The U.S. Government and Global Polio Efforts
Polio, a highly infectious and sometimes deadly disease that has plagued the world since ancient times,1 is now at its lowest levels ever, and a global push for polio eradication by 2019 is underway.2 Since eradication efforts began in earnest 28 years ago (when cases numbered 350,000 annually), polio has been eliminated in more than 120 countries and remains endemic in only two.3 Progress against the disease has been made possible by the development and expanded use of effective vaccines, particularly the more easily administered and less expensive oral poliovirus vaccine (OPV), and mass immunization campaigns supported by the Global Polio Eradication Initiative (GPEI) and others since 1988. If polio is eradicated, it would only be the second time in history that a disease affecting humans has been eradicated (smallpox being the other),4 a “once-in-a-generation opportunity for global public health.”5
The U.S. government (USG) has been engaged in efforts to address polio for decades, as a partner in and the largest donor to the GPEI and supporter of developing countries’ efforts. USG commitment to polio eradication efforts has been reaffirmed in recent years: in 2009, President Obama called greater attention to polio eradication efforts, including the need for greater cooperation with leaders of endemic countries and others in reaching those areas where the virus persists.6 In 2013, the USG signed onto the Polio Eradication and Endgame Strategic Plan, 2013-2018, which included the global goal of eradicating polio and preparing for a post-polio world; global progress toward the milestones outlined in the Plan has most recently been evaluated as part of a midterm review, which was completed in 2015.7
Current Global Snapshot
Today global polio efforts are focused on sustaining efforts to eradicate the disease, which have already resulted in a 99.9% reduction in cases since 1988 (see Table 1).
|Table 1: Polio Cases and Endemic Countries8|
|Year||Cases||Number of Endemic Countries|
|2015||749||2 (Afghanistan, Pakistan)|
|2016||44*10||2 (Afghanistan, Pakistan)|
|NOTES: * indicates year to date cases, as of May 25, 2016.|
The development of effective vaccines against polio in the 1950s and 1960s led to their widespread use in many industrialized countries, including the United States, and resulted in the elimination of polio in a number of countries; these early successes suggested that global polio eradication (through the use of mass immunization campaigns) might be achievable.11 Soon thereafter, in 1988, the World Health Assembly launched the GPEI – constituted as a public-private partnership led by national governments and spearheaded by the World Health Organization (WHO), Rotary International, the U.S. Centers for Disease Control and Prevention (CDC), and the United Nations Children’s Fund (UNICEF) – to work toward this goal.12 GPEI partners have invested approximately $14.3 billion globally in eradicating the disease.13 If the eradication of polio were achieved by 2018, it has been estimated that the GPEI will have saved the world $40 to $50 billion from 1988 through 2035.14
Status of Eradication
Since 1988, the global effort to interrupt transmission of wild poliovirus (WPV, the cause of polio) has seen successes and setbacks: The virus was gradually eliminated across the Americas (in 1994), the Western Pacific (in 2000), Europe (in 2002), and South-East Asia (in 2014).15 Still, in other regions, it remained endemic in some countries and today continues to be endemic in two countries (see Table 1). Current efforts focus on interrupting transmission of two types of wild poliovirus: WPV 1 and WPV 316 (one of the three WPV types, WPV 2, was eliminated in 1999 and declared eradicated in 2015).17 In addition, polio-free countries must remain vigilant to prevent reintroduction of the virus, which can lead to re-establishment of polio transmission.18 Importation of the virus from another country is a continuing threat, with countries stretching across west Africa to central Africa to the Horn of Africa most often affected.19
Impact of Polio
In 1 of 200 persons infected with WPV, permanent paralysis (usually of the legs) occurs, and of these, 5-10% die when paralysis affects the respiratory muscles.20 The disease is most prevalent among underserved populations in developing countries, typically striking children under five who live in poverty and who lack access to clean water, good sanitation, immunization and other health services. Young children are more vulnerable to and disproportionately affected by polio.21
Several strategies are important in preventing the spread of polio, including:
- Ensuring high levels of routine immunization coverage (greater than 80%) among infants (children under one year old), including at least three doses of OPV. Eventually, polio efforts will transition from using OPV to using only inactivated poliovirus vaccine (IPV) through a phased process over several years.22 A key step in this transition was making a “switch” from OPV that targets all three types of WPV to OPV that targets the remaining two types of WPV (types 1 and 3). This switch occurred in April 2016, preceded by efforts to introduce at least one dose of IPV into routine immunizations before the switch; introducing IPV maintains immunity against type 2, thereby reducing the risks of removing type 2 from OPV.23
- Mass immunization campaigns through National Immunization Day campaigns or supplementary immunization activities (SIAs). Designed to complement the individual protection provided by routine immunization and build herd immunity,24 mass immunization is intended to immunize children under five who have not been immunized or may only be partially protected, while also boosting the immunity of children who have been immunized. It is only through high levels of sustained herd immunity that virus transmission will stop. A large cadre of volunteers vaccinates thousands, and often millions, of children during these campaigns.
