Sustaining Our

Commitment

World’s

Children T h e U S A I D P o l i o E r a d i c a t i o n I n i t i a t i v e

2001 Report

tothe
"I appeal to all parents both in African and Asian countries to know that the Global

Polio Eradication Initiative was created to eradicate this ugly disease, polio, from

attacking our infants. They should know that the initiative was created to serve as a

positive and possible means to eradicate polio from our society and throughout the

world ... Kudos to the U.S. Agency for International Development kick off campaign

for world wide polio eradication, the Voice of

America, other organizations, and millions of

volunteers around the world who are

engaged in the Polio Eradication

Initiative."

Mr. Barnabas Okoro

A self-employed agent to create

awareness of the eradication of polio

Imo State, Nigeria

November 28, 2001
II.

III.

I.

2001 Report 1

Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

The USAID Polio Eradication Initiative

The PEI Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Polio Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

PEI Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

2001: Achievements and Program Developments . . . . . . . . . . . . . . . . . . . . . . . . . 10

2002 and Beyond . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Progress Through Effective Partnerships

Strategies and Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

–Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

–Strengthening Health Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

–Supplemental Immunization Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

–AFP Surveillance and Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

–Information Collection and Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

The Global Picture and Regional Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

–Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

–South East Asia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

–Eastern Mediterranean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

–Europe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

–Western Pacific . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

–Americas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Challenges

–Reaching the “Unreached” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

–Ensuring the Supply of OPV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

–Improving Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

–Improving Routine Immunization Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

–Improving and Sustaining Health Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

–Working in Conflict Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

–Political and Financial Commitment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

–Virus Containment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

–The End of Immunizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Next Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Financial Annex: Funding Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Contents

USAID Polio Eradication Initiative

2001 Report
2001 Report 3

Acronyms and Abbreviations

AFP acute flaccid paralysis

AFRO Africa Regional Office (WHO)

AMRO Americas Regional Office (WHO) 

ANE Asia/Near East (USAID region)

BASICS Basic Support for Institutionalizing Child Survival

CDC U.S. Centers for Disease Control and Prevention

CHANGE Behavior Change Innovations

CORE Child Survival Collaboration and Resources

cVDPV circulating vaccine-derived poliovirus

DR Congo, DRC Democratic Republic of Congo

E&E Europe and Eurasia (USAID region)

EMRO Eastern Mediterranean Regional Office (WHO)

EPI Expanded Program on Immunization

EURO Europe Regional Office (WHO)

FY fiscal year

GAVI Global Alliance for Vaccines and Immunization

ICC interagency coordinating committee

INCLEN International Clinical Epidemiology Network

IPV inactivated polio vaccine

LABNET Global Polio Laboratory Network

LAC Latin America/Caribbean (USAID region)

MECACAR Middle East, Caucasus, and Central Asia Republics

MEDS Monitoring, Evaluation and Design Support 

NGO nongovernmental organization

NID national immunization day

OPV oral polio vaccine

PEI Polio Eradication Initiative

PHNIP Population, Health and Nutrition Information Project

PHR Partnerships for Health Reform 

PVO private voluntary organization

SEARO South East Asia Regional Office (WHO)

SNID subnational immunization day

UNICEF United Nations Children's Fund

USAID United States Agency for International Development

VOA/IBB Voice of America/International Broadcasting Bureau

VVM vaccine vial monitor

WHO World Health Organization

WPRO Western Pacific Regional Office (WHO)
2001 Report

5

The U.S. Agency for

International Development

(USAID) has allocated more

than $160 million to its Polio

Eradication Initiative (PEI)

since 1996. In 2001, USAID

programmed approximately $27

million for polio eradication,

making the United States one of

the leading bilateral donors in

the global eradication campaign. In the long term, USAID

sees its investment in polio

eradication as a way to help

build stronger systems for

immunization and other disease

control programs in developing

countries.

As the largest public health initiative in history, the campaign

to eradicate polio is a successful

public-private partnership. The

campaign’s partners include

Rotary International, the World

Health Organization (WHO),

the United Nations Children’s

Fund, the U.S. Centers for

Disease Control and

Prevention, USAID and other

bilateral donor agencies, national governments, the World

Bank, the United Nations

Foundation, the Bill & Melinda

Gates Foundation, the Aventis

Pasteur and De Beers companies, private voluntary

organizations, and nongovernmental organizations (NGOs). 

The eradication campaign has

prevented more than 4 million

cases of paralysis. When the

global eradication of polio is

certified and routine immunizations are no longer needed,

WHO estimates that the U.S.

government will save an estimated $230 million per year in

vaccine costs alone. Global savings from this effort could reach

$1.5 billion per year, money

that could be well spent on

other pressing health needs.

The post-certification era is

likely to have continuing costs,

but the savings will be significant.

This report documents the polio

eradication activities supported

by USAID in 2001. It also

reviews regional progress toward

the global eradication goal and

the remaining challenges to

eliminating polio from the

world.

Achievements in 2001

• The number of laboratoryconfirmed polio cases

declined from 2,971 in

2000 to 542* in 2001, an

80 percent reduction.

• The number of countries with wild poliovirus

dropped from 20 to 10.

• Synchronized multicountry national immunization days in 20 West

and Central African

countries, including

the Democratic

Republic of Congo

(DR Congo) and

Angola, reached more

than 96 million children.

• Two traditional poliovirus

reservoir countries,

Bangladesh and DR Congo,

did not record a single case in

2001.

• USAID health-related projects

with NGOs in India and

Angola were instrumental in

reaching children in high-risk

areas.

• All polio specimens were tested in an accredited laboratory.

Executive Summary

Photo: Ellyn Ogden/USAID

* All poliovirus data in this document are reported from WHO as of

April 17, 2002.
The USAID Polio Eradication Initiative 6

Continued Progress

Toward Eradication

• Since 1988, the number of

polio cases has declined by

more than 99 percent.

• Type 2 poliovirus has not

reappeared since 1999.

• Europe will soon become the

third (after the Americas and

Western Pacific) of WHO’s six

regions to be certified poliofree.

• 135 of WHO’s 147 laboratories that test and report on

polio have received accreditation. All countries are served

by an accredited laboratory.

• 122 countries now have

national task forces to address

virus containment and have

started planning and implementing containment

procedures.

Remaining Tasks 

and Challenges

USAID supports WHO’s goal of

global certification of polio

eradication by 2005. This will

require:

• Reaching all children with oral

polio vaccine (OPV). This is an

especially formidable task in

areas of conflict. 

• Maintaining the political, financial, and programmatic

commitments to improve routine immunization coverage,

eliminate outbreaks of vaccine-derived polio, and carry

on heightened surveillance.

Convincing governments to

maintain these commitments

will become more difficult as

fewer and fewer polio cases

appear. 

• Increasing the current level of

funding. WHO conservatively

estimates that present funding

commitments through 2005

fall $275 million short of

required amounts. Should

transmission extend beyond

2003, estimated resource

requirements could increase

by more than $150 million.

Planning for the post-certification era has already begun.

Efforts are underway to minimize the risk of reintroducing

the virus into populations and

to prevent circulating vaccinederived poliovirus (cVDPV)

from causing polio outbreaks.

The potential for cVDPV to

cause outbreaks exists as long

as OPV use continues. The

eradication of all poliomyelitis

disease thus requires the cessation of OPV use, which cannot

occur until surveillance systems

and a global infrastructure with

virus containment procedures

are fully in place. USAID is

therefore working with its “Polio

Partners” to support research,

outline scenarios for stopping

OPV use, and develop the most

appropriate and effective timeframe and strategy for safely

stopping polio immunizations.

Polio Eradication Progress: 1988-2001
2001 Report 7

In 1988, the United States

joined 165 other member

nations of the World Health

Assembly to adopt a global 

resolution to eradicate polio.

