Polio
Eradication
Strategy2022–2026
Delivering on
a promise

﻿

Polio
Eradication
Strategy2022–2026
Delivering on
a promise

Polio Eradication Strategy 2022–2026: Delivering on a promiseISBN 978-92-4-003193-7 (electronic version)
ISBN 978-92-4-003194-4 (print version)
Published by the World Health Organization (WHO) on behalf of the Global Polio Eradication Initiative (GPEI).
© World Health Organization 2021
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Design and layout by Evalueserve.
Cover photo credits: UNICEF Pakistan / Syed Mehdi Bukhari

CONTENTS
Foreword..........................................................................................................................................................v
Acknowledgements........................................................................................................................................vi
Acronyms and abbreviations.......................................................................................................................vii
Executive summary........................................................................................................................................ix
Overview...........................................................................................................................................................1
Goal One: Permanently interrupt all poliovirus transmission in endemic countries................................7
Epidemiological context................................................................................................................................7
Current challenges........................................................................................................................................7
Path to permanently interrupt all poliovirus transmission in endemic countries............................................8
1. Create urgency and accountability through advocacy to generate greater political will........................ 10
2. Generate vaccine acceptance through context-adapted community engagement............................... 12
3. Improve frontline success through changes to campaign operations..................................................... 14
4. Expedite progress through expanded integration efforts and unified partnerships ............................... 15
5. Improve detection and response through sensitive surveillance............................................................. 17
Goal Two: Stop cVDPV transmission and prevent outbreaks in non-endemic countries....................... 19
Epidemiological context .............................................................................................................................19
Current challenges......................................................................................................................................19
Path to stop cVDPV2 transmission and prevent outbreaks in non-endemic countries...............................20
1. Create urgency and accountability through advocacy to generate greater political will........................ 21
2. Improve detection and response through sensitive surveillance ............................................................ 22
3. Improve frontline success through changes to outbreak response operations....................................... 24
4. Generate vaccine acceptance through context-adapted community engagement............................... 27
5. Expedite progress through expanded integration efforts and unified partnerships................................ 29
Enabling environment...................................................................................................................................31
1. GPEI structure..........................................................................................................................................31
2. Gender equality.......................................................................................................................................32
3. Communications .....................................................................................................................................33
4. Vaccine supply........................................................................................................................................34
5. Research..................................................................................................................................................36
6. Monitoring and evaluation framework......................................................................................................36
7. Finance and costing ...............................................................................................................................38
Preparing for the post-certification world...................................................................................................40
Containing poliovirus...................................................................................................................................41
OPV cessation.............................................................................................................................................42
Annex A. Stakeholder consultation list............................................................................................................43
Annex B. Current epidemiological state..........................................................................................................44
Annex C. Immunization Agenda 2030.............................................................................................................46
Annex D. Integration........................................................................................................................................47
Annex E. Risks.................................................................................................................................................50
Annex F. Strategy objectives and key performance indicators ......................................................................54
Annex G. nOPV2 contingency planning..........................................................................................................58
Annex H. Management review........................................................................................................................60
Annex I. Gender mainstreaming.....................................................................................................................62
Annex J. Research and development.............................................................................................................63
Annex K. Polio containment update................................................................................................................66iii

© UNICEF Pakistan / Syed Mehdi Bokhari

Polio Eradication Strategy 2022–2026: Delivering on a promiseiv

FOREWORD
The promise of a polio-free world has been a driving force behind the Global Polio Eradication Initiative (GPEI), contributing
to critical health gains over the past three decades. Indeed, before the coronavirus disease (COVID-19), polio eradication
signified to many what the world could achieve by joining together to protect and promote the health of all children.
As the world – and especially country health systems – adjusted to a new global health threat in COVID-19, the GPEI
launched an intensive review to identify barriers to eradication and develop a new strategy to deliver on the promise of apolio-free world. The complexity of the task grew as the programme had to take inventory of challenges faced in the years
before COVID-19 and define solutions that will work in a world perhaps forever altered in the wake of COVID-19. Without adoubt, the single greatest asset for this exercise has been more than 300 stakeholders who, through interviews, workshops
and reviews, lent knowledge and insight into the new and unfamiliar terrain of eradicating polio while mitigating the risks andresponding to the needs of a global pandemic.
Over the past few months, it has become clear that to place the GPEI back on the path to eradication, we must operatewith an emergency tempo while also becoming more accountable to the collective partnership, more responsive to theintersecting needs of impacted communities, more welcoming of intersecting fields of expertise, and more integrated withsocial and health programmes that deliver critical interventions to vulnerable populations.
The Polio Eradication Strategy 2022–2026 reflects the kind of integrated approaches that will be required to deliver on thepromise of eradication.
Through this new strategy, we believe the GPEI has re-envisioned its relationship with governments, deepened its
commitment to polio-affected communities, made changes to empower and safeguard the frontline workforce, and expanded
its partnerships to achieve broader impact in polio-priority geographies, alongside key innovations that will improve detection
and response. The strategy also sets clear goals for strengthening the programme’s gender-responsiveness, in recognition
that the more women’s meaningful participation and empowerment becomes a cornerstone of GPEI efforts, as outlined in its
Gender Equality Strategy, the more progress towards eradication will be made. In further alignment with the Immunization
Agenda 2030 (IA2030) and Gavi, the Vaccine Alliance’s strategic plan (Gavi 5.0), the new strategy offers a more holistic
approach to immunization and shares with IA2030 its principles of being people-centred, country-owned, partnership-based
and data-guided.
With an updated strategy and a defined path to eradication, we must accelerate progress as we enter the 2022–2026 period.
Stakeholders articulated the challenge well during the consultation process when they said, “Now is the time to do not just thegood things or the hard things, but the very hard things.”
As members of the Polio Oversight Board (POB), we join with the broader partnership in expressing our commitment togreater accountability on the path to eradication. In our meetings, POB members will routinely review the strategy’s newmonitoring and evaluation and risk management framework. We stand with you all, rededicated to polio eradication.
Working together and in close partnership with impacted countries, we can make up lost ground against polio during the
COVID-19 pandemic, while continuing to leverage the programme’s infrastructure to support fragile health systems. Even as
COVID-19 continues to pose challenges to health programmes around the world, we recognize an opportunity to come backstronger in our effort to create a healthier and more equitable world, which includes eradicating one of the cruellest infectious
diseases and thereby ensuring polio is no longer a threat to children and families anywhere in the world.
The GPEI Polio Oversight Board

Chris Elias
President, Global Development Division,
Bill & Melinda Gates Foundation
2021 Chair of the Polio Oversight Board

Mike McGovern
Chair, International PolioPlus Committee,
Rotary International

Seth Berkley
Chief Executive Officer, Gavi, the Vaccine
Alliance

Tedros Adhanom Ghebreyesus
WHO Director-General

Henrietta Fore
Executive Director, United Nations Children’s
Fund (UNICEF)

Rochelle Walensky
Director, US Centers for Disease Control andPrevention (CDC)v

ACKNOWLEDGEMENTS
The GPEI engaged a broad set of stakeholders throughout the development of Polio Eradication Strategy
2022–2026: Delivering on a promise. The engagement process benefited from the generous inputs of country
teams, national governments, donors and over 40 external and internal expert groups, many that encouraged thepartnership to embrace a more holistic approach to polio eradication (see Annex A).
The contributions of all participants resulted in a strategy that seeks to overcome the remaining challenges
through a recognition that polio eradication depends upon a spectrum of partners and a diversity of actors.

© WHO / Afghanistan

For their invaluable contributions to world health byvaccinating children and delivering other health services
to their communities, the GPEI dedicates this strategy
to frontline workers, and particularly those workers who
have lost their lives. The strategy is also dedicated tochildren, adolescents and adults affected by polio and to
the polio-affected advocates who have used their voice
and experience to play a key role in the eradication effort.

vi

ACRONYMS AND ABBREVIATIONS
AEFIAdverse event following immunization

NGO

Nongovernmental organization

AFP

Acute flaccid paralysis

nOPV1

Novel oral polio vaccine type 1

bOPV

Bivalent oral polio vaccine

nOPV2

Novel oral polio vaccine type 2

C4D

Communication for development

COVID-19

Coronavirus disease (2019)nOPV2 WG Novel Oral Polio Vaccine Type 2 Working
Group

CSO

Civil society organization

cVDPV

Circulating vaccine-derived poliovirus

cVDPV1

Circulating vaccine-derived poliovirus type 1

cVDPV2

Circulating vaccine-derived poliovirus type 2

cVDPV3Circulating vaccine-derived poliovirus type 3

EI

Essential immunization

EOC

Emergency operations centre

EPI

Expanded Programme on Immunization

ES

Environmental surveillance

EUL

Emergency Use Listing

GAPIII

Global Action Plan to minimize posteradication poliovirus facility-associated risk,
third editionnOPV3

Novel oral polio vaccine type 3

NPAFP

Non-polio acute flaccid paralysis

OPV

Oral polio vaccine

OPV2

Oral polio vaccine type 2

ORPG

Outbreak Response and Preparedness
Group

PCS

Post-Certification Strategy

PEF

Poliovirus-essential facility

PHC

Primary health care

POB

Polio Oversight Board

PQ

Prequalification

PRC

Polio Research Committee

PSEA

Protection from sexual exploitation and
abuse

R&D

Research and development

GCC-CWG Containment Working Group of the Global
Commission for the Certification of theEradication of Poliomyelitis

SAGE

Strategic Advisory Group of Experts on
Immunization

GIS

Geographic information system

SC

Strategy Committee

GPEI

Global Polio Eradication Initiative

SIA

Supplementary immunization activity

GPLN

Global Polio Laboratory Network

SOP

Standard operating procedure

HSS

Health system strengthening

TAG

Technical Advisory Group

IA2030Immunization Agenda 2030

tOPV

Trivalent oral polio vaccine

IHR

International Health Regulations

UNICEF

United Nations Children’s Fund

IMB

Independent Monitoring Board

VAPP

Vaccine-associated paralytic poliomyelitis

IPV

Inactivated polio vaccine

VDPV

Vaccine-derived poliovirus

KPI

Key performance indicator

VDPV1

Vaccine-derived poliovirus type 1

LQAS

Lot quality assurance sampling

VDPV2

Vaccine-derived poliovirus type 2

M&E

Monitoring and evaluation

VLP

Virus-like particle

MNCAH

Maternal, newborn, child and adolescenthealth

VPD

Vaccine-preventable disease

WHE

mOPV1

Monovalent oral polio vaccine type 1

World Health Organization Health
Emergencies ProgrammemOPV2

Monovalent oral polio vaccine type 2

WHO

World Health Organization

mOPV3

Monovalent oral polio vaccine type 3

WPV

Wild poliovirus

mRNA

Messenger ribonucleic acid

WPV1

Wild poliovirus type 1

NAC

National authority for containment

WPV2

Wild poliovirus type 2

NEAP

National Emergency Action Plan

WPV3

Wild poliovirus type 3

GCC

Global Commission for the Certification of
the Eradication of Poliomyelitisvii© UNICEF / Ghana

Polio Eradication Strategy 2022–2026: Delivering on a promiseviii

EXECUTIVE SUMMARY
Over the last decade, the Global Polio Eradication Initiative (GPEI) made steady progress on the path toeradication. Wild poliovirus types 2 and 3 (WPV2 and WPV3) were declared eradicated in 2015 and 2019,respectively; the World Health Organization (WHO) South-East Asia Region was declared free of poliovirus in
2014; and most recently, the WHO African Region was certified free of wild poliovirus (WPV) in August 2020.
However, the final steps towards eradication have proven the most difficult.
The GPEI now faces programmatic and epidemiological challenges that demand new approaches to place thepartnership and impacted countries on an emergency footing (see Annex B). To achieve a polio-free world, theGPEI has re-envisioned the endgame pathway with an urgent call for collective ownership and accountability
across the GPEI partnership and with governments, communities and all other stakeholders.
The Polio Eradication Strategy 2022–2026 offers a comprehensive set of actions that will position the GPEI todeliver on a promise that brought the world together in a collective commitment to eradicate polio. These actions,many of which are already under way in 2021, will strengthen and empower the GPEI to meet challenges head-on
and achieve and sustain a polio-free world.
The GPEI will transform its approach in each region and country through five mutually reinforcing objectives that
lay the foundation to achieve two elemental goals: Goal One to permanently interrupt all poliovirus transmission in
the final WPV-endemic countries of Afghanistan and Pakistan, and Goal Two to stop circulating vaccine-derived
poliovirus (cVDPV) transmission and prevent outbreaks in non-endemic countries.

Strategic objectives
Create urgency and accountability to generate greater political will by re-envisioning the
GPEI’s relationship with governments and systematizing political advocacy.

Generate vaccine acceptance through context-adapted community engagement that reduces
refusals and increases community commitment to child immunization.

Expedite progress through expanded integration efforts with a broader range of partners inimmunization, essential health care and community services.

Improve frontline success through changes to campaign operations and outbreak response
operations, including the recognition and empowerment of the frontline workforce.

Enhance detection and response through sensitive surveillance that provides the programmewith critical information for action.

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Polio Eradication Strategy 2022–2026: Delivering on a promise

Goal One: Permanently interrupt all poliovirus transmission in endemic countries
To protect the investment generations have made in polio eradication, Goal One offers a pathway towards
permanently interrupting all poliovirus transmission in Afghanistan and Pakistan. The path to eradication in the
final endemic countries will take:•increased political will at all levels of government and with all local actors through a commitment to theapolitical value of polio eradication;•a deep and enduring partnership with marginalized communities, especially those living in the highest-risk
districts for polio;•

a well-functioning programme with a motivated and appropriately staffed frontline workforce who consistently
deliver vaccines to the doorstep of every household or at every opportunity in areas where household accessis restricted;•

an integrated service delivery approach that prioritizes essential immunization and the provision of other
health services (see Fig. 1); and•a continued investment in and improvement of surveillance quality and timeliness of detection.

Collectively, these approaches will improve the effectiveness of programme operations, change the way the
programme listens and responds to communities, and increase local, provincial and national stakeholder
commitments to eradication.

Goal Two: Stop cVDPV transmission and prevent outbreaks in non-endemic countries
Outbreaks of circulating vaccine-derived poliovirus type 2 (cVDPV2) have become a global concern, as the world
has seen more annual cases of cVDPV2 than wild poliovirus type 1 (WPV1) since 2017. While 27 outbreaks havebeen declared closed by the GPEI in the past two years, the scale and speed of disease spread pose a risk for
global polio eradication. In this context, Goal Two outlines strategies and tactics to put the GPEI and impacted
countries on an emergency footing to stop cVDPV2 transmission. In addition to maintaining sensitive surveillance
to quickly detect and rapidly respond to any poliovirus, new approaches to interrupt cVDPV2 transmission will
include:•targeted and coordinated political advocacy in outbreak countries to link polio outbreak preparedness andresponse to broader country health priorities;•

emergency command structures for response at the country, regional and global levels for rapid decisionmaking during outbreak detection and response;•

increased regional and country capacity to support surveillance and outbreak response;•

deployment of novel oral polio vaccine type 2 (nOPV2) to minimize outbreak seeding, and other new tools,
approaches and partners to improve surveillance, outbreak response speed and quality, and community
engagement; and•strong coordination with in-country Expanded Programme on Immunization (EPI) and essential immunization
partners to identify zero-dose and under-immunized communities in polio-priority geographies (see Fig. 1).1

Fig. 1. Integration modalities and regions
Pandemic response, including support to COVID-19 vaccine delivery, wherever the
GPEI is needed.
Integrated service delivery in the high-risk districts of Afghanistan.
Integrated service delivery for priority communities in Pakistan.
Multi-antigen immunization campaigns to increase immunity to vaccine-preventable diseases.
Coordination with Gavi and the Expanded Programme on Immunization on the “zero-dose”
initiative, including in outbreak response.
Acceleration of the transition of polio-essential functions in areas where polio is alreadyintegrated.
Source: WHO.

“Zero-dose children” are children who have received no essential immunization, often due to weakened country health systems. This attention to deprived communities wherelarge numbers of zero-dose children reside is an opportunity for collaboration and efficiencies with Gavi. See Gavi, the Vaccine Alliance. Phase V Strategy (2021–2025). Geneva:
Gavi, the Vaccine Alliance; 2019 (https://www.gavi.org/our-alliance/strategy/phase-5-2021-2025, accessed 9 June 2021).

1

x

Executive summary

Milestones and measures for success
The Polio Eradication Strategy 2022–2026 has set aggressive benchmarks to measure progress towards
eradication (see Fig. 2). Because of unprecedented uncertainties faced by the partnership, this timelinefunctions as a budget and planning tool and will be regularly appraised, with intensive programme review
planned for 2023. Achieving the last milestones for WPV1 certification and cVDPV2 interruption will launch
the Post-Certification Strategy (PCS),2 for which steps have been initiated towards long-term integrated polio
surveillance, response capacity, essential immunization strengthening and containment.

Fig. 2. Polio Eradication Strategy 2022–2026 planning and budgeting timeline, 2021–2027+
Interruption of WPV1 transmission
and last cVDPV2 isolate reported

Goal one

Certify the eradicationof WPV1

Strategy
milestones

Rigorous review ofthe 2022–2026 Strategy

2021

2022

2023

2024

2025

2026

2027+

Rigorous review ofthe 2022–2026 Strategy

nOPV2
Wider use
initial use of nOPV2

Goal two

SecondIPV doses &nOPV2 PQ

Report thelast isolate
of cVDPV2

Validate the Phase out
absence ofbOPV &cVDPV2
advancethe PCSbOPV = bivalent oral polio vaccine; cVDPV2 = circulating vaccine-derived poliovirus type 2; IPV = inactivated polio vaccine; nOPV2 = novel oral polio vaccine type 2; PCS = PostCertification Strategy; PQ = prequalification; WPV1 = wild poliovirus type 1.
Source: WHO.

The new strategy also introduces a more comprehensive and systematic approach to performance and risk
management at all levels of the programme. To track progress and adjust to unforeseen risks, a new monitoringand evaluation (M&E) matrix has been developed with milestones, outcomes and key performance indicators(KPIs) that will help to identify programme weaknesses in a timely way and implement corrective and mitigating
measures as appropriate. A separate risk register maps interrelated threats to the success of the strategy.
Global technical leads will regularly review M&E indicators and outcomes, and the Polio Oversight Board (POB)
will review goal-level milestones on a quarterly basis. To reinforce global health monitoring, this M&E system
contributes to and is aligned with the monitoring framework of the Immunization Agenda 2030 (IA2030).3

Immunization Agenda 2030 strategic alignment
IA2030 is an ambitious global vaccine and immunization strategy endorsed by the Seventy-third World
Health Assembly and supported by global health partners. Building on its predecessor, the Global Vaccine
Action Plan (GVAP) for a new decade (2021–2030), IA2030 supports national efforts to improve immunization
programmes and primary health care (PHC) as a means to reduce and eliminate vaccine-preventablediseases.
In recognition of the critical importance of strong immunization programmes to reach and sustain polio
eradication, the GPEI will make contributions to IA2030 strategic priorities (see Annex C). Aligning GPEI
milestones and measures for success to the IA2030 M&E framework will integrate the GPEI with global healthmonitoring and contribute to streamlined measurement and reporting. The GPEI will also be a part of theownership and accountability mechanisms of IA2030, including the Partnership Council, which will ensurealignment and joint accountability with immunization partners.
As a central pillar for programme success, accountability will be upheld through distinct country- and globallevel mechanisms that are collectively reinforced through the assessment of independent bodies, such as the
Independent Monitoring Boards (IMB), the Strategic Advisory Group of Experts (SAGE) on Immunization andthe global and regional certification commissions. Ultimately, the polio eradication programme and its partners
are accountable to the world’s children to ensure they are fully protected and no longer at risk from this highly
infectious communicable disease (see Accountability pillar, next page).

2

“Global Polio Eradication Initiative (GPEI). Polio Post-Certification Strategy. Geneva: World Health Organization; 2018 (http://polioeradication.org/wp-content/uploads/2018/04/
polio-post-certification-strategy-20180424-2.pdf, accessed 10 June 2021).
“Implementing the Immunization Agenda 2030: Draft framework for action through coordinated planning, monitoring & evaluation, and ownership & accountability. WHO
Immunization, Vaccines and Biologicals (IVB). Geneva: World Health Organization; 2020 (https://www.who.int/publications/m/item/implementing-the-immunization-agenda-2030,
accessed 10 June 2021).

3

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Polio Eradication Strategy 2022–2026: Delivering on a promise

Accountability
pillarMember State bodies
World Health AssemblyInternational Health Regulations
Emergency Committee

Independent bodies• Independent Monitoring Boards• Strategic Advisory Group of Experts• Global and regional certification commissions

Global programme
M&E framework with KPIs
and risk management

Endemic country
programmes
Frameworks supporting
National Emergency Action Plans

Non-endemic country
programmes
Frameworks supporting
outbreak response

KPI = key performance indicator; M&E = monitoring and evaluation.
Source: WHO.

Enabling factors
To ensure the partnership is fit for purpose, the GPEI will realign its structure to strengthen accountability andtransfer more decision authority to where programmes are implemented – at the national and provincial levels.
Additional factors that contribute to an enabling environment include:•

optimizing GPEI management structures to promote role clarity and speed up decision-making;•applying a gender equality lens to the implementation of programme activities;•

developing a communication strategy that utilizes social and behavioural data analyses to increase vaccine
acceptance and minimize risk;•

ensuring vaccine supply mechanisms are resilient and remain uninterrupted;•

investing in the research and development (R&D) of new innovations that support eradication;•

preparing for and responding to risks through a monitoring framework; and•resourcing the programme through appropriate costing and financing.

xii

Executive summary

The way forward
The challenges of the next five years require unified commitments from GPEI agencies, governments and global,
national and local stakeholders. A principal intent of the new strategy will be to align the efforts of all partners
in polio eradication and focus support to the frontline delivery of polio immunization and related services (seePartners in polio eradication, next page). Through an emergency focus and a more integrated approach todelivering critical health interventions to polio-affected and at-risk countries and regions, the GPEI will achieve a
polio-free world – and remind the global community of the enormous achievements that can be gained throughcollaborative engagement and collective pursuit.

Partners in polio eradication

Partners in polio eradication
Frontline vaccinatorsand surveillance
Country programmes
Regional support
Global support

Member States of theWorld Health AssemblyPoliosurvivors

World
Bank

Diversity of actors
Research
institutions
Local
influencers

Healthprofessional
associations

District &subdistrictleadership

Traditionalbirthattendants
Provincial
governments
Media
partners &influencers

Local
healthfacilities

Rotarians

DonorsNational
governments
CSOs/
NGOs/
nonprofits
Think
tanks

Humanitarian
actorsAdjacent
healthprogrammes
Humanitarian
actorsLaboratories
Women’sgroupsSocialmobilizers

Immunization
partners

Religious
supportadvocates

Schools in
endemic
countries

Mothers,
fathers,
caregivers

CSO = civil society organization; NGO = nongovernmental organization.
Source: WHO.

xiii

Polio Eradication Strategy 2022–2026: Delivering on a promise

COVID-19: a case study in emergency action and effective partnership
When COVID-19 emerged in 2020, countries with a strong GPEI presence were able to use expertise andinfrastructure put in place by the polio eradication programme to coordinate an effective COVID-19 response.
Thousands of polio workers shifted their focus to help contain the spread of the SARS-CoV-2 virus. Polio
emergency operations centres (EOCs) pivoted to respond to COVID-19 through surveillance, contact tracing
and specimen transport, provision of soap and hand sanitizer, distribution of training materials for medical
personnel and frontline workers, and community engagement on mitigation measures.†
In Pakistan and Nigeria, GPEI assets were especially valuable. In Pakistan, polio labs provided COVID-19
testing and sequencing, the polio call centre became (and remains) the national COVID-19 call line, polio
staff trained more than 18 600 health professionals, and polio community mobilizers engaged 7 000 religious
leaders and 26 000 influencers. In Nigeria, COVID-19 response teams used EOC data systems and analytics
to track and visualize PHC delivery, which helped identify gaps and target catch-up services.
To support pandemic response while delivering polio and broader immunization and surveillance activities,
the GPEI and EPI accelerated their integration initiative and launched an interim Programme of Work for
Integrated Actions in the context of COVID-19 (iPOW).‡ The iPOW provides guidance to synergize polio
eradication and EPI efforts in mutually beneficial areas.
In the coming years, countries may continue to depend upon GPEI support to combat COVID-19 or other
health emergencies. By building upon this spirit of cooperation, joint planning and emergency response, polio
eradication can be achieved amid competing health priorities and a resource-limited environment.
Nearly 50 countries reported polio support for COVID-19 in the African Region (36), the Eastern Mediterranean Region (8) and the South-East Asia Region (5), totalling US$
26.7 million as of June 2020. See Contributions of the polio network to the COVID-19 response: turning the challenge into an opportunity for polio transition. Geneva: World
Health Organization; 2020 (https://www.who.int/publications/i/item/contributions-of-the-polio-network-to-the-covid-19-response-turning-the-challenge-into-an-opportunity-forpolio-transition, accessed 10 June 2021)‡
See Global Polio Eradication Initiative (GPEI). Polio Eradication and Essential Programme on Immunization Interim Programme of Work for Integrated Actions in the context
of the COVID-19 pandemic. Geneva: World Health Organization; 2020 (https://polioeradication.org/wp-content/uploads/2020/09/Integration-POW-under-Covid-v2.0.pdf,
accessed 10 June 2021).

