The long and expensive fight to eradicate polio

Success is now tantalisingly close. There has been a greater than 99.9 per cent drop in the number of cases since 1988, but has the campaign to eliminate the disease now stagnated?

A child is given two drops of a vaccine in Delhi (Demotix/Louise Dowse)

For more than a quarter of a century a group of a few hundred experts based in Switzerland has been masterminding the most complex medical campaign of all time – to eradicate polio, the nerve-destroying virus that has caused death and disability on a terrifying scale.

Working out of an anonymous office block in Geneva, headquarters of the World Health Organisation (WHO), they have recruited more than 20 million vaccinators worldwide who have administered more than 10 billion doses of oral polio vaccine to more than 2.5 billion children. They have scoured city slums and mountain villages, toured war zones and refugee camps, reached nomadic tribes and jungle communities and have chased the virus to the brink of extinction.

Success is now tantalisingly close. There has been a greater than 99.9 per cent drop in the number of cases since 1988, when the Global Polio Eradication Initiative was launched and 1,000 children worldwide were being paralysed by the disease every day. More than 13 million people have been saved from severe paralysis and a generation of children has been protected from devastating disability and death. The virus is holed up in a few communities straddling the border between northern Pakistan and Afghanistan, where it is making its final stand. With one last push, it could be gone for good.

But the campaign has not been quite the success that some have suggested. On 24 October 2017, World Polio Day, the UK Department for International Development (DFID) – a supporter of the eradication campaign – set out the progress achieved in a series of tweets:

“New polio cases in 1988: 350,000.”

“New polio cases in 2016: 37.”

“A 99.9 per cent drop in less than 30 years.”

No one can deny the extraordinary scale of this achievement against a disease that has been the scourge of mankind for centuries. In 2017 there were just 21 confirmed cases of infection with wild polio virus causing paralysis worldwide, another record low. The disease that was endemic in 125 countries in 1988, including huge swathes of South America, Europe, Africa and Asia, is now endemic in just three – Pakistan, Afghanistan and Nigeria.

But while DFID’s tweets were not inaccurate, what they omitted to say was that we have been on the brink of eliminating the disease for the whole of the present century. In little more than a decade between 1988 and 2000, the number of cases fell by 99 per cent. In the near two decades since then the programme has striven to eliminate that final 1 per cent. Again and again, it has failed.

From 2000 to 2010 cases hovered between 500 and 2000 a year. Enormous effort was expended to chase the last ones out and spending rose to $1bn a year. But the virus evaded its captors. Since 2010, the numbers have begun to creep down again. Yet it is still hanging on. Nigeria, declared polio-free in 2015, recorded four cases in 2016, caused by a virus that had been circulating undetected for five years in Borno, in the north of the country.

The final 1 per cent has proved remarkably resistant. “We can end polio for good,” DFID tweeted in October, a refrain that has been repeated by all partners involved for almost two decades. But the programme has missed every deadline it set itself for eliminating the disease – in 2000, 2004, 2009, 2012 and 2016. Some critics allege it has become a lifestyle, not a mission.

Why did the polio eradication programme stall? And can it still succeed? Some say that if it does so, it will rank as mankind’s single most ambitious accomplishment. But the answer to the second question depends critically on the answer to the first.

A virus that has existed for millennia

Poliomyelitis, also called infantile paralysis, has existed for thousands of years. By the early 20th century it was one of the most feared diseases in industrialised countries. Outbreaks occurred regularly across the world until the 1950s, paralysing hundreds of thousands of children annually and causing panic whenever new cases were detected.

In his novel Nemesis, Philip Roth describes the arrival of polio in Newark, New York, in the summer of 1944. No one understands how polio spreads and as children succumb, panic and paranoia grow. Neighbours of sick children demand they be quarantined, a local hot dog joint is shunned and a mentally disabled man called Horace is accused of being a carrier.

The polio virus infects nerve cells, destroying muscle function and eliminating tendon reflexes, especially in the legs, leaving the victim severely paralysed. In the worst cases it spreads into the brain stem, destroying the nerve cells that control breathing and swallowing. Survival then depends on artificial ventilation – thousands were treated in iron lungs in the 1950s – until the acute phase of the illness is past.

