Q&A: WHO Director Aidan O'Leary on GPEI’s new plan to eradicate polio

The Global Polio Eradication Initiative has an ambitious timeline for the next five years, including certifying the eradication of wild poliovirus type 1 by the end of 2026.

The GPEI has recorded just three cases of wild poliovirus type 1 in the past six months. But that’s still “too many,” Aidan O’Leary, the World Health Organization’s director for polio eradication, told Devex.

“The only yardstick for an eradication program is zero. Everything else is [a] failure,” he said.

Under a new, five-year strategy to be officially launched on June 10, the GPEI aims to double down its campaigns to eradicate the virus in endemic areas in Afghanistan and Pakistan. It also aims to integrate other community needs into the polio program better and scale the introduction of the novel oral vaccine for poliovirus type 2 in countries to help stop outbreaks of circulating vaccine-derived poliovirus type 2.

But the road to eradication will depend mainly on increasing vaccination coverage, which remains a challenge in places such as parts of Afghanistan, where a Taliban-imposed ban on house-to-house polio campaigns since 2018 remains in place. Violence against polio workers also puts a damper on efforts toward eradication.

“When it comes to the areas that are inaccessible, clearly the major focus for us is to try and gain access to those children as quickly as is feasible. It's very, very clear though with the announcement of the U.S. and NATO troop withdrawal [in Afghanistan], there has been a significant increase in conflict activity levels,” said O’Leary.

The GPEI and its partners are exploring all options possible to reach children in these areas safely. A primary focus will be in accessible areas of the country, until the security situation stabilizes, O’Leary said.

Devex spoke to WHO director for polio eradication on the draft strategy’s emphasis on accountability. He also discussed polio surveillance during the COVID-19 pandemic, challenges in integrating the needs of communities in polio programs, and the status of the introduction of the novel oral polio vaccine type 2 in countries.

This conversation has been edited for length and clarity.

You’ve identified just three cases of wild poliovirus over the past six months. How accurate is that picture, given the challenges posed by the COVID-19 pandemic?

The importance for the eradication program is really around the quality of our surveillance system. And that surveillance system basically takes two forms. One is obviously the reporting of cases through the various different clinics. The second is a network of almost 100 environmental surveillance sites across both Afghanistan and Pakistan, where we basically take samples from the sewage once a month to evaluate the extent of transmission that’s taking place.

I think it’s important to recognize that the surveillance system is functional and has remained functional throughout. And what we have seen is a very sharp reduction not just of cases but also of the proportion of environmental surveillance sites that are reporting positive isolates for wild poliovirus.

And ... even in the inaccessible areas of Afghanistan, we continue to be able to … conduct these surveillance activities. So, I think we are reasonably confident that we have an accurate picture overall. But we continue to review the functionality of our surveillance, and to work to tweak at the maximum extent feasible.

What's been challenging in integrating other community needs into the polio program?

I think this has been happening in what I would call an ad hoc and patchy way. And what we are seeking to do is to become much more comprehensive and much more systematic in terms of how we address these kinds of demands.

The Polio Oversight Board ... clearly signaled at the start of the pandemic that polio staffing and infrastructure would be available to support pandemic response. And more recently, they have confirmed that the same staffing and resources would be available to support the introduction of COVID-19 vaccines into countries where that support was needed.

Secondly, I think the Polio Oversight Board has also kind of previously decided that, again, staffing and infrastructure would be available to support multi-antigen campaigns [such as measles campaigns].

A key element of your new strategy is introducing a novel oral vaccine for poliovirus type 2. At what stage are you of its introduction? What are the anticipated challenges in scaling its use?

There are 29 countries at different stages of verification to meet the conditions that have been set under the initial use phase of the emergency use listing [of the vaccine] that was granted last November. We have basically seven countries at the moment that are fully verified. So they are Nigeria, Liberia, Sierra Leone, Benin, Niger, Tajikistan, and most recently, Chad.

And of those seven countries, three have already conducted campaigns — Nigeria, Liberia, and Benin — with the others due to conduct campaigns in the coming days and weeks. So what we feel we have is really good momentum in terms of the introduction.

Nigeria, in particular, has conducted campaigns at scale, with between 14 and 15 million children reached over the course of two campaigns. And essentially, what we have been doing is extensive safety and surveillance work to make sure that the vaccine is fully safe.

And we will be working with our SAGE [Strategic Advisory Group of Experts] and its vaccine safety group over the course of the coming weeks, with a view to move to the next stage of the emergency use listing, which is the wider use phase.

The strategy also puts an emphasis on accountability. How do you envision this working out in practice?

There's a number of different levels of which accountability is practiced … there's a whole range of different oversights taking place at country level.

At the global level, through the strategy, we have identified or we put in place both what I would call key performance indicators as well as a risk management framework to make sure that we're able to clearly follow whether or not we're on track, and to provide basically a follow-up mechanism where we either need to improve implementation or if we're actually pursuing the wrong strategy at that particular point in time, to work to adjust that strategy.

And that work would be overseen by the strategy committee, the financial accountability committee, as well as the Polio Oversight Board.

I think that the third element of accountability is what I would call in the form of independent assessment. And in that regard, we have the GPEI’s independent monitoring board … [and the] framework for the regional certification commissions and the global certification commission … And again, the whole primary purpose of that is to really make sure that the program is on track in terms of the different standards that have been put in place.

And then I think the final mechanism for accountability is at the level of the [74th] World Health Assembly, which is taking place this week, as well as the International Health Regulations Emergency Committee, which meets on a quarterly basis to deal with countries that are either endemic or [where there are] outbreaks.

What we're looking at is to have a program that is fit for purpose and is delivering on the goals. And ultimately, depending on the different levels, we need to be clear about what's working well [and] what's working less well.