© UNICEF / Pakistan

†

xiv

OVERVIEW
The GPEI stands at a crossroads, needing new approaches to overcome the last remaining hurdles and achieve
polio eradication. In the final two endemic countries, Afghanistan and Pakistan, WPV1 persists alongside
cVDPV2. Globally, cVDPV2 outbreaks are occurring in four of the six geographical regions of WHO.4(See Annex B for the current epidemiological state.)
The GPEI put forth a strategy in 2019 that presented guidance to eradicate polio,5 but negligible progress andwaning population immunity in high-risk countries and regions have contributed to a deteriorating epidemiologicalstate, as traditional methods have proven insufficient.6
As the GPEI works to generate collective urgency, engagement in and accountability for polio eradication, it
faces the following challenges:•

difficulty in achieving and maintaining political will due in part to inadequate approaches to securing
ownership of the eradication effort by the governments of polio-impacted countries;•

under-engagement with and from affected communities as polio eradication is not positioned within theirbroader needs and as mistrust in the programme remains unresolved;•

undefined and largely unfunded commitments to integrate the polio programme with other health anddevelopment initiatives that have been prioritized by governments or are needed by communities;•

gaps in campaign performance left unresolved due to the absence of strong M&E frameworks and purposefulcommunity engagement; and•delayed detection of poliovirus transmission, compounded by a series of logistical challenges that extend
response time beyond the window of maximum impact.

New strategic framework
To address these challenges and permanently interrupt poliovirus transmission, the GPEI has launched a
new strategy to transform its approach – by employing all opportunities to vaccinate children, build collective
ownership and accountability of the eradication effort, and ensure a level of urgency commensurate withthe 2014 designation of polio as a Public Health Emergency of International Concern.7
The new strategic framework has been developed to identify innovative ways to overcome the most intractablebarriers to eradication while optimizing the core strategies that have enabled progress against polio to date(Fig. 3). This more holistic strategy will bring the partnership beyond a strictly epidemiological and “vertical”
approach to eradication through transformational and sustainable solutions.

In 2020, 140 WPV1 cases were reported in Afghanistan (56) and Pakistan (84), and 1418 cVDPV2 cases and isolates were reported through acute flaccid paralysis surveillance(971) and environmental surveillance (447), with the most consequential outbreaks in Afghanistan (269), Pakistan (135), Chad (98), Democratic Republic of the Congo (75) andCôte d’Ivoire (71).
5Global Polio Eradication Initiative (GPEI). Polio Endgame Strategy 2019–2023: Eradication, integration, certification and containment. Geneva: World Health Organization; 2019(https://polioeradication.org/who-we-are/polio-endgame-strategy-2019-2023, accessed 10 June 2021).
6
For more on the insufficiency of past approaches, see Independent Monitoring Board (IMB). The world is waiting: Nineteenth report; December 2020 (https://polioeradication.org/
wp-content/uploads/2020/12/19th-IMB-Report-The-World-is-Waiting-20201223.pdf, accessed 10 June 2021).
7
WHO statement on the meeting of the International Health Regulations Executive Committee concerning the international spread of wild poliovirus. Geneva: World HealthOrganization; 5 May 2014 (https://www.who.int/news/item/05-05-2014-who-statement-on-the-meeting-of-the-international-health-regulations-emergency-committee-concerning-theinternational-spread-of-wild-poliovirus, accessed 10 June 2021).
4

1

Polio Eradication Strategy 2022–2026: Delivering on a promise

Fig. 3. Polio Eradication Strategy 2022–2026 strategic framework

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GPEI structure
Source: WHO.

Integration on the path to eradication – and beyond
The GPEI is committed to an integrated approach to programme implementation that enables countries to fully
leverage existing polio programme assets and serve the health needs of vulnerable communities. The GPEI
defines integration as joint efforts between the polio eradication programme and a range of partners with theobjective of improving immunization outcomes in targeted geographies. Integration efforts are pursued throughtwo primary means: strengthened collaboration with other immunization programmes and context-appropriate
strategies for delivering vaccines alongside PHC and other services.
The Polio Eradication Strategy 2022–2026 brings integration into focus through two transformations ofapproach. The first is a recognition that for polio eradication to succeed, chronically low immunization coverageand demand-based refusals of polio vaccines in key geographies and populations must be addressed, forwhich integration provides targeted solutions. The second is a revaluation of integration as a step towards thelong-term, sustainable transition of polio functions to other health programmes and national health systems as
the world nears polio eradication.

2

Overview

The GPEI will have multiple roles in implementing integration activities, and a decision-making framework will
guide the evaluation and selection of integration opportunities (see Annex D). While the roles may vary, theintention is consistent and reflective of this evolved approach. Across all modalities and regions, the push for
integration will allow the GPEI to better reflect the needs, voices and capabilities of the spectrum of stakeholders
needed to achieve eradication.
GPEI integration efforts at a global level will entail:engaging in multisectoral discussions with governments and relevant health and humanitarian programmes to
identify and plan integration initiatives;•

providing co-funding and operational assistance for the co-delivery of the bivalent oral polio vaccine (bOPV)
in other campaigns;•

providing co-funding for integrated service delivery in the high-risk districts of Afghanistan and priority
communities in Pakistan;•

providing resource mobilization and advocacy to direct existing funds for expanding PHC, including essential
immunization in targeted subnational areas at high risk for polio;•

working with national governments to determine how polio-essential functions will be managed and eventuallytransitioned to EPI;•

providing technical assistance and strategic oversight for areas related to essential immunization delivery andvaccine-preventable disease (VPD) surveillance; and•participating in governance structures of the IA2030 and World Bank country and regional review
mechanisms.

© UNICEF / Mariam Al-Hariri•

3Polio Eradication Strategy 2022–2026: Delivering on a promise

Readiness for what lies ahead
As the COVID-19 pandemic demonstrated, sudden and unexpected events can delay progress towards
eradication. Drawing upon these hard-earned lessons, the partnership enters this strategic period equipped witha new risk management approach to proactively monitor risks and their potential cascading effects upon the
programme (see Annex E).
Braced with new tools and frameworks, the GPEI launches this strategy with a renewed sense of how precarious
gains in public health and global health security can be, how urgently they must be protected, and how evident
it is that collaboration and partnership remain the programme’s strongest asset. By emphasizing urgency in all
activities, by becoming a willing and responsive partner to governments, communities and other health initiatives,and by rebalancing capacity and decision-making towards regional and country teams, the polio programme andits partners will collectively generate greater accountability and increased ownership of eradication efforts – andachieve a polio-free world.

Navigating transition
Over more than three decades, the GPEI has set up infrastructure
to pursue polio eradication in countries around the world. Thishas supported not only polio eradication-related activities but
also functions that go well beyond this core purpose, including
VPD surveillance and laboratory functions; essential immunization
activities; new vaccine introductions in many countries; emergency
preparedness and response; and health system strengthening.
The GPEI has also cross-subsidized operations support. Services suchas logistics, data, finance, human resources and administration are
essential to running polio eradication work – and they, too, have beenshared much more widely. Countries in a substantial part of the world,
particularly in the African, Eastern Mediterranean and South-East Asia
Regions, have become heavily reliant on GPEI infrastructure to sustain
broader public health functions. Against the backdrop of COVID-19
pandemic response and an ever-tightening fiscal environment, theGPEI will endeavour to eradicate WPV1, interrupt cVDPV transmission
and maintain polio-free status while supporting an expedited, riskbased transition of United Nations Children’s Fund (UNICEF) andWHO staffing and infrastructure to Member States and essential
immunization or health emergency programmes.
See the Transition Independent Monitoring Board’s report on Navigating Complexity* for more on the transitionof polio assets and functions.
*Polio Transition Independent Monitoring Board (TIMB). Fourth report, Navigating complexity. January 2021 (https://polioeradication.org/wp-content/uploads/2021/02/4thTIMB-Report-Navigating-Complexity-20210131.pdf, accessed 11 June 2021).

4

© UNICEF Pakistan / Syed Mehdi Bokhari

Overview

5© UNICEF / K. ShahPolio Eradication Strategy 2022–2026: Delivering on a promise

6Goal One

Permanently
interrupt allpoliovirustransmissionin endemic
countries

Interrupting WPV1 and cVDPV2 transmission in the final
two endemic countries is the primary goal on the path
to global polio eradication. To interrupt all poliovirustransmission in Afghanistan and Pakistan, the GPEI
plans to first limit circulation to core reservoirs andshared corridors of transmission and then interrupt
all poliovirus within the reservoirs by 2023, with theglobal eradication of all wild poliovirus certified by
2026. The programme has made progress towards
cVDPV2 interruption and will continue to respond to
breakthrough events to stop cVDPV2 transmission.

EPIDEMIOLOGICAL CONTEXTPoliovirus has never been stopped simultaneously
across Afghanistan and Pakistan. Due to deep social,
cultural and economic ties and large-scale crossborder population movement, Afghanistan and Pakistan
represent a single epidemiological block and bothcountries must interrupt poliovirus transmission for either
country to achieve and sustain eradication. After an
emergence of cVDPV2 in 2019, waning type 2 mucosal
immunity and gaps in immunization activities enabledcVDPV2 spread, and Afghanistan and Pakistan are now
experiencing the co-circulation of WPV1 and cVDPV2.
(See Annex B for the current epidemiological state.)

CURRENT CHALLENGESIn Afghanistan, a ban on house-to-house immunization
has resulted in more than 1 million children persistently
missed in southern areas by polio vaccination
campaigns since May 2018. As a result, in 2019 and2020, respectively, 90% and 75% of Afghanistan’s
WPV1 cases8 originated in areas not currently
accessible for vaccination. In accessible areas,
progress is hampered by several factors, most notably
poor-quality campaigns due to insufficient planning andstaffing issues within national and provincial EOCs, aswell as a lack of rigorous accountability mechanisms.
In Pakistan, progress has been forestalled by a
combination of factors: complacency with decliningcases from 2015 to mid-2018,9 including a few months
without a single case; transitions in national leadershipand a subsequent politicization of polio; an increasein vaccine hesitancy; and a misalignment between
newly emerging challenges in priority areas andvaccination approaches that were better suited for apast era. Additionally, misinformation about vaccinesand vaccination programmes circulates widely
through social media platforms, contributing to risingrefusal rates. Campaign reach has been impacted byineffective engagement with marginalized populations
at high risk for polio, specifically Pashto-speaking
communities that represent 15% of the country’s
population yet bear a disproportionate burden (81%)
of Pakistan’s WPV cases over the last 10 years.9 Thisdifficult context, in tandem with operational gaps invaccine delivery, has resulted in increased WPV1
cases and has contributed to cVDPV2 spread.
See Technical Advisory Group (TAG) on Polio Eradication in Afghanistan, March
2021 (https://polioeradication.org/wp-content/uploads/2021/04/Afghanistan-TAGReport-20210317-20.pdf, accessed 23 August 2021).
9
See Meeting of the Technical Advisory Group (TAG) on Polio Eradication in Pakistan,February 2021 (https://polioeradication.org/wp-content/uploads/2021/04/Pakistan-TAGReport-20210209-11.pdf, accessed 23 August 2021).
8

7

Polio Eradication Strategy 2022–2026: Delivering on a promise

For both countries, the COVID-19 pandemic has added to these challenges. In early 2020, COVID-19’s firstwave led to restrictions on movement and the temporary suspension of polio activities between March and July.
During this operational pause, surveillance quality deteriorated and immunization campaigns were postponed.
In 2021 and beyond, the introduction of COVID-19 vaccines will present an opportunity to synergize immunization
messaging, even as the vaccination misinformation epidemic (now termed the “infodemic”) will need to beaddressed to achieve high vaccination coverage.

PATH TO PERMANENTLY INTERRUPT ALL POLIOVIRUS TRANSMISSION IN ENDEMIC
COUNTRIESInterrupting all poliovirus transmission in Afghanistan and Pakistan will require national governments, country
programmes, GPEI implementing agencies and core partners to undertake an emergency posture. UNICEF
and WHO will continue to operate under their respective emergency declaration authority to expedite resource
mobilization and allocations, shorten staffing and deployment processes, and provide greater delegation of
authority closer to the field.
The path to eradication (see Fig. 4) will take:•increased political will at all levels of government and with all local actors through a commitment to theapolitical value of polio eradication;•a deep and enduring partnership with marginalized communities, especially those living in the highest-risk
districts for polio;•

a well-functioning programme with a motivated and appropriately staffed frontline workforce who consistently
delivers vaccines to the doorstep of every household or at every opportunity in areas where household accessis restricted;•

an integrated service delivery approach that prioritizes essential immunization and the provision of other
health services; and•a continued investment in and improvement of surveillance quality and timeliness of detection.

Fig. 4. Goal One strategic objectives and key activities

Political advocacy• Gain and maintain
access in
Afghanistan
through systematic
advocacy with all• Intensify advocacy
with provincial
governments inPakistanCommunity
engagement

Campaigns

Integration

Surveillance• Conduct
multidisciplinary
research into
vaccine hesitancy
and community
mistrust• Recruit, train, andappropriately
support a motivatedworkforce thatmeets the needs ofthe community• Improve timelinessfor detection —from case onset to
final results• Foster allianceswith priority
communities forco-design,
ownership anddelivery ofgender-responsive
programme
innovations• Introduce
monitoring
innovations toenable faster data
feedback loops andimprove quality• Deliver polio
vaccinesalongside basic
public services toincrease the reachof both essential
and supplementary
immunization, witha focus on high-risk
areas

Enabling
environment
Source: WHO.

8

• Facilitate
strengthening ofessential
immunization• Establish pathway
towards asustainable
integrated
surveillancesystem• Partner withgovernments,
communities, andadjacent healthprogrammes tosupport access andreduce missed
communities andzero-dose children• Increase the representa�on and empowerment of women at every level andacross all areas of the programme• Provide targeted assistance for country programmes through the GPEI hub.

Goal OneTo ensure both endemic countries remain on track for milestones towards successful interruption (see Fig. 5),
the GPEI will closely monitor progress through KPIs that prioritize advocacy, community engagement andthe integration of polio vaccine delivery with other desired services, alongside focused programmatic andoperational improvements (see Monitoring and evaluation framework and Annex F).

Fig. 5. Milestones for interrupting poliovirus transmission in Afghanistan and Pakistan, 2021–2026
Afghanistan
Intensified
negotiation
efforts to gain
accessContinued
implementation ofcomplementary
approaches tovaccination
in inaccessible
areas

Rigorous
reviewof the2022–2026
Strategy

Continued long-term
strengthening of
immunization
systems

Beginning of the
programme’s
transition planning for
certification(2024–2026)

Strategy
milestones

High-quality
deliverymonitored andmaintained inboth accessible
and inaccessible
areas

2021

2022

2023

Wider useof nOPV2

Implement
programmatic
improvements:• Changes to frontline
team management

2025

Interruption of WPV1transmission and lastcVDPV2 isolate reported

Mechanisms inplace forequitable EI
access and OPV
co-delivery
through
integrated
services• New approaches
for inclusive
engagement forpriority communities• Systematic,
consistent dialogue
with provincial
leadership2024

Widespreadtransmission
limited to only
core reservoirs

2026

Certify theeradicationof WPV1

Rigorous
reviewof the2022–2026
Strategy

National andprovincial
governments own
and are accountablefor polio eradicationand certification
implications

Beginning of the
programme’s
transition planningfor certification(2024–2026)

Final, sporadic
chains oftransmission
eliminatedPakistan

Joint milestones

cVDPV2 = circulating vaccine-derived poliovirus type 2; EI = essential immunization; nOPV2 = novel oral polio vaccine type 2; OPV = oral polio vaccine; WPV1 = wild poliovirus
type 1.
Source: WHO.

9

Polio Eradication Strategy 2022–2026: Delivering on a promise

1. Create urgency and accountability through advocacy to generate greater political will
A renewed focus on and evolved approach to stakeholder engagement and political advocacy will be central toachieving eradication in Afghanistan and Pakistan.
In Afghanistan, widespread conflict and insecurity disrupt campaign operations due to restricted access in
key geographies. These barriers to reaching children who have been inaccessible to the programme will only
be resolved by engaging all local actors, directly or through intermediaries, to negotiate access and achieve
broad consensus that polio immunization is apolitical and that all children, regardless of where they live, deserve
protection from polio. Given uncertainties around the ongoing subnational political situation, the polio programme
will proactively utilize all means and opportunities to reach children in areas that are inaccessible to house-tohouse vaccinators.
In Pakistan, programme success depends on increasing government ownership of polio service delivery. The
government has the capacity to ensure nationwide vaccination coverage, but polio is no longer a public healthpriority, particularly at the district and provincial levels where health decision-making authority resides. Rebuilding
a commitment to polio eradication requires systematic dialogue with the national and provincial leadership andother influential stakeholders. The programme will use every available opportunity to ensure polio eradication
remains a top public health priority for the government, including the National Task Force chaired by the Prime
Minister, the Provincial Task Forces chaired by provincial chief ministers, and through direct engagement by
world leaders and the POB in all appropriate forums. The GPEI will also continue to provide full support to thegovernment and country programme, including through National Emergency Action Plans (NEAPs).10

Government ownership in Nigeria
On 18 June 2020, after responding to challenges related to insecurity, inaccessibility, vaccine hesitancy andweakened health systems, Nigeria was declared free of wild poliovirus. A key element in the country’s success
was government ownership and engagement.* Nigerian heads of state played a visible and active role,even launching national campaigns by vaccinating their own grandchildren on television. Domestic financial
contributions signalled the government’s firm commitment. Between 2011 and 2019, Nigeria contributed
US$ 190 million through loan funds and taxpayer support to the country’s financial resource requirements
under the GPEI.† In a large, federated country, commitment was needed at the state level. All 36 executive
governors signed an agreement to provide leadership,‡ meeting regularly to review progress against a strong
monitoring and accountability framework. This state commitment was further amplified by community leaders
who championed polio eradication.
Vaz RG, Mkanda P, Nsubuga P, Ado M, Etsano A. Best Polio Eradication Initiative (PEI) practices in Nigeria with support from the WHO. J. Infect. Dis. 2016;213(suppl_3):
S65–S66 (https://academic.oup.com/jid/issue/213/suppl_3, accessed 11 June 2021).
See Global Polio Eradication Initiative (GPEI). Historical Contributions, 1985–2019 (https://polioeradication.org/financing/donors/historical-contributions, accessed
11 June 2021).
‡
See the Global Polio Eradication Initiative (GPEI). Abuja Commitments to Polio Eradication in Nigeria (https://polioeradication.org/tools-and-library/policy-reports/declarationsand-resolutions, accessed 11 June 2021).
*†

Key areas of evolution
Restoring the emergency posture needed to interrupt transmission will require reinstating polio as a publichealth priority to generate a renewed focus of national and provincial governments and stakeholders at all levels
within both countries. To reprioritize polio eradication and create urgency and accountability to generate greater
political will, the GPEI will:•take a proactive and strategic approach to open dialogue with all stakeholders – from the national andprovincial levels to local community settings – to build personal relationships, increase trust and develop abetter understanding of the benefits of an effective polio programme;•

explore every option to address the ban on house-to-house vaccinations, including negotiating intermediate(though less effective) vaccination options, such as mosque-to-mosque, site-to-site and expanded permanenttransit point vaccinations;•establish a specific work stream on political advocacy with staffing capacity to support countries andcoordinate regionally and globally, where needed. The GPEI hub will help countries carry out stakeholder
mapping by tracking outreach and consolidating information. The hub will also liaise with GPEI politicaladvocacy and global communication groups and facilitate multidisciplinary expertise (social, political,
economic) from outside of the GPEI to develop new approaches that will strengthen ties with key stakeholders
and communicate better with specific audiences; andNational Emergency Actions Plans are available on the GPEI website via dedicated country pages for Afghanistan and Pakistan (https://polioeradication.org/where-we-work/
afghanistan and https://polioeradication.org/where-we-work/pakistan, both accessed 11 June 2021).

10 

10

Goal One•utilize regional and national platforms to rally broader support for polio eradication. At the regional level, the
new Eastern Mediterranean Ministerial Regional Subcommittee on Polio Eradication and Outbreaks will playa key role in building and maintaining regional commitment to the polio programme. Regional, national andsubnational communications efforts will also build and maintain an enabling environment for the eradication
effort as well as support ongoing dialogue and engagement with communities to minimize communicationrelated risks and generate vaccine demand.

Taken together, these changes will provide the GPEI with greater opportunities to convey the value of polio assets
and infrastructure to other health priorities and explore the best mechanisms to advocate for domestic financing
and strengthened government accountability.

What success looks like
Outcome 1: Heightened national ownership in the form of statements and political commitments displayed
through the frequency and regularity of National Task Force meetings chaired by the head ofstate or government and the frequency and regularity of Provincial Task Force meetings chairedby province-level government leadership; and a decline in the number of children remaining
inaccessible in Afghanistan.

© UNICEF Pakistan / Syed Mehdi Bokhari

Outcome 2: H eightened provincial and local government ownership demonstrated by qualified staff in place
to act swiftly and in the right localities, and vacancies in key positions filled within three months.
The availability of sanctioned positions for required personnel at the provincial level and in all
high-risk areas at the district and subdistrict level and the proportion of these positions filled will
be used to assess progress.

11Polio Eradication Strategy 2022–2026: Delivering on a promise

2. Generate vaccine acceptance through context-adapted community engagement
The GPEI will overcome hesitancy and generate vaccine acceptance by developing a better understandingof cultural and social barriers and other key drivers that influence the decision of caregivers and by building
meaningful partnerships with high-risk communities disproportionately affected by polio. Drawing upon expertisein behavioural science, human-centred design, intersectional gender analysis and diverse levers of socialchange, the programme will develop and deploy new approaches to reinforce vaccination as a key social normand family care practice. By partnering with communities and local governance structures and using contextadapted vaccination strategies, the programme will facilitate better health opportunities for children, while alsoreaching the goal of global polio eradication.
Pashto-speaking communities in Afghanistan and Pakistan have accounted for a disproportionately higher
percentage of WPV1 cases than other ethno-linguistic groups (see Fig. 6 for cases in Pakistan). While thesecommunities represent a higher polio burden, they are also numerous and diverse – with their relative polio risk
distributed unevenly across different areas, localities and contexts. As many Pashto communities live and travel
across the common Afghanistan and Pakistan border and many have been displaced due to political turbulence,
actualizing a robust partnership with these communities will be critical to achieving polio eradication in the twocountries.