Through technical assistance

and financial support, USAID’s

Polio Eradication Initiative

(PEI) supports a variety of activities that are critical to the

success of this effort. Through

the PEI, the Agency supports

eradication activities that

enhance other disease control

and surveillance efforts and

strengthen the foundations of

national health care systems

that maintain ongoing childhood immunization programs

and other primary health care

services.

The PEI Strategy

After 10 years of significant

USAID support for polio eradication in its Latin America/

Caribbean (LAC) region,

USAID launched the PEI in

1996. The Initiative incorporated lessons learned from the

LAC region in its strategy in

Asia and Africa. These lessons

included the need for close collaboration with other donors;

the importance of having effective national and regional

interagency coordinating committees (ICCs); the value of

using specific indicators to

measure program effectiveness;

and the benefits of building

partnerships to harness the confidence, expertise, and

enthusiasm of all involved in

polio eradication.

Through the PEI, USAID funds

support national immunizations

days (NIDs) and other special

immunization campaigns that

supplement routine immunization services. Support includes

assistance for advocacy, communication, social mobilization,

microplanning, and the logistics

of “cold chain” delivery of oral

polio vaccine (OPV) under temperature-controlled conditions.

The PEI assists with improvements in acute flaccid paralysis

(AFP) surveillance, laboratory

accreditation, and research into

the best ways for supplemental

immunization campaigns to

reach children in hard-to-reach

populations or populations reluctant to accept immunization. 

I. The USAID Polio 

Eradication Initiative

Results Framework for the

USAID Polio Eradication Initiative
The USAID Polio Eradication Initiative 8

The PEI has five strategies

within its results framework:

• Building effective partnerships

• Strengthening health systems

• Supporting supplemental

immunization

• Improving AFP surveillance

and laboratory investigation

• Improving information collection and use of data

Building effective partnerships:

More and more countries have

ICCs that bring together

resources to implement polio

eradication activities. The ICCs

take a proactive approach to

identifying areas to be strengthened and targeting resources to

these areas. Through this effort

at coordination, USAID has

gained recognition as a leader 

in providing technical expertise

and facilitating collaborative

activities.

Strengthening health systems:

USAID supports activities to

enhance national capacity to

provide polio immunizations

through high-quality routine

and supplemental immunization

systems. This support includes

training, supervision, logistics,

planning, cold-chain assessment

and management, and program

management for polio and other

childhood illnesses. USAID

seeks to use the skills, infrastructure, staff, and laboratory

capacity developed under polio

eradication to strengthen routine immunization and other

health care systems. Where 

feasible, USAID supports vitamin A supplementation and

immunizations against measles

during NIDs or through the

Expanded Program on

Immunization (EPI) of the

World Health Organization

(WHO).

Supporting supplemental immunization: USAID resources are

used to plan and implement

supplemental polio immunization campaigns. These activities

include NIDs, subnational

immunization days (SNIDs),

and targeted “mop up” activities

in high-risk areas to reach children still unvaccinated at the

end of larger campaigns or in

response to an identified case.

Improving AFP surveillance and

laboratory investigation:

Surveillance pinpoints where

and how wild poliovirus is circulating. Tests can determine

the strain and genetic sequencing of the virus, which tells

epidemiologists where the virus

originated. USAID strengthens

and expands existing surveillance systems to detect, report,

and respond to outbreaks of

polio and other infectious diseases. USAID also provides

substantial support to WHO’s

Global Polio Laboratory

Network, or LABNET. 

Improving information collection

and use of data: Improved surveillance reporting provides

timely data to program managers and donors. USAID

supports data and information

Progress and Plan to Eradicate Polio
9

• $4.8 million in support to the

Asia and Near East (ANE)

region

• $200,000 in support to the

Europe and Eurasia (E&E)

region

• $172,000 in support to the

LAC region

• More than $5 million in 

global funds to support international, regional, and country

eradication activities

collection to monitor, evaluate,

and continuously improve the

quality of polio eradication programs. Monitoring and

evaluation are supported by

USAID grants to WHO, the

United Nations Children’s Fund

(UNICEF), the International

Clinical Epidemiology Network

(INCLEN), and the Child

Survival Collaboration and

Resources (CORE) Group of

private voluntary organizations

(PVOs).

Polio Partners

The spearheading “Polio

Partners” are Rotary International, WHO, UNICEF, and the

U.S. Centers for Disease

Control and Prevention (CDC).

In 2001, the public-private 

partnership also included the

United Nations Foundation; 

the Bill & Melinda Gates

Foundation; the World Bank;

Aventis Pasteur; De Beers; the

Voice of America/International

Broadcasting Bureau (VOA/

IBB); the governments of

Australia, Canada, Denmark,

Japan, the Netherlands,

Sweden, and the United

Kingdom; PVOs; and nongovernmental organizations

(NGOs).

USAID and the Polio Partners

work with governments in

Africa, South and Southeast

Asia, the Near East, and Europe

and Eurasia to promote and

strengthen eradication efforts

and improve links with other

immunization services. The

Partners provide technical

advice and report on polio and

EPI coverage at country, regional, and international meetings.

They are also exploring ways to

align the polio eradication 

program infrastructure with

broader immunization and disease prevention programs. 

As the global campaign

approaches the benchmark of

interrupting wild poliovirus

transmission in many countries,

funding gaps remain. WHO

estimates that $1 billion in

external funding is needed for

global eradication activities

from 2002 through 2005, and

that a shortfall of $275 million

exists for country programs

alone. These are conservative

estimates, and actual funding

requirements could be much

higher. Through the PEI,

USAID will continue to work

with the Polio Partners to find

ways to close this gap with

funding from new donors and

the private sector.

PEI Funding

In fiscal year (FY) 1996, USAID

allocated $20 million for the

PEI. From FYs 1997 through

2000, an additional $25 million

for the Initiative was allocated

each year. The allocation grew

to over $27 million in FY 2001,

for a total allocation of more

than $160 million since PEI’s

inception. USAID Missions

have provided additional funds

from bilateral child survival

funds to support the PEI and

fill country-level gaps. USAID

assistance focuses on those

countries in Africa, South Asia,

the Near East, Europe, and

Eurasia where polio remains or

until recently was endemic. 

Most USAID resources directly

support country-level programs.

Regional and global activities

also receive assistance. In FY

2001, USAID’s contribution

was distributed as follows:

• $17 million in support to the

Africa region

2001 Report

Distribution of USAID PEI

Funding by Implementing

Organization, FY 2001* 

USAID PEI Funds

for FYs 1996-2001
(56), Afghanistan (11), and Niger (6). Four of the

10 priority countries – Afghanistan, Angola,

Somalia, and Sudan – are at war or experiencing

internal conflicts and thus pose especially difficult

obstacles to immunization campaigns.

Among other countries reporting poliovirus in

2001, Bulgaria and Georgia had “imported” cases

from other endemic countries. These cases

delayed WHO’s Europe region from being certified polio-free in 2001 as originally anticipated. 

2001: Achievements 

and Program Developments

Ten countries – Afghanistan, Angola, Egypt,

Ethiopia, India, Niger, Nigeria, Pakistan, Somalia,

and Sudan – reported wild poliovirus transmission

in 2001, down from 20 countries in 2000. These

countries are the focus of the final phase of polio

eradication. Five of these countries have reported

high-intensity indigenous transmission: India,

with 268* cases, Pakistan (116 cases), Nigeria

The USAID Polio Eradication Initiative 10

What Is Polio?

Polio is an infectious viral disease caused by the poliovirus. The virus is spread from person to person, usually through fecal contact. Transmission is most intense in densely populated areas with poor sanitation. In one

in 200 cases, the virus kills the nerve cells that activate the muscles. The dead nerve cells cannot be

replaced, and the result is usually lifelong paralysis or, in some cases, death.

