1. Polio Eradication An International Perspective
Hamid Jafari, M.D.
National Immunization Conference
March 23, 2005
It is a privilege for me to be able to speak to you here today about polio eradication from an international perspective.
It is also an honor for me to be on this panel with Dr. Bill Foege and Dr. Jennifer Howse

2. Polio eradication has become the largest health initiative ever….
From a global Perspective, Polio eradication has become the largest public health initiative ever!
It has mobilized nations, with support from heads of states, as seen here in some of many such photos,
and more than 20 million volunteers to vaccinate children across the globe.

3. Polio Eradication Progress 1988 - 2003
Remarkable progress with more than 99% reduction in cases worldwide.
From >125 countries to 6
From 350,000 cases
to 784

4. Polio Eradication, 2003-2004 Challenges: Response: Outbreak in Africa
Progress slow in Asia
Funding shortfalls
Response:
Program intensification & innovation
Political commitment
New funding partners
The program faced major challenges in 2003 and 2004
Outbreak in Africa originating in northern Nigeria as a result of suspension of vaccination for > a year
Progress in Asia was slower than expected because of gaps in immunization campaigns in critical high risk areas AND where virus was tenaciously persisting in its historic niche requiring much more intensive efforts.
Severe funding shortfalls in early 2003 forced the program to prioritize and focus campaigns only in countries with active transmission thereby opening immunity gaps in African countries with low routine immunization coverage.
The program responded by intensifying immunization activities through deploying and concentrating more resources and innovation.
Political commitment was enhanced with active involvement of the G8, AU and OIC, in supporting and mobilizing funding.
The in turn led to new and enhanced funding by donor governments.
There was also a tremendous response from Rotarians around the world during their second fundraising drive

5. Remaining endemic countries responded by the ministers of health reaffirming their commitment to polio eradication at the Geneva Declaration in January 2004.

6. 'Intensification' Activities, 2004
Asia:
8 polio campaigns in infected areas
200 million children
> 1.5 billion doses of OPV
Africa:
3-6 polio campaigns in infected areas
100 million children
500 million OPV doses

7. Impact of Intensification, Asia and Egypt Children with Polio, 2003-4
Reported Polio Cases
The impact of intensification in Asia and Egypt was impressive with a more than 40% reduction in cases.

8. Opportunity in Asia, 2005 Cases of polio, 2004
Lowest number of cases ever
Most focal transmission ever
Highest quality activities ever
Challenge: reaching every child in key districts
There is now a real opportunity to stop transmission in Asia by the end of 2005 with lowest number of cases ever, most focal transmission ever, and highest quality activities ever
However, the challenge is to reach every child in these key districts where the virus is deeply entrenched – leaving no margin of error in quality of vaccination campaigns. Especially in these densely populated areas with poor hygiene, high birth rate as well as security and cultural barriers.
Wild virus type 1
Wild virus type 3

9. Epidemic Spread in Africa, 2003-4
The epidemic in Africa originated in northern Nigeria and spread to surrounding countries and as far as Saudi Arabia and Ethiopia.
Wild virus type 1
14 polio-free countries had importations from Nigeria.
Polio was 're-established' in 5 of these polio-free countries.
Wild virus type 3

10. Africa's Response: Synchronized Polio Campaigns
Synchronized Polio Campaigns Oct-Nov 2004
23 countries
80 million children
Africa responded with synchronized campaigns across 23 countries targeting 80 million children in west and central Africa from Oct to November 2004.
Professor Konare, Chair of African Union and President Obasanjo launching the campaign in northern Nigeria.
African Union Launch Oct 2004, Nigeria

11. Impact of Previous Synchronized Polio Campaigns in Africa
14 Country Synchronized
Immunization Days, 2000
Looking back at impact of previous synchronized campaigns in west Africa between 1999 and 2001, there was rapid elimination of virus from all countries except Nigeria and Niger. Even in Nigeria the southern and more densely populated part of the country became polio free.
The conditions and related epidemiology of poliovirus circulation in Africa seem different from the tenacious adherence of virus observed in ancient poliovirus reservoirs of the Nile and the Ganges river valleys.
1999
2001

12. Progress in Africa Polio cases, Nigeria & Niger, 2004
NIDS
SNIDS
NIDS
Early signs of progress are evident in Nigeria and Niger, that make up the epicenter of the outbreak, with reduction in the monthly incidence after the National Immunization Days or NIDs.
Rapid progress can be expected in Africa if campaigns can be implemented with consistently good quality.