Fig. 6. Trends in the proportion of WPV cases by linguistic group in Pakistan, 2011–2020
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2011

Pashto

2012

2013

2014

BalochiSindhi

Siraiki2015

Punjabi

Source: Pakistan Polio Eradication Initiative, National Emergency Action Plan 2021–2022.

12

2016

2017

Bravi

2018

Urdu

2019

Hindko

2020

Other

Goal One

Key areas of evolution
To generate vaccine acceptance, the programme must first identify at a granular level the dynamics driving
hesitancy and resolve them through sustained communication, engagement and alliance-building. The country
programmes will:•

expand the use of social data, behavioural science, behavioural interventions and social media analytics toinform communication strategies “on” and “offline” and develop new digitally integrated and context-adapted
approaches, thereby contributing to a more enabling environment;•

invest in strengthening the communication competencies of frontline workers and supervisors, with anemphasis on enhanced interpersonal skills, coaching, motivation and supportive supervision that are focusedon establishing credibility and rapport at the “doorstep”. Frontline worker training will be responsive to local
needs and informed by social data to address specific community issues and challenges;•

work with influencers in Pashto-speaking communities, including traditional birth attendants and women’sgroups, to create a multidisciplinary, Pashto-centred approach that aims to understand the health-seeking
behaviours of pregnant women in underserved communities and offers polio vaccination as supportive of
their broader childcare practices. Methods that will be pursued include participatory knowledge-building
and programme design that aggregate gender-sensitive ethnographic, demographic and health system
information;•

institute a paradigm shift towards priority community engagement through the creation of Community
Immunization Committees, where community members can interface directly with the programme, contributeto campaign planning and relay broader health needs that can be explored for integrated service packages.
Targeted interventions beyond immunization and health will be pursued for areas with persistently high levelsof mistrust. To ensure ownership and co-implementation of any initiatives, analyses will be carried out in close
coordination with frontline teams and Community Immunization Committees. Where possible, Community
Immunization Committees will be developed in coordination with existing mechanisms, such as health shuras
and rural development committees; and•capitalize on private-sector technical assets by working with entities that are committed to social impact andhave demonstrated expertise with Pashto-speaking communities. These entities, which include academic andsocial institutions, think tanks, the corporate sector, family-owned businesses, start-ups and local non-profit
organizations, can provide fresh perspectives and alternative diagnoses of barriers to vaccine acceptance.

Furthermore, in coordination with the government and development partners, the GPEI will work to become aneffective ally of these communities by advocating for increased commitments on basic health service delivery(see section 4 below).

What success looks like
Outcome 1: Increased
campaign awareness ahead of all immunization campaigns, ensuring that at least 90%of the households are aware of campaigns before visits by vaccination teams.
Outcome 2: Improved vaccine acceptance in priority subnational areas and increased community
participation in immunization campaigns reflected in an increase in the proportion of local
female frontline workers serving as vaccinators and area supervisors, in compliance with GPEI
measures for protection from sexual exploitation and abuse (PSEA) and safeguarding, helping
with an overall decline in vaccine hesitancy in high-risk districts.
Outcome 3: Increased use of innovative approaches to improve community engagement (including social
and behaviour change research, analytics and campaign design) demonstrated through locallydesigned and implemented solutions in polio and essential immunization campaigns.

Transformative potential: the role of gender equality in eradication
In Afghanistan and Pakistan, recruiting, training and retaining women as vaccinators, community mobilizers
and surveillance officers is a priority for the GPEI and is considered essential to campaign success, as accessto children is frequently contingent on the presence of female health workers. For the life of this strategy,
the Technical Advisory Group (TAG) for Afghanistan and Pakistan will regularly provide recommendations toensure country programmes are more gender-responsive in their planning and implementation.** For
more information, see the meeting reports for Pakistan and Afghanistan (https://polioeradication.org/wp-content/uploads/2021/04/Pakistan-TAG-Report-20210209-11.
pdf and https://polioeradication.org/wp-content/uploads/2021/04/Afghanistan-TAG-Report-20210317-20.pdf, both accessed 14 June 2021) from February and March 2021,
respectively. See also the NEAPs that can be accessed via the GPEI’s dedicated country pages for Afghanistan and Pakistan (https://polioeradication.org/where-we-work/
afghanistan and https://polioeradication.org/where-we-work/pakistan, both accessed 14 June 2021).

13

Polio Eradication Strategy 2022–2026: Delivering on a promise

3. Improve frontline success through changes to campaign operations
Polio eradication ultimately depends on the delivery of high-quality vaccination through the administration of polio
vaccines in essential immunization and in supplementary immunization activities (SIAs) by capable, motivatedfrontline workers who reach every boy and girl of the appropriate age with appropriate vaccines. In areas where
essential immunization coverage is inadequate, SIAs are the means by which the GPEI has increased polio
vaccine coverage and made progress towards polio eradication. However, operational gaps and under-motivatedstaff within endemic country programmes have contributed to suboptimal campaign quality. These gaps are notlimited to the high-risk and core reservoir areas, but are more systemic, impacting many campaigns. Achieving
eradication requires addressing these gaps that have remained unresolved in areas outside the core reservoirs.

Key areas of evolution
To improve campaign quality, the GPEI will improve frontline programme delivery and address operational
challenges. Country programmes will:
ensure the right vaccinators and supervisors arein place for each community by recruiting, training
and retaining personnel who come from the local
community, speak the local language dialect andare preferably female, including older women
who often convey experience that can positively
influence caregivers;•

create a supportive environment for frontline
workers by ensuring they have the necessary
supplies, facilities and security support to performtheir jobs and are well-trained, including in“soft” management skills such as team-building,stewardship and interpersonal communicationthat contribute to their professional development,
thereby boosting motivation;••

revamp training and guidelines on proper
microplanning and support government efforts
to adopt impactful technology, including digital
mapping; and•ensure regular and effective review processes that
identify and solve problems at the appropriate level.

To drive these changes, the programme will strengthen
campaign monitoring mechanisms. The GPEI will aide
and accelerate government efforts to adopt digital toolsthat simplify data collection, provide greater precisionand enable faster, data-driven feedback to identify
gaps in microplanning and improve campaign quality.
Through these efforts, timely data will be provided todecision-makers at all programme levels.

Duty of care: protecting communities andpolio workers“Safeguarding” means taking all reasonable
steps to prevent death and harm, including
sexual exploitation, abuse and harassment; toprotect people, especially vulnerable adults
and children, from that harm; and to respond
appropriately when harm occurs. In polio
eradication, this applies to the safety and welfareof polio-affected communities and polio workers,
with special attention to the needs of women andthe communities where they work.
In line with the POB’s 2018 statement, the GPEI
will focus on three work streams to prevent andaddress sexual exploitation and abuse:(1) policy through rapid analysis of existing
policies and standards at the country level;(2) operations to ensure support for survivors,
enhance accountability and transparency,
strengthen reporting and tackle impunity; and(3) cultural change and capacity-building
to promote cultural change and strengthenorganizational capacity (including building thecapability of implementing partners) to meet theminimum standards to prevent and respond to
exploitation and abuse.

What success looks like
Outcome 1: Improved campaign quality, particularly to reduce persistently missed children (evidenced
through age- and sex-disaggregated data) in SIAs, demonstrated through an increase in the
proportion of microplans developed via integrated workshops (inclusive of EPI; maternal,
newborn, child and adolescent health [MNCAH]; communications and geographic information
systems [GIS]) leveraged in a gender-responsive way; and campaigns achieving at least
90% coverage (based on lot quality assurance sampling [LQAS] and/or intra-campaign
monitoring [ICM]).

14

Goal One

4. Expedite progress through expanded integration efforts and unified partnerships
Afghanistan and Pakistan polio assets have been used to conduct multi-antigen immunization campaigns anddeliver other critical health interventions, including the distribution of vitamin A and deworming tablets and thedissemination of maternal and child health messaging. Polio eradication staff deployed in the field have provided
campaign support for broader immunization goals, surveillance for vaccine-preventable and epidemic-pronediseases, and response to other outbreaks and health emergencies, most recently through the COVID-19
pandemic. While polio support has helped local health and broader immunization goals, assistance often has
been need-based and incident-specific.
The GPEI will develop a broader, systematic, multisectoral approach to integrated service delivery with a special
focus on underserved communities in high-risk areas. Specifically, in the high-risk districts of Afghanistan
and priority communities in Pakistan, the GPEI will co-fund integrated service delivery and utilize investments
across the health sector to address persistently low essential immunization coverage. Moreover, as part of theimplementation of the global vision for immunization outlined in IA2030 and Gavi 5.0,11 the GPEI will support
efforts in Afghanistan and Pakistan to strengthen immunization programmes with a PHC focus to reach zerodose children with all vaccines, including polio vaccines. The GPEI is also committed to supporting COVID-19
surveillance and vaccine rollout in 2021 and beyond.12

Key areas of evolution
In Afghanistan and Pakistan, the areas at highest risk for polio have the highest concentration of zero-dose
children for polio and other VPD. In inaccessible areas of Afghanistan, where house-to-house campaigns arebanned, and in accessible areas of Pakistan that have high refusal rates, integrated service delivery will becomea lynchpin of the strategy. By integrating polio vaccines within a broader package of health and related services
that reflect community needs, the programme will restore trust, gain access and increase vaccine acceptance.
Additionally, close collaboration with nongovernmental organizations (NGOs), such as the International
Committee of the Red Cross, the International Federation of the Red Cross and Red Crescent Societies and otherreputable private entities will help in understanding and responding to underlying drivers of vaccine refusal,
thereby helping to reduce zero-dose children.
To support immunization for polio and other VPD efforts, the programme will:•

provide operational assistance and funding for the co-delivery of bOPV in essential immunization activities;•

increase access to and utilization of essential immunization services by supporting birth-dose oral polio
vaccine (OPV) in health facilities, integrating operational microplans, enhancing supportive supervision andmonitoring outreach activities, harmonizing social mobilization and health promotion efforts, and using newtechnology (such as mobile money and GIS) to support operations, where necessary;•track and follow up on polio zero-dose children and analyse birth-dose OPV coverage;•

support the M&E framework for all immunization activities and unifying data analytic approaches and review
processes, including the use of technology to provide granular vaccination coverage and zero-dose data; and•more broadly, ensure strategic objectives of the polio eradication programme are reflected in wider
investments in EPI and health system strengthening (HSS).

To identify interventions that meet the broader needs of communities and are co-developed through their active
engagement and partnership, the programme will advocate with national and local governments for the provisionof basic services and will coordinate with partners to align operational support and funding for these targeted
activities. A decision-making framework will guide countries through evaluating integration opportunities andactivities (see Annex D).13 To support country programmes, the GPEI will also conduct a comprehensive andtransparent stakeholder mapping of potential integration partners among NGOs and adjacent health and related
programmes and develop an action-oriented engagement policy that will provide regular evidence-based
updates to the highest levels of government.

Immunization Agenda 2030: A global strategy to leave no one behind (IA2030). WHO Immunization, Vaccines and Biologicals (IVB). Geneva: World Health Organization; 2020
(https://www.who.int/teams/immunization-vaccines-and-biologicals/strategies/ia2030, accessed 10 June 2021). Gavi, the Vaccine Alliance. Phase V Strategy (2021–2025).
Geneva: Gavi, the Vaccine Alliance; 2019 (https://www.gavi.org/our-alliance/strategy/phase-5-2021-2025, accessed 14 June 2021).
12 
For more information, see Contributions of the polio network to the COVID-19 response: turning the challenge into an opportunity for polio transition. Geneva: World HealthOrganization; 2020 (https://www.who.int/publications/i/item/contributions-of-the-polio-network-to-the-covid-19-response-turning-the-challenge-into-an-opportunity-for-poliotransition, accessed 14 June 2021).
13 
Key subnational areas at high risk for polio have been defined by the national programmes of the endemic countries and include the southern region in Afghanistan and the corereservoir districts in Pakistan. These are subject to change, based on the epidemiology.
11 

15

Polio Eradication Strategy 2022–2026: Delivering on a promise

What success looks like
Outcome 1: Integrated services tailored to a community context and delivered with a gender lens in targeted
geographies (as per NEAPs) as demonstrated through the implementation of integrated service
package in high-risk areas.
Outcome 2: Alignment between polio and immunization objectives resulting in HSS and EPI investments
reflecting polio programme strategic objectives, and polio contributing to IA2030 and country
immunization goals to reduce zero-dose children, demonstrated through the proportion of multiantigen campaigns.

© UNICEF / Pakistan

Outcome 3: Continued support to broader global and national public health initiatives as a pathway towards
a successful programme transition, demonstrated through an increase in the amount of PHC
investments in high-risk districts in endemic countries and contributions of polio-supported
personnel to the COVID-19 response.

16

Goal One

5. Improve detection and response through sensitive surveillance
In contrast to immunization activities that are restricted in parts of Afghanistan, the poliovirus surveillance system
has access in all districts and is well-functioning in Afghanistan and Pakistan. The two countries have a strong
acute flaccid paralysis (AFP) surveillance system and an extensive network of environmental surveillance (ES)sites that are supplemented by routine contact sampling and occasional healthy children sampling.
The sensitivity of the surveillance system at the subnational level and in hard-to-reach areas, however, shows
evidence of gaps in detection. In the last two years, the number and proportion of orphan viruses (chains oftransmission not detected in a timely manner) have increased. These are clustered in areas with regular nomadic
population movements and seasonal migrations in southern Afghanistan and central Pakistan. The spread of
COVID-19, the resulting lockdowns and changes to health-seeking behaviour have also resulted in a transientdecline in the number of AFP cases reported.
The GPEI will address these gaps and maximally utilize technological innovations and new methods in detection
to further enhance the quality, sensitivity and timeliness of surveillance at the subnational level.14

Key areas of evolution
To improve surveillance quality, the GPEI will close subnational surveillance gaps in all underperforming districts
while working to deliver incremental improvements throughout the system. In the two endemic countries, theprogramme will:•

enhance AFP surveillance in underperforming districts by focusing on improving active surveillance andenhancing the use of community-based surveillance in hard-to-reach areas;•

support ES expansion in Afghanistan while optimizing the size of the ES network in Pakistan;•shorten the time frame from the onset of symptoms of an AFP case to the availability of final results by:•seeking gains at every stage of the process between case onset and sample arrival at the Regional
Reference Laboratory; and•substantially decreasing the time between sample arrival in the laboratory and final results byimplementing direct detection and other new technologies for early virus detection and characterization;•

expand web-based surveillance systems currently in use to improve data quality and accuracy by shifting all
remaining field-level, paper-based data collection tools to an electronic format;•

establish a national surveillance capacity-building strategy that delivers regular national and subnational
trainings to mitigate personnel attrition;•

ramp up the integration of VPD surveillance into the polio surveillance workplan,15 starting with COVID-19 andmeasles, in coordination with country-level disease surveillance and response offices under the leadership ofthe national and provincial EOCs; and•ensure a monthly review of surveillance at the subnational level and a quarterly review of surveillance
performance at the country level; adopt self-reinforcing national and subnational supervisory, monitoring andoversight activities that provide opportunities for continuous system evaluation, staff training and mentoringand (importantly) data for rapid response.

What success looks like
Outcome 1: Consistent global implementation of surveillance standards, with a focus on polio-priority districts
measured through the proportion of districts meeting AFP surveillance standards and the
proportion of ES sites meeting high-sensitivity thresholds.
Outcome 2: Increased speed of detection and precision of the surveillance system demonstrated through(at least) 80% of cases with adequate stool sample collection disaggregated by sex, and the
proportion of WPVs and vaccine-derived polioviruses (VDPVs) reporting final lab results within
35 days of onset for AFP cases or ES sample collection.

Global Polio Eradication Initiative (GPEI). Global Polio Surveillance Action Plan, 2018–2020. Geneva: World Health Organization; 2019 (https://polioeradication.org/wp-content/
uploads/2016/07/GPEI-global-polio-surveillance-action-plan-2018-2020-EN-1.pdf, accessed 14 June 2021). Revision in development.
See the surveillance recommendations in Global Polio Eradication Initiative (GPEI). Meeting of the Technical Advisory Group (TAG) on Polio Eradication in Pakistan. Geneva:
World Health Organization; June 2020; p. 15 (https://polioeradication.org/wp-content/uploads/2020/07/Pakistan-TAG-Report-June-2020-FV.pdf, accessed 14 June 2021).

14 

15 

17

© UNICEF / Christopher Herwig

Polio Eradication Strategy 2022–2026: Delivering on a promise

18

Goal TwoStop cVDPVtransmission
and prevent
outbreaks in
non-endemic
countries

By 2026, the GPEI plans to achieve cVDPV2
interruption and validation of the absence of cVDPV2
in all current outbreak countries by shifting to an
emergency management structure with clearly
defined roles and responsibilities, developing andimplementing a comprehensive accountability
framework, increasing government ownership thoughpolitical advocacy, and strengthening regional andcountry capacities for sensitive surveillance and rapid,
high-quality response. Innovative tools and methods,
as well as new partnerships, will be pursued tostrengthen outbreak response operations.

EPIDEMIOLOGICAL CONTEXTIn April 2016, following the 2015 declaration of type
2 WPV eradication, a global switch from the trivalentoral polio vaccine (tOPV) to a bOPV containing only
type 1 and type 3 was implemented to remove all
live-attenuated type 2 vaccine and its associatedrisk. While this coordinated withdrawal was precededby the introduction of one dose of inactivated polio
vaccine (IPV) into national immunization schedules
and intensified efforts to increase type 2 population
immunity, these efforts were not successful or timely
in many countries, creating type 2 immunity gaps.
Furthermore, outbreak responses to the expectedcVDPV2 outbreaks were of uneven quality, used
substantially more monovalent oral polio vaccine type
2 (mOPV2) than planned, and resulted in considerably
more vaccine-derived poliovirus type 2 (VDPV2)
emergences and cVDPV2 outbreaks than predicted.
Since the switch, 64 cVDPV2 outbreaks haveemerged, spreading to 33 countries in four regions
and resulting collectively in 1572 cases of paralytic
polio through 2020.16 In 2020, there were 1051 caseswith cVDPV2 detected in 29 countries, of which 14
countries were affected for the first time in 2020.16
The recent increase in cases has been driven by
expansive outbreaks in Afghanistan, Pakistan, Chadand Côte d’Ivoire, which collectively represent 59% of
the 2020 reported case total. The COVID-19-relatedpause on polio campaigns from March to July 2020,
coupled with related disruptions to essential
immunization and IPV catch-up activities, also led
to increased transmission. At the start of 2021, therisks associated with the spread of ongoing cVDPV2
outbreaks grew, as widening outbreaks threatenedlarge populations that lack type 2 immunity. (SeeAnnex B for the current epidemiological state.)

CURRENT CHALLENGES
The spread and continuation of current cVDPV2
outbreaks are driven by several factors, most notably
declining mucosal immunity to type 2 virus among
young children born after the switch; low essential
immunization coverage with IPV; regional migration
patterns that allow the virus to jump from one
population to another; delays in detecting cVDPV2

The GPEI provides weekly updates on the global epidemiology of circulating
vaccine-derived polioviruses, which can be accessed online (https://polioeradication.org/polio-today/polio-now/this-week/circulating-vaccine-derivedpoliovirus).

16 

19

Polio Eradication Strategy 2022–2026: Delivering on a promise

outbreaks; limited SIA scope driven by limited global vaccine stockpile availability; delayed implementation ofoutbreak responses; and variable quality SIAs in outbreak response. When mOPV2 campaigns of large scope
and uneven quality are carried out in these environments, it increases the risk of seeding new emergences inareas with low coverage and areas bordering response zones, thus prolonging the cycle.17 Competing country
and donor priorities, limited political commitment and a lack of accountability for both countries and GPEI
partners underpin these challenges.

PATH TO STOP cVDPV2 TRANSMISSION AND PREVENT OUTBREAKS IN NON-ENDEMIC
COUNTRIESThe GPEI will work on an emergency footing to ensure rapid case detection and strong outbreak response toquickly stop transmission of cVDPV2 and minimize the risk of seeding new emergences. Key to successful
response is maintaining sensitive surveillance to quickly detect any poliovirus, followed by rapid response
campaigns delivered with sufficient quality to achieve high levels of vaccination coverage linked to strong
essential immunization services to minimize the risk of a poliovirus re-establishing a foothold.
New approaches to interrupt cVDPV2 transmission (see Fig. 7) include:•targeted and coordinated political advocacy in outbreak countries to link polio outbreak preparedness andresponse to broader country health priorities;•

emergency command structures for response at the country, regional and global levels for rapid decisionmaking during outbreak detection and response;•

increased regional and country capacity to support surveillance and outbreak response;•

deployment of nOPV2 to minimize outbreak seeding, and other new tools, approaches and partners to
improve surveillance, outbreak response speed and quality, and community engagement; and•strong coordination with in-country EPI and essential immunization partners to identify zero-dose and underimmunized communities in polio-priority geographies.

Fig. 7. Goal Two strategic objectives and key activities

Political advocacy

SurveillanceCampaigns• Engagegovernment andpolitical
stakeholders via
integrated healthadvocacy toensure emergency
posture, resourcing
and joint
accountability fortimely and effective
outbreakresponses• Implement
technical
innovations insurveillance andsample analysis
to more rapidly
detect, sequenceand initiate
response activities• Deploy nOPV2
and improve
campaign
planning andexecution throughoptimized
response scope,
mobile money
payments,
campaign
digitization andother innovations

Enabling
environment

Community
engagement

Integration• Engage nomadic
and settledcommunities both
before and during
outbreakcampaigns• Ensure success of
the Gavi zero-dose
strategy andleverage
multi-antigen
campaigns.
• Support global
healthemergencies witha near-term focus
on COVID-19• Pivot away from Sabin OPV2 to nOPV2 and ensure sufficient vaccine supply• Move to a regional structure with global support that holds the GPEI and countries
accountable for progress• Utilize a rapid gender analysis to shape the outbreak response.

nOPV2 = novel oral polio vaccine type 2; OPV2 = oral polio vaccine type 2.
Source: WHO.

Sabin OPV has been critical to the worldwide reduction of polio cases and the global eradication of WPV2 and WPV3, as declared by the Global Commission for the Certificationof the Eradication of Poliomyelitis (GCC) in 2015 and 2019, respectively. In rare instances, however, the live attenuated virus in the vaccine can cause neurological symptoms ofpoliomyelitis and become VDPV. Where population immunity is low, this VDPV can begin to circulate, causing an outbreak of cVDPV.

17 

20

Goal Two

The programme aims to report the last isolate of cVDPV2 by the end of 2023, develop novel OPV for types 1
and 3 to stop all cVDPV transmission in 2028, and eventually transition to IPV-exclusive essential immunization.
Key milestones and measures for success in relation to interrupting cVDPV transmission in outbreak and at-riskcountries are identified below (see Fig. 8).

Fig. 8. Milestones for interrupting cVDPV transmission in outbreak and at-risk countries, 2021–2030+
Phase out
mOPV2,tOPV

cVDPV2Strategy
milestones

nOPV2
initial use

Second IPV doses/
nOPV2 PQ

Wider use ofnOPV2,
includingsynchronized
sub-regional
campaigns

2021

Report thelast isolate
of cVDPV2

Validate theabsence of
VDPV2 by2026

Rigorous
review of the2022–2026
Strategy

2022

2023

2024

2025

2026

2027

2028

2029

2030+

Validate the absence of
cVDPV1 and 3

Decision to continuemono- vs multivalent

Report the lastisolate of WPV1

AnticipatednOPV1,3

Anticipatedtrivalent nOPV

Completephase outof Sabin
bOPV
in EI

Stop
cVDPV1and 3transmission

Completephase outof all OPV
and use IPV
exclusively
in EI

cVDPV 1,3
bOPV = bivalent oral polio vaccine; cVDPV1 = circulating vaccine-derived poliovirus type 1; cVDPV2 = circulating vaccine-derived poliovirus type 2; cVDPV3 = circulating vaccinederived poliovirus type 3; EI = essential immunization; IPV = inactivated polio vaccine; mOPV2 = monovalent oral polio vaccine type 2; nOPV1,3 = novel oral polio vaccine types
1 and 3; nOPV2 = novel oral polio vaccine type 2; OPV = oral polio vaccine; PQ = prequalification; tOPV = trivalent oral polio vaccine; VDPV2 = vaccine-derived poliovirus type 2;
WPV1 = wild poliovirus type 1.
Source: WHO.