“Silent” Infection. Polio infects silently and is difficult to recognize. More than 95 percent of cases occur

in children less than 5 years old. Although paralysis is the most visible sign of polio infection, it occurs in less

than 1 percent of all cases. Instead, most infected children have mild flulike symptoms or no symptoms at all.

Even these children are infectious, however, and more than 200 children can be silently infected before the

first visible case of paralysis emerges. This is why one case of paralysis is considered a sign of a polio outbreak. Polio is particularly difficult to recognize in infants and young children who are not yet walking.

Reporting and Surveillance. In some countries, families hesitate to bring a paralyzed child to a health

facility because they think nothing can be done or they prefer the advice of traditional healers. They may not

bring their children to a health facility for weeks or months, if at all.

Since two stool samples must be collected within 14 days of the

onset of paralysis to confirm poliovirus transmission, reporting

delays can delay responding to confirmed cases with supplemental

immunizations to protect other children and prevent further transmission. Polio programs also must guard against the tendency of

some governments not to acknowledge and report cases. A confirmed polio case should not be perceived as a program failure

but as a rallying point for an intensive, targeted response to curtail the outbreak.

Routine vs. Supplemental Immunization. Routine polio

immunization for infants, as recommended by WHO, consists of

a dose of OPV at birth and then at 6, 10, and 14 weeks of age.

In polio-endemic areas, supplemental immunizations are given to

every child under 5, regardless of prior immunization history. To

ensure each child receives a minimum of two doses per year, two

rounds of supplemental immunizations must be held annually for

at least three years, until no polio cases have been detected for

three consecutive years. High levels of routine immunization coverage

and surveillance then must continue in order to minimize the possibility

of polio reappearing. If routine immunization coverage drops, more

rounds of supplemental immunizations will be necessary to keep immunity levels high. In 1999, the World Health Assembly resolved that

supplemental immunizations be intensified by adding rounds in

endemic and recently endemic countries.

*All cases in this document are reported as of April 17, 2002. Photo: Neal Halsey
2001 Report 11

The region’s 51 countries have been free of

indigenous wild poliovirus for three years, and

regional certification is now expected in June

2002. The Dominican Republic, Haiti, and the

Philippines had outbreaks of circulating vaccinederived poliovirus (cVDPV), and Mauritania

reported cases of wild poliovirus of unknown origin. In Zambia, three imported cases of wild

poliovirus occurred in January 2002 in refugee

children whose family had migrated from Angola

in 2001.

According to WHO, more than 300

supplemental immunization days were

held worldwide in 2001. A record number of 575 million children in 94

countries received OPV through intensified supplemental immunization

activities. These included house-tohouse and child-to-child efforts, which

are the most intensive phase of polio

eradication. Between July and

September, 16 million children were

immunized during synchronized NIDs

in Angola, the Republic of Congo, the

Democratic Republic of Congo (DR

Congo), and Gabon. In October and

November, another 80 million children

were immunized during synchronized

NIDs in 16 West African countries.

Polio teams mapped cross-border

regions to cover each village and set up

immunization posts at border crossings.

They also immunized children in

refugee camps. Tens of thousands of

volunteers and health workers participated in these momentous child 

health events. 

In 2001, USAID’s PEI stepped up

efforts to help countries improve their

surveillance and laboratory investigation

by training and deploying communitylevel surveillance officers and supporting increased effectiveness, efficiency,

and accuracy in detecting suspected

AFP cases and analyzing stool samples.

The PEI is closely monitoring recently

endemic countries where surveillance

may remain weak, as well as countries

where routine immunization programs

and supplemental immunization activities are not keeping pace with local needs.

In addition, USAID’s Boost Immunization

Initiative continued to help immunization programs improve routine immunization coverage in

many countries, particularly in Africa. Through

the Global Alliance for Vaccines and Immunization (GAVI), USAID and other donors are building bridges from polio to other health programs in

order to strengthen the capacity developed for

polio eradication for use in other immunization

and disease control efforts.

2001 Confirmed Number 

of New Polio Cases*

2000 Confirmed Number 

of New Polio Cases*
2002 and Beyond

The coming years are critical.

Large numbers of vaccination

teams are needed to reach all

children under 5. Gaining and

maintaining access to every

child continues to be a major

challenge, especially in countries in conflict. Children

missed in previous vaccination

efforts can increase target population estimates by as much as

40 percent, with resource requirements increasing accordingly.

Routine immunization levels

need to be raised in many

African and South Asian countries to ensure that all children

are fully immunized by age 1

and that populations are protected against reintroduction of

the poliovirus. Keeping countries focused on certification is

proving to be a challenge in

countries with competing health

priorities and limited resources.

Surveillance is improving in

Asia and Africa, but many areas,

even non-endemic areas, still

need to focus on meeting and

maintaining global standards.

More surveillance officers and

higher-quality surveillance programs are needed in many

countries. The WHO laboratory

network must be fully functional and accredited to

identify and analyze

all cases.

The USAID Polio Eradication Initiative

In 2001, the continuing presence of cVDPV in the

Dominican Republic, Haiti, and

the Philippines underscored the

need for all countries, including

those that have been polio-free

for several years, to maintain

high immunization coverage

and ensure certification-standard surveillance. Surveillance

and research have confirmed

that it is possible for vaccine

virus to mutate back to virulence by circulating among

populations with low vaccination coverage. USAID-funded

research into people who carry

and excrete poliovirus and people with rare B-cell deficiencies

who shed poliovirus may clarify

the situation and help determine how and when polio

immunizations may be stopped.

Planning for the secure containment of laboratory specimens of

poliovirus will require more

intensive efforts, especially in

developed countries. The eradication of polio raises the threat

of poliovirus being released into

increasingly or fully susceptible

populations by accident or

through acts of biological warfare or bioterrorism. Compared

with smallpox and other infectious pathogens, polioviruses

are considered poor agents for

biological warfare because the

vast majority of infections

would not result in paralysis.

Release of poliovirus into a

highly susceptible population

would nonetheless cause great

public anxiety. Plans and budgets must be in place to control

outbreaks should they occur,

whether through a laboratory

accident or through bioterrorism. A stockpile of vaccine is

now considered a necessity in

the event of an emergency.

A boy in Ethiopia demonstrates how

he received OPV drops.

Photo: Richard Franco

Photo: Ellyn Ogden/USAID

12
2001 Report 13

This section highlights the 2001

activities and accomplishments

of USAID, the Polio Partners,

and other participating organizations in achieving five

objectives: building partnerships, strengthening systems,

supporting supplemental immunization, improving surveillance,

and improving information collection and use.

Strategies and Results:

Partnerships

Partnership activities in 2001

included:

• Programs of the CORE Group.

PVOs belonging to the CORE

Group, a network of 35 U.S.-

based PVOs that work in

USAID health and nutrition

projects, have established programs in the most hard-toreach places in Angola,

Bangladesh, India, Nepal, and

Uganda. CORE PVOs are represented on the national ICC

in all five countries. They help

with district-level planning and

training, monitoring and evaluation, social mobilization,

advocacy, and assistance to

families with paralyzed children. CORE Group PVOs

supplement USAID funding

with a matching contribution

of 25 percent, bringing additional resources to the

program. CORE launched

activities in DR Congo and

Ethiopia in 2001, applying lessons from other countries.

• WHO Support for Africa

NIDs. WHO’s Regional Office

for Africa helped 20 West and

Central African countries,

including the conflict countries of DR Congo and Angola,

conduct synchronized multicountry NIDs. The synchronized NIDS featured

cross-border activities between

countries and reached more

than 96 million children in an

extraordinary display of multinational cooperation and

coordination.