It is an intestinal virus that penetrates the lining of the gut and becomes lodged in the lymph nodes. There it causes fevers and stomach upsets, and passes back into the faeces. It can survive for up to 60 days outside the body, and in the absence of good hygiene and sanitation it can contaminate drinking water.

The introduction of effective vaccines in the 1950s and 1960s brought it under control and in 1988, the WHO conceived the idea of a campaign to eradicate it for good, to ensure no more children were crippled for life. Billions of dollars have been spent, millions of volunteers recruited and billions of children immunised as the battle has been carried to the remotest corners of the globe.

2018 could be the year that it is ultimately driven to extinction. But if history is any guide, the final push will demand a superhuman effort. Past attempts to eliminate diseases have almost all failed. In his book Better, Atul Gawande recounts how in the early part of the 20th century billions of dollars were spent on successive campaigns to eliminate hookworm, yellow fever, yaws (which causes purulent skin ulcers) and malaria – all without success.

The shining exception was the battle against smallpox, eradicated in 1978 following a mammoth campaign that was, even so, much simpler than the one against polio. Smallpox is marked by a distinctive rash. When it occurred, a team could be dispatched to vaccinate everyone the victim may have had contact with, in a technique known as “ring immunisation”.

The same method is not available with polio because for every case of paralysis there are at least 200 – and possibly as many as 1,000 – who suffer, at worst, a fever and an upset stomach. They soon recover but remain silently contagious for weeks after their symptoms disappear. Ring immunisation would require a huge target area. And as the oral vaccine does not always “take”, especially in children with diarrhoea whom it may pass straight through, repeat vaccination is required.

India’s achievement

Vaccination is the cornerstone of the polio eradication strategy. The target is to deliver at least three doses of oral vaccine to every child within the first year of life, and to keep repeating for all children under five to ensure none miss out. The vaccination programme in each country is a huge logistical operation. Worldwide, more than 20 million volunteers are involved in repeated sweeps as many as 10 times a year. The easiest areas were cleared of polio many years ago. Those still infected are places where eradication is most difficult, because of conflict, political instability or hard to reach populations with poor infrastructure. Moreover, as the number of cases falls, finding them becomes more difficult.

Poverty and poor sanitation are key factors in the spread of the disease (Demotix/Louise Dowse)

The virus can hide away, travel hundreds of miles and then spring out. Corruption, insecurity and poor management are its aids. Every last drop has got to be squeezed out – even if the programme is down to the last dozen cases it is not down to zero. No one knows what that will take.

Confidence that it can be done comes from India’s success in eliminating the disease. The last case of polio in India was recorded in 2011. In one of the most chaotic, densely populated and deprived nations on earth, that is an astonishing achievement.

The centrepiece of the Indian campaign is the national immunisation days (NIDs), begun in 1995, around which all other activities are organised. They are still held regularly to ensure it does not return – most recently on 28 January 2018 – even though the last case of polio in India was recorded almost seven years ago.

The aim is to vaccinate 172 million children under five on a single day, employing 2.5 million vaccinators who are moved in 155,000 vehicles (including boats, elephants and camels) carrying more than six million ice packs (to keep the vaccine cool) and supplying more than 700,000 vaccination booths – set up in hospitals, on street corners and out of the back of cars. The NID is followed by a five day mop-up phase in which vaccinators move from house to house, following a meticulously planned route, seeking out those missed.

To see how it is done, I travelled to India for The Independent in 2013 to accompany two neighbourhood workers, Poonam and Mamta, on an earlier national immunisation day as they made their rounds in the Madipur district of Delhi, squeezing through narrow alleyways, pushing past dogs and children while dodging buckets of waste and ducking under electric cables.

Poonam clutched a ledger with names and addresses and Mamta carried the insulated box containing the vaccine nestled on a bed of ice – half a dozen vials each enough for 20 children. They had 400 houses to visit over four days with a fifth day reserved for “mopping up”.

