests [it],” Zaffran said.

WHO and partners have also kick-started a process to revise the current global polio eradication strategy, which Zaffran said he hopes will be finished in time for the World Health Assembly in 2021.

The strategy requires fresh thinking in light of the challenges posed by and needs arising from COVID-19, and Zaffran said they will be looking for input from a range of stakeholders, such as behavioral scientists and civil society organizations that have not been previously involved in the development of the strategy.

While global polio eradication efforts have achieved significant milestones over the past three decades — the latest being the certification of the WHO African region as free of wild poliovirus — significant barriers remain to global polio eradication. There have been increases of wild poliovirus type 1 cases in Pakistan and Afghanistan and outbreaks of vaccine-derived poliovirus in several countries, such as the Philippines.

Early in the year, the Global Polio Eradication Initiative postponed polio vaccination campaigns amid the risk of COVID-19 transmission and repurposed polio infrastructure in countries to support governments’ efforts against the pandemic, leading to a rise in polio cases.

“We're thinking that perhaps the restriction of movements and sort of the fact that people were being [in lockdown] could actually sort of slow down the spread, [but the] impact has been negligible,” he said. “We have more children vulnerable because they haven't been vaccinated, and not only vulnerable to polio, but vulnerable to many vaccine-preventable diseases.”

A new approach

Part of what they want to achieve in the next strategy — and what other stakeholders could provide fresh thinking around — is getting communities to demand the vaccine themselves.

“We want to make it something that is less driven outside of the community and more demanded by the community. How do we make this happen?” Zaffran asked.

“If the communities want to vaccinate their children, then there's nothing that will prevent it. [But] at the moment, they're not really asking for this vaccination,” he added.

One of the biggest lessons he learned in years of leading global polio eradication efforts is the importance of getting communities to own the response, as was the case in India, which was declared polio-free in 2014 after years of accounting for the majority of the world’s polio cases.

“I think we probably have underestimated — at least with the two remaining [polio endemic countries of Pakistan and Afghanistan] and with this resistance to finish the job of vaccinating — the need for engaging the countries and the communities in doing the job themselves,” Zaffran said.

“We thought that we could convince those communities to finish the job and the virus would disappear. Unfortunately … many things have played against us,” he said, noting that the hard push for polio eradication needs to be sufficiently combined with engaging communities to the point that they champion the goal themselves.

Part of the challenge is the circulation of rumors and fake news, which leads to vaccine hesitancy, as was the case in Pakistan in 2019 when a rumor spread that the polio vaccine was killing children. The other challenges are community engagement and the absence of other basic but essential community needs, Zaffran said — a situation evident among Pashtun communities in Pakistan. Tensions with the government and the lack of basic needs and services have created a sense of resentment among communities.

“For them, seeing the health workers come with drops of polio, when in fact the children were suffering from lack of access to water or lack of access to other vaccines, perhaps … created a bit of resentment,” the WHO polio director said.

He said they are now trying to integrate vaccination for other vaccine-preventable diseases in their anti-polio drive and collaborate with other health programs. But he admits slow progress, as these activities require agreements and coordination with the government and other health services.

“The difficulty here is that it's always easier and faster to do it alone than to do it with others, but it's more important to do it with others if we want to really serve the needs of the community,” he said.

The future ahead

Zaffran said he will continue to be involved in polio even after his retirement by advocating and raising resources for polio and PolioPlus, an initiative by Rotary International that provides other interventions or assistance in support of polio eradication efforts.

“I am a Rotarian myself. I've joined Rotary myself in a small club in France, and I intend to continue to advocate for raising resources to support PolioPlus and the Rotary International efforts,” he said.

This will be much needed, given the financial challenge awaiting polio eradication efforts in 2021. While GPEI was able to raise $2.6 billion during a pledging conference in November 2019 in Abu Dhabi and some other pledges have come in since, Zaffran said the initiative is short of money.

“We actually are facing a very challenging situation for 2021. And we'll have to ... either be able to raise more resources or make some ... programmatic decisions that will be associated with some risks. We may decide to actually cut some areas of the program in order to be able to focus on [others],” he said, adding that these will be part of the discussions in revising the GPEI strategy.

GPEI had a funding gap of $500 million as of June 30. This is likely to increase, as additional time and precautions needed in carrying out polio vaccination campaigns amid the COVID-19 pandemic are likely to cost the program at least 10% more than what was budgeted, Zaffran said. But of the $2.6 billion in pledges from November, only 22% has been made available to date.