• WHO’s Operation MECACAR

Plus. In WHO’s Europe and

Eastern Mediterranean

regions, Operation Middle

East, Caucasus, and Central

Asia Republics (MECACAR)

Plus carried on the activities

of the former Operation

MECACAR. This coordinated

program of NIDs in 18 highrisk countries vaccinates up to

65 million children under age

5 each year.

• UNICEF. With USAID support, UNICEF procured

cold-chain equipment and provided other logistics and

communications support for

country-level operations.

These activities help to ensure

successful supplemental

immunization activities,

increase demand for immunization, and promote AFP

surveillance. UNICEF/India

provides funds to Rotary India

for social mobilization on

behalf of USAID.

• U.S.-Japan Cooperation.

Under the U.S.-Japan

Common Agenda for

Cooperation in a Global

Perspective, USAID and the

Government of Japan are

working together on behalf 

of the PEI. Japan Overseas

Cooperation Volunteers and

Peace Corps volunteers are

helping with communitylevel AFP surveillance in 

many countries.

II. Progress Through Effective

Partnerships

Vaccinators administer OPV during

Angola's 2001 NIDs campaign.

Photo: WHO

“In our effort to eradicate

this crippling disease, it is

crucial that every child be

immunized against polio, no

matter where they live. One

poliovirus infection threatens

all children who aren't protected – at the village level,

in the province, and in

neighboring countries.”

Dr. Jean-Marie Okwo-Bele

WHO Africa Region Office

February 11, 2002 
14 The USAID Polio Eradication Initiative

Strengthening 

Health Systems

In 2001, national

ICCs added GAVIsupported activities to

their agendas to

improve routine

immunizations. Coldchain equipment and

transportation funds

procured for polio

eradication increasingly are used in an

integrated manner to

enhance EPI activities. EPI services are

increasing their use

of polio program data

on zero-dose children

to identify high-risk

areas for other diseases. Lessons learned from

polio eradication about vaccine

forecasting and distribution

helps countries reduce vaccine

wastage and achieve more efficient resource management.

Innovations in service delivery

for polio immunizations (such

as the use of vaccine vial monitors that indicate if vaccine has

been damaged by heat exposure) can be used in routine

immunization programs.

Technical assistance for polio

eradication spills over to other

areas. In Africa, more than 150

international consultants and

320 national consultants were

recruited at a cost of $4 million

to help prepare polio NIDs

campaigns. Their technical

assistance in planning the disbursement of funds, importation of cold-chain equipment,

communications and logistics,

and administrative support also

help planning activities for

other health programs such as

Integrated Management of

Childhood Illness.

Communication activities to

promote polio immunizations

and surveillance strengthen the

overall capacity of health systems to mobilize communities

and promote other health

issues. USAID-supported programs play a key role in

expanding the broader use of

communication approaches,

particularly the promotion of

evidence-based, data-driven

strategy development. Data collected through case investigation and independent monitoring are used to fine-tune

communication and social

mobilization efforts. VOA/IBB,

WORLDNET Television, and

the CHANGE and BASICS II

projects have helped countries

improve community mobilization and outreach to isolated

communities. BASICS II has

also synthesized and distributed

the lessons learned from a fivecountry assessment of

communication strategies for

polio and other immunization

activities.

In 2001, VOA/IBB and

WORLDNET Television

expanded their coverage of polio

activities. Sixty-four reporters

traveled to 39 countries to publicize NIDs and explore barriers

hindering the eradication effort.

VOA/IBB’s 16 language services

produced more than 1,000 news

reports, stories, promotions, and

public service announcements.

In Africa, 24 television stations

broadcast a two-hour, four-part

series examining different elements of the polio eradication

effort. The series was also

broadcast via satellite. VOA/IBB

investigated polio eradication

efforts on both sides of the conflict in Sudan, traveling to

northern and southern Sudan

for the first time in 15 years.

Voice of America reporter interviews

polio eradication staff in India.

Photo: Shahnaz Aziz/VOA
identify children in their

respective areas. The Ministry

of Health used the information

in logistics planning for supplemental immunization

activities and to ensure that

adequate amounts of vaccine

were available.

• In India, CORE Group PVOs

helped reach Muslim families

in the high-risk state of Uttar

Pradesh. At the request of the

Ministry of Health, the PVOs

and their local partners provided support for social mobilization and marshalling volunteers to counsel Muslim

families who were resisting

immunizations for their children. In Calcutta, a local

NGO partner of a CORE PVO

was asked to cover slum wards

because of its outstanding

record of service. The high

quality of the volunteers’ work

led the health department to

assign them the task of crosschecking missed children

during mop-up efforts.

AFP Surveillance 

and Investigation

AFP surveillance and investigation at the community, facility,

and laboratory levels continued

to improve worldwide. PEI

assistance supported national

and local surveillance efforts

and expanding analysis to district and block levels.

USAID continued to support

WHO’s LABNET. WHO established LABNET to ensure that

stool specimens from AFP cases

undergo appropriate processing

for viral isolation. The laboratories confirm the presence or

absence of polio in collected

specimens and provide supporting data required for certification. Several laboratories

15

During the post-September 11

conflict in Afghanistan, VOA’s

Pashto and Dari language services expanded their coverage

with a comprehensive profile of

Afganistan's nationwide eradication effort. Finally, USAID

continued to support the Polio

Partners’ semiannual

Communications Partners meetings to share lessons learned

from polio eradication programs

worldwide.

Supplemental

Immunization Activities

In 2001, supplemental immunization activities were

conducted in 94 countries.

USAID staff traveled to many

priority countries to monitor the

quality and effectiveness of the

planning and implementation of

these activities and provide

rapid feedback and guidance.

Supplemental immunization

activities in 2001 used surveillance data, estimates of the

number of zero-dose children,

rapid assessment survey techniques, and reports from

monitors to further target highrisk areas. Programs made

better efforts at mapping local

areas and took greater care to

involve community religious

leaders and use vaccinators

from the community who speak

the local language. NGOs 

were often asked to take the

lead in communities that 

resist immunization.

Accomplishments in supplemental immunization activities

included the following:

• Angola conducted three

rounds of NIDs in all accessible areas and one SNID round

in high-risk areas. Social mobilization activities were marked

by collaboration among NGOs,

the private sector, churches,

and the Boy Scouts. Smallscale cross-border activities

took place in border areas with

DR Congo, the Republic of

Congo, and Zambia.

• In October, Nigeria conducted an immunization campaign

in 16 of the country’s 36

states to curb the incidence of

wild poliovirus transmission.

The last remaining focus of

intense transmission is in the

northern Nigeria/southern

Niger border region, where

wild poliovirus types 1 and 3

were isolated in 2001.

• CARE, one

of the CORE

PVOs operating in

Bangladesh,

identified

more than

41,500 zerodose children

during two

rounds of

NIDs and distributed the

list to other

partners so

they could

2001 Report

A vaccinator marks a boy's hand as he receives OPV

during 2001 NIDs in India.

Photo: Richard Franco
16 The USAID Polio Eradication Initiative

now are able to perform genetic

sequencing, which helps pinpoint a virus’ origin and determine if it is indigenous or

imported. LABNET has the

potential to be transferable to

other public health endeavors.

Many individual laboratories

have been transformed from small

research facilities

into state-of-the-art

public health laboratories that can

support national

health programs.

By the end of

2001, LABNET

was operational in

all six WHO

regions and comprised 84 national

laboratories, 40

subnational laboratories, 16 regional

reference laboratories, and seven global specialized laboratories. Of the 147

laboratories, 135 are fully

accredited, six are provisionally

accredited, and four are pending an accreditation review.

USAID assistance to the

accreditation process and review

visits has been essential to

upholding standards and maintaining quality practices

required for accurate certification of polio eradication.