1. Create urgency and accountability through advocacy to generate greater political will
Political advocacy will be critical to increase government ownership and accountability and urgently stop cVDPV2
outbreaks. In the African Region, for example, there is a lack of awareness around the need for continued
efforts to stop the growing spread of cVDPV2 outbreaks due to the region’s recent certification as WPV-free inAugust 2020. Additionally, the COVID-19 pandemic has shifted the focus of national public health to COVID-19
response, economic recovery and health security. While health and immunizations have never been higher on
the global agenda, long-standing programmes like polio eradication are heavily impacted by severe politicaland financial resource constraints, resulting in insufficient urgency and prioritization of activities to end cVDPV2
outbreaks and keep regions WPV-free. The broader landscape of vaccine-related mis/disinformation also requires
new advocacy tactics to garner political interest and engagement.

Key areas of evolution
To meet these challenges, the GPEI will rebuild political advocacy expertise across country, regional andglobal levels of the partnership, as well as bring in external partners with multidisciplinary expertise to ensuresufficient, dedicated capacity to this key area of work. Targeted political advocacy strategies will be essential tostrengthening government ownership and accountability.
To achieve greater government support, the GPEI will:•proactively and regularly engage government stakeholders and third-party influencers to ensure a consistentunderstanding of the challenges and actions needed to end cVDPV2 outbreaks, to listen and collectfeedback on how the GPEI can better support governments, and to promote joint accountability in the GPEI’s
partnerships with governments to urgently end all forms of polio;•

leverage regional platforms and partners (e.g. African Union and its health-focused entities), existingmechanisms (e.g. IA2030), ministerial subcommittees in the Eastern Mediterranean and African Regions, newtargeted scorecards, local champions, civil society and faith-based organizations to elevate polio and drive
accountability to end cVDPV2 outbreaks;

21

Polio Eradication Strategy 2022–2026: Delivering on a promise•communicate to government stakeholders the relevance of polio assets to other pressing country priorities,
highlighting the value of polio tools, workforce and infrastructure as a key investment in broader emergency
response and future pandemic preparedness. This will require coordination and collaboration with other healthprogrammes to develop joint advocacy approaches, including essential immunization coverage for polio andother VPDs;•

with immunization partners, as well as with humanitarian actors and civil society organizations (CSOs), issue acall for urgent recovery from the impact of COVID-19 on immunization coverage to protect the most vulnerablefrom VPDs and to ensure children are immunized against polio in fragile states; and•explore innovative financing opportunities to strengthen accountability and incentivize effective, urgent
outbreak response. Where feasible, the GPEI will advocate for domestic contributions to support polio
activities and assets to drive action towards ending cVDPV2 outbreaks while ensuring these assets areavailable to support health systems in the longer term.

This proactive advocacy approach will be informed by country- and regional-level political landscape analysis
and stakeholder mapping; adapted in the context of other pressing country priorities; and continuously updated
through ongoing, two-way dialogue with political and third-party stakeholders. Furthermore, global and regional
advocacy efforts will be closely linked to the ministerial subcommittees, to regional and country accountability
mechanisms and to expanded integration in outbreak countries.

What success looks like
Outcome 1: Heightened government ownership and political commitment measured by monitoring thenumber of countries declaring a public health emergency within a week of outbreak confirmation.
Outcome 2: Q ualified staff who are quickly and reliably available to support outbreak response documented
for both GPEI and government staff for every outbreak response and regularly reviewed as partof the regional accountability framework.
Outcome 3: Measurable domestic contributions towards outbreak response activities documented andreviewed for all outbreak responses.

2. Improve detection and response through sensitive surveillance
Interruption of cVDPV2 across all regions can only be achieved if outbreak response activities are informedby sensitive, pervasive and adequately rapid surveillance networks and tools. With the expansion of cVDPV2
outbreaks and additional countries considered to be at risk, surveillance methodologies must be rapidly
expanded to include ES and community-based surveillance in more geographies as a supplement to traditional
AFP surveillance.18 Furthermore, surveillance capacities must evolve and be maintained indefinitely to support
IA2030 commitment to wider integration of VPD surveillance, maintaining International Health Regulations(IHR) reporting requirements, and to monitor for community transmission in the highly unlikely but high-impact
case of a containment breach from a laboratory or vaccine manufacturing facility (see the Preparing for the
post-certification world section).

Key areas of evolution
Although AFP surveillance and the Global Polio Laboratory Network (GPLN) continue to be the gold standard inpoliovirus surveillance, concerns over the spread of cVDPVs and the need to sustain surveillance in perpetuity
have prompted changes in the GPEI’s approach to surveillance.
This transformed approach will be achieved via:•

supporting countries in transitioning to electronic surveillance systems that are adapted to national healthinformation systems and national e-health policies and strategies to ensure all programmes can benefit frompolio investment and interoperability;19•

supporting countries in establishing and taking ownership of rigorous quality standards for AFP surveillance;
implementing and optimizing efficient, sustainable ES and community-based surveillance systems; andshifting poliovirus laboratory testing and sequence analysis to the country level, where possible;•

implementing innovations in sample tracking and transportation, targeted to geographies with the mostpronounced delays;
Global Polio Eradication Initiative (GPEI). Global Polio Surveillance Action Plan, 2018–2020. Geneva: World Health Organization; 2019 (https://polioeradication.org/wp-content/
uploads/2016/07/GPEI-global-polio-surveillance-action-plan-2018-2020-EN-1.pdf, accessed 15 June 2021). Revision in development.
For example, GIS data sets for polio microplanning can be integrated into national health information management systems and used for bednet delivery, alternate population
estimates generated for polio can be integrated into existing national systems and used by other programmes, and mobile technologies that benefit polio can be used for otherprogrammes.

18 

19 

22

Goal Two•

implementing direct detection and other new technologies for virus detection and characterization;•

adopting national and subnational supervisory, monitoring and oversight systems and activities thatprovide opportunities for continuous system evaluation, staff training and mentoring, and use of datafor rapid response, such as web-based Information for Action (WebIFA) and electronic surveillance(eSURV);•

integrating with other VPD surveillance systems and meeting the GPEI’s commitments as an integral
component of the global strategy on comprehensive VPD surveillance;20 and•evolving surveillance, particularly in countries without active outbreaks, to be a shared responsibility between
governments and the GPEI, laying the groundwork for transition to the post-certification world.

Reflecting GPEI priorities for integration, special focus will be brought to developing shared capacity
within countries to support long-term VPD integration objectives, including field activities. In the near term,
poliovirus diagnostic resources will be aligned and integrated with other VPD diagnostic procedures, where
possible. Over the longer term, the GPEI will work to establish shared surveillance networks, laboratory
capacity and information systems to improve efficiency, timeliness and coordination across all VPD
surveillance.
Solutions to achieve faster detection of poliovirus (see the Time is of the essence panel) will be initiallyprioritized for current cVDPV2 outbreaks and high-risk countries to allow for improvements in campaign
timeliness and effectiveness, including the transition to nOPV2 use. Some detection delays in the African
Region (and some African countries in the Eastern Mediterranean Region) have slowed some outbreak
responses and contributed to the spread of cVDPV2. Given the risk of outbreak spread, these countries must
be prioritized for improvements in surveillance speed and sensitivity, tools and indicators, including ES. To
shorten the process for launching a rapid response in places without recent oral polio vaccine type 2 (OPV2)
use and following confirmation of poliovirus type 2 detection, risk assessment development should begin
immediately rather than waiting for cVDPV2 confirmation.

What success looks like
Outcome 1: Consistent global implementation of surveillance standards measured by monitoring thepercentage of districts achieving a non-polio acute flaccid paralysis (NPAFP) rate of >2/100 000
and environmental sites meeting a sensitivity threshold of at least 50% samples positive forenterovirus over six months or more.
Outcome 2: Increased speed of detection and precision of surveillance system demonstrated through(at least) 80% cases with adequate stool sample collection disaggregated by sex, and the
proportion of WPVs and VDPVs reporting final lab results within 35 days of onset for AFP cases or
ES sample collection.

Time is of the essence
Critical to detecting and launching timely outbreak responses is the timeline between sample collection andcVDPV confirmation. As outbreaks have spread to countries that have long been polio-free, this timeline has
expanded and contributed to delays in the notification of cVDPV2 outbreaks.
Opportunities for improvement at each step in the journey from field to laboratory confirmation will speed up
outbreak response times. Detection of poliovirus directly from stool specimens is a new, faster methodology
for poliovirus identification that will help reduce laboratory analysis time by up to one week. The reduction
in analysis time additionally improves if direct detection is paired with on-site sequencing, avoiding
bottlenecks in international sample transport (see Fig. 9). By reducing the length of time for processing
AFP samples from the time of collection, results would be more promptly available for rapidly planning andimplementing response activities. This process might also help achieve GAPIII containment targets on
reducing the inoculation of cell cultures that allow poliovirus replication.* To be most effective in reducing
time to laboratory results, direct detection needs to be further optimized for analysis of sewage samples,and complementary methods need to be developed to characterize polioviruses detected through rapid
genetic sequencing in more laboratories.
* GAPIII:WHO Global Action Plan to minimize poliovirus facility-associated risk after type-specific eradication of wild polioviruses and sequential cessation of oral polio
vaccine use, third edition. Geneva: World Health Organization; 2015 (http://polioeradication.org/wp-content/uploads/2016/12/GAPIII_2014.pdf, accessed 15 June 2021).

Global strategy for comprehensive Vaccine-Preventable Disease (VPD) surveillance. WHO Immunization, Vaccines and Biologicals (IVB). Geneva: World Health Organization;2020 (https://www.who.int/publications/m/item/global-strategy-for-comprehensive-vaccine-preventable-disease-(vpd)-surveillance, accessed 15 June 2021).

20 

23

Polio Eradication Strategy 2022–2026: Delivering on a promise

Fig. 9. Desired future state for detection and outbreak response
Detection

Outbreak response
Notification to completion of response: ~50-55 days

AFP case
date of onset

Stool
samplestransport

Sample collection to notification: 35 days

Directdetectionandsequencing
at nationallabs
High-risk
PV2

ES sample
collection

30 dayscVDPV2
confirmation

WHO HQ
notification

Risk assessment
development

AG / nOPV2
releasegroup review

Budget review

ApprovedmOPV2 /
nOPV2
response~20-25 days

Round 1 SIA

Round 2 SIA

Mop-ups

Budget approvalContinuous monitoring, community engagement and political advocacy
AFP = acute flaccid paralysis; AG = Advisory Group; cVDPV2 = circulating vaccine-derived poliovirus type 2; ES = environmental surveillance; HQ = headquarters; mOPV2 =monovalent oral polio vaccine type 2; nOPV2 = novel oral polio vaccine type 2; PV2 = poliovirus type 2; SIA = supplementary immunization activity.
Source: WHO.

3. Improve frontline success through changes to outbreak response operations
To quickly stop cVDPV outbreaks, vaccination response must be deployed rapidly following outbreak response
identification in appropriately scoped, high-quality campaigns to stop transmission and prevent spread outside
the outbreak response area (see Fig. 9). To do this, the GPEI will further optimize outbreak response throughupdated operational guidance, streamlined decision-making and emergency response structures, cross-bordercoordination, adequate resourcing and operational improvements to facilitate rapid mobilization for outbreak
response in countries.

Key areas of evolution
The introduction and scale-up of nOPV2 for cVDPV2 outbreak
response is a primary focus in this new strategy. The expected
reduced risk of nOPV2 seeding new outbreaks will permit
increasing the scope of vaccine use in OPV2-naïve populations,which should allow countries to more quickly stop transmission
and prevent spread outside of response zones. To be effective,nOPV2 use must be accompanied by improvements in response
planning, execution and monitoring to ensure rapid, high-quality
responses. (See the nOPV2: a much-anticipated tool panel.)
Outbreak response planning and execution improvements will
include:•ensuring optimal vaccine use, including nOPV2, based on aprevailing epidemiological situation and country readinessfor nOPV2 use under the Emergency Use Listing (EUL)
procedure;•

accelerating emergency response through rapidly endorsed
outbreak response plans at the regional level and afunctioning incident command structure at all levels within
the GPEI to guide and direct outbreak response, including
the rapid transfer of funds from regions to countries to field
workers (see the Moving money faster panel);

24

Moving money faster
Cash-based payments for outbreak
campaign operations have led to delayed
campaigns, poor-quality operations
and a demotivated workforce due tolate payments.† In the new strategy, theGPEI will scale up mobile money (digital
payment) programmes to acceleratefunding distribution, improve the qualityof outbreak response and boost worker
satisfaction.‡ In one country (Côted’Ivoire), the average payment time
for the second campaign round was
two hours, as opposed to a three-week
average for cash payment processing,which demonstrates the substantial
impact mobile money has on outbreak
campaigns.
In the first quarter of 2020, 50% of polio outbreak campaigns
in the African Region were delayed or negatively impacted bydelayed distribution of funds to the operational level.
‡
More than 50 000 frontline campaign workers in Côte d’Ivoire,
Mali and Ghana were paid rapidly and transparently using
mobile money in 2020.
†

Goal Two•utilizing and expanding existing in-country government coordination mechanisms to establish polio control
rooms, enabling the use of real-time data for decision-making and an incident management structure to
streamline emergency operations;•

optimizing outbreak preparedness and response capacity in high-risk countries via a regional contracting
mechanism providing both rapid deployment and flexibility to move technical support staff between
countries based on the evolving epidemiology, performance and accountability and through identifying
synergies with the outbreak response plans reported annually to the regional certification commission,actions of the measles outbreaks strategic response plan and other VPD initiatives;21•

utilizing rapid gender analyses, local risk assessments and modelling inputs to optimize the outbreak
response scope, including approaches specifically targeting nomadic and other mobile communities;•

digitizing the entire outbreak response, from planning to intra- and post-campaign monitoring, to utilize anevidence-based approach for clear assessments of response coverage and quality, including age- andsex-disaggregated monitoring data; and•ensuring a stronger role for women in outbreak response operations through increased participation inoutbreak response oversight, management, supervision and delivery.

The GPEI is updating the standard operating procedures (SOPs) and SIA manuals, reflecting new
developments, realities and tools, and the need to improve the speed and quality of campaigns to ensure
outbreaks are stopped rapidly and efficiently.22 To ensure the successful rollout of nOPV2, comprehensiveplanning has mapped potential scenarios and identified pivotal decision points to support country nOPV2 use(see Annex G).

nOPV2: a much-anticipated tool
OPV has been used for 50 years and has been effective in stopping cVDPV2 in response areas. Between
2019 and 2020, nearly 80% of cVDPV2 outbreaks were stopped after two rounds of Sabin OPV2. However,
due to the risk of the vaccine virus originally contained in OPV regaining neurovirulence and seeding newoutbreaks, the programme began investments in 2011 towards the development of a nOPV2. The new vaccine
entered Phase I and II trials in 2017 and 2019, respectively, which demonstrated safety, immunogenicity
and genetic stability that will make the vaccine virus less likely to revert to a form that can cause paralysis.
With EUL received in late 2020, nOPV2 is now being introduced in the first outbreak countries to complete
readiness verification.
The need for nOPV2 is urgent. Introducing nOPV2 is a decision made by national immunization partners andauthorities, such as the ministry of health, the national immunization TAG and national regulatory authorities.
As countries meet the requirements for nOPV2 use, they must commit to continuously monitoring the vaccine’s
safety and effectiveness under the EUL agreement and in partnership with the GPEI and the vaccine
manufacturer. As more countries complete readiness verification for nOPV2 and the initial use period gives
way to wider use, Sabin OPV2 use in outbreak response is expected to decrease throughout 2021. If datafrom the field and ongoing studies with nOPV2 continue to be assessed as favourable, mOPV2 will be phased
out. For strategy planning purposes, the GPEI anticipates substantially larger SIAs with nOPV2 in responseto any outbreak and assumes that any individual outbreak will be stopped per the timelines in the outbreak
response SOPs. (See Annex G for details on contingency planning.)
Responsibility and accountability for outbreak response will rest with three GPEI groups (see Fig. 10). The
Outbreak Response and Preparedness Group (ORPG) will interface between the global and regional teams
working to respond to polio outbreaks. Activities in regions most impacted by cVDPV2 outbreaks will rest with
two groups focused on outbreaks and response: the Sub-Saharan Africa Rapid Response Team and the regional
Incident Management Support Team for non-endemic nations in the Eastern Mediterranean Region. These teams
are the decision-making bodies for response operations in their respective regions, with responsibility for thecomprehensive management of outbreak response activities. ORPG will manage operational capabilities in theevent of outbreaks in other regions.

Measles outbreaks strategic response plan 2021–2023. Geneva: World Health Organization; 2021 (https://apps.who.int/iris/bitstream/handle/10665/340657/9789240018600-eng.
pdf, accessed 15 June 2021).
Updated outbreak SOPs and SIA manuals will be posted on the GPEI website as they become available (https://polioeradication.org/tools-and-library/resources-for-polioeradicators/gpei-tools-protocols-and-guidelines, accessed 15 June 2021).

21 

22 

25

Polio Eradication Strategy 2022–2026: Delivering on a promise

RegionGlobalFig. 10. Global and regional outbreak response teams

Outbreak Response & Preparedness Group (ORPG)

Sub-Saharan Africa
Rapid Response Team

Eastern Mediterranean
Incident Management Support Team*Country

Additional regional groups (e.g., Polio Ministerial Regional Committee, regional certification commissions).
Country-level groups, with support from regional teams, will develop and execute country-levelplans, conduct advocacy and campaign efforts, provide domestic financing and identify potential
integration opportunities*Includes non-endemic countries in the Eastern Mediterranean Region and overlaps with countries in the Middle East and North African Region (United Nations).
Source: WHO.

An accountability framework will be established in alignment with the outbreak SOPs and regularly monitored byan independent audit function to assess performance. The regional operations teams will be linked to ministerial
subcommittees to facilitate country accountability within existing regional mechanisms and review outbreakindicators regularly.23 Additionally, the Africa Regional Certification Commission, the Afghanistan and Pakistan
TAGs and other appropriate advisory bodies will increase their focus on VDPV response review and validation toprovide independent voices on regional operations and GPEI performance.

What success looks like
Outcome 1: Improved campaign quality, particularly to reduce persistently missed children in SIAs, measured
by monitoring the percentage of outbreaks closed in two rounds plus mop-up within six monthsof outbreak identification.
Outcome 2: Timely outbreak preparedness and response measured by monitoring the average number ofdays between outbreak confirmation and the start of the first SIA.
Outcome 3: Successful and timely nOPV2 rollout measured by tracking the percentage of target countries
that meet the requirements for nOPV2 use and tracking the number of countries using nOPV2 foroutbreak response.

Rapid gender analysis in outbreak response
When gender becomes integral to rapid outbreak assessment, it enables a more effective response. Rapid
gender analyses, as defined in the SOPs, strengthens outbreak response and supports interruption.* Bycollecting and analysing sex-disaggregated data and gender-sensitive information, frontline teams develop
a more robust understanding of the population that improves community engagement and increases vaccine
acceptance. To support the mainstreaming of gender activities in outbreak contexts, a forthcoming checklist
will outline activities from the recruitment of gender-balanced teams (including surge staff), to the collection
and analysis of sex-disaggregated data for AFP surveillance and campaign monitoring, to the incorporation ofgender-specific social data into social mobilization, communication and community engagement activities.
* Global Polio Eradication Initiative (GPEI). Standard operating procedures: responding to a poliovirus event or outbreak, version 3.1. Geneva: World Health Organization; 2020
(https://polioeradication.org/wp-content/uploads/2020/04/POL-SOP-V3.1-20200424.pdf, accessed 15 June 2021). GPEI rapid gender analysis in outbreak response will be
guided by the Inter-Agency Standing Committee Multi-Sector Initial Rapid Assessment (MIRA) and CARE International’s Rapid Gender Analysis. See Inter-Agency Standing
Committee (IASC) Needs Assessment Task Force. Multi-sectoral initial rapid assessment guidance; revised July 2015 (https://interagencystandingcommittee.org/system/files/
mira_manual_2015.pdf, accessed 15 June 2021); In Practice, Rapid gender analysis [website]. Geneva: CARE International; 2021 (https://insights.careinternational.org.uk/
in-practice/rapid-gender-analysis, accessed 15 June 2021).

These committees will include country ministers of health with support from WHO and UNICEF regional directors who will provide the oversight and monitoring of country
performance.

23 

26

Goal Two

4. Generate vaccine acceptance through context-adapted community engagement
In outbreak and at-risk countries, the GPEI will adopt tactics to optimize community engagement and promote
vaccine awareness and acceptance. The GPEI will expand its community engagement and listening models
to include digital platforms and utilize larger social networks and consortia of partners to build momentum foroutbreak response through combating misinformation and supporting nOPV2 and COVID-19 vaccine rollouts.

Key areas of evolution
The polio programme’s outbreak communications will begin well in advance of a vaccinator showing up at thedoorstep to offer polio vaccines. Using lessons learned and universal best practices, the GPEI will reimagine its
approach to rapidly create enabling environments for outbreak campaigns by:shifting from a campaign-focused approach to instead making investments in sustained trust and relationshipbuilding with communities, as well as outbreak preparedness and prepositioning of communication resourcesin the context of local social norms;•

utilizing the Minimum Quality Standards and Indicators for Community Engagement to review successes andseek opportunities for improving social mobilization activities in outbreak settings;24 and•including community engagement indicators in campaign preparedness dashboards to ensure social
mobilization activities are tracked against meaningful indicators and evidence-based “online” and “offline”
improvement strategies.

© UNICEF / Christopher Herwig•

Minimum quality standards and indicators for community engagement. New York: United Nations Children’s Fund; undated (https://www.unicef.org/mena/media/8401/file/19218_
MinimumQuality-Report_v07_RC_002.pdf, accessed 11 June 2021).

24 

27

Polio Eradication Strategy 2022–2026: Delivering on a promise

Furthermore, the GPEI will explore new local partnerships, social networks and digital platforms to collectqualitative data that will inform communication action aimed at reaching all types of missed children andprepositioning communication resources. A better understanding of the social reasons behind and challenges
to community resistance to polio vaccines in the context of outbreaks is of utmost importance, particularly incountries at the highest risk of cVDPV emergence in the African and Eastern Mediterranean Regions.
Robust and well-supported communication related to cVDPV2 outbreaks and nOPV2 preparedness, readinessverification and use – carefully balanced and managed in the broader vaccine misinformation landscape – isbecoming an integral part of the GPEI’s outbreak response strategy.
To address the many complexities around vaccine introduction in this context, the GPEI will develop
communication products and tactics that capitalize on key milestones to reiterate the crises of cVDPV2 outbreaks
and the GPEI’s strategy to interrupt them, including the potential role of nOPV2. This content will be preparedfor rapid deployment in case of an outbreak and will help to gain the momentum across the broad range ofstakeholders for swift and high-quality outbreak response.

What success looks like
Outcome 1: The creation and deployment of capacities and products to rapidly increase campaign
awareness and build confidence in polio vaccines in all settings, conducting polio outbreak SIAs,
measured by monitoring the percentage of SIAs showing evidence that campaign awarenesswas >90% of all households (based on ICM and/or LQAS).