The virus can leave people paralysed (Getty) (Getty Images)

As they knocked on doors, or called to upper floors, summoning families by name or simply with the words “Polio drops!”, dark-eyed children emerged from cell-like rooms, ready to receive their medicine in a ritual that had become routine.

The secret of India’s success is contained in the two-inch thick ring binder I found laid out on Dr Sucheta Bharti’s desk, the vaccine coordinator for Madipur, in a dimly lit office in the Jagwan Ram Government Hospital. Beside her on the floor, dozens of insulated boxes containing vials of vaccine on a bed of ice were standing ready to be loaded into 15 vehicles to be distributed to 160 vaccination booths across the north-west of the city.

The ring binder held the “microplan” – hundreds of pages of coloured maps that detailed every corner of the district, with its allocated health workers. Here was identified every dwelling in the neighbourhood in a triumph of bureaucratic planning. The yellow section marking the slum we had just visited contained 18,000 houses covered by 28 teams of vaccinators, each with their designated route.

“Each paralysed person is a burden on themselves and on society,” Dr Bharti said. “This is the only programme that has reached to every doorstep. We have the vital statistics [for the country]. We can use this for anything.”

The major players

The polio eradication programme relies on the support and financial backing of a range of partners, led by the WHO. The key donors are Rotary International, the US Centres for Disease Control and Prevention, Unicef and the Bill and Melinda Gates Foundation who together have raised more than $16bn.

By the mid-2000s, with the programme going nowhere, they were becoming restive. The programme was spending $1bn a year and supplying hundreds of millions of doses of vaccine across the affected countries – yet making no progress. There was frenetic activity but little analysis of what was holding up the programme’s advance. Its leaders believed they just had to push on.

Bruce Aylward, the charismatic director of the programme, was a talented leader who had been in post for 10 years and was known as Mr Polio. But there were complaints that there was too much power in his hands, he was not taking account of other partners and was driving on with the same methods he had used for years. He left the programme in 2014 to take charge of the WHO’s efforts against the ebola outbreak in West Africa.

Reaching every child poses huge challenges – mapping the houses, monitoring the vaccination teams, maintaining the supply lines (AFP/Getty)

Unicef’s role was to obtain the vaccine, ensure it was kept cool throughout its journey, educate families about the importance of vaccination and ensure they were helped to attend. The emphasis had been on delivering the vaccine rather than communicating around it.

The Centres for Disease Control in Atlanta was accustomed to dealing with outbreaks of, for example, Lassa fever. Their role in the polio campaign was to analyse data and send out field workers as advisers but Tom Frieden, their go-getting director from 2009-17, was critical of the programme’s performance.

Rotary International had been in the polio eradication drive from the beginning and had raised a lot of money. They too were critical of the eradication efforts in some countries but their focus was on fundraising and they became agitated about the criticisms becoming too widely known because of its dampening effect on their supporters. They had begun planning celebration parties around the world in 2012 in anticipation of the end of polio and when it emerged the target might be missed they received thousands of emails from worried supporters.

Bill Gates had made the eradication of polio his personal mission and invested hundreds of millions pounds as well as raising hundreds of millions more from other donors. It was clear that he would not allow it to fail. The Gates Foundation had many senior staff with expertise in vaccine-preventable disease. But he too had doubts about the leadership of the programme.

What the eradication programme lacked was a rigorous analysis of its shortcomings. It needed a hard look at what it wanted to achieve, how to build confidence, what levers worked and how to motivate frontline staff.

Reaching every last child

In 2010, Margaret Chan, then director-general of WHO, decided to act. She established an independent monitoring board (IMB) of international experts to hold the programme to account. The board, chaired by Sir Liam Donaldson, former UK government chief medical officer, quickly discovered all was not well. Discontent was growing with the lack of progress but the partners felt unable to challenge the programme’s leaders, particularly health ministers who were representatives of their member states.

An early IMB report contained a killer statistic: the number of missed children worldwide – 2.5 million – who had never had a single dose of vaccine. It pointed out that the programme could run 10 campaigns in a country but if the same 500,000 children were missed each time, repeating the campaign wouldn’t help. The programme’s slogan was “Every last child” so the IMB titled its report “Every missed child”.

