A historic achievement in a year of turmoil
Authors: None The Lancet Global Health
Journal: The Lancet Global Health (2020)

On World Polio Day 6 years ago, we wrote in an Editorial that “2014 has not felt like a good year for infectious disease control”. Little did we know what lay ahead. Yet in 2020—a year of unprecedented disruption at the hands of a new human pathogen—the transmission of an old and more deadly and disabling virus was formally declared over on a continent with some of the weakest health systems in the world. The certification on Aug 25 that the African region is now free of wild poliovirus was a truly historic moment. Back in 2014, WHO declared a Public Health Emergency of International Concern over markedly increased international spread, including from Africa, and in 2016 WHO revoked Nigeria's recently achieved polio-free status after several cases of wild poliovirus were discovered in Borno state. Genetic analysis pointed to long-term undetected transmission—a devastating setback borne of prolonged conflict that had destroyed health-care delivery infrastructure and severely restricted surveillance. The multi-pronged response that this event triggered, together with a detailed account of the certification process, is described by the members of the Africa Regional Commission for the Certification of Poliomyelitis Eradication in a Health Policy paper in this month's issue. The story it tells is one of extraordinary coordination, collaboration, and innovation across international and regional agencies, national governments, armed forces, traditional leaders, community health workers, and civil society. The response spanned 13 nations in west and central Africa and saw the immunisation of 116 million children during a single week in March, 2017. Both the immunisation activities and the enhanced surveillance that took place alongside it were planned and monitored by use of GPS and mobile technologies that enabled community informants to report suspected cases. Such community informants, including those in inaccessible areas who had regular contact with accessible ones, proved the key ingredient in the remarkable increase in surveillance demonstrated in Borno by early 2020. Similar successes were seen in immunisation coverage, largely thanks to initiatives that partnered military and security personnel with national polio eradication programme staff and civilian vaccinator teams. In addition to conflict, the other significant roadblock on the journey towards polio-free status has been vaccine refusal, fuelled by rumours and loss of community trust. In 2003, regional authorities of the northern Nigerian states of Kano, Zamfara, and Kaduna issued a boycott of the oral polio vaccine after religious leaders warned that it might have been adulterated with anti-fertility drugs designed to harm Muslims. Suspicion was further augmented by the conspicuous door-to-door activities of vaccinators offering free medicine in a socioeconomically disadvantaged region where health services for other, more prominent, illnesses were scant; national politics pitching north against south; and the controversy surrounding alleged lack of consent in an earlier Pfizer-sponsored clinical trial in Kano. In 2013, nine women delivering vaccines in Kano were killed by gunmen suspected of belonging to the militant Islamist group Boko Haram. Recognising the complexity of these factors, government officials and partners engaged the assistance of traditional leaders and organisations such as the Federation of Muslim Women's Associations in Nigeria, polio survivors, community health workers, and traditional birth attendants to educate and sensitise communities to immunisation activities. There now remains a single WHO region in which wild poliovirus continues to circulate. Here, in Afghanistan and Pakistan, the number of cases continues to fluctuate year-on-year, with conflict and vaccine refusal again proving the limiting factors. To reach the last mile, the Polio Endgame Strategy 2019–23 emphasises better communication and generation of demand for the vaccine, particularly through women's and religious groups, and expansion of partnerships with development agencies to enable provision of basic services such as safe water and sanitation alongside vaccines. The road to the global eradication of polio has been decidedly rocky for communities and health workers alike, particularly those whose lives have been threatened. For bringing Africa to the point of being polio-free, we express our admiration and gratitude to all the agency workers, government officials, military personnel, vaccinators (paid and unpaid), community informants, polio survivors, religious leaders, and others who, through their dedication and collaboration, have made the seemingly impossible possible. Certifying the interruption of wild poliovirus transmission in the WHO African region on the turbulent journey to a polio-free worldOn Aug 25 2020, the Africa Regional Commission for the Certification of Poliomyelitis Eradication declared that the WHO African region had interrupted transmission of all indigenous wild polioviruses. This declaration marks the African region as the fifth of the six WHO regions to celebrate this extraordinary achievement. Following the Yaoundé Declaration on Polio Eradication in Africa by heads of state and governments in 1996, Nelson Mandela launched the Kick Polio out of Africa campaign. In this Health Policy paper, we describe the long and turbulent journey to the certification of the interruption of wild poliovirus transmission, focusing on 2016–20, lessons learned, and the strategies and analyses that convinced the Regional Commission that the African region is free of wild polioviruses. Full-Text PDF Open Access