Information Collection

and Use

USAID continued to work

closely with UNICEF and

WHO to support data collection, operations research,

communications evaluation, and

other information, education,

and communication activities.

For example:

• USAID continued to support

the implementation of surveys,

rapid assessments, and data

collection in nearly all countries receiving USAID

assistance.

• In Brazil, Ethiopia,

Guatemala, Haiti, Mexico,

Pakistan, and Zimbabwe, a

USAID-funded Johns Hopkins

University research project

continues to study the extent

and duration of poliovirus

shedding among immunodeficient children.

Non-Polio AFP Rate by WHO Region,

1996-2001*

Polio surveillance team in Ethiopia

follows up on suspected AFP cases.

Photo: Ellyn Ogden/USAID 
transmission occurred in

Bulgaria and Georgia as a result

of importation from northern

India. Zambia also had imported

cases in Angolan refugee children. Mauritania reported

poliovirus of uncertain origin.

The Philippines reported a

cVDPV outbreak, and the

Dominican Republic and Haiti

continued to report cases resulting from the 2000–2001

cVDPV outbreak.

Africa: Impressive Declines 

In 2001, 118 virologically confirmed cases of poliomyelitis

were reported, compared with

147 in 2000 and 246 in 1999.

The quality of AFP surveillance significantly improved.

No wild poliovirus was detected during 2001 in DR Congo.

At the end of November 2001,

only four countries in the

region were considered endemic. All polio network

laboratories are accredited.

NIDs received special emphasis

in Angola, Ethiopia, and

Nigeria, and will continue in

2002. SNIDs were conducted

mainly in countries of East and

Southern Africa, with all participating countries achieving at

least 80 percent coverage.

Some countries, however, chose

not to conduct supplemental

immunization activities, contrary to the Polio Partners’

technical recommendations. All

supplemental immunization

activities in polio-endemic

countries used the house-tohouse approach, with great

improvements in quality.

Synchronized NIDs with crossborder activities were conducted

in 16 West African countries.

During three rounds of synchronized NIDs in Angola, the

2001 Report 17

• In DR Congo, Mali,

Mozambique, Nigeria, and

Zambia, USAID-funded projects (BASICS II, CHANGE,

and Johns Hopkins University’s Population Communication Services) are working

with polio partners to improve

planning and monitoring and

evaluation. The projects are

also helping to guide regional

and national initiatives for

communication activities related to polio and routine

immunizations. These projects

increase advocacy for immunization, strengthen routine

immunization programs, and

establish and monitor community surveillance activities

using the Community

Surveillance Kit developed by

the CHANGE project.

• USAID supported WHO’s

polio eradication Web site

(http://www.polioeradication.org/)

and Polio News newsletter,

which has a global distribution

of 3,500. USAID also supported the EURO Polio Page

newsletter and weekly surveillance reports of WHO’s

Regional Office for Europe;

AFP weekly reports and the

Indian AFP Alert of the WHO

South East Asia Regional

Office; and monthly surveillance reports of the WHO

Africa Regional Office.

• The USAID-funded Partnerships for Health Reform

(PHR) published its study of

PEI’s impact on donor financing. PHR is about to complete

an analysis of the cost of phasing in injectable polio vaccine

for possible use in the posteradication era.

• The Population, Health and

Nutrition Information Project

(PHNIP) continued to serve as

USAID’s PEI Secretariat.

PHNIP documents and disseminates lessons learned,

maintains the polio and photography archives, and

produces Mission information

kits, the annual PEI report,

and other PEI materials.

• USAID’s Monitoring,

Evaluation and Design

Support (MEDS) project supported an external review of

the PEI. MEDS also coordinates the PEI International

Polio Observers.

• USAID’s Quality Assurance

Project is developing a tool to

validate laboratory containment procedures.

The Global Picture 

and Regional Highlights

The interruption of polio transmission is more than 99 percent

complete; only 10 endemic

countries remain. Five of these

are low-transmission countries

where polio transmission could

be interrupted by mid-2002 if

(in the case of Egypt and

Ethiopia) political commitment

to eradication is sustained, or

(in Angola, Somalia, and Sudan)

eradication efforts are able to

continue in areas of conflict.

Continued polio transmission 

in 2003 is probable in the hightransmission areas of India,

Pakistan/Afghanistan, and

Nigeria/Niger. In these areas,

high-density populations, high

birth rates, pockets of marginalized minority populations,

poor sanitation, and low routine

immunization coverage make 

it difficult to stop poliovirus

transmission.

Regardless of their certification

status, all six WHO regions

observed some form of polio in

2001. Instances of poliovirus
Republic of Congo, DR Congo,

and Gabon, 16.3 million children were vaccinated, 1.7

million receiving OPV for the

first time. In 2002, São Tomé

and Príncipe will join the group

of West African countries that

synchronize NIDs.

In East Africa, five countries participated in limited coordinated

cross-border activities. Since

January 2001, border districts in

Djibouti, Ethiopia, Sudan,

Kenya, and Somalia have shared

data about wild polioviruses and

surveillance indicators. These

activities will continue and

expand during 2002.

Polio eradication activities in

Africa’s areas of conflict made

progress but face continuing

challenges. Angola’s long military conflict has been the

greatest constraint to polio

eradication in the country and

continued to prevent uniform

OPV coverage in all areas. The

number of cases dropped from

53 in 2000 to one in 2001, but

polio cases among Angolan

refugee children in Zambia

highlight the country’s presence

as a continuing polio reservoir.

The DR Congo held NIDs in

July, August, and September,

reaching approximately 11 million children despite limited

access to some health zones

because of poor security. Even

with improved surveillance, no

polio cases were virologically

confirmed in 2001. The major

outstanding issue is the high

number of stools collected. The

DR Congo remains under close

observation because of poor

case identification and reporting

in various zones that are not

sufficiently covered. The program expects surveillance

quality to improve and increase

confidence.

18 The USAID Polio Eradication Initiative

The Africa region’s overriding

priority in 2002 will be to interrupt poliovirus transmission.

Emphasis will be placed on

improving the quality of NIDs

and surveillance in Angola,

Nigeria, and Niger; increasing

the quality of synchronized

NIDs in West and Central

Africa and the Greater Horn of

Africa countries; and improving

access to all children in countries in conflict. Countries in

East and Southern Africa must

pay increased attention to possible importations, cVDPV, and

maintaining certification-standard surveillance and high

levels of immunity.

South East Asia:

India Sole Remaining

Reservoir Country

WHO’s South East Asia region

accounted for half of the global

total of polio cases in 2001.

Recently endemic countries such

as Bangladesh reported no cases.

Virus circulation was limited to

India, where transmission of wild

poliovirus occurred in 63 districts, down from 89 in 2000.

The region’s 268 cases of wild

poliovirus were concentrated in

northern India’s Uttar Pradesh

and Bihar states. Across the

region, OPV delivery, surveillance, and laboratory capacity

are maintained at near certification standards. There are,

however, weaknesses in the ability of programs to reach all

children. Renewed emphasis will

be placed on training and mobilizing vaccinators and community leaders in supplemental

immunization activities.

In 2001, USAID grants to

WHO, UNICEF, and INCLEN

were used to strengthen partnerships, planning, surveillance,

“In DRC, Angola, Somalia –

and other countries where

there’s war – not only do you

need the vaccine, not only do

you need the campaign, but

you’ve got to try to get the

parties to agree to stop fighting, at least for that period of

time . . . The clock is ticking

and we cannot afford to fail

our children.” 