It is feared that health services in the most vulnerable countries will suffer if polio is eradicated (Getty)

Reaching every child in each country posed huge challenges – mapping the houses, monitoring the vaccination teams, maintaining the supply lines, with all the potential for errors, poor practice and corruption. But no one at that stage was asking if it was being done right. At their weekly meetings, the programme leaders in the WHO were focused on technical issues – how many children were being vaccinated. They did not ask how they could improve the quality of the programme.

A frequent defence offered was the security situation. In some areas the polio programme had become toxic. It was not helped by the Bin Laden episode – the CIA had used a fake hepatitis B vaccination campaign as cover to obtain vital DNA evidence that helped locate Osama bin Laden before he was assassinated – or by the reenactment of those events in the Hollywood blockbuster Zero Dark Thirty, where, for reasons known only to the filmmakers, the hepatitis B campaign was replaced by a fake polio campaign.

Dozens of vaccinators had been killed in Pakistan, Afghanistan and Nigeria, because their activities were seen as part of a Western conspiracy. (A mother and daughter administering polio drops were shot dead in Quetta in the south-west of Pakistan in January 2018.) Everyone recognised that the courage and commitment of the vaccinators was remarkable and the programme owed it to their memory to succeed. But even in these areas, good management was key.

In 2012 there was a window of opportunity in the endemic countries when the programme had access to all the children it needed to reach. It very nearly succeeded – but corruption, and the poor quality of the vaccinators meant it didn’t happen. It was not security but the delivery that was at fault.

In North Waziristan in Pakistan, the Taliban temporarily opened its doors in December 2012 and the programme was a few months off halting the virus and might have succeeded if it had seized the moment. Then there was a huge orchestrated uprising with 12 vaccinators killed. The window had been missed.

The lesson of that failure was that unblocking the security issues and creating a window was not enough. There had to be a properly managed programme ready to seize the opportunity. In North Waziristan it wasn’t properly managed – and it failed.

In Afghanistan, the programme leaders complained that beyond the security issues they did not know what the problems were. A team was appointed to conduct an independent review which found the programme was good at negotiating access with the Taliban. But once the vaccinators got in, the review team discovered they were underage, missing lots of houses, and the cold chain – which ensures the vaccine is kept cool from depot to delivery – was not working. All the basic things were going wrong.

Security nevertheless posed an immense challenge. There were also darker political forces in play. There was a suggestion, though it was only hinted at, that in the wider geopolitical agenda, something might be given in return for something else. Drone attacks, for example. Would the terrorists back off for long enough to allow polio to be eradicated in return, say, for the suspension of drone attacks? It was never made clear.

One factor was critical to success: ownership. Some countries – India, for example – had taken ownership of the problem but others hadn’t. India made polio a priority because it was sensitive about its reputation as a 21st century nation. But it didn’t work for Pakistan where there was evidence of massive corruption. Supervisory managers were pocketing funds which had a hugely damaging impact. The government was thought to be unembarrassable.

What turned things around in Pakistan was the appointment of a senior official brought in as the prime minister’s adviser on polio who grasped the nettle. It was decreed that all vaccinators had to be over 18, each team had to have at least one woman and each had to have one government employee to increase accountability. From that point, Pakistan’s programme began to make progress. Having stalled for years, the numbers started coming down again.

In its December 2017 report the IMB commended the “strong political engagement and leadership from all levels in Pakistan” but warned the targets were “incredibly complex”.

India made polio a priority because it was sensitive about its reputation as a 21st century nation (Rotary International) (Rotary International India National PolioPlus Committee)

In August 2017, the government of Balochistan allocated an extra 1000 vaccinators and 300 technicians and there were signs of progress. The proportion of female community health workers, who can find missed and hidden children, had been increased to 88 per cent and the number of vaccine refusals had been reduced from 1500 in 2016 to 400 a year later.