New tactics on the digital front line

© WHO Somalia / Ismail Taxta

To address vaccine infodemics and combat misinformation that leads to vaccine hesitancy or refusals, theGPEI has adopted new tactics: (a) “listening” by systematically monitoring the digital and social media
ecosystem through analytical platforms and technology; (b) assessing the scale and potential impact ofvaccine-related rumours and misinformation to immunization activities; and (c) proactively debunking or
prebunking harmful digital content, fake news and misinformation about vaccines. To mitigate the risk ofrumours about nOPV2, the GPEI has operationalized projects in outbreak countries that successfully track
harmful social media and digital content to adapt strategies to respond to vaccine refusals and mitigate
risks to the programme, including potential violence or harm to polio workers. This data-driven, innovative
approach will continue to evolve with available technologies to inform preparedness and response systems in
high-risk outbreak countries.

28

Goal Two

5. Expedite progress through expanded integration efforts and unified partnerships
The GPEI will transform how it delivers vaccines to children in and beyond outbreak countries. Integration efforts,
particularly with essential immunization programmes and VPD surveillance, will play a critical role in addressingcVDPV outbreaks by working to elevate population immunity, detect outbreaks in all regions with a focus on
unreached and under-immunized communities and sustain capacity to respond to future outbreaks.
Within outbreak and at-risk countries, essential immunization coverage continues to be variable, which hinders
the ability to maintain sufficiently high levels of population immunity to poliovirus. In addressing these challenges,
integration will promote greater efficiencies through the co-delivery of interventions deemed to be on the critical
path to eradication, as well as through enhanced coordination, planning, management and resource mobilization.

Key areas of evolution
The GPEI will evaluate opportunities to integrate with other health programmes and initiatives using the integration
decision-making framework (see Annex D). Outbreak response teams will coordinate with EPI and immunization
partners to boost essential immunization performance in outbreak areas and neighbouring geographies from theinitial planning stages and between OPV rounds. Using the outbreak event as an opportunity to flag systemic EPI
weaknesses, the programme will work with local authorities and broader immunization partners, such as Gavi, tomobilize support to strengthen essential immunization and PHC. During the latter phases of outbreak response,
multi-antigen or intervention activities will be considered.
The GPEI at the global and regional levels has a role in resource mobilization and advocacy to direct existing
funds for expanding PHC services including essential immunization performance and outreach vaccination,
along with IPV. This will be done by using the incident management structure to coordinate broadly withgovernments, EPI, PHC and partners to identify zero-dose and under-vaccinated communities for outreach,sharing microplan information to improve essential immunization targeting and coverage, and integrating
communication and messaging to promote essential immunization and PHC.
To drive towards alignment and accountability with integration, the GPEI will:•

engage within partner operational frameworks and review mechanisms, such as the World Bank annual
review, IA2030 ownership and accountability mechanisms and structures, and Gavi 5.0 operationalization andreview mechanisms, to ensure investments mutually support polio eradication and broader health benefits;
and•use polio assets and high-level advocacy, including through the POB, in support of COVID-19 vaccine
procurement, registration, targeting and rollout.

By leveraging the outbreak event to re-energize national, provincial and local health authority planning andaction, the GPEI – in collaboration with Gavi and other partners – will aim to leave the system on a path torecovery at the closure of an outbreak and strengthen outbreak preparedness measures.

What success looks like
Outcome 1: Alignment between polio and immunization, resulting in HSS and EPI investments reflecting polio
programme strategic objectives, and polio contributing to IA2030 and country immunization
goals, measured by monitoring VPD SIAs that co-deliver bOPV and the percentage of poliopriority subnational geographies where joint or collaborative investment is taking place by Gaviand the GPEI.
Outcome 2: Continued support to broader global and national public health initiatives as a pathway towards
a successful programme transition, measured by monitoring the amount of PHC investments
directed towards polio high-risk areas in outbreak and at-risk countries, as well as polio humanresource contributions towards the COVID-19 response.

29© UNICEF / Pakistan

Polio Eradication Strategy 2022–2026: Delivering on a promise

30Enabling Environment
Successful execution of the Polio Eradication Strategy 2022–2026 requires an enabling environment createdthrough efficient operational structures; critical commitments to gender-responsive programming and operations;effective, clear and well-coordinated communication strategies; carefully managed vaccine supply; ongoinginvestments in research innovations; a data-driven M&E framework; and financial modelling and resource
mobilization.

1. GPEI STRUCTURE
The GPEI conducted a comprehensive governance and management review to restructure the programme to be
fit for the purpose of polio eradication. The restructuring process included input from a broad range of partners(donors and governments), advisory groups (including the Independent Monitoring Board) and management
groups. The resulting assessment identified several key areas requiring structural change to address role clarity,
decision-making and accountability.
Critical changes are under way to enhance the agility, efficiency and effectiveness of the GPEI programme
across the global and regional levels, including streamlining the GPEI’s organizational structure (see Fig. 11),
empowering implementers and introducing a system of accountability across the polio partnership.

Fig. 11. GPEI revised organigram
Strategic leadership
Develop and adapt
GPEI strategy while
ensuring the availability ofsufficient programmatic
resources, oversight andaccountability to achieveand sustain polio
eradication.

Global programme
support
Provide strategic,
financial andoperational guidance
and resources for
implementation and insupport of regional
operations activities.

Global advisory& consultative
support

Polio Oversight Board (POB)

Financial
Accountability
Committee (FAC)

Provide independent
external feedback &technical support on
key strategic issues

Strategy Committee (SC)

Executive Management Unit (EMU)

Independent
Monitoring Board

Finance group
has additional
accountability to
the FAC

Finance

OutbreakResponse &Preparedness*

SurveillanceContainment

Polio
research

Gendersupport

VaccinesupplyResource
mobilization

Globalcommunications

Political
advocacy*nOPV2 WG
(time-limitedgroup)

GPS
groupsreportupthrough
EMU*Includes a Global
RRT for regional
deployment asneededIMST & RRT engage ORPG for operational support

Eastern Mediterranean IncidentManagement Support Team(IMST)*SAGE Policy
Working Group

GlobalCertification
Commission

Regional operations
Support country-led
eradication activities
while holding countries
accountable forprogress against
eradication targets.

mOPV2 AdvisoryGroup

Sub-Saharan Africa
Rapid Response
Team (RRT)

Afghanistan &Pakistan
Endemics Hub

RO groups
report up
through EMU
on overall
performanceaccountability

Containment
Advisory Group

Polio Partners
Group* Includes non-endemic countries in the Eastern Mediterranean Region and overlaps with countries in the Middle East and North African Region (United Nations).
Note: The GPEI organigram is under review and further structural changes may be implemented as part of the continued management review and governance process.
GPS = global programme support; mOPV2 = monovalent oral polio vaccine type 2; nOPV2 WG = Novel Oral Polio Vaccine Type 2 Working Group; RO = regional operation;
SAGE = Strategic Advisory Group of Experts on Immunization.
Source: WHO.

31

Polio Eradication Strategy 2022–2026: Delivering on a promise

Broadly, these changes to the GPEI structure reflect the programme’s commitment to:•giving staffing priority to national, provincial and district teams that will have decision-making authority todetermine all field-level actions;•redefining the relationship between regional and global offices to orient both towards more effective country
support. Regional offices will provide technical advisement and administrative and logistical support. Global
offices will carry out research, define technical guidance, provide high-level advocacy, mobilize and manage
resources, and provide assistance to regions and countries where local resources are insufficient to overcome
challenges; and•building new strategic alliances where they have comparative advantage, such as engagement and advocacy
with hard-to-reach communities.

Further information on the process, assessment and recommendations that informed these changes to the GPEI
structure is available in Annex H.

2. GENDER EQUALITYThe GPEI Gender Equality Strategy 2019–2023, endorsed by the POB, guides the programme on genderequality as a powerful determinant of health outcomes and a critical enabling factor for progress towards polio
eradication.25 To strengthen the programme’s gender-responsiveness and achieve polio eradication, a gender
perspective will be mainstreamed into the different stages of programme planning and design, implementationand M&E (see Fig. 12).26 By taking a systematic approach to gender mainstreaming, the programme addresses
gender-related barriers to vaccination, improves immunization outcomes and increases women’s meaningful
participation in decision-making and leadership roles,27 demand creation and health service delivery.

Fig. 12. Gender-responsive programming

Gender analysis

Monitoring &evaluation

Programme
planning &designCollection, analysis and use of
sex-disaggregated data

Gender-sensitive indicators

Implementation

Equal participation at all stages

Source: Gender Equality Strategy 2019–2023.

Global Polio Eradication Initiative (GPEI). Gender Equality Strategy 2019–2023. Geneva: World Health Organization; 2019 (https://polioeradication.org/wp-content/
uploads/2020/10/Gender-Strategy.pdf, accessed 15 June 2021). See also Gender [website]. Geneva: World Health Organization; 2021 (https://polioeradication.org/gender-andpolio/gender-and-polio-eradication, accessed 15 June 2021).
26 
There are several approaches and tools to mainstream gender in health. The GPEI will be guided by the WHO Gender Analysis Matrix and the practical guide on Immunization
and Gender by the UNICEF Regional Office for South Asia. These approaches will be complemented with additional tools and guidance, depending on the country context andscope of the analysis.
27 
A GPEI-wide staff survey carried out in 2018 identified women’s under-representation in senior-level roles and gender parity gaps.
25 

32

Enabling Environment

This systematic approach to gender mainstreaming, particularly within country programmes, will:•

increase ownership of and accountability for mainstreaming gender considerations into all aspects of the
programme;•

institute specific field-level mechanisms to prioritize the safety of polio workers and beneficiaries;•

create a safe work environment for all staff and contractors and enforce GPEI policies on PSEA andsafeguarding;•strengthen data collection and analysis and complement quantitative data with robust qualitative social data,
especially through the community engagement work stream;•build a formal GPEI partner coordination mechanism on gender that will address areas such as training, datacollection and analysis, and technical support; and•ensure specified and dedicated financial resources.

Through the budget process, the GPEI will develop gender markers to ensure adequate resources for genderactivities and to track allocations and expenditures, with at least 1% for direct funding allocations to support
gender-related activities (see the Tracking resources to target gender equality panel under Finance andcosting).
Programme performance and leadership on gender mainstreaming are guided by the Gender Equality
Strategy logframe (see Annex I), with dedicated KPIs to monitor progress towards defined expected results(see Annex F).

Closing the gender data gaps
The collection, analysis and use of sex-disaggregated data are crucial components of gender-responsive
programming. The GPEI is one of the few global health programmes with the ability to universally collectsex-disaggregated data through the poliovirus surveillance system and communication for development(C4D) data.
The GPEI Gender Equality Strategy is committed to:•ensuring that all relevant programmatic data are disaggregated by sex and other critical variables and thatthese data are analysed to find and address gaps; and•providing training for all relevant staff on the importance of and requirements for collecting and analysing
disaggregated data.

Through the GPEI Gender Data Working Group, polio partners commit to further strengthening data collection
and analysis and other gender metrics to inform and guide programming and ensure that sex or gender
discrepancies can be effectively identified, tackled and resolved.

3. COMMUNICATIONS
Like other immunization programmes, the GPEI is adapting to a fast-paced communications and media
environment where issues around vaccines, testing, access and equity are in the public discourse and can bepolitically charged, particularly in a post-COVID-19 context. While unprecedented public interest and media
attention on COVID-19 and vaccines have provided an opportunity to highlight the importance of immunization,it also comes with complex risks. The pandemic and the intense focus on vaccines have profoundly affected the
public awareness of and trust in global health authorities and organizations. Even in communities less saturated
by media technologies, parents and caregivers are inundated with information and misinformation that shape andreinforce health beliefs and behaviours.
Effective, clear and well-coordinated communication strategies are essential to restore and reinforce social norms
around vaccination, increase vaccine uptake and manage public narratives in the context of the COVID-19
pandemic, related mis/disinformation and vaccine hesitancy. Communication efforts will continue to be criticalto support polio immunizations, to ensure stakeholders’ clear understanding of the remaining challenges tointerrupting WPV1 transmission and ending cVDPV outbreaks, and to sustain confidence in polio eradication.
Strong communication efforts will be prioritized to help build the enabling environment needed to support key
areas of this strategy, including successful nOPV2 introduction, strengthened community engagement andpolitical advocacy, and overall confidence in the feasibility of achieving a polio-free world.

33

Polio Eradication Strategy 2022–2026: Delivering on a promise

The GPEI will continue to invest in communication solutions at the country, regional and global levels by:•addressing social and behaviour barriers, mitigating risk to the programme and leveraging opportunities forpolio vaccine delivery and acceptance;•developing and implementing GPEI crisis communication strategies for early detection and response
to vaccine infodemics, informed by continuously improved social listening data, research tools andcommunications interventions;•engaging social influencers, programme advocates and other prominent public figures to help reframe polio
immunizations as an apolitical public health agenda and a global priority;•

building capacity and strengthening coordination efforts across communication partners and staff, as well as
frontline workers and other personnel, to navigate the complex public immunization space, use interpersonal
skills for community engagement and hone digital skills to expand reach, influence and capacity for timely
and targeted action; and•continuing to help shape and manage global, regional and country narratives on the polio programme andpolio vaccines by ensuring the availability of clear, accurate information to mitigate communications-relatedrisks and maintain confidence in polio eradication.

To ensure the alignment of global and community-level communication strategies, the GPEI’s Global
Communication Group brings together C4D, crisis and emergency risk communication and external
communication expertise with coordination across global and regional communication teams. The Global
Communication Group also coordinates closely with the Political Advocacy Group and Resource Mobilization
Group to support the work required to ensure clear, aligned messaging across the GPEI partnership aroundpolitical advocacy and fundraising opportunities (see GPEI structure, Fig. 11).

4. VACCINE SUPPLY
A reliable and well-managed vaccine supply is essential to achieve polio interruption; it is also required to reachpolio eradication certification. To ensure an uninterrupted supply of requisite oral and inactivated polio vaccines(see Fig. 13), the GPEI aims to:•

supply a mix of effective and affordable bOPVs and monovalent OPVs, licensed in countries the GPEI
supports, to stop endemic poliovirus transmission and mitigate the risk of transmission in non-endemic
countries;•

establish and maintain a global stockpile of OPVs to respond to poliovirus outbreaks that may occur after
global certification of eradication and after OPV withdrawal from essential immunization; and•ensure a supply of a mix of inactivated vaccines to protect populations from polio-induced paralysis.

Fig. 13. Polio vaccines, current and future, 2022–2026

tOPV

wIPV

mOPV2

bOPV

nOPV2

mOPV1

sIPV

nOPV3

nOPV1

DeployedmOPV3

In development

bOPV = bivalent oral polio vaccine; mOPV1 = monovalent oral polio vaccine type 1; mOPV2 = monovalent oral polio vaccine type 2; mOPV3 = monovalent oral polio vaccine type3; nOPV1 = novel oral polio vaccine type 1; nOPV2 = novel oral polio vaccine type 2; nOPV3 = novel oral polio vaccine type 3; sIPV = Sabin inactivated polio vaccine; tOPV =trivalent oral polio vaccine; wIPV = wild-strain inactivated polio vaccine.
Source: WHO.

34

Enabling Environment

Polio vaccine supply landscape
Global stockpile of OPV: The global stockpile of OPV is a long-term mechanism that will ensure a supply of OPV
beyond the current GPEI strategy into the post-certification period (see Fig. 14). The stockpile was establishedto supply OPVs in response to poliovirus outbreaks in the post-certification period and after OPV withdrawal fromessential immunization. The composition of the stockpile will consist of a range of monovalent, polyvalent, Sabin
and novel vaccines for all three poliovirus types. The global stockpile currently ensures the supply of the novel
and Sabin OPVs against poliovirus type 2 (nOPV2, Sabin mOPV2 and tOPV). Vaccines against poliovirus types
1 and 3 will be added within the lifetime of this strategy. WHO owns and governs the global stockpile on behalf of
the GPEI. Its day-to-day management is conducted jointly by UNICEF and WHO based on a bilateral agreement
between the two agencies. In the scope of the current strategy, the planning and oversight of the global stockpile
is conducted by the Vaccine Supply Task Team in collaboration with the Novel Oral Polio Vaccine Type 2 Working
Group (nOPV2 WG), ORPG and other technical teams, when necessary. Changes to the global stockpile require
review and endorsement by the Strategy Committee (SC) and POB.
bOPV: During the lifespan of the current GPEI strategy, as the programme approaches and achieves WPVinterruption, bOPV supply will be gradually reduced. The programme will maintain a steady supply of low-cost
vaccines to meet preventive SIA needs and a sufficient buffer stock to mitigate short-term increases in vaccine
demand, which include changes to the SIA calendar and responses to poliovirus types 1 and 3 outbreaks andevents.
IPV: Working closely with Gavi, the GPEI will continue its focus on a healthy market for IPV, which includes
sufficient availability, a diversified supplier base and affordable prices. This collaboration will allow IPV to be
managed holistically as part of overall immunization system vaccine procurement efforts, whether as a standalone vaccine or as part of an IPV-containing hexavalent vaccine. Guidance from advisory bodies, including
SAGE, its Polio Working Group and the IMB, will be critical to proposing appropriate, evidence-based strategies
for mitigating risks through prioritized IPV allocation, where needed. In the coming years, GPEI partner agencies
will support countries as they introduce a second IPV dose into their essential immunization systems in alignment
with the SAGE recommendation.28
New products: The GPEI is also working to expand its portfolio of polio vaccines. Over the lifespan of thisstrategy, the GPEI is expected to deploy novel OPV types 1 and 3 as monovalent and combination vaccines,
which, like nOPV2, are expected to be more genetically stable than their Sabin counterparts. In addition, a rangeof new IPV products are being developed.

Fig. 14. Global OPV stockpile objectives and planning horizon

3-5 years

Planning horizon

5-7 years or more

• Ensure uninterrupted supply of
OPV2 to the ongoing cVDPV2
outbreaks• Establish preparedness topotential catastrophic
contingencies: failure to deploy
nOPV2, rapidly expanding
outbreaks exceeding GPEI
response capacity• Establish stockpiles of OPV1, 3
and new products (n)tOPV• Maintain adequate supply of
OPVs to respond to potential
polio outbreaks in the post
certification period (10–15 years)• Integrate the global stockpile
within the global emergency
preparedness and response
systems

Eradication• Incorporate new products andinnovations to improve viability of
the global stockpile mechanism

Post-certification

TransitioncVDPV2 = circulating vaccine-derived poliovirus type 2; nOPV2 = novel oral polio vaccine type 2; (n)tOPV = (novel) trivalent oral polio vaccine; OPV = oral polio vaccine; OPV1,3 =oral polio vaccine types 1 and 3; OPV2 = oral polio vaccine type 2.
Source: WHO.

Meeting of the Strategic Advisory Group of Experts on Immunization, 31 March–1 April 2020: conclusions and recommendations. Wkly Epidemiol Rec. 2020;22:241–56(https://apps.who.int/iris/bitstream/handle/10665/332218/WER9522-eng-fre.pdf, accessed 15 June 2021).

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35

Polio Eradication Strategy 2022–2026: Delivering on a promise

5. RESEARCH
R&D has played and continues to play a critical role in polio eradication. Research is an enabling factor for
identifying effective eradication activities, securing and consolidating the programme’s achievements, anddefining policies for the post-certification era (see Annex J for the current R&D pipeline).
The Polio Research Committee (PRC) ensures strong coordination and collaboration on the programme’s overall
research agenda across GPEI partner agencies. Research teams from partner agencies, in coordination withgroups such as the PRC, contribute to identifying knowledge gaps, advising on research needs, and tracking
new data and outcomes. Research data coordinated by this mechanism are fed to SAGE for strategic decisions
and recommendations.
One key area of focus is the R&D of new polio vaccines, including:•novel, genetically more stable oral polio vaccines (nOPV2 as the current high-priority vaccine, as well as
novel oral polio vaccine type 1 (nOPV1) and type 3 (nOPV3)) to eventually replace Sabin OPV following theprequalification and eventual licensure of these vaccines;•

Sabin IPV to provide a cost-effective supplement to current IPVs to satisfy global market requirements;•

polio virus-like particle (VLP) vaccines that could become the ideal vaccine for the post-certification period, as
they can be produced outside of containment requirements; and•messenger ribonucleic acid (mRNA) platform technologies for developing non-infectious polio vaccines.

Prioritizing the solutions laid out in this strategy requires targeted research (see the Array of polio researchareas and impact table in Annex J). Identifying knowledge gaps and pursuing new R&D areas to support
innovation will go a long way towards creating an enabling environment for achieving and sustaining global polio
eradication.
With this strategy’s focus on the intensified delivery of polio vaccines in essential and supplementary
immunization, research will support improved coverage through field pilots that span epidemiological andoperational areas. Pilots will contribute to improving programme communication, strengthening community
engagement, minimizing vaccine hesitancy, ensuring gender equity and integrating polio activities with other
health and development services. Increased coordination with surveillance and the GPLN will strengthen
innovation around rapid detection and diagnostic tools, further enabling the strategy’s success.
R&D has always been rated as providing high value for money and has become even more relevant in the current
context of polio eradication. The data and experiences of polio research will be very useful in leveraging thelegacy of scientific contributions in the delivery of other global public health interventions.

6. MONITORING AND EVALUATION FRAMEWORKTo assess progress against the major milestones and targets outlined in this document, the GPEI has developed
a high-level M&E framework with specific desired outcomes and KPIs (see Annex F). While programme-specificareas have dedicated in-depth designed indicators, this framework provides a tool to review progress madeagainst the strategic objectives and success-driving elements for achieving eradication. The GPEI will assess
progress made against each of the KPIs on a quarterly basis. The SC will review progress against KPIs at theoutcome level and, if necessary, will raise any key areas of concern to the POB, while the POB will review KPIs
at the goal level on a quarterly basis. A rigorous assessment of the programme’s progress against the strategy’s
milestones will be conducted near the end of 2023.

Risk management
The management of operational risk drives many aspects of the GPEI’s work, including the planning of preventive
immunization campaigns, surveillance, outbreak response, vaccine supply, R&D and financial management.
For this Polio Eradication Strategy 2022–2026, the GPEI takes risk management further by identifying andmonitoring key higher-level risks and strategic risks (see Table 1), which will be periodically reported through
GPEI governance.

36

Enabling Environment

Table 1. Key strategic risks
Short description

Description

Risk of VDPV spread

A high risk of continued international spread and multicountry cVDPV2 outbreaks exists
due to declining type 2 population immunity, weak essential immunization systems andfurther seeding because of Sabin OPV2 usage. Continued spread may overwhelm the
GPEI’s ability to respond both in terms of technical capacity and funding available to theprogramme.

Inadequate resources

Increased requirements for outbreaks, vaccine supplies and lack of progress in theendemic countries could cause programme demands to exceed available resources. This
could result in the risks of not being able to sustain the level of support needed by the GPEI
and running out of funds before the job is finished.

Insufficient access

The inability to reach all children with OPV in remaining polio reservoirs is due toinsecurity, access restrictions, community indifference and mistrust resulting in pockets ofunvaccinated children, increasing the risk of not being able to eradicate poliovirus.

Weak surveillance

The risk of the ongoing undetected transmission of polio is due to weak surveillance in highrisk areas. Surveillance can be weakened through limited access in security-compromised
areas, infrequent training of surveillance, laboratory and data officers, and the diversionof polio assets towards other areas, such as COVID-19. The potential withdrawal of GPEI
support could weaken countries' health capacities and systems without robust surveillance.

Gender notmainstreamed

Insufficiently reflecting gender in strategies, planning, budgets, operations and governancecould have a detrimental effect on the programme's capacity to achieve the eradication
goal.

Poor integration

The risk that eradication could be compromised without the provision of integrated services
is largely due to inadequate resources and no clear management focus on integrated
services within the GPEI.

Poor government
commitment

Governments’ insufficient political, financial or resource commitments could compromise
the polio eradication response effort.

Loss of donor
confidence or support

The loss of donor support due to poor eradication performance or to the GPEI’s failure toaddress key donor criteria could lead to reduced resources for the programme.