13. Children with Polio in 2004 Geographic Distribution (total = 1262)
A total of 1262 cases have been reported with onset in This slide shows the six remaining endemic countries, the spread across Africa and five countries that have re-established transmission.
Next I want to talk about the innovation the program will be applying in selected areas.
You may notice there is no type 2 poliovirus in this map. That is because globally type 2 polio was last detected in Egypt has had persistent type 1 transmission but has not detected type 3 polio since India as you see has very sparse type 3 poliovirus transmission.
Wild virus type 1
Wild virus type 3
Endemic countries
Re-established transmission countries
Case or outbreak following importation

14. A ‘new’ vaccine for Egypt & India monovalent OPV type 1 (mOPV1)
No competition among three virus types
Marked increase in protection to type 1 polio with 1st dose.
The disappearance and reduction of poliovirus types 2 and 3 provide a strategic opportunity to add monovalent type 1 oral polio vaccine to campaigns in Egypt and parts of India. There is no reduction in immunogenicity due to competition among the three serotypes observed with tOPV. mOPV1 leads to a marked increase in protection to type 1 polio compared with tOPV.
mOPV will be used this spring in Egypt and India.
Protection against type 1 polio after 1 dose of mOPV vs. 1 dose tOPV

15. Risk: Not Reaching Every Child in the Polio Campaigns
Polio continues because campaigns still miss too many children in limited geographic areas.
In the remaining endemic areas, missing any children is a special problem:
Asia due to large populations & mobility.
Africa due to the low routine OPV coverage.
Let us look at the major risks faced by the polio eradication initiative.

16. NIDs Monitoring, India Marking children Marking houses
Program in India now rigorously monitors campaigns including using marking children’s fingers and houses.

17. Risks: Financing & Gap, 2005-2006
USCDC
Funding shortage remains a major challenge for the program. Despite new donors and increased funding by longstanding partners, costs to the program have increased due to the outbreak in Africa and the intensification undertaken.
2005 Funding Gap = US$ 75 million
2006 Funding Gap = US$ 200 million
‘Other’ includes: the Governments of Austria, Australia, Belgium, Finland, Ireland, Italy, Luxembourg, Malaysia, Monaco, New Zealand, Oman, Portugal, Qatar, Republic of Korea, Russian Federation, Spain, Switzerland, Saudi Arabia, the United Arab Emirates; AGFund, De Beers, Inter-American Development Bank, International Federation of Red Cross and Red Crescent Societies, Millennium Fund, Oil for Food Programme, OPEC Foundation, Sanofi Pasteur, Saudi Arabian Red Crescent Society, Smith Kline Biologicals, UNICEF National Committees, UNICEF Regular Resources, United Arab Emirates Red Crescent Society, WHO Regular Budget and Wyeth.

18. Prospects for 2005
Asia & Egypt: will intensify SIAs & add mOPV1 to stop polio by end 2005.
Africa: progress can be very rapid, if
NID quality improves & is sustained
synchronized NIDs cover all countries
surveillance gaps are closed.
sufficient financing is available.

19. Legacy of Polio Eradication
A global surveillance system with a network of 147 accredited laboratories
A Trained public health work force
A strong public health platform for immunization, surveillance and response

20. Summary Polio eradication is technically & politically feasible
Strong political commitment and immediate financing is critical to sustain progress
These challenges have included armed conflict, community resistance, unfounded vaccine concerns, political interference, severe funding shortfalls and fatigue among health workers and communities. I am confident we will overcome the remaining challenges as well.
The program has a history of overcoming extraordinary challenges

21. In the end I want to share with you a personal perspective
In the end I want to share with you a personal perspective. I see some very compelling images in this photo of a polio affected child standing across from the Taj Mahal.
While I see the immediate obstacles facing global polio eradication, I am more inspired by the victory in sight, and the clear vision of the lasting impact of polio eradication on the lives of children around the world.
However, in contrast to the lone child in this picture, there is a strong international partnership that supports global polio eradication and is the source of the incredible achievements of this effort.

22. Best example of international cooperation – diverse agencies and governments working together
Largest in global public health
Led by Rotary International, WHO, UNICEF and CDC
National governments at the center
Rotary: inspiring commitment, a guiding light for building partnerships