Carol Bellamy 

UNICEF Executive Director

July 5, 2001

Photo: C. McNab/WHO

President Joseph Kabila and Minister

of Health Mashako Mamba of the DR

Congo give OPV to children in

Kinshasa during the 2001 Central

Africa synchronized NIDs campaign. 
2001 Report 19

provincial levels and assisting

strategic planning, social mobilization, monitoring and evaluation, and supervision. Despite

these efforts, AFP performance

indicators declined in 2001,

mainly as a result of the country’s continuing political, social,

and economic turmoil (as well

as a declining motivation to

pursue polio eradication in view

of the absence of cases).

Indonesia is planning to conduct NIDs in the fall of 2002 to

reduce the number of susceptible children.

Eastern Mediterranean:

Moving Closer to

Eradication

In 2001, WHO’s Eastern

Mediterranean region had 140

laboratory-confirmed cases of

polio, all wild poliovirus.

Poliovirus transmission has

been interrupted in 18 of the

region’s 23 countries and is now

localized in five countries –

Afghanistan, Egypt, Pakistan,

Somalia, and Sudan.

laboratory, and immunization

systems; conduct NIDs and

mop-up campaigns; provide

training; improve social mobilization and information

collection; and provide countryspecific program support in

Bangladesh, India, Indonesia,

and Nepal. WHO’s South East

Asia Regional Office asserts

that USAID’s contributions to

polio eradication in the region

have been invaluable.

India continues to make

progress toward polio eradication. Although the number of

cases increased in 2001 to 268

from 265 in 2000, the geographic area of transmission

became more limited, as did the

genetic diversity of the virus –

fewer strains are circulating.

Several states with high-quality,

sensitive AFP surveillance have

emerged as polio-free with no

evidence of poliovirus transmission. The non-polio AFP rate in

2001 was 1.87 per 100,000

children under age 15. Ninetyfour percent of AFP cases were

investigated within 48 hours of

notification, well above the

global target of greater than 80

percent, and 99 percent of primary isolation results were

reported from national polio

laboratories within 28 days of

receipt. These data were consistently used to prioritize and

guide program activities, with

areas of highest risk being redefined and targeted appropriately.

The Indian government has

focused its efforts on implementing intensified supplemental immunization activities

to address persistent polio

transmission in Uttar Pradesh

and Bihar. These two states

reported 243 of the region’s 268

cases. Surveillance data indicate

that 83 percent of these cases

occurred among children less

than 24 months of age and of

those, 70 percent were from

Muslim communities. During

the low-transmission season,

preemptive mop-up activities

targeted 33 million children in

63 high-risk districts in these

states and West Bengal. These

campaigns were coordinated

with border districts in Nepal.

After further virus transmission

was detected, another 15 mopup activities targeted 47 million

children.

USAID support has been critical to the success of the

National Polio Surveillance

Project, the Indian Polio

Laboratory Network, intensified

activities in Uttar Pradesh and

Bihar, and technical assistance

for mop-up immunization campaigns. Rotary International’s

PolioPlus Program, WHO, and

CORE PVOs are other key players in India.

In Bangladesh, no polio cases

were detected in 2001. The

country’s outstanding progress

is a result of the government’s

implementation of the three

critical strategies for polio eradication – routine immunizations,

NIDs, and AFP surveillance.

The USAID-funded Immunization and Other Child Health

project, which began in June

1999, has made a significant

contribution to this success.

USAID also funds most of

WHO’s surveillance, laboratory,

and communication activities in

the country.

Indonesia has had no wild virus

isolated since 1995. USAID

supports technical assistance

from WHO that focuses on

strengthening management

capacity at the national and

A child with polio is fitted for a

brace at a health center in Pakistan.

Photo: M. Agboutwalla/Project HOPE
Polio eradication efforts in

Afghanistan have made

remarkable progress. The

intensity and geographic range

of wild poliovirus was substantially curtailed in 2001, despite

the country’s long borders with

Pakistan, a high-transmission country.

Afghanistan conducted

two fall rounds of NIDs

after the crisis of

September 11 and the

withdrawal of international staff from the

country. The postSeptember 11 hostilities

significantly disrupted

AFP surveillance in several regions as international and national

staff were evacuated or

relocated from surveillance and reporting sites and

U.N. flights for specimen

transportation ceased. The

immediate program priority is

to rapidly reestablish the AFP

surveillance system as areas

become accessible. USAID will

support this effort.

As one of the 10 remaining

polio-endemic countries, Egypt

poses some particular challenges to polio eradication. In

2001, the Egyptian government

requested that a WHO technical advisory group study Egypt’s

unique circumstances and outline recommendations to

improve program quality and

achieve eradication as rapidly

as possible. Environmental

sampling data have demonstrated that widespread transmission

(all governorates tested positive), substantial genetic

diversity of the virus, and yearround transmission combine to

pose a particular challenge to

eradication. These data are in

stark contrast to data provided

20 The USAID Polio Eradication Initiative

by the suboptimal AFP surveillance system, which exists only

in limited geographic transmission areas, suggesting that the

system is undoubtedly missing

paralytic cases. To address

these concerns, in 2001 Egypt

conducted three rounds of

NIDs and eight more rounds of

targeted SNIDs over a 12-

month period in high-risk areas

of Upper Egypt. These intensified NIDs and other mass

campaigns were characterized

by detailed microplanning, multisectoral involvement,

intensified supervision, greater

focus on high-risk areas, and,

most importantly, house-tohouse vaccine delivery.

Monitoring and evaluation

activities have demonstrated

that these intensified campaigns are very effective in

increasing the coverage of children under 5 years of age, and

more need to be conducted in

high-risk areas. Egypt is an

ideal home for the poliovirus

and extraordinarily high-quality

program performance is needed

to eradicate the disease.

Despite a decline in the intensity of polio transmission,

Pakistan reported 116 cases in

2001. Supplemental immunization efforts in the country

increased. The country conducted a three-round spring campaign, followed by SNIDs in

high-risk districts and a tworound fall campaign. Somalia

and Sudan, the region’s other

endemic countries, conducted

four NIDs and SNIDs campaigns. Iraq conducted two

rounds of NIDs in the spring

and two in the fall.

Regional activities for certification of polio eradication are

gaining momentum. The

Regional Commission for

Health workers in Egypt review

microplans for upcoming NIDs.

Photo: Ellyn Ogden/USAID
2001 Report 21

Certification has received

national documentation reports

from countries with high-quality

AFP surveillance that have not

reported any cases of

poliomyelitis for several years.

The Commission has favorably

reviewed reports from Bahrain,

Cyprus, Iran, Jordan, Kuwait,

Morocco, Oman, Qatar, Saudi

Arabia, Syria, Tunisia, and the

United Arab Emirates. The

Commission has begun to

implement a regional plan 

for containment.

Europe: Certification

Delayed by Importations

Containment and surveillance

are key challenges in WHO’s

Europe region as it prepares to

become the next certified poliofree region. The 873 million

people in the region’s 51 countries have been free of

indigenous polio for three years.

Up to 65 million children under

age 5 have been vaccinated

each year. Supplemental immunization activities that

vaccinated 5.5 million children

in the Russian Federation,

Tajikistan, Turkey, Turkmenistan, and Uzbekistan received

special emphasis. In 2001, 36

of 37 polio laboratories had

attained full accreditation status.

Imported cases were detected in

Bulgaria and Georgia in 2001,

slightly delaying the region’s

expected polio-free certification.

In Bulgaria, three polio cases

were confirmed in March and

April. The outbreak is an example of months-long transmission

of imported virus in a country

that had been polio-free since

1982. In Georgia, polio eradication continues to suffer from

the effects of political and economic difficulties. Routine

immunization services and surveillance activities are not provided evenly throughout the

country. In a district with persistently low immunization

coverage, a case of nonparalytic

polio was confirmed in an

unvaccinated child.

USAID funds supported surveillance visits and supervision;

communications and laboratory

equipment and services; and

transportation for fecal specimen collection. More than 600

field staff and clinicians were

trained in workshops in many of

the Newly Independent States.