However, the small border community of Killa Chaman, which accounts for 70 per cent of polio cases in the region, is one of the most dangerous places in the world. It is difficult to get staff to go there. In late 2017, a district police officer was killed. The IMB said: “The border town is a hub of insecurity, illicit activities and community resistance.” In Quetta, 100km to the south, a woman and her daughter were shot dead in January 2018 while administering oral polio drops.

There are further hotspots in Karachi, where campaign fatigue has produced a backlash, and in the twin cities of Rawalpindi and Islamabad. In slum areas, where all amenities are practically non-existent, people ask: why the focus on polio? Why not on other health services?

In Afghanistan concern is centred on 15 districts in Kandahar and Helmand in the south with a population of just over one million. They account for 90 per cent of polio cases in the region – owing to periodic inaccessibility, vaccine refusals and a high-risk mobile population. Yet even here there is progress. The proportion of missed children in Kandahar has been reduced from 13 to 6 per cent.

Nigeria delivered a grievous shock to the programme when polio recurred in Borno in 2016, after the country had been declared polio-free. No new cases have been detected in the months since August 2016, but insecurity in the region, large cross border movements and a patchy immunisation campaign have left the IMB “deeply concerned”. Between 160,000 and 230,000 children and 30-40 per cent of settlements remain trapped by Boko Haram. “Unless there is a breakthrough to reach those areas the entire polio programme is at risk,” it says.

An outbreak of monkey pox has set Nigeria afire with rumours that the government vaccination campaign is the cause, undermining public trust. Political engagement has also waned.

Overall, the IMB warns of a “pervading sense of fatigue”. Poor quality programmes in key areas, a “worrying number” of inaccessible populations, and unreliable data are additional concerns. “The polio programme seems to have hit a wall, familiar to athletes in endurance sports in the final stages of a race,” it says.

A public health emergency

Back in 1988 at the launch of the eradication programme, the plan had been to drive out polio by improving routine immunisation, which protects children against a range of diseases from infancy, and add in additional “vertical” campaigns (focused on polio alone) where necessary. The strategy proved successful in the easier countries but in others, with less well established routine programmes, more vertical campaigns were needed.

Over time the view developed that the routine programmes were never going to deliver, so the focus switched to the additional vertical campaigns. That was where a number of the problems – with management, political alignment, and communication – originated.

By 2014, 10 countries had active polio outbreaks and, under pressure from the IMB, the director-general of WHO, Margaret Chan, declared the international spread of the virus a “public health emergency of international concern”. That enabled the coordination of an expansive international response, including measures requiring travellers from the worst affected countries to be vaccinated to prevent the virus from crossing borders. A WHO emergency committee was established which meets every three months to reassess the situation. At the Centres for Disease Control in Atlanta, an emergency operating centre was established that is normally activated only in a flu pandemic.

Yet the programme itself did not respond to the heightened sense of urgency. The people running it had secured their funding and the problems they faced – terrorists – were completely outside their control so they couldn’t be held to account for them. They seemed to say: “Well, this is going to take a while now.” They slipped into complacency.

Eliminating a disease is not like any other project. By common consent it is an incredible thing to be trying to do and is untested. So the programme could always defend itself by appealing to the scale of the challenge it faced.

When it ran into difficulties the donors were more forgiving. Instead of saying, “You asked for $10bn and said that would be enough, so that’s it, no more”, they said: “We accept it is hard and you have some really tough challenges – have another $10bn.”

The great worry now is that the programme has run out of ideas. The IMB speaks of a “pervasive sense of fatigue and low spirit”. Some leaders have even wondered privately whether eradication is possible. Yet the goal is now so close that the pain of slipping back to a state where there were thousands of cases is impossible to contemplate.

The programme is too big to fail.

Preparing for the endgame

As the campaign enters its final phase, preparations have begun for the endgame. One challenge of using oral polio vaccine to eradicate polio is that when cases fall very low there will be a small number of cases caused by the vaccine itself. The oral vaccine contains a live, but weakened virus which replicates in the intestine for a short time while producing an immune response. During that period it is also excreted and in areas of poor sanitation it can spread in the local community. This has advantages because it offers protection to other unvaccinated children through “passive” immunisation, before eventually dying out.

