GENEVA (NYTIMES) - As the world adjusts to the idea of co-existing with the coronavirus for the foreseeable future, global health organisations are laying plans to eradicate another scourge that has already lingered for thousands of years: poliovirus.
The Global Polio Eradication Initiative, a public-private partnership led by national governments and health groups, on Wednesday (June 9) released a US$5.1 billion (S$6.7 billion) plan to eradicate polio by 2026.
Polio can cripple or even kill those afflicted with it. For decades, the initiative has been trying to achieve a polio-free world by immunising every child against the virus, but with limited success.
Many countries were dealing with sporadic outbreaks of polio before the coronavirus emerged, but the pandemic brought some polio vaccination programmes to a halt, at least for a few months, and worsened the trend. Last year, there were 1,226 cases of polio worldwide, compared with 138 in 2018.
There was also some good news. In August, African countries were declared free of wild poliovirus, leaving Afghanistan and Pakistan as the only two countries where polio is endemic.
And in November, the World Health Organisation granted the first emergency authorisation to a new vaccine that promises to minimise polio outbreaks.
"Now is the time to double down and really make sure that we stop transmission and that we're able to deliver a polio-free world," said Mr John Vertefeuille, chief of the polio eradication branch at the Centres for Disease Control and Prevention, one of the partners in the global initiative.
Previous efforts to end polio have been hamstrung by inadequate funding and a lack of political commitment - factors that may pose an even tougher challenge now with Covid-19 continuing to siphon attention and resources.
The new strategy includes policies intended to increase political commitment while taking the pandemic into account, Mr Vertefeuille said. It embraces two key goals: integrating polio programmes with other healthcare programmes and focusing on areas with chronically low immunisation rates.
The plan also ensures vaccine supply and outlines a communication strategy to increase vaccine acceptance.
The architects of the plan consulted with more than 40 civil society organisations, academic institutions and donors to help them integrate polio eradication with other health challenges.
Trying to engage communities in regions where there is hesitancy, or even hostility, to vaccines "is easier said than done, obviously, but at least in my opinion, it's in the right direction", said Dr Walter Orenstein, associate director of the Emory Vaccine Centre and a former director of the United States' Immunisation Programme.
Dr Orenstein was optimistic about the new strategy overall, and particularly the tactic of combining polio with other health programmes to gain political support.
"Eradication is a very unforgiving goal - one infection is one infection too many," he said. But the new plan "clearly has shown they're taking into account lessons they have learned".
From March to July last year, polio immunisation campaigns were suspended in more than 30 countries, resulting in more unvaccinated children and more outbreaks of vaccine-derived polio.
The oral polio vaccine that is currently used widely contains a weakened strain of the virus. Children who are immunised with this vaccine can pass the virus into the environment through their faeces; from there, it can infect unprotected people.
As the virus passes from one unvaccinated person to another, genetic changes can cause it to revert to a form that can cause paralysis.
About 90 per cent of polio outbreaks are a result of this vaccine-induced poliovirus. In 2020, there were more than 1,000 cases detected in 29 countries, many more than in previous years. A new oral vaccine introduced in November is designed to make the virus more genetically stable and is thought to minimise the risk of vaccine-induced cases.
"It's not a magic bullet that will solve all of our problems - the vaccines still need to reach people in order for them to work," said Ms Simona Zipursky, an adviser to the WHO on polio eradication.
"But we do feel it will really help us in sustainably stopping these outbreaks."
The new vaccine is approved only for emergency use, and countries that qualify must commit to monitoring its safety and effectiveness. More than 20 million doses have already been distributed.
Outbreaks of wild poliovirus - the original scourge - now occur only in Pakistan and Afghanistan. Since 2018, vaccination campaigns have missed about three million children in Afghanistan because of a Taleban ban on house-to-house immunisation.
The vast majority of outbreaks in Afghanistan in 2019 and 2020 originated in these areas.
"Understanding how we can gain access through dialogue with them remains a critical focus of the of the programme," Mr Vertefeuille said, referring to the Taleban.
In Pakistan, Pashto-speaking communities near the Afghanistan border represent about 15 per cent of the country's population but more than 80 per cent of wild polio cases. Vaccine hesitancy and misinformation spread via social media have led to a rise in cases since 2018.
"Those issues certainly were there before, and Covid-19 pauses allowed case numbers to increase pretty dramatically, pretty quickly," Mr Vertefeuille said.
Polio eradication programmes will focus on immunising hard-to-reach communities in the two countries, and training older female health workers, who are more successful in persuading caregivers to vaccinate their children.
The global initiative has set up two teams to respond to outbreaks within 72 hours: one in the eastern Mediterranean region (which comprises 21 countries, including Pakistan and Afghanistan), and the other in sub-Saharan Africa. This time, the strategy also involves health ministers in the eastern Mediterranean region, so that governments are urged to focus on polio by their peers, rather than by a global health organisation.
"Eradication remains a top health priority," said Dr Faisal Sultan, special assistant on health to the prime minister of Pakistan. "We look forward to working with international partners to achieve a polio-free world."
Nigeria, another country where polio was endemic, was declared polio-free last June, after addressing some of the same challenges. Commitment from political leaders at every level of government - including having their grandchildren vaccinated on television - turned the tide.
To reinstate polio as a priority, even with competing health challenges in these cash-strapped countries, officials emphasise that programmes to squelch polio can also be used to help turn back Covid-19 and other diseases, Mr Vertefeuille said: "It allows you to be prepared for any emergency."
During the coronavirus pandemic, more than 31,000 polio workers in more than 30 countries pivoted to working on Covid-19 surveillance, contact tracing, distribution of supplies for hand hygiene, and training for medical personnel and frontline workers.
In Pakistan, polio labs provided testing and sequencing for the coronavirus, and a polio telephone line became the national information centre for information on Covid-19.
Polio workers trained nearly 19,000 health care workers and engaged 7,000 religious leaders and 26,000 influencers.
In Nigeria, health workers used data systems and analytics set up for polio to track health care needs for Covid-19. Polio workers were similarly helpful during the Ebola outbreak in Nigeria.
In Pakistan and Afghanistan, polio immunisation was bundled with delivery of other vaccines or other health necessities, like vitamin A and deworming tablets.
Polio workers can also combine their immunisation efforts with delivery of Covid-19 vaccines, even though the children vaccinated for polio are too young for coronavirus vaccines.
At the same time, confusion about Covid-19 vaccines has affected polio immunisation campaigns, said Ms Melissa Corkum, senior manager for polio outbreak response at Unicef.
Polio workers are "having to spend a lot more time educating and communicating at the doorstep with parents and caregivers", she said.
In Nigeria, the first country to introduce the new polio vaccine, the immunisation campaign began "almost in parallel with their Covid-19 roll-out, it may have actually been exactly on the same days and slightly different areas", Ms Zipursky said.
Polio workers faced a lot of questions and concerns about the two vaccines, she said, underscoring the need to be prepared with the right information. "It was really a good lesson learnt."