Funds from Rotary International and CDC helped teams

in Tajikistan, Turkmenistan, and

Uzbekistan with surveillance,

supervision, and monitoring.

Surveillance in the Europe

region is approaching the standards required for certification.

Maintaining optimal surveillance performance, however,

will require continued training

in selected areas and logistical

support for supervision and surveillance. WHO’s Regional

Office for Europe is working

with GAVI to provide further

funding for such activities. In

addition, improvements are

needed in communications and

data exchange from national

and subnational laboratories 

to EPI personnel, regional 

laboratories, and AFP surveillance centers.

Western Pacific: Three

cVDPV Cases Confirmed

in the Philippines

Less than one year after WHO’s

37-country Western Pacific

region received polio-free certification, three cVDPVassociated AFP cases were

reported between March and

July in the Philippines. In a

rapid and appropriate response

to interrupt further transmission, the Philippine government

and the Polio Partners implemented a large-scale

three-round vaccination campaign. A mop-up activity was

conducted on December 8,

2001, followed by a SNID campaign on January 19, 2002, and

a NID on February 2, 2002.

Seventy percent of the vaccine

needed for the mop-up and

SNID activities was already in

country, and UNICEF provided

A cartoon from the Philippines portrays the Department of Health slaying

the polio dragon.

Philippine Daily Inquirer, Jan. 27, 2002
14.5 million additional doses.

Low routine immunization coverage appears to be an

important cause of cVDPV, and

social mobilization activities and

a high-profile press campaign

have stepped up the effort to

heighten public awareness of

the importance of routine

immunization.

Americas: cVDPV

Outbreaks Highlight Need

to Maintain Immunization

Coverage

A vaccine-derived polio outbreak occurred in the

Dominican Republic (11 confirmed cases) and Haiti (one

confirmed case) in mid-2000

because of low polio immunization levels. Nineteen cases of

paralysis and two deaths resulted from the outbreak. Vaccinederived virus continued to circulate on the island of

Hispaniola with three more

cases confirmed in the

Dominican Republic and seven

in Haiti. NIDs were held in

Haiti in March, June, and

August 2001, and in the

Dominican Republic in May

2001 and January 2002. The

outbreak confirmed that vaccine-derived virus can circulate

and cause paralysis. It also 

reaffirmed the need for the

global polio eradication strategy

to include:

• High polio immunization coverage in all countries until

OPV immunization ceases

• Certification-standard AFP

surveillance with genetic

sequencing of all polioviruses

• Global coordination of the

cessation of OPV immunization after certification

• Eventual containment of

Sabin strains of the virus

22 The USAID Polio Eradication Initiative

Infant in Haiti receives OPV during

2001 NIDs.

Photo: Neal Halsey
2001 Report 23

USAID and its Polio Partners

face continuing challenges. All

children in polio reservoir countries must be immunized to

prevent poliovirus from further

circulating and entering neighboring countries. Reaching all

children in conflict-ridden

countries and regions is an

equally serious challenge that

requires flexibility and innovative, decentralized approaches.

The investigation network must

continue to improve and provide

high-quality surveillance data

pinpointing where poliovirus

occurs and originates. The data

must then be used to tailor and

fine-tune eradication efforts

aimed at interrupting polio

transmission in remaining highrisk areas. 

At the same time, polio-free

areas must be kept polio-free

through continuing routine

immunization coverage.

Communities must be mobilized

to support both supplemental

and routine immunization

efforts. A sufficient supply of

affordable OPV must be

ensured. Each laboratory in the

global laboratory network must

be fully accredited. The final

steps toward certification, virus

containment, and possibly ending immunizations must be

carefully planned and implemented.

Reaching the “Unreached” 

In 2002, the global campaign

will focus on fine-tuning supplemental immunization

activities so that they become

more efficient and effective in

applying community-specific

innovations – such as use of

local guides, extended vaccination hours, and more convenient immunization sites – to

contact previously unreached

populations. Attitudinal, behavioral, and operational barriers to

immunization, and solutions to

the problems they pose, must be

identified. Community-level

microplanning for all NIDs,

SNIDs, and mop-up activities

emphasizing the child-to-child

approach must incorporate such

innovations and solutions.

Improved social mobilization

and collaboration with local

political and religious leaders

will help increase coverage, as

will improvements in vaccinators’ interpersonal communication skills. To enhance such

efforts, targeted activities in

2002 will seek improvements in

community-level technical and

administrative capacity. USAID

and the Polio Partners will help

III. Challenges

“The overriding lesson is the need for urgency – 

urgency to finish the job . . .”

Dr. Gro Harlem Brundtland

WHO Director-General

Ministerial Meeting at the World Health Assembly

May 15, 2001

This little boy lives on a small grassy

island in the Congo River. By reaching such inaccessible areas,

vaccination teams identify children

and families for future health services. 

Photo: S. Torfinn/WHO
24 The USAID Polio Eradication Initiative

participating organizations

improve their planning, build

stronger public-private partnerships, and develop and implement better community-level

communication and social

mobilization activities.

Ensuring the Supply 

of OPV

OPV must be produced in sufficient quantity and quality, and

at an affordable price, so that

there are no vaccine shortages.

Vaccine supply issues continue

to arise as obstacles to immunization campaigns. In 2001,

Nigeria and Indonesia were victims of vaccine shortages. In

place of a national immunization day, Nigeria was able to

conduct SNIDs in only 16

states, and Indonesia had to

delay scheduled SNIDs.

Improved forecasting of vaccine

requirements is also necessary

to ensure that adequate supplies

are shipped to areas of unexpected polio outbreaks, such as

those that occurred in the

Philippines and Zambia.

Improving Surveillance

Improved community- and facility-based surveillance are

USAID priorities. Making communities aware of the need to

report cases of paralysis is a

critical part of this effort.

Surveillance systems need to

target children who do not visit

health clinics and establish reliable communication channels,

timely stool collections, and

effective logistics for transporting stool samples to laboratories. They must communicate

laboratory results back to communities for program action and

inform families, especially

mothers, of the final diagnosis.

These tasks can pose major

challenges in remote regions

with difficult terrain and poor

communications and transport.

Many countries will continue to

need support in improving and

maintaining surveillance systems after they achieve

polio-free status.

Improving Routine

Immunization Rates

USAID is addressing routine

immunization coverage at a

number of levels. Agency funding for its Boost Immunization

Initiative and for GAVI is supporting routine immunization

activities. In June 2001, the

GAVI Board adopted the 2005

target for achieving a certified

polio-free world as a GAVI milestone, thus strengthening the

link between polio eradication

and routine immunization and

enabling countries to capitalize

on gains made in polio eradication. USAID is encouraging

ICCs to expand their PEI-related activities to include support

for routine immunizations and

to stress to local partners the

importance of promoting routine immunizations during

NIDs and social mobilization

efforts. A renewed focus on routine immunizations will serve to

strengthen the connection

between polio eradication and

broader activities of health care

systems.

Improving and Sustaining

Health Systems

Polio eradication has had a

great impact on the improvement of health systems

management, community relations, social mobilization, and

intersectoral collaboration.

However, the positive synergies

Logistics workers in India store

OPV in coolers for cold-chain

transport.

Photo: Richard Franco
Republic of Congo, Gabon, and

Zambia demonstrated the feasibility of this approach. 

Political and Financial

Commitment

As polio eradication draws closer, keeping countries focused on

the goal of certification is proving to be a greater challenge

than expected. Some countries

with competing health care priorities have been reluctant to

continue their support for supplemental activities targeting

small segments of their populations for more than three years.