Failure of effective
GPEI response

The GPEI may fail to respond to the complex challenges of polio eradication in terms of thequality and/or timeliness of emergency operations.

Civil society
indifference

Civil society indifference to polio eradication could lead to suboptimal results and thepotential failure to eradicate WPV1 or contain VDPVs.

The risks outlined in Table 1 are cross-cutting, allow for a broader, balanced view of the strategy’s risk
environment and are closely aligned with the four pillars of GPEI risk management: operational risks (internal),
government engagement and commitment (external), donor or stakeholder confidence (financial), andcommunity or civil society engagement (communities served).
In addition to identifying and actively managing these strategic risks, the GPEI will continue to implement
risk management activities (through the activities of partner agencies, management groups and technicalcommunities of practice) appropriate to the respective functional and operational needs. These operationalrisks – as evidenced in other parts of the strategy – continue to be dealt with at an operational level. Such
operational and administrative risk management activities are supplemented by corporate risk management
processes established within the respective partner organizations.

37Polio Eradication Strategy 2022–2026: Delivering on a promise

Risk management framework. In addition to identifying the strategic risks, the framework calls for a transparent
risk management process within GPEI governance to monitor the key risks to the achievement of the strategy.
This process is built on best practices and incorporates standard risk management tools and processes that
include:•a strategic risk register identifying the risk, risk owner(s), the associated impact and likelihood, as well as
mitigation measures and current risk status (see Annex E, Table E1); and•a six-monthly periodic assessment process envisaged to take stock of the risks through a self-assessment
process, to provide management with changes to the risk environment, vet new risks, compare the current risk
environment with the previous period and enable a timely managerial response to address changes in the risk
environment. Periodic risk reports are relayed through the SC to the Financial Accountability Committee and
POB, as required.

GPEI risk management will be implemented within the broader M&E framework and will be coordinated in the
Executive Management Unit with direct reporting lines to the SC (see GPEI structure, Fig. 11).

7. FINANCE AND COSTING
The timeline to interrupt transmission is the biggest driver of cost and determines the trajectory of spend
throughout the duration of the Polio Eradication Strategy 2022–2026. Therefore, the programme developed
cost estimates based on four unique modelling scenarios with varying eradication timelines (see Table 2). The
scenario best aligned to the strategy, which assumes interruption of WPV within two years of launching thestrategy (by the end of 2023) and certification within five years, has an initial cost estimate of US$ 5.1 billion over
five years.29

Table 2. Estimated cost of various eradication timelines
Eradication timeline

Projected five-year cost (US$)

Interrupt WPV transmission in 1 year and certify in 4 years

4.5 billion

Interrupt WPV transmission in 2 years and certify in 5 years

5.1 billion

Interrupt WPV transmission in 3 years and certify in 6 years

5.5 billion

Interrupt WPV transmission in 5 years and certify in 8 years

6.2 billion

Key areas of spend in the indicative US$ 5.1 billion estimate include SIAs (primarily in endemic countries), robust
surveillance, large-scale response to cVDPV outbreaks and an appropriately sized OPV stockpile, integrated
campaigns and gender (which, for the first time, is a discrete planning assumption in the cost estimate),30 andessential health and community services, campaign quality enhancements and the staffing of country, regionaland headquarter offices to support eradication (see Fig. 15).
The US$ 5.1 billion scenario assumes that total costs remain high over the initial two years and then decrease
once the programme achieves interruption and begins certification efforts in the third year. Once the certification
milestone has been achieved, costs will plateau as the programme begins implementing the Post-Certification
Strategy (see the Preparing for the post-certification world section). The early transition of polio-supported
functions onto other programmes with alternative sources of support would reduce the GPEI’s resource
requirements, but the projections of these shifts have not been factored into these scenarios.
As details of this new strategy are further elaborated, and as potential lingering impacts of the pandemic on
implementation planning become clear, the programme will leverage this initial estimate as one of the inputs
for the GPEI to build a detailed multiyear operational budget. The GPEI operating budget for 2022–2026 will beapproved by the GPEI leadership towards the end of 2021. Variables such as the size and duration of outbreaks,
the potential for the transition of current GPEI-supported functions to other programmes and other factors (e.g.
integration strategies and stockpile requirements) could push the financial requirements up or down. This
strategy’s resource mobilization will be guided by an investment case for the GPEI that will be put forward in 2021
and will rely on both existing and new sources of funding. The budget will be reassessed regularly to ensure
lasting alignment with programmatic priorities and to fund the most impactful and cost-effective interventions.

The POB-approved budget and budget details will be available on the GPEI website (www.polioeradication.org/financing).
The estimated cost to implement this strategy includes a 1% allocation for gender-related activities, which is included in Fig. 14 but is not visible given the relatively small amount.

29 
30 

38

Enabling Environment

Fig. 15. Estimated yearly cost of the new polio strategy (US$ billions)Year 2: Interrupt
transmission$1,400$1.3B

Year 5: Certification
milestone$1.3B$1,200$1.0B$1,000
$800

$0.8B

$0.8B

Yr 4

Yr 5

$600
$400
$200
$-

Yr 1

Yr 2

Yr 3

Planned SIAs

Surveillance & containment

VDPV outbreak responseCore staffing (HQ, regional, country)

OPV procurement (for outbreak & stockpile)

Innovative strategies & tactics

Integration

GenderIndirect costs

HQ = headquarters; OPV = oral polio vaccine; SIA = supplementary immunization activity; VDPV = vaccine-derived poliovirus.
Source: WHO.

Additional costs required to achieve eradication
The GPEI budget will not be sufficient on its own to fully implement this strategy and achieve eradication. In
addition to the programme elements captured within an indicative resource requirement of US$ 5.1 billion, forexample, the programme will require funds to support IPV through Gavi and essential immunization, additional
pre-cessation stockpiles, research and any major integration initiatives beyond those initially scoped within thisbudget scenario. (For example, many of these integration initiatives will require collaboration with other healthprogrammes to deliver a combined package of services, so the budget will be refined as discussions advance.)
As in previous years, the GPEI is committed to working with Gavi to strengthen global immunization and advocate
for funding in this space.

Tracking resources to target gender equality
Mainstreaming gender “visibility” throughout the budget cycle ensures accountability for commitments togender equality and eradication. To provide greater visibility, the GPEI will develop a new gender marker
tool as a scoring system (see Table 3) to ensure resources for gender activities and to track allocations for
activities that target gender equality, both direct and indirect funding allocations (see Fig. 15). Activities
with a score of 2 will go against the direct or dedicated gender budget line. The gender markers will becomplemented by additional gender metrics to measure investment and outcomes (see Annex I).

Table 3. Gender marker three-point scoring system
Activity

Definition

Not objective (score 0)

Activity does not target gender or gender equality (e.g. the procurement ofvaccine)Significant objective (score 1)

Gender and gender equality are important but not the principal objective of
the activity (e.g. AFP surveillance)

Principal objective (score 2)

Gender is the main objective and contributes to gender equality (e.g. gender
training, technical assistance or safeguarding)

39

PREPARING FOR THE
POST-CERTIFICATION WORLDThe Post-Certification Strategy (PCS) describes the technical functions and standards needed to maintain apolio-free world, functions that include containment, immunization with appropriate polio vaccines, poliovirus
surveillance and outbreak response (see Fig. 16).31
The PCS offers three main goals to guide activities in the post-certification period:
1. Contain polioviruses. The focus of Goal One is to achieve and sustain the restricted safe handling ofpolioviruses in laboratories, vaccine manufactures and other facilities (such as research institutions) to prevent
their reintroduction in a polio-free world. The key focus areas will be to reduce the number of facilities storing andhandling poliovirus globally, and to implement and monitor appropriate safeguards in those facilities that retain
poliovirus.
2. Protect populations. The focus of Goal Two is to protect populations from VDPVs and vaccine-associatedparalytic poliomyelitis (VAPP) by preparing and coordinating the global withdrawal of bOPV, and from any
poliovirus re-emergence by providing access to safe, effective vaccines.
3. Detect and respond to a polio event. The focus of Goal Three is to promptly detect any poliovirus in a humanor in the environment through a sensitive surveillance system and to maintain adequate capacity and resourcesto effectively contain or respond to a polio event.

Fig. 16. Post-Certification Strategy high-level timeline
Polio Post-Certification Strategy

Polio Eradication Strategy
TodayInterruption

CertificationbOPV cessation+3 years+1 year

Pre-certification

Pre-cessation

Post-cessation• Containment• Immunization• Vaccine management• Surveillance• Outbreak preparedness
and response• ResearchbOPV = bivalent oral polio vaccine.
Source: Polio Post-Certification Strategy.

To anticipate the transfer of skills, knowledge and resources of a programme that is over 30 years old, it isimportant to start implementation planning now as the GPEI partnership will dissolve at certification. A significant
portion of polio staff time is spent supporting activities related to broader immunization and health care goals.32
Current polio resources, funding and systems will need to be transitioned either to groups that will support
maintaining a polio-free world, or groups that have relied on polio resources to accomplish their health goals.
Many such activities have been included in relevant sections of this strategy, including, for example, stronger
collaboration with the immunization community and health emergency programmes to prevent and respond tooutbreaks.
The PCS will be revised by the GPEI and ideally co-developed with the broader immunization community, as
well as with other “future owners” of sustaining a polio-free world. For this 2022–2026 strategy, the two areas withadditional details are containment and OPV cessation.

Global Polio Eradication Initiative (GPEI). Polio Post-Certification Strategy. Geneva: World Health Organization; 2018 (http://polioeradication.org/wp-content/uploads/2018/04/
polio-post-certification-strategy-20180424-2.pdf, accessed 8 June 2021).
For examples of activities and time spent towards broader immunization and health care goals, see Van den Ent MM, Swift RD, Anaokar S, Hegg LA, Eggers R, Cochi SL.
Contribution of Global Polio Eradication Initiative – Funded Personnel to the Strengthening of Routine Immunization Programs in the 10 Focus Countries of the Polio Eradicationand Endgame Strategic Plan. J Infect Dis. 2017;216(S1):S244–9 (https://doi.org/10.1093/infdis/jiw567, accessed 8 June 2021).

31 

32 

40

Preparing for the post-certification world

CONTAINING POLIOVIRUS
In 2015, WHO Member States committed to containing all type 2 polioviruses, including Sabin and Sabin-likestrains, in specially designated poliovirus-essential facilities (PEFs). Similar commitments will be made fortypes 1 and 3 in the near future, beginning with inventories of materials containing WPV and VDPV of theseserotypes. These activities were included in the resolution that Member States adopted at the Seventy-first World
Health Assembly in 2018, which urges the intensification of efforts to accelerate progress towards poliovirus
containment globally.33 As of May 2021, 24 countries have designated 74 PEFs for the retention of poliovirus type 2materials. These facilities are mainly located in high-income countries and include polio vaccine manufacturers,
research laboratories and other facilities storing or processing biological materials. The process of PEFs obtaining
Certificates of Participation is nearing completion, to be followed in the near future by obtaining Interim Certificatesof Containment and, ultimately, Certificates of Containment for all three types of poliovirus. These activities willcontinue during this strategy’s time frame to ensure that all poliovirus type 2 materials are destroyed or safely andsecurely contained, and that further progress is made for inventorying types 1 and 3 materials and reducing thenumber of PEFs.
Implementing and monitoring long-term poliovirus containment in facilities with appropriate safeguards will be key
to maintaining a polio-free world. Bridging activities are needed now for containment to be in full force in the PCS(see Fig. 17). Facilities retaining poliovirus materials and designated as PEFs will need to meet and maintain thesafeguards required by GAPIII and allow periodic assessment by auditors and national authorities for containment(NACs).34 The NACs will renew, modify or withdraw the Certificates of Containment, in coordination with WHO andthe Containment Working Group of the Global Commission for the Certification of the Eradication of Poliomyelitis(GCC-CWG) or other oversight bodies. The NACs are relatively new bodies and, as such, require political support
within their Member States. Advocacy remains critical to the process, and all bodies, from the national to the global
level, need a common understanding of the global containment certification process and requirements.
In preparing for a possible breach, WHO has developed guidance for managing exposed persons in PEF-hosting
countries.35 The containment breach scenario has also been incorporated in polio outbreak simulation exercises.
These two-day tabletop exercises have proven informative in identifying differences in national authorities andmandates for isolation and quarantine and IHR reporting.
See Annex K for updates on progress towards containment goals.

Fig. 17. Major activities for containment, 2022–2026

Major activities

Reduce theglobal number offacilities storingand handlingpoliovirus
Achieve and sustain
the containmentof polioviruses inlaboratories, vaccine
manufacturing andother facilities

Implement& monitor
appropriate
safeguards forthe long-term
containment ofpoliovirus• Finalize national• Develop quality
poliovirus surveys
standards forand inventories forverification of
all WPVs + Sabin 2
national poliovirus
viruses as per defined
surveys andquality standards
inventories• Further reduce thenumber of required
PEFs as researchdevelopments1 andvaccine requirementsallow• Remove allpoliovirus materials
from facilities notdesignated as PEFs

• Advocate to
avoid excessive
designation of PEFs

• Maintain and regularly
update a global
inventory of PEFs

• Issue, renew,
modify, or withdraw
the certificatesof containment,
throughcoordination of
NACs, WHO and• Provide technical
GCC-CWG2
assistance and expert
containment advice• Conduct periodic
to countries, including
PEF assessments
strengthening
by auditors andauditing capacity
NACs• Incorporate
containment breach
response plans into
national emergency
response plans• Ensure PEFs meetand maintainthe safeguards
required by national
requirements and
GAPIII2• Regularly update
guidelines andtechnical materials
related to poliovirus
containment

Communications and advocacy

2022–2026¹ Possible developments include the replacement of virus cultures with other assays for the diagnosis of poliovirus infection or the production of vaccines using genetically modified
poliovirus strains or virus-like particles.
² GCC-CWG will continue to implement the CCS until global WPV certification, at which time this oversight will be taken on by the appropriate body.
CCS = Containment Certification Scheme; GAPIII = Global Action Plan to minimize post-eradication poliovirus facility-associated risk, third edition; GCC-CWG = Containment Working
Group of the Global Commission for the Certification of the Eradication of Poliomyelitis; NAC = national authority for containment; PEF = poliovirus-essential facility; WPV = wild poliovirus.
Source: WHO.

Resolution WHA71.16. Poliomyelitis – containment of polioviruses. In: Seventy-first World Health Assembly, Geneva, 26 May 2018. Geneva: World Health Organization; 2018(http://apps.who.int/gb/ebwha/pdf_files/WHA71/A71_R16-en.pdf, accessed 16 June 2021).
GAPIII: WHO Global Action Plan to minimize poliovirus facility-associated risk after type-specific eradication of wild polioviruses and sequential cessation of oral polio vaccine
use, third edition. Geneva: World Health Organization; 2015 (http://polioeradication.org/wp-content/uploads/2016/12/GAPIII_2014.pdf, accessed 8 June 2021).
35 
Public Health Management of Facility Related Exposure to Live Polioviruses. Geneva: World Health Organization; October 2019 (https://polioeradication.org/wp-content/
uploads/2016/07/Public-Health-Management-of-a-facility-PV-exposure.pdf, accessed 11 June 2021).
33 

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41

Polio Eradication Strategy 2022–2026: Delivering on a promise

OPV CESSATIONOPV cessation is critical to stop the occurrence of VAPP and to remove the primary risk of emergence of all
types of VDPVs. Planning for OPV withdrawal will start at least two years in advance of cessation, building on thelessons learned from the switch from tOPV to bOPV. The OPV cessation policy will address three main issues:
strategies for pre-cessation SIAs; the availability of new, more genetically stable vaccine options; and the timeinterval between certification of eradication and OPV cessation. SIAs with types 1 and 3 containing OPV (Sabinor novel) should be implemented over a period of time in the years prior to cessation and not just during theimmediate pre-cessation period, to maintain persistently high population-level immunity. Uncertainties remain
regarding the optimal number of such SIAs.
As of the second quarter of 2021, nOPV1 and nOPV3 are projected to be available through the WHO
prequalification (PQ) process by the second quarter of 2025 and the first quarter of 2026, respectively,
assuming successful clinical development and manufacturing efforts in the coming years. A decision on clinicaldevelopment of multivalent novel OPV is expected to be taken by the second quarter of 2022. For each of thesenovel OPV products, the option of EUL could be explored, which could result in availability for outbreak response
use at least one year before the projected PQ timelines.

© UNICEF / Christopher Herwig

Several factors may contribute to the optimal estimates for the period between certification of eradication and
OPV cessation; these include assessment of the coverage and quality of SIAs in the years before cessation, IPV
coverage in essential immunization, assessment of stockpile size, and the feasibility of early use of novel OPV
formulations in pre-cessation SIAs. Also, better estimates of circulating vaccine-derived poliovirus type 1 and 3
risks and an updated VAPP burden by serotype would strengthen policy formulation around cessation. The
availability of tools for risk mitigation, such as polio antivirals, could further enhance the chances of minimizing
community transmission risks from long-term shedders of poliovirus in the post-cessation era.

42Annexes
ANNEX A. STAKEHOLDERCONSULTATION LISTThe GPEI solicited input from a broad set of stakeholders to shape the future direction of the programme in the
final, collective effort to achieve polio eradication. This external engagement was the most extensive to date of
any GPEI strategy and included those stakeholders listed below.36 Common themes among the feedback andquestions raised over the strategy’s development can be reviewed in a Stakeholder Consultation Report.37
Afghanistan Red Crescent Society
Bill & Melinda Gates Foundation Polio and Vaccine
Delivery Teams
Camber Collective
Center for Integrated Health Programs (CIHP)
Centre for Health Sciences Training, Research andDevelopment (CHESTRAD), Global
Christian Medical College, Vellore
Civil Society Group
Civil Society Human and Institutional Development
Programme
Common Thread
Communication Initiative
CORE Group
Emergency Committee under the International HealthRegulations (IHR) regarding the International Spread of
Poliovirus
Gavi, the Vaccine Alliance
Global Commission for the Certification of the Eradicationof Poliomyelitis (GCC)
Global Financing Facility
Global Vaccine Action Plan (GVAP) Working Group, now
the Immunization Agenda 2030 (IA2030)
Global Virome Project
Government of Afghanistan
Government of Australia
Government of Canada
Government of Egypt
Government of the European Union
Government of Germany
Government of the Islamic Republic of IranGovernment of Japan
Government of Norway
Government of Pakistan
Government of Sudan
Government of the United Arab Emirates
Government of the United Kingdom
Government of the United States of America
GPEI Management Groups and Task Teams
GPEI Partners (immunization and emergency teams at
the global and regional levels)
Imperial College London
Independent Monitoring Board (IMB)
Institute for Disease Modeling (IDM)

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International Centre for Diarrhoeal Disease Research(ICDDR)
John Snow, Inc.
Johns Hopkins Bloomberg School of Public Health
Kid Risk, Inc.
Pakistan Polio Eradication Initiative
Polio Partners Group (PPG)
RESULTS UK
RotaryStrategic Advisory Group of Experts (SAGE) on
Immunization and its Polio Working Group(SAGE-WG)
Technical Advisory Groups (TAGs) for endemic countries
and regions
The Women’s Storytelling Salon
Transition Independent Monitoring Board (TIMB)UNICEF Health Section, NY headquarters
UNICEF Immunization Unit
UNICEF Supply Division
United Nations Foundation (UNF)
University of Michigan
University of North Carolina at Chapel Hill, Gillings
School of Global Public Health
University of Oxford
US Centers for Disease Control and Prevention (CDC)
Polio and Immunization Teams
Vaccine manufacturers
Vaccine Network for Disease Control
VITAL Pakistan
World Health Assembly Member States
WHO and UNICEF regional office focal points for polio
and the Expanded Programme on Immunization (EPI)
WHO Country Offices
WHO Director-General’s Envoy Multilateral Affairs
WHO Division for Science
WHO Division for Communicable andNon-Communicable Diseases
WHO Global Health Workforce Network Gender Equity
Hub
WHO Health Emergencies Programme (WHE)
WHO Health System Strengthening
WHO Immunization, Vaccines and Biologicals
WHO Polio Transition TeamWHO Resource Mobilization

A full list by organization and focal point is available upon request.
To view or download the Strategy Consultation Report, visit the GPEI website (https://polioeradication.org/wp-content/uploads/2021/07/Stakeholder-ConsultationReport-20210708.pdf).

36 
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43

ANNEX B. CURRENTEPIDEMIOLOGICAL STATE
Fig. B1. Monthly WPV1 cases, Afghanistan and Pakistan, January 2018–June 2021
2018

35

2019

2020

2021

• The case counts weresignificantly higher in2019 and 2020 than inprevious years.

30
25
20

23
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Jan
Feb
Mar
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Aug
Sep
Oct
Nov
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Jan
Feb
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Jul
Aug
Sep
Oct
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WPV1 highlights

Afghanistan

Pakistan• In 2020, 140 WPV1
cases were reported(56 from Afghanistan
and 84 from Pakistan),compared to 176
cases in 2019 (29 fromAfghanistan and 147
from Pakistan) (seeFig. B2).

Source: WHO.

Fig. B2. WPV1 cases in
Afghanistan and Pakistan,January 2020–June 2021

cVDPV2 highlights
Between 2019 and 2020, cVDPV2 cases tripled (see Fig. B3).
In 2020, cVDPV2 cases totalled 1056 globally (with 308 fromAfghanistan, 135 from Pakistan, 99 from Chad and 81 from the
Democratic Republic of the Congo); whereas cases in 2019 totalled
366 (with only 22 from Pakistan and none in Afghanistan). The virus
continued to spread across the African Region, with outbreaks
spanning from the Atlantic to the Indian Ocean; virus from thePhilippines spread domestically and regionally to Malaysia; andvirus in Afghanistan and Pakistan spread to the Islamic Republic of
Iran and Tajikistan (see Fig. B4). These regions and countries havecontinued to see the expansion of existing cVDPV2 outbreaks.
* The GPEI provides weekly updates on the global epidemiology of circulating vaccine-derived polioviruses(https://polioeradication.org/polio-today/polio-now/this-week/circulating-vaccine-derived-poliovirus/).

Map Scale: 1cm = 64km
Coordinate System: GCS WGS 1984, Datum: WGS 1984, Units: Degrees

AFP cases

Not applicable

AFP = acute flaccid paralysis.
Source: WHO.

Fig. B3. Monthly cVDPV2 cases, by area of case, January
2018–June 2021
150

AFP cases

100

50

0

2018

Province of emergence

Source: All data is from WHO POLIS and is up to dateas of August 2021.

44

AFP = acute flaccid paralysis.
Source: WHO.

2019

2020

Spread within country of emergence2021
Spread internationallyAnnex B. Current epidemiological state

Since 2018, the GPEI has seen an increase in both WPV1 and cVDPV2 cases globally. While WPV1 cases continue
to remain localized to the final two endemic countries, Afghanistan and Pakistan (see Fig. B1), outbreaks of cVDPV2
have been detected in four regions. The inability of campaign operations to engage and reach remaining communities
has contributed to this trend, as have external disruptions such as political shifts and the COVID-19 pandemic.

Fig. B4. Global cVDPV environmental surveillance isolates, January 2020–June 2021
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Virus type

Map Scale: 1cm = 456km
Coordinate System: GCS WGS 1984, Datum: WGS 1984, Units: Degrees

VDPV1 = vaccine-derived poliovirus type 1; VDPV2= vaccine-derived poliovirus type 2.

VDPV1

VDPV2

Not applicable

Source: WHO.

Fig. B5. Completed, delayed and cancelled polio supplementary immunization activities, 2020

Highlight•

The COVID-19
pandemic
disrupted
preventive SIAs
(see Fig. B5)
and outbreak
response
activities in
the first half of2020, with allplanned bOPV
and mOPV2
campaigns fromMarch to July
2020 delayed
across all WHO
regions.
Cancelled
Map Scale: 1cm = 456km
Coordinate System: GCS WGS 1984, Datum: WGS 1984, Units: Degrees

DelayedCompleted with delay

Not applicable

Source: WHO.

