Polio Eradication: It's not over until it's over

By: Garba Abdu

It has been a long time coming, but when the World Health Organization (WHO) officially declares Africa polio-free, our challenges may only be beginning. We need to sustain the momentum to ensure that the virus is not only eradicated from every continent but that it stays that way forever.

This milestone declaration, which most experts expect in the next couple of years, comes too late for Hadiza, a 1-1/2 year old girl from Gezawa village, in Kano state in Nigeria. Hadiza was attacked and paralyzed by polio virus, crippling both limbs, destroying her capacity to stand, walk and play like normal children. The impact of the virus robbed her of the chance to go to school, and devastated her parents and her community. Hadiza and her family are among the thousands ruined by the crippling virus which is easily preventable but has no cure.

It is easy to have a short memory: As early as 1988 polio was still a deadly and a ferocious virus responsible for crippling over 350,000 children every year, according to the Independent Monitoring Board which oversees the Global Polio Eradication Initiative.

When African health ministers and major donors met in Addis Ababa in February 2016, they stressed the critical need to sustain the tempo of support for polio eradication to avoid the risks of resurgence of polio virus. Such resurgence would result in the loss of billions of dollars invested over the last 20 years, the continued crippling of innocent children and the possible spread to other countries with serious consequences.

As the world moves towards the historic milestone of polio eradication, the polio end game strategy is in full throttle. It is therefore critical to ensure that we don't lose momentum. Nigeria, my home country, is a case study for hope.

The recent declaration that Nigeria was effectively polio-free was a major turnaround for a country that, as recently as 2011, was seen as the biggest single global risk for spreading polio. Nigeria was responsible for the export of polio virus to 19 other countries, including Niger, Chad and Sudan.

Similar to Pakistan and Afghanistan, the last two remaining endemic countries, Nigeria had experienced setbacks that pushed the goal of global polio eradication back by years at the cost of more than $300 million. Chronic security problems, political unrest, fragile infrastructure, poverty and low levels of literacy and awareness all played their part in slowing eradication efforts. When nine members of a local polio team were assassinated by Boko Haram insurgents in Kano in 2013, followed by similar attacks in Afghanistan and Pakistan, polio eradication began to seem like an impossible goal.

We know that the quality of immunization program in all three countries was not optimal. But Nigeria took up the challenge, and implemented a series of measures which are now yielding results.

All high risk states in Nigeria developed a "micro-census" to ensure that every child was reached by immunization workers. A robust system was developed using GPS to ensure that each settlement was reached, as well as nomadic populations. Similarly a tracking system was developed to ensure that the health workers actually vaccinate children, thus holding them accountable. Nigeria created Polio Emergency Operation Centers at the national level and in six high risk states, enabling quick response to outbreaks and locally-tailored strategies for hunting down the virus. In addition, "health camps" were created to provide incentives such as nutritional supplements and other basic needs such as soap in addition to routine immunization services. The camps also provide basic emergency drugs for malaria and other ailments.

While Pakistan is moving towards adopting parts of this strategy, it has a long way to go. The Pakistani government in recent years launched emergency operation centers, but still struggles with high numbers of unimmunized children and a patchy vaccination program. Key parts of the Nigerian approach, including securing the support of powerful traditional leaders and developing a "micro-census" to account for all eligible children, are yet to be implemented. Pakistan is making significant effort to strengthen its surveillance system.

In October 2015, the Independent Monitoring Board stressed that countries need to shift to a resilient mindset: moving from eradication to prevention of transmission, re-introduction and resurgence. Such a mindset relies on tenacity - not just of the affected governments but most importantly donors and governments of developed countries who bear the cost for program execution.

While there is no doubt that the polio eradication campaign has been very expensive, the cost of dealing with a resurgence of the virus would be far more expensive.

And the threat remains. Polio outbreaks have been recorded in Ukraine and Syria, and these risks could rise with the mass movement of refugees to Europe and increasing numbers of internally displaced people in Sudan, Nigeria and other countries. While the world has done a tremendous job working toward eradicating polio, we are not finished. It means renewed commitment from donors, greater effort from governments and a focus on the details by health workers. As the Independent Monitoring Board stated, "As the finishing line draws tantalizingly nearer, the potential cost of any mistake is magnified."

Garba Abdu, Director Vaccines at the Clinton Health Access Initiative, former Senior Child Survival Advisor, USAID and an Aspen New Voices Fellow. Follow him on twitter @garbaabdu.