This support is crucial, however,

because the wild poliovirus can

easily be transmitted back into

areas with low immunization

levels. Program commitments to

routine immunization and ongoing surveillance are also crucial,

because low-level polio transmission can continue undetected for more than three years

in areas with suboptimal surveillance. As long as poliovirus

transmission continues, so too

does the risk of reinfection in

polio-free areas. Countries must

budget for and accelerate eradication activities, establish

multisectoral approaches to

eradication and surveillance,

and be prepared to respond to

unexpected polio outbreaks.

Many countries, especially the

poorest, will require significant

funding support. While USAID

and the Polio Partners are advocating for increased local

commitments of resources from

both government and private

sources, funding gaps remain.

GAVI’s adoption of the 2005

milestone for global certification should strengthen international advocacy and fundraising capacity, but WHO still

estimates that a minimum of

25

and linkages between polio

eradication and other health

programs need to be more vigorously exploited. The lessons of

polio eradication need to be

applied against diseases such as

measles and maternal and

neonatal tetanus. Countries can

strengthen their health systems

by expanding AFP surveillance

activities to include other diseases, by conducting vitamin A

supplementation during routine

immunization contacts, and by

including other health services

in polio eradication training and

supervision. Strengthening and

sustaining immunization programs, surveillance systems, and

laboratory networks requires a

well-defined strategic approach.

WHO is developing a transition

plan that will provide guidance

to and objectives for such an

approach. The need is evident

to use specific data to measure

progress and for ICCs to review

and improve tools such as

checklists and guides and

strengthen linkages among

implementing partners. A top

priority is sustaining the surveillance infrastructure to detect

outbreaks of polio and other

diseases well into the future.

Working in Conflict Areas

In five of the 10 endemic countries – Afghanistan, Angola, DR

Congo, Somalia, and Sudan –

recent or current conflicts have

caused massive population

movements, weakened or

destroyed infrastructure, and

threatened immunization workers. Efforts to declare truces or

cease-fires on “Days of Tranquility” and establish safe corridors for polio workers and

target populations will be needed to help ensure that no

children miss being immunized.

Such efforts can draw on the

past successes of the U.N.

Secretary-General, international

agencies, and national authorities in cooperatively promoting

temporary cease-fires and supporting logistics operations.

Among the Polio Partners,

WHO, UNICEF, CDC, Rotary,

and USAID have brokered

cease-fires in the past. Their

efforts, and those of others,

must continue. When conflict

situations arise in countries

without a USAID Mission (such

as Afghanistan, Somalia, Sri

Lanka, and Sudan), USAID can

assist through the Polio Partners

and local NGOs. USAID and

the Polio Partners are also

exploring new means of supporting polio eradication in

conflict areas. In the past year,

cross-border immunization campaigns between Liberia and

Sierra Leone and in border

areas of Angola, DR Congo, the

2001 Report

Vaccination efforts in Sudan continue

despite the ongoing civil war. 

Photo: VOA
26 The USAID Polio Eradication Initiative

$275 million in addition to

funds already pledged is needed

to meet the costs of countrylevel eradication activities

through 2005. Certificationand containment-related activities at the regional and global

levels will increase this shortfall. The cost of not meeting

these needs is substantial –

should all remaining polioendemic countries have

continued transmission into

2003, the cost of eradication

will increase by a minimum of

$150 million.

Virus Containment

The final step in polio eradication is to contain all hospital,

laboratory, and medical sources

of poliovirus. Containment

committees have been formed

in 122 countries to address

these issues. Containment

efforts begin before eradication,

with the identification and

inventory of all sources of

poliovirus and establishment of

biosafety level 2 procedures.

One year after the last virus is

reported, level 3 procedures will

be instituted, and viruses may

be transferred to central locations or rendered “noninfectious.” After immunizations

end, level 4 procedures, the

highest safety level for hazardous agents, will be put into

effect. These are complex and

expensive tasks, especially in

developed countries. They are

also necessary, because once

childhood polio immunizations

end, immunity against polio will

gradually decline and finally

cease. Any chance reintroduction of wild poliovirus into the

community from a laboratory,

accidentally or intentionally,

could then have devastating

global effects. 

The End of Immunizations

The question of stopping immunizations is receiving careful

consideration but is yet unanswered. In 2001, the Global

Technical Consultative Group

for Poliomyelitis Eradication

identified four conditions that

must be met with certainty

before OPV immunizations can

cease: 1) wild poliovirus transmission must have been interrupted; 2) wild virus stocks in

laboratories must be appropriately contained; 3) vaccinederived viruses do not continue

to circulate and cause disease;

and 4) a global stockpile of vaccine, with a clear strategy for its

use, is available if needed. 

Uncertainty still surrounds the

issues of vaccine-derived polio

outbreaks and the world’s

future vaccine supply requirements. USAID is already

supporting research into carriers and shedders of vaccine

virus. The mechanism by which

vaccine-derived virus becomes

virulent circulating virus, and

the conditions in which this

occurs, must also be determined. The use of inactivated

polio vaccine (IPV) would

greatly reduce the likelihood of

poliovirus being reintroduced

into populations, but it has several drawbacks. IPV coverage

must be very high – nearly 100

percent – because, unlike OPV,

it does not provide “herd”

immunity in unimmunized people. Only trained people can

administer it, and needle disposal is an issue. It is also more

expensive than OPV, with limited manufacturing capacity.

Continuing long-term production of OPV is another

important and timely issue as

polio vanishes. USAID is work-
2001 Report

ing closely with the Polio

Partners, ICCs, and vaccine

manufacturers to address OPV

production needs in the postcertification era. Manufacturers

need information on which to

base their plans for continued

OPV production following the

elimination of wild-type

poliovirus transmission. There

is a concern that companies

will stop producing OPV as

they increase production of

other more profitable vaccines.

In fact, increases in OPV production may be necessary to

create vaccine stockpiles for

use in responding to outbreaks.

The question of how long the

protective immunity granted by

polio vaccine lasts, even in a

polio-free world, also remains

unanswered. For the foreseeable future, continued OPV use

is recommended.

The costs of the “endgame” of

polio eradication are being

assessed using possible scenarios and timeframes for stopping

immunizations. A global commitment from all Polio Partners

and countries to reach a consensus on a coordinated

approach is required. Time is

needed to collect and analyze

data, answer outstanding

research questions, and address

operational and programmatic

considerations. Only then can

technical experts, the scientific

and medical communities,

donors, governments, manufacturers, and other stakeholders

reach a well-considered, worldwide consensus on stopping

immunizations.

Next Steps 

The technical feasibility of

interrupting wild poliovirus

transmission is well established.

If current levels of participation

are maintained or, in some

cases, accelerated, most chains

of transmission will be interrupted by the end of 2002,

although it is likely a few countries will still have wild

poliovirus transmission in 2003.

WHO’s Europe region anticipates being eligible for poliofree status in June 2002, pending a final determination of the

Regional Commission for Certification. The remaining regions

will not be eligible for certification until three years have

passed with no recurrence of

virologically confirmed wild

polio under high levels of surveillance. Once all regions are

certified, and after a period of

vigilant surveillance, decisions

on when and how to discontinue polio immunizations will be

determined by the status of

laboratory containment activities, occurrences of vaccinederived polio outbreaks, and

other factors.

Eradicating polio will be one of

the 21st century’s greatest gifts

to the world’s children. It poses

many challenges but will bring

significant benefits. It will eliminate the disease and the social

and cultural isolation experienced by polio-stricken children

and their families. According to

WHO, the savings of polio eradication are potentially as high as

$1.5 billion annually – funds

that could be used to address

other public health priorities. In

2002, USAID and the Polio

Partners will continue to collaborate in this major investment

in global health.

Photo: Ellyn Ogden/USAID

27
A boy in Somalia participates in a social

mobilization campaign.

Photo: C. McNab/WHO