45

ANNEX C. IMMUNIZATION AGENDA 2030

Comm
itme
& Dem nt
andPeopleCentred

ty

e
rag
ve
Co

Co
& ver
Eq ag
ui e
ty

Out
b
Em reaks
erg
enc &
ies

lth

ary Health Careandr Prim
o
f
Un
es
ive
m
m
rs
a
r
al
g
o
He
r
P
a
n
rse &
Cou
Life egration
Int

Im
mu
ni
za
tio

Fig. C1. GPEI contributions to Immunization Agenda 2030 (IA2030) strategic priorities

& ili
ly ab
p
p ain
Su ustS

rch
Resea tionva
& InnoCountry
Owned

Partnership
Based

Data
GuidedSP1 Primary Healthcare and Universal Health Coverage

Support the delivery of a comprehensive package including primary
healthcare services in targeted geographies

SP2 Commitment & Demand

Generating acceptance of polio vaccines through context-specificcommunity engagement

SP3 Coverage & Equity

Reaching zero dose communities with targeted, gender-sensitive
integrated delivery strategies

SP4 Life-course & Integration

Reaching and sustaining eradication through expanded integrationand through unified partnerships

SP5 Outbreaks and Emergencies

Using emergency capacities to stop cVDPV transmission andpreventing future outbreaks

SP6 Supply & Sustainability

Securing adequate supply of polio vaccines and working towards
sustainable transition out of GPEI support

SP7 Research & Innovation

Fostering polio research and programmatic innovations, including theuse of nOPV and digital technologies

cVDPV = circulating vaccine-derived poliovirus; nOPV = novel oral polio vaccine; SP = strategic priority.
Source: WHO.

46

ANNEX D. INTEGRATION
Fig. D1. Integration decision-making framework

Core to polio eradication
Why

Addresses a gap on thecritical path to achieving
and sustaining polio
eradication?

What

Joint/shared responsibilityorStrengthens activities aimed
at achieving and sustaining
polio eradication?

orSupports a public health or GHS
initiative that is mutually beneficial
to the GPEI and can be supported
by existing assets?

The core GPEI asset categories to be leveraged (assets organized to become increasingly local context dependent, from left to right)

Global assets

Regional assets

National assets

Supply chain

Disease surveillance &laboratory systems

Implementation andservice delivery

Resource mobilization
and advocacy

Monitoring anddata management

Management andoperations

Partnerships andcoordination

Capacitystrengthening

Communications andcommunity engagement

Localized assets

Policy and strategy
development

Where

The geographic level or epidemiological context in which this is occurring
Country-level: Endemics
GlobalRegional
Country-level: Outbreaks/other non-polio countries

When• Will the opportunity have immediate
impact (<2 years; e.g.,eradication
critical, integrated service delivery)?
• Will the desired impact be achieved in
the near-term (~2–5 years; e.g., periodleading to certification, transition,
preparing GPEI closure)• Will the desired impact be realized
during the VDPV
interruption/containment timeline (i.e.,
post-OPV cessation)?

Who• Which GPEI partners(including donors andministries of health) will
lead, be involved orotherwise organize /support the effort?
• Are there non-GPEI
partners to beengaged?

How• Should and can additional funds (beyond FRR) be
raised to support this effort? Is this within the scopethat donors agree to support?
• Does the opportunity offer compelling value formoney?
• What coordination, management, accountability andplanning processes need to be modified or created tofacilitate integration?
• Does this require assets from other programmes,or the use of polio assets to support related but
non-polio activities?
• Are additional resources (e.g., workforce) required?

FRR = functional resource requirements; GHS = global health security; OPV = oral polio vaccine; VDPV = vaccine-derived poliovirus.
Source: WHO.

47

Polio Eradication Strategy 2022–2026: Delivering on a promise

Table D1. GPEI integration role in endemic countries
Where

Geography: endemics

Why

Addresses a gap on thecritical path to achieving andsustaining polio eradication

Strengthens activities aimed atachieving and sustaining polio
eradication

Supports a public health or
global health security initiativethat is mutually beneficial to the
GPEI and can be supported byexisting assets

What
activities

Enhancing the quality,
timeliness and reach of bothessential immunization activities
and SIAs for polio and othervaccine-preventable efforts in
the highest risk areas by:

Supporting the delivery ofa broader comprehensive
package, including PHC
services in targeted
geographies by:

Supporting the broader global
and national public healthinitiatives as a pathway towards
a successful programmetransition by:• ensuring the strategic
objectives of the polio
programme are reflected inwider investments in HSS
and EPIs• ensuring polio contributes
to global and country
immunization goals,
including reducing zerodose children and IA2030
core principles of delivering
people-centred, countryowned, data-guided
and partnership-based
interventions• advocating for the provisionof other basic services tovulnerable communities• supporting efforts towards
containing COVID-19
through active engagementwith all national andsubnational authorities
coordinating response efforts• continuing to conduct
COVID-19 surveillance,
including testing andtracing, data management,risk communication andvaccination• providing other emergency
response capacity during
periods of acute need

• Adjacent humanitarian andhealth programmes• Sehatmandi and National
Health Support Project• Endemics hub• National and provincial
governments• Endemics hub• increasing the access toand utilization of essential
immunization services
in the southern region of
Afghanistan and the highestrisk districts of Pakistan• integrating SIA planning that
increases the opportunity to
co-deliver polio and othervaccines or other healthinterventions, such as the
distribution of vitamin A,
deworming tablets and thedissemination of maternaland child health messaging

Indicative
partners• National and provincial
EOCs• Pakistan Polio Eradication
Initiative-Expanded
Programme on Immunization
Synergy Task Team• Endemics hub• EPIsCOVID-19 = coronavirus disease; EOC = emergency operations centre; EPI = Expanded Programme on Immunization; HSS = health system strengthening; IA2030 = Immunization
Agenda 2030; PHC = primary health care; SIA = supplementary immunization activity.

48

Annex D. Integration

Table D2. GPEI integration role in outbreak countries
Where

Geography: outbreaks

WhyStrengthens activities aimed at achieving and sustaining
polio eradication

Supports a public health or global
health security initiative that is mutually
beneficial to the GPEI and can besupported by existing assets

What
activities

Coordinating outbreak response activities with EPI and
immunization partners to boost essential immunization
performance in outbreak and adjacent geographies
between OPV rounds by:

Supporting the broader global andnational public health initiatives asa pathway towards a successfulprogramme transition by:• using the outbreak event as an opportunity to flagsystemic EPI weaknesses and mobilize support frombroader immunization partners (i.e. Gavi) to boost
essential immunization performance and outreachvaccination, including IPV• using its incident management structure to coordinate
with governments, PHC-EPI and partners tocoordinate and improve outreach, microplanning andcommunication to promote essential immunization and
PHC• in collaboration with Gavi and other partners, aiming toleave the system on a path to recovery at the closureof an outbreak, leveraging the outbreak event to reenergize national, provincial and local health authority
planning and action• supporting efforts towards
containing COVID-19 through active
engagement with all national andsubnational authorities coordinating
response efforts• continuing to conduct COVID-19
surveillance, including testing andtracing, data management, risk
communication and vaccination• providing other emergency response
capacity during periods of acuteneed• Gavi (joint appraisals, targeted country assistance andregional working groups)• Rapid Response Team• EPIs• POB• GaviIndicative
partners

COVID-19 = coronavirus disease; EPI = Expanded Programme on Immunization; IPV = inactivated polio vaccine; OPV = oral polio vaccine; PHC-EPI = primary health careExpanded Programme on Immunization; POB = Polio Oversight Board.

49

ANNEX E. RISKS
High-level strategic risks
Table E1. Risk register (as of the second quarter of 2021)
Risk

Description

Likelihood Impact

Risk level

Risk of VDPV
spreadA high risk of continued international spread and multicountrycVDPV2 outbreaks exists due to declining type 2 population
immunity, weak essential immunization systems and further
seeding because of Sabin OPV2 usage. Continued spreadmay overwhelm the GPEI’s ability to respond both in terms oftechnical capacity and funding available to the programme.

4

4

SevereInadequate
resources

Increased requirements for outbreaks, vaccine supplies
and lack of progress in the endemic countries could cause
programme demands to exceed available resources. This
could result in the risks of not being able to sustain the level of
support needed by the GPEI and running out of funds before
the job is finished.

3

4

Significant

Weaksurveillance

The risk of the ongoing undetected transmission of polio isdue to weak surveillance in high-risk areas. Surveillance canbe weakened through limited access in security compromised
areas, infrequent training of surveillance, laboratory and data
officers, and the diversion of polio assets towards other areas,such as COVID-19. The potential withdrawal of GPEI support
could weaken countries’ health capacities and systems
without robust surveillance.

3

4

Significant

Gender not
Insufficiently reflecting gender in strategies, planning,
mainstreamed budgets, operations and governance could have a detrimental
effect on the programme’s capacity to achieve the eradication
goal.

4

3

Significant

Loss of donor
confidence
and support

The loss of donor support due to poor eradication
performance or to the GPEI’s failure to address key donor
criteria could lead to reduced resources for the programme.

2.5

4

Significant

Insufficient
access

The inability to reach all children with OPV in remaining polio
reservoirs is due to insecurity, access restrictions, community
indifference and mistrust resulting in pockets of unvaccinatedchildren, increasing the risk of not being able to eradicate
poliovirus.

3

3

Significant

Poor
integration

The risk that eradication could be compromised without theprovision of integrated services is largely due to inadequate
resources and no clear management focus on integrated
services within the GPEI.

3

3

Significant

Civil society
indifference

Civil society indifference to polio eradication could lead tosuboptimal results and the potential failure to eradicate WPV1or contain VDPVs.

2.9

2.9

ModeratePoor
government
commitment

Governments’ insufficient political, financial or resource
commitments could compromise the polio eradication
response effort.

2

4

Moderate

Failure ofeffective GPEI
response

The GPEI may fail to respond to the complex challenges ofpolio eradication in terms of the quality and/or timeliness of
emergency operations.

2

4Moderate

COVID-19 = coronavirus disease; cVDPV2 = circulating vaccine-derived poliovirus type 2; OPV2 = oral polio vaccine type 2; VDPV = vaccine-derived poliovirus; WPV1 = wild
poliovirus type 1.
Note: Mitigation measures will be included in future updates to the risk register.

50

Annex E. Risks

Operational risk examples
Table E2. Key risks to the vaccine supply and risk mitigation activities (as of the second quarterof 2021)
Risk category

Description

Response

Global OPV
stockpile

Limited pool of suppliers andattrition of suppliers from themarketWork with UNICEF, vaccine
manufacturers, containment and thenOPV2 WG to bring new suppliers to
the market

Risk of Sabin OPV2 stock rupturesin 2021–2022 in case of slow
nOPV2 rollout

Negotiate larger Sabin OPV2 supply

StatusRisk of OPV2 shortages in• Closely monitor nOPV2 rollout,
2021–2023 if suspending or
nOPV2 WG/VSTT collaboration,
discontinuing nOPV2 use on safety
and revise the GS plan as needed
or stability concerns• Pre-position Sabin OPV2 bulk
as a contingency preparedness
measure• Declining demand for bOPV,
making it less attractive tosuppliers with the risk ofincreased costs and supplierattrition• Large oversupply or expiring
stock due to SIA cancellationsin 2020• Advocate with countries to accept
short shelf-life vaccine• Improve demand forecasting andlead times• Introduce mechanisms to sharethe financial risks with vaccine
suppliers

Inability to maintain a large rolling
buffer stock to meet bOPV needs
in case of polio outbreaks andshort-term changes in SIA plans• Expand the OPV supplier pool
• Establish a physical bOPV buffer
as a contingency preparedness
measureReduced pool of suppliers
accepted by Pakistan

Advocate for licensure of new bOPVs
in the country

Financing

Irregular financing, affecting thetimelines of implementing the GS
plan

Develop and implement a 2022–2026
vaccine supply strategy, plan andbudgetCOVID-19/
Access to
COVID-19 Tools(ACT) Accelerator

The impact of COVID-19 and its
response on polio vaccine supply

Develop long-term polio vaccine
supply plans, and collaborate
with suppliers, IVB and WHE
on contingency planning andcoordination

bOPV

bOPV = bivalent oral poliovirus; COVID-19 = coronavirus disease; GS = global stockpile; IVB = Immunization, Vaccines and Biologicals; nOPV2 = novel oral polio vaccine type2; nOPV2 WG = novel oral polio vaccine type 2 Working Group; OPV = oral polio vaccine; OPV2 = oral polio vaccine type 2; SIA = supplementary immunization activity; VSTT =Vaccine Supply Task Team; WHE = WHO Health Emergencies Programme.

51

Polio Eradication Strategy 2022–2026: Delivering on a promise

Table E3. Risks to the nOPV2 deployment (as of the second quarter of 2021)
Risk category

Description

Likelihood

Potential impact

SafetyInsufficiently low seeding rate from nOPV2

Low

High

AEFI/AESI clusters

Low

High

Effectiveness (vaccine)

Poor effectiveness in interrupting
outbreaks

Low

MediumEffectiveness (delivery)

Inadequate campaign quality/ speed/
scope

Medium-highHigh

Vaccine supply

Production issues

Medium

High

Stockpile funding shortage

MediumHigh

Loss of vaccine (e.g. shelf life)

Low

MediumReluctance to use nOPV2 bygovernments;

Low-medium

High

Government acceptanceor readinessInability to achieve readiness to deploy
nOPV2
Community acceptance• Rejection of nOPV2 specifically(e.g. apprehensions with “genetic
modifications”, expedited vaccine
without PQ, new vaccine)• Reaction to real or perceived AEFI
• Collateral impact to nOPV2 confidence
due to COVID-19 vaccines, etc.
• Widespread misinformation andrumours on immunization broadly or
nOPV2 specificallyMediumHigh

Funding

Loss of donor confidence or funding incase of unsuccessful nOPV2 rollout

MediumHigh

Epidemiology

Massive co-circulation of poliovirus types
1 and 2MediumMediumRe-established endemicity of cVDPV2 in
multiple regions

Low

High

Suspended or revoked EUL
recommendation for nOPV2

Low

High

Non-PQ of nOPV2 because of safety or
efficacy signals in field use and clinical
trials or other data issues

Low

High

Regulatory

AEFI = adverse event following immunization; AESI = adverse event of special interest; COVID-19 = coronavirus disease; cVDPV2 = circulating vaccine-derived poliovirus type 2;
EUL = Emergency Use Listing; nOPV2 = novel oral polio vaccine type 2; PQ = prequalification.

52© WHO Pakistan

Annex E. Risks

53

ANNEX F. STRATEGY OBJECTIVES AND
KEY PERFORMANCE INDICATORS
Polio Eradication Strategy 2022–2026
Table F1. Create urgency and accountability through advocacy to generate greater
political will
Outcomes

KPIs

1.1 Heightened government
ownership in the form ofstatements and demonstration ofpolitical commitment

1.1.1 % of countries with new detection of poliovirus that declare a national publichealth emergency within one week of outbreak confirmation
1.1.2 % of previously inaccessible districts made accessible through appropriate
negotiation/agreements
1.1.3 At least two meetings of the national task force on polio eradication (chairedby the head of state) convened each year to review progress and address
challenges

1.2 Qualified staff in place to act
swiftly and in the right localities
in endemic and outbreak/at-riskcountries

1.2.1 % of medical officer and vaccination staff positions that remain vacant forthree or more months in polio high-risk districts

1.3 Greater domestic financial
contributions towards the polio
eradication programme

1.3.1 % of outbreak countries contributing domestic resources to outbreak
response aggregated by income profile

1.2.2 A review by provincial task forces (chaired by provincial chief secretaries,
governors, health ministers or provincial health directors) of the number of missed
children and the quality of operations after each mass vaccination campaign inthe province, with corrective actions

Table F2. Generate vaccine acceptance through context-adapted community engagement
Outcomes

KPIs

2.1 Increased campaign
awareness in all settings
conducting SIAs

2.1.1 % of all OPV SIAs showing evidence that campaign awareness was >90% of
all households (based on ICM and/or LQAS)

2.2 Increased community
participation in SIAs in priority
subnational areas (as per
NEAPs) in the endemic countries

2.2.1 % of female vaccinators per SIA in priority subnational areas in compliancewith GPEI PSEA and safeguarding measures

2.3 Increased use of innovative
approaches to improve
community engagement(including social and behaviourchange research, analytics andcampaign design)

2.3.1 Qualitative demonstration of the use of locally designed and implemented
solutions informed by gender analysis to improve community engagement in polio
and essential immunization campaigns

2.2.2 % decrease of missed children in priority subnational areas in endemic
countries

ICM = intra-campaign monitoring; LQAS = lot quality assurance sampling; NEAP = National Emergency Action Plan; OPV = oral polio vaccine; PSEA = protection from sexual
exploitation and abuse; SIA = supplementary immunization activity.

54Annex F. Strategy objectives and key performance indicators

Table F3. Expedite progress towards eradicating polio and reducing zero-dose children throughexpanded integration efforts and unified partnerships
Outcomes

KPIs

3.1 Package of integrated
services, tailored to community
context, delivered with a genderlens in targeted geographies(as per NEAPs) in the endemic
countries

3.1.1 % of integrated service initiatives that are designed and implemented in agender-responsive way

3.2 Alignment between polio and 3.2.1 % of polio priority subnational geographies where joint or collaborative
immunization resulting in HSS
investment is taking place by Gavi and the GPEI
and EPI investments reflecting
3.2.2 % increase of VPD SIAs that co-deliver bOPV*
polio programme strategic*in endemic settings: co-delivery of bOPV with VPD campaigns in addition to polio SIAs; in non-endemic settings: coobjectives, and polio contributing delivery of bOPV with VPD campaigns instead of stand-alone OPV SIAs
to IA2030 and country
immunization goals reducing thenumber of zero-dose children
3.3 Continued support to broader 3.3.1 Increasing the amount to PHC investments directed towards polio high-risk
global and national publicareas in endemic and outbreak/at-risk countries
health initiatives as a pathway
3.3.2 Continue to track polio HR contributions towards COVID-19 response
towards a successful programmetransitionbOPV = bivalent oral polio vaccine; COVID-19 = coronavirus disease; EPI = Expanded Programme on Immunization; HR = human resources; HSS = health system strengthening;
IA2030 = Immunization Agenda 2030; NEAP = National Emergency Action Plan; OPV = oral polio vaccine; PHC = primary health care; SIA = supplementary immunization activity;
VPD = vaccine-preventable disease.

Table F4. Improve frontline success through changes to campaign and outbreak response operations
Outcomes

KPIs

4.1 Improved campaign quality,
4.1.1 % of campaigns for which microplans were developed via integrated
particularly to reduce persistently planning workshops (inclusive of EPI, MNCAH, communication and GIS) in a
missed children in SIAs
gender-responsive way
4.1.2 No. of previously missed children (including those in inaccessible areas)
subsequently vaccinated per quarter
4.1.3 % of all OPV SIAs showing evidence of sex-disaggregated and agedisaggregated coverage ≥90% (based on LQAS and/or ICM)
4.1.4 % of outbreaks closed in two rounds and a mop-up
4.2 Timely outbreakpreparedness and response

4.2.1 Average no. of days between outbreak confirmation and onset of the first
SIA
4.2.2 % of funds available at a district level 72 hours prior to the campaign start

4.3 Successful and timely nOPV2 4.3.1 % of target countries that meet the requirements for nOPV2 usage
rollout
4.3.2 No. of countries successfully rolling out nOPV2 according to the definedroadmapbOPV = bivalent oral polio vaccine; EPI = Expanded Programme on Immunization; GIS = geographic information system; ICM = intra-campaign monitoring; LQAS = lot quality
assurance sampling; MNCAH = maternal, newborn, child and adolescent health; nOPV2 = novel oral polio vaccine type 2; OPV = oral polio vaccine; SIA = supplementary
immunization activity.

55

Polio Eradication Strategy 2022–2026: Delivering on a promise

Table F5. Improve detection and response through sensitive surveillance and containment
Outcomes

KPIs

5.1 Consistent global
implementation of surveillance
standards, with a focus on poliopriority districts

5.1.1 % of districts achieving NPAFP rate of >2/100 000
5.1.2 % of ES sites meeting a sensitivity threshold of at least 50% of samples
positive for enterovirus over six months

5.2 Increased speed of detection 5.2.1 % of cases with adequate stool sample collection disaggregated by sex
and precision of the surveillance (target: 80% of cases)
system
5.2.2 % of WPV and VDPVs reported within 35 days of onset for AFP cases or ES
sample collection
AFP = acute flaccid paralysis; ES = essential immunization; NPAFP = non-polio acute flaccid paralysis; VDPV = vaccine-derived poliovirus; WPV = wild poliovirus.

Gender Equality Strategy 2019–2023
Table F6. Expected Gender Equality Strategy results and key performance indicators
Expected results
1

2

The GPEI designs andimplements gender-responsive
programming and applies
a gender perspective in its
interventions.

The GPEI leadership, structures andsystems support gender-responsive
programming and gender-sensitive
approaches.

• % of GPEI interventions thatare informed by genderanalysis and that collect andanalyse sex-disaggregateddata (including technicaldocuments, donor reports,
NEAPs, SOP guidelines,
TAG recommendations,communications and C4D
interventions)• % of the GPEI 5-year budget
allocation to gender mainstreaming
including HR, training and genderanalysis at the HQ and country
levels• Existence of a policy on PSEA andsafeguarding measures, and aworkplan to implement the policy;
staff member awareness of theexistence of the policy on PSEA/
safeguarding and their appraisal of
its effectiveness (% at baseline andafter 3-5 years through a survey)• % of staff trained and reporting
increased knowledge levels,
resulting in applying a gender
perspective to their work

3
The GPEI is closer to gender parity
and increases women’s meaningful
participation and agency at all levels of
the partnership.

Monitored through the following KPIs
• No. of women in decision-making
roles at the HQ, regional and country
levels out of total no. of women(disaggregated by level, through abaseline HR analysis and after 3-5
years, including GPEI management,
advisory and monitoring groups)• Perceptions of women and men
in the GPEI on gender equality
in decision-making (baseline
survey and after 3-5 years – staff,
governments and GPEI partners)

C4D = Communication for development; HQ = headquarters; HR = human resources; NEAP = National Emergency Action Plan; PSEA = protection from sexual exploitation andabuse; SOP = standard operating procedure; TAG = Technical Advisory Group.

56Annex F. Strategy objectives and key performance indicators

The Gender Equality Strategy 2019–2023 is a stand-alone strategy that is linked to and supports the
Polio Eradication Strategy. On the path to eradication, gender plays an essential role. A gendered lens, whenapplied across the GPEI and at all levels, improves programme performance and increases impact (see Fig. F1).
The Polio Eradication Strategy and Gender Equality Strategy are both overseen by the GPEI SC and have beenendorsed by the POB.

Fig. F1. The alignment of the Gender Equality Strategy and Polio Eradication Strategy

Gender Equality
Strategy outputs

Polio Eradication
Strategy objectives

Systematic integration of genderaspects in programming

1

Systematic collection and analysis ofsex- and age-disaggregated data anduse of gender-sensitive indicators

2

Gender-sensitive communications
and C4D interventions

3

Commitment of senior leadershipto cultural change and to PSEA

4

Capacity-building to GPEI staff ongender mainstreaming and PSEA

5

Quotas implemented and progress towards
gender parity staffing made at all levels

6

Create urgency andaccountability through advocacy
to generate greater political will.

Generate vaccine acceptancethrough context-adapted
community engagement.

GENDER
LENS

Expedite progress throughexpanded integration efforts
and unified partnerships.

Improve frontline success throughchanges to campaign operations.

Improve detection and response
through sensitive surveillance.

C4D = communication for development; PSEA = protection from sexual exploitation and abuse.
Source: WHO.