However, in areas where vaccination coverage is low, the excreted virus can circulate for a longer time, undergo genetic changes and, very rarely, develop into a form that can paralyse. This has happened in the past year in Syria, where there were 74 cases of circulating vaccine-derived poliovirus in 2017, after vaccination levels in the country dropped from 80 per cent to 40 per cent. There were also 12 cases in two outbreaks in the Democratic Republic of Congo (DRC).

The programme in Syria responded by vaccinating 355,000 children up to August 2017 in the governorates of Deir Ezzor and Raqqa where the continuing violence has devastated the health service and severely disrupted the routine immunisation service. Previous outbreaks of vaccine-derived virus have been rapidly stopped with two to three rounds of high quality immunisation campaigns and are regarded as less serious and more easily contained than outbreaks caused by the wild virus. But the impact on public trust when it becomes clear that the last cases of polio are to be blamed on the vaccine itself, can only be guessed at. The anti-vaccine conspiracy theorists will have a field day.

In order to avert more outbreaks like the ones in Syria and the DRC as eradication approaches, the oral vaccine containing the live virus is being phased out and replaced by an injectable vaccine which contains a killed virus. This inactivated polio vaccine confers longer lasting immunity than the oral vaccine (which may not “take” in a child with diarrhoea) but it does not spread protection to others, is more expensive and more complicated to administer, and requires trained healthcare staff to give it.

About 30 per cent of countries worldwide have so far switched to the injectable vaccine with the rest to follow once transmission of wild polio virus has been interrupted. There is a global shortage of the vaccine and stocks are being directed to countries in greatest need.

There is a bigger risk: the impact on health services in the most vulnerable countries once the last case of wild polio is eliminated and funding of the programme is wound down. Ending polio is the first challenge. Disassembling the enormous global organisation established over decades to do it, is the next. As the IMB has put it the “high-profile, assertively top-down enterprise now needs to turn the entire juggernaut around as it prepares to put itself out of business”.

This is already starting. The programme currently spends $1bn a year, of which 90 per cent is directed to the 16 most vulnerable countries. It has 30,000 staff on substantive contracts and a workforce of millions within local communities who are either volunteers or paid on a daily basis. Funding has already declined by $330m in the last year and a further drop of $300m is expected by 2019.

Some governments have woven polio-funded staff and infrastructure, built up over 30 years, into nearly every aspect of their public health systems. Their withdrawal could have a severe impact on health services in some of the world’s poorest countries, affecting their ability to respond to disease outbreaks. The WHO itself is threatened – around 20 per cent of its budget comes through polio programme donors.

It would be a cruel irony if the success of the greatest medical campaign of all time were followed by the collapse of public health services in the most poverty stricken parts of the world.

In South Sudan, for example, a country that has suffered through a catastrophic civil war and is among the poorest countries in the world according to the UN Human Development Index, the polio programme currently pays for 673 staff. They would be lost without careful transition planning.

Ethiopia has a polio budget of $39.8m which will drop to $4.6m in 2019, an 88 per cent cut in three years. Countries like these which are expected to take over the staff and infrastructure currently paid for by the polio programme are under great pressure.

When the transmission of wild polio virus is deemed to have been interrupted there will be three years at least before the remaining endemic countries – and thus the world – can be declared polio-free. Maintaining vigilance, with the highest quality surveillance activities and the most thorough vaccination programmes will pose an immense challenge, with the potential of catastrophic outbreaks ever present. It will be a very hazardous time because of the large numbers of “missed” children in the mobile populations in Pakistan and Afghanistan, the trapped and inaccessible populations in Nigeria, weaknesses in surveillance systems and low levels of routine immunisation. Yet the temptation to celebrate prematurely will be intense.

For some, however, it is already too late. In January 2018, Ghulam Ishaq, a shopkeeper from Karachi, was pictured on Instagram by National Geographic holding his daughter, Rafia, aged four. One of Rafia’s legs was shown withered by polio, the other encased in plaster after it was broken by a car she couldn’t dodge.

“I didn’t trust the polio vaccine,” Ghulam said.