57

ANNEX G. nOPV2 CONTINGENCY
PLANNING
The successful deployment of nOPV2 will depend on a wide variety of factors, including the properties of thevaccine, the quality of polio immunization activities that will deliver it, community acceptance, financing andvaccine supply, among other factors (see Annex E for operational risks). Each factor can be influenced by one orseveral risks that individually or cumulatively may affect nOPV2’s impact and overall polio eradication.
The GPEI has considered a range of potential scenarios with nOPV2 rollout, the critical decisions required toaddress these scenarios and their possible consequences for polio eradication (see Fig. G1).
The primary scenarios have been defined as follows:•

Current approach: nOPV2 will be rolled out as countries meet criteria for readiness. If data from the fieldcontinue to assess nOPV2 as favourable, mOPV2 and tOPV will be phased out with some supply options
maintained until prequalification and full licensure of nOPV2.

•

Parallel option: If the continuous monitoring of nOPV2 use indicates major issues around the vaccine safetyor heightened risk of VDPV2 emergences consequent to its use (leading to changes in its EUL or projected
prequalification status), the programme will explore the feasibility of developing backup novel OPV candidates
and operationalizing use as soon as possible.

•

Approach B: If major issues cannot be resolved and the programme must move away from nOPV2, either
mOPV2 or tOPV will be used in outbreak response. An independent monitoring board would assess on atwice-yearly basis the feasibility of Approach B to achieve cVDPV2 interruption.

•

Approach C: If mOPV2 or tOPV use in outbreak response fails to control outbreaks or if there is a majorchange in the epidemiology, such as co-circulation of different strains or endemicity of cVDPV2, theprogramme will move to reintroduce Sabin OPV2 into preventive and essential immunization, effectively“reversing the switch”. According to the situation, the programme may continue responding to cVDPV2
outbreaks using mOPV2 or tOPV in SIAs or entirely rely on essential immunization to keep the disease burden
at low levels.

The programme has also considered vaccine use under an essential immunization contingency plan, with thegoal of reducing the rate of paralysis due to poliovirus while also maintaining an opportunity to resume thepursuit of eradication pending developments such as new vaccines suitable for the endgame. Four options wereidentified (IPV and OPV; double-mutant labile toxin (dmLT) adjuvanted IPV only; stand-alone or combination IPV
only; and OPV only) and the final decision will ultimately depend upon the epidemiological situation, as well as
the capacity for campaigns, development and production timelines and price structures, the maintenance ofstockpiles for countries at risk due to immunization gaps, and future ongoing risks of VDPVs and VAPP if the GPEI
must consider a long-term control strategy.

nOPV2 rollout and contingency planning
Optimal vaccine choice should be determined based on the existing and prevailing local epidemiological andvirologic reality, to ensure circulating serotypes can be most effectively addressed for interruption. This includes
the rapid rollout and use of nOPV2 in response to cVDPV2 circulation, where appropriate.
Ensuring that the pivotal decisions influencing nOPV2 use are adequately defined, including the geographic
scope and mode of administration, will be critical and will need to be supported by a relevant communication
strategy (including crisis communications), based on the mapping of potential scenarios and the identification ofpivotal decision points.

58

Annex G. nOPV2 contingency planning

Fig. G1. Flowchart of key decisions and potential outcomes for novel OPV rollout
Current(beginning of 2021)~18–24 months(mid/late 2022)

Continuous
monitoring of nOPV2 safety, effectivenessin OBR

Upon PQ, consider expanded nOPV2
use (e.g., preventive campaigns)

2

mOPV2 / tOPV:
fails to control
outbreaks^

3

nOPV2: backup
option fails safety,
effectiveness,regulatory milestones

Duringmonitoring, end
nOPV2 use if
serious signal;
return toApproach A if
resolved

Approach B:
mOPV2 / tOPV in OBR(only viable pending otheroperations improvements)

At least twice-yearly independent
monitoring of path viability
2

Approach C:
Reverse the ‘Switch’(Sabin OPV2 in OBR,
preventive, and EI)

Ongoingrisks /
PossibledelaysIn Parallel:
Explore backup nOPV2 option

Delayed cVDPV2Interruption:
Phase out mOPV2 andreport last cVDPV2 isolateby 2024–2025

EI
Contingency
3

Repeat new
vaccine rollout

Contingency plan

1

cVDPV2 Interruption:
Phase out mOPV2 by 2022
Last cVDPV2 isolate by 2023

1

Pivotal decisionsnOPV2: seeding, no
PQ, fails to control
outbreak^2025+

Base case

Current Approach A: nOPV2 (phasing out
mOPV2 / tOPV) in OBR**

2023–2025

DelayedcVDPV2
Interruption:
last isolate by2030+• Vaccine supply (production / financing): ongoing challenge that may result in ~1 year delay in overall timelines• Operational: after distinguishing nOPV2 vs operational failure; operational improvements prioritized for all approaches• Community acceptance / engagement: increased community hesitancy around nOPV2 could hinder execution• Epidemiology: ^if we see massive co-circulation or endemicity of VDPV2, need to re-evaluate eradication goalposts• Routine Immunization: IPV use in EI maintained in Approaches A and B. Approach C may include modifications to EI vaccine choice.

Passes pivotal decision point?

Yes

No

Note: **Potential to expand definition and scope of OBR

cVDPV2 = circulating vaccine-derived poliovirus type 2; EI = essential immunization; mOPV2 = monovalent oral polio vaccine type 2; nOPV2 = novel oral polio vaccine type 2;
OBR = outbreak response; PQ = prequalification; tOPV = trivalent oral polio vaccine.
Source: WHO.

59

ANNEX H. MANAGEMENT REVIEWIn July 2020, following a governance review, the GPEI launched a comprehensive review of internal and externalmanagement groups that report to the SC to ensure strategic alignment, streamlined operations and successful
execution of the Polio Eradication Strategy 2022–2026. This management review was conducted independently
by Camber Collective from September 2020 to January 2021 to ensure a confidential and objective review.
The management review involved three phases (see Fig. H1) and culminated in highly collaborative andextensive engagement with the SC to design and refine changes to the GPEI structure and ensure the alignmentand shared commitment to proposed recommendations.

Fig. H1. GPEI management review process, 2020–2021

2

1
Discovery

Assessment• Review and clarify preliminary findings from thegovernance review and prior stakeholder engagementin the parallel polio strategy process• Conduct a survey across all groups seeking
individual input on areas of inefficiency that canbe streamlined, capability gaps to be filled, andopportunities to make decision-making within andacross groups more accurate and effective• Utilize survey findings to engage in individualinterviews to specifically characterize points ofinefficiency• Review current task team structures and terms ofreference to identify initial hypotheses on points of
misalignment and inefficiency• Identify individuals to target for solo interviews andsurvey participation at the ensuing assessment stage

3
Collaborative design and refinement
Camber:SC:• Design a proposed future state organizational
structure based on assessment findings• Provide iterative feedback on the design• Approve and commit to final design andproposed terms of reference• Oversee the implementation of changes tostructure and operating model or terms ofreference• Revise and iterate the structure based on SC
input and decisions

SC = Strategy Committee
Source: WHO.

Findings
The assessment phase gathered stakeholder perspectives via a survey of over 100 unique respondents anddirect interviews with over 35 individuals from the SC, management groups, task teams, partner agencies andexternal donors.
The assessment found that the GPEI structure required change to become fit for purpose and to effectively
deliver on the current strategy. A key theme raised in relation to the emerging strategy was the need to engage
regionally in more context-specific and culturally responsive ways. To support the required change within thepartnership, imperatives for change were identified across three primary categories: role clarity, decision-making
and accountability (see Fig. H2).
While these areas of change became the primary objectives of the recommended structural changes, theassessment also acknowledged several foundational issues that require more concerted focus, deeper
understanding and ongoing attention and adjustments by the partner agencies. These issues include:•

Authority: Given that the GPEI is not a formal legal entity, individual stakeholders do not have the authority
to compel the action of others. This more fundamental condition of the partnership is further challenged bydecentralized partner agencies that complicate the programme’s ability to coordinate country- and regionallevel activities at the level of the SC and the POB.

•

Agility: The way that partner agency resource commitments are structured makes it difficult to shift allocations
or to penalize or replace underperforming staff.

•

Trust: The assessment found areas where trust between partners and with external stakeholders is strained,
particularly by a perception that individual agency interests have at times been placed ahead of the GPEI
as a whole. This trust deficit will need to be remedied to operate effectively and achieve solid footing for theeradication effort.

60Annex H. Management review

Fig. H2. Imperatives for changeRole clarity
Insufficient specificity on roles and responsibilities of individuals, management groups, and management levels limits theircollective and individual achievement of effectiveness and efficiency
The intended division of responsibilities between the global, regional and country-level has not beenadequately articulated, nor have the respective roles of partners within groups
There is wide variation in how the purposeand mandate of many management groups
are understood, even among group members
themselves.

Decision-making
Suboptimal information flow, teamcomposition and decision-making processes
limit is the partnership’s effectivenessThe perception is that country-level
perspectives and realities should carry
more weight in both strategic andoperational decision-making.

Several management groups play
partially overlapping roles, leading toprogramme inefficiencies and confusion on
boundaries of responsibility.
Role clarity

Foundational
issues
Decisionmaking

Accountability

Accountability
The partnership’s limited ability to measuresuccess and incentivize progress is a barrier totimely polio eradication.
While the programme goal of polio
eradication is clear, there is no alignmenton the identification and prioritization ofintermediate outcomes to get there.

Multiple, complex layers of consensus-based
decision-making significantly hinder the quality andspeed of response to the public health emergency.

The lack of performance measures, incentives, andpenalties for management and advisory groups is seen
as an impediment to programmatic improvement.

Many groups would welcome the addition of representatives
and overlooked expertise from outside the core partner
agencies to help raise decision-making quality

There is a significant trust deficit among partners thatpermeates all managerial and advisory groups.

Source: WHO.

Recommendations
Based on the assessment’s findings, the GPEI’s structure was revised and updated to help the partnershipbecome more fit for purpose in delivering this strategy on the path towards global eradication (see Fig. H3). In
addition to rechartering all management groups with consistent terms of reference in alignment with the revised
strategy and the core objectives of increasing accountability, role clarity and decision-making effectiveness,changes are already under way to the GPEI’s organizational structure across the global and regional levels.
Key changes are focused on:
•

•

•
•
•

establishing and realigning regional structures to confer greater authority to and strengthen accountability
with country programmes – specifically, the Outbreak Response & Preparedness Group and the Endemics
hub serve to bridge regional response teams with global systems, providing consistent guidance and support
while minimizing points of contact and friction to support greater campaign agility and elevate the role ofcommunity input and engagement in shaping campaign approaches;
expanding the stakeholders engaged in and consulted by senior decision-making groups, including therevision of the POB and SC to include one donor representative in order to be more directly responsive todonor input;
establishing a new Executive Management Unit to support operational accountability for global programme
support and regional operations teams, enabling the SC to focus more fully on strategic imperatives;consolidating teams to promote efficiency and shifting global functions to the regional level within terms ofreference where they can better support targeted response activities; andestablishing new global programme support groups, where necessary, such as political advocacy groups
coordinating efforts across the strategy to build political will and government ownership for polio eradication.

61

ANNEX I. GENDER MAINSTREAMING
Fig. I1. Gender Equality Strategy vision and logframe
OVERALL GOALSIMPACT

GPEI interventions, guidelines, strategies
and policies systematically integrate genderconsiderations and address genderequality, equity and women’s equal
participation at all levels.

Increased number of girls
and boys reached with
polio vaccines to support
the achievement of apolio-free world.

INPUTS

ACTIVITIESOUTPUTSOUTCOMES/RESULTS

Gender responsive programming

Organizational and cultural changes

Result 1

Result 2

Result 3

The GPEI designs and implements
gender-responsive programming and applies agender perspective into its interventions.

GPEI leadership, structuresand systems support
gender-responsive
programming andgender-sensitive
approaches.

The GPEI is closer togender parity andincreases women’s
meaningful
participation andagency at all levels of
the partnership.

1. Systemic
integration ofgender aspects
in programming

1. Gender
analysis andprojectmanagement

2. Systemiccollection andanalysis of
disaggregateddata and use ofgender-sensitive
indicators

3. Gendersensitive
communications
and C4D
interventions

2. Sex- andage-disaggrega
ted data andgender-sensitive
indicators

3. Advocacy
andcommunication

Technical expertiseon gender

External consultant forgender analysis andgender budget analysis

4. Seniorleadership iscommitted to
cultural change
and to PSEA

4. Seniorleadershipcommitment

5. Provided
capacity building
to GPEI staff ongendermainstreaming
and PSEA

5. Training andcapacitybuilding

External consultant
for gender training

6. Quotas
implemented
and progress
towards gender
parity in staffing
at all levels.

6. Human
resources andgender parity

Preconditions
andassumptions• Sufficient humanresource
allocations
dedicated togender expertise• Adequate
financialresources for
programmatic andinstitutional
gendermainstreaming• Senior
management
ownership andleadership on
gendermainstreaming• Strong global,
regional and local
partnerships• Staff and partners
have the capacity
and willingness toaddress gender
equity issues.

Financialresources

C4D = communication for development; PSEA = protection from sexual exploitation and abuse.
Source: Gender Equality Strategy 2019–2023.

Table I1. Additional gender metrics
Area

Indicators reported through sex-disaggregated data

Gender analysis andmainstreaming• No. of gender-sensitive or gender-specific indicators developed and consistently
monitored• No. of clinical research studies and resulting publications reporting sex-disaggregateddata and applying sex and gender equity in research (SAGER) guidelines38

Area

Indicators reported through human resource data

Women’s
engagement,
equitable recruitment
and protection fromsexual exploitation
and abuse

•
•
•
•
•

No. of GPEI advisory and oversight groups reaching gender parity (baseline 1/16)
No. of job descriptions reviewed with a gender lens% of selection panels with both women and men% of selection panels with a gender focal point presence% of job interviews with gender competencies tested

Training and capacity- • No. of implemented gender trainings offered to staff
building• % of staff that take a gender training course
Area

Indicators reported through financial data

Adequate financial
resources

•
•
•
•
•
•

% of funding allocated to gender technical expertise% of funding allocated to human resource practices in hiring more women% of funding allocated to conducting a gender analysis% of funds to implement training and capacity-building activities on gender% of funding allocated to improve data metrics% of countries that submit a budget request with a dedicated funding request for gender

Heidari S, Babor TF, De Castro P,Tort S, Curno M. Sex and gender equity in research: rationale for the SAGER guidelines and recommended use. Res Integr Peer Rev 1. 2016;2(https://doi.org/10.1186/s41073-016-0007-6, accessed 19 June 2021).

38 

62

2024

2025

2026

Antiviral drugs4 and monoclonal antibodies

Need-based and ongoingnOPV2 for programmatic use, enhanced safety monitoring during initial use under EUL
nOPV2 candidate strains for clinical researchnOPV1 and 3 for programmatic use

IPV from new developers

2023

nOPV1 and 3 candidate strains for clinical research

Clinical study data

2022

Need-based and ongoing

Mucosal immunity assays

Use of safer strain viruses for serology

Enhanced environmental surveillance methods

2021

Spread from release of WPV, VDPV, Sabin

Community spread of iVDPV viruses

VDPV emergence leading to cVDPV outbreaks

2027

2028

2029

2030+

High

Implementation need

• Driven by programme demands• Support containment by replacing Sabin viruses fordiagnostic assays• Improved detection and characterization in the field (RDT,NGS)• Effective risk estimates and response abilities (e.g. diseasemodelling)• Enhanced surveillance for iVDPV excretors• Effective treatment for iVDPV excretors• To assess population immunity in high-risk areas and after
introduction of new vaccines or schedules• Safer OPV strains for use in outbreak control• Affordable IPV supply for Gavi and LMIC market• Hexavalent vaccines• Sabin strain IPV and safer IPV production (further
attenuated Sabin strains, VLPs)• dmLT IPV, Microarray IPV patches• Optimized post-certification IPV immunization schedule for
IPV and fractional-dose IPV

Research goals

Low

Ongoing R&D1

Latest expected availability

Earliest expected availability

Source: WHO.

cVDPV = circulating vaccine-derived poliovirus; dmLT = double-mutant labile toxin; EUL = Emergency Use Listing; IPV = inactivated polio vaccine; iVDPV = immunodeficiency-associated vaccine-derived poliovirus; mRNA = messenger
ribonucleic acid; NGS = next generation sequencing; nOPV 1 & 3 = novel oral polio vaccine types 1 & 3; nOPV2 = novel oral polio vaccine type 2; OPV = oral polio vaccine; PID = primary immunodeficiency disorder; RDT = rapid diagnostic test;
VDPV = vaccine-derived poliovirus; VLP = virus-like particle; WPV = wild poliovirus.

Basicimmunology,
epidemiologicaland operational
research

Improved
diagnostic
laboratory
methods

Environmental
surveillance
research

Antiviral drug
development
and PID
surveillance

Monitoring andevaluation
throughseroprevalence
surveys

Geneticallystable OPV(nOPV)New IPVvaccines andenhancedvaccine delivery
technology

Clinical trials
to support
vaccination
schedule

Priority R&D
Areas3

Primary
risks2Endemic WPV circulation

1. R&D to introduce new products may not always be complete before implementationneed begins
2. Timeline of risks assumes current certification timeline; research will continue
regardless of certification timeline changes
3. Specific research projects that are listed are examples, not an exhaustive list
4. Earliest availability by way of emergency use authorization

ANNEX J. RESEARCH AND DEVELOPMENT

Fig. J1. R&D pipeline, 2021–2030+

63

Polio Eradication Strategy 2022–2026: Delivering on a promise

Table J1. Array of polio research areas and impact
S No.

Research area

Impact1

Basic immunology – humoral immunity, mucosal
immunity, duration of immunity, waning immunity,
effect of malnutrition and other variables inrelation to polio vaccine; many studies conducted
and ongoing

Helps understand the impact of vaccines and vaccination
on immunity against poliomyelitis; this knowledge has
driven and continues to drive the vaccination policy andthe choice of vaccines, and the policy of polio vaccination
for travellers was developed based on this knowledge

2Type-specific monovalent oral polio vaccines(mOPV1, mOPV2, mOPV3)

Higher per-dose efficacy helps wipe out the transmission
in several highly endemic areas; continued vaccine usefor outbreak response and part of the stockpile

3

Bivalent (types 1 and 3) OPV – trials, licensure,
WHO prequalification resulting in accelerated
development and use

Helps overcome alternating SIAs with mOPV1 andmOPV3 or tOPV, with significant savings and success;continues to be used widely

4

Accelerated development of genetically morestable nOPV2 for outbreak response

Developed at scale and at risk with EUL approval foroutbreak response use, based on phase II clinical andother key data

5

Safer production of IPV – Sabin IPV, further
attenuated S19 strains and more

Contribute to the GPEI IPV pool to overcome the shortfall
in supplies; may reduce containment requirements

6

Fractional dose (1/5th dose) IPV, fIPV
Used in many South-East Asian countries and someimmunogenicity well documented, recommended countries in the Americas; an antigen-sparing and costand adopted for use; intradermal injectionsaving option working well in the countries that adopted it
devices developed; one device WHO
prequalified and available for use in EI and fIPV
campaigns

7

Other antigen-sparing and affordable IPV
options, such as adjuvanted IPV, IPV withmucosal immunity, dmLT-IPV, under evaluation

Will help overcome the drawbacks of IPV, including highcost and that it does not provide mucosal immunity per se

8

Immunization schedules for now and the future –OPV-IPV combination or sequential schedules,
IPV only schedules to phase out Sabin OPV

bOPV-IPV schedules with full/fractional IPV dose(s)replaced tOPV schedules; IPV only schedules will cover
the OPV cessation era and later will maintain immunity

9

Non-infectious polio vaccines such as VLPs andmRNA vaccines

Could, if successful, be vaccines of choice, more so inthe post-certification era; could be manufactured outside
the containment requirements and are essential tomaintain polio eradication status

10

M&E through seroprevalence surveys in selected
high-risk areas

Helped managers to better understand the quality, impact
and challenges of the vaccination programme andovercome operational issues

11

Risk assessment of VAPP, VDPV and iVDPVHelped refine the vaccination policy and develop
guidelines for poliovirus surveillance in primary
immunodeficiency subjects

12

Genetic studies including phylogenetics andassociation with virus mutation

May help better understand the evolution of VDPVs

13

ES, safer and sensitive lab diagnostics, use ofpseudo viruses for mucosal assays, S19 andother new strains

Added to the knowledge about the duration of shedding
after the campaigns, faster laboratory results; will reducethe containment requirements and increase rates ofdetection
Continued ...

64

Annex J. Research and development

S No.

Research area

Impact14

Use of digital technology – innovations insurveillance and vaccination in security
compromised areas, remote estimation of target
population through satellite imaging

GIS mapping down to settlements and households
helped reduce the problem of missed pockets forincreased vaccinator reach15

Mobile phone data for microplanning, innovative
monitoring tools and practices for assessing SIA
coverage and quality

Vaccinator tracking, LQAS helped monitoring andprovided insight for improving operations

16

Operational research to enhance community
engagement, ensure gender equity, integrationof polio activities with other community levelservices

Ongoing pilots/research projects may help improve
operations and vaccine coverage in specific challenging
areas

17

Exploration of any new ideas/tools/innovative
approaches on demand

A continuous process to understand challenges andprovide solutions

bOPV = bivalent oral polio vaccine; dmLT = double-mutant labile toxin; EI = essential immunization; ES = environmental surveillance; EUL = Emergency Use Listing; fIPV =fractional inactivated polio vaccine; IPV = inactivated polio vaccine; iVDPV = immunodeficiency-associated vaccine-derived poliovirus; LQAS = lot quality assurance sampling;
M&E = monitoring and evaluation; mOPV1 = monovalent oral polio vaccine type 1; mOPV2 = monovalent oral polio vaccine type 2; mOPV3 = monovalent oral polio vaccine type3; mRNA = messenger ribonucleic acid; nOPV2 = novel oral polio vaccine type 2; OPV = oral polio vaccine; SIA = supplementary immunization activity; tOPV = trivalent oral polio
vaccine; VAPP = vaccine-associated paralytic poliomyelitis; VDPV = vaccine-derived poliovirus; VLP = virus-like particle.

65

ANNEX K. POLIO CONTAINMENT UPDATEKey progress and milestones(as of 15 March 2021)

Phase I
Fig. K1. Percentage of countries/territories with completed poliovirus inventories (total n=214)

Total

93%
82%
0%

20%

40%

60%

80%

PV Type 2(end 2016 target date)100%

PV Type 1 & 3(no current target date)

PV = poliovirus.
Source: WHO.

Phase II
National containment governance

NAC designation

Fig. K2. Progress towards the nomination of national authorities for containment
88%
100%
0%

20%

40%

60%

80%

100%

Global achievement(end 2018 target date)

Global target

Note: n =24

NAC = national authority for containment.
Source: WHO.

Number of countries indicating the intention to retain poliovirus type 2 materials = 24
Number of identified designated type 2 poliovirus-essential facilities: 74
NACs designated by December 2018: Target 100%
Certificate of Participation for PEF:
Certificate of Participation submitted by January 2020: Target 100%
Certificate of Participation awarded by March 2022: Target 100%

Fig. K3. Certificates of Participation submitted and awarded

Total

81%
62%
0%

20%

40%

60%

% CP submitted(target date Jan 2020)
80%

100%

Note: Expected n =74

CP = Certificate of Participation.
Source: WHO.

Country preparedness towards Interim Certificate of Containment (ICC)/CC (current GAPIII compliance)
Number of national lead auditors qualified by end 2021: Target 10
Status: 0 national auditors qualified in the GAPIIIICC submission
Number of ICC submitted by 24 countries by May 2022 (>70): Target 100%
Status: 0 ICC submitted

66% CP awarded(target date Mar 2022)© WHO Pakistan / Asad Zaidi

Annex K. Polio containment update67www.polioeradication.org