- Heightened poliovirus surveillance and lab capacity to detect new cases and importations.25
- Targeted campaigns (“mop-up” campaigns) to respond to outbreaks in specific areas the virus is known or suspected to be circulating.26
These four main strategies are supported by health worker training, communication campaigns, community outreach, engagement with community and religious leaders, new technological and scientific advances, technical assistance, sharing of best practices, and vaccine production efforts.
Although polio vaccination is relatively inexpensive, challenges persist in delivering the vaccine to the most at-risk populations in endemic regions, as affected areas are often geographically remote and struggle with extreme poverty, conflict, and religious or other social barriers that hamper the ability of health care workers to reach all children who need to be vaccinated. Attacks on health care workers engaged in polio vaccination activities, most recently in Pakistan, have highlighted security concerns that threaten continued progress. To address some of these challenges, approaches have included: building political will among national and community leaders, mobilizing community support of sustained vaccination efforts, retaining public trust in the safety of the vaccine, ensuring vaccine supply, improving coordination among key players, and securing adequate financing.27
In 2012, the World Health Assembly stated that successfully eradicating polio was a “programmatic emergency for global public health,” given ongoing challenges that threatened the gains that had already been made.28 More recently, in 2014, WHO declared the continued spread of polio a “public health emergency of international concern” due to the global risks posed by the disease; under the International Health Regulations, this declaration required certain countries to heighten their efforts against polio.29
With the Global Polio Emergency Action Plan 2012-2013 and the subsequent Polio Eradication and Endgame Strategic Plan, 2013-2018, key public and private stakeholders agreed to redouble efforts in the remaining endemic countries and to adopt a strategic plan for attaining the goal of eradicating polio by 2018 and for preparing for a post-polio world; however, a midterm review of progress, conducted in 2015, pushed the eradication goal date to 2019.30 Polio eradication is also a major milestone in the Global Vaccine Action Plan 2011-2020, which outlines a vision for delivering universal access to immunization by 2020 as part of the “Decade of Vaccines” effort,31 as first called for by Bill and Melinda Gates in 2010.32 The Gates Foundation has committed over $10 billion to achieving the Decade of Vaccines vision and is also the second largest contributor to the GPEI.33
The U.S. Government’s Response
The USG has long been a leader in supporting global polio eradication, with CDC and the U.S. Agency for International Development (USAID) engaged in efforts to assist affected countries through bilateral activities as well as the GPEI. In recent years, growing international attention to progress made toward eradication has led the USG to emphasize the urgency of sustaining efforts until eradication is achieved and spurred USG involvement in new collaborations aimed at better reaching the areas and populations most affected by new cases. In 2009, President Obama launched a new joint effort with the Organization of Islamic Cooperation (an inter-governmental organization with 57 member-states spread over four continents) to eradicate polio globally, bringing high level support to efforts to counter the disease in endemic countries with large Muslim populations.34 The resulting 2010 joint work plan aimed “to strengthen diplomatic advocacy, technical support and resource mobilization” on the part of the USG and OIC member-states.35 More recently, in April 2013, the USG signed onto the Strategic Plan to eradicate polio by 2018 and to prepare for a post-polio world.
Protecting children from polio by ensuring they are fully immunized is part of the USG maternal and child health strategy36 and meeting the USG’s Commitment to Child Survival as part of A Promise Renewed, a global initiative that aims to eliminate preventable child deaths.37
Structure and Approach
CDC and USAID are the major implementing agencies for U.S. global polio efforts, with CDC serving as the U.S. lead agency. The State Department and the National Institutes of Health (NIH) also play important roles in the U.S. response.
CDC. CDC’s efforts focus on technical and financial assistance for efforts to interrupt WPV transmission. In addition to its polio surveillance expertise,38 it offers field support through the deployment of public health professionals to polio-affected areas who support capacity building of surveillance and laboratory networks, immunization campaign planning and monitoring, social mobilization, and other activities.39 In December 2011, CDC activated its Emergency Operations Center to “support the final push for polio eradication.”40
USAID. USAID provides technical support to country partners in immunization campaign planning and implementation, social mobilization and communications efforts, and strengthening surveillance and monitoring systems.41 The agency’s early polio efforts focused on Latin America in the late 1980s and early 1990s, until the disease was eliminated in the region.42 Since 1996 it has supported and worked with the GPEI.43
Other USG Polio Efforts. The State Department supports these efforts through diplomatic initiatives to engage political and community leaders in affected areas.44 NIH and CDC efforts also focus on encouraging research into and adoption of new polio vaccines. Additionally, the USG works closely with international institutions and other partners, including WHO, UNICEF, and Rotary International. It is also the largest donor to the GPEI, having contributed over $2.6 billion since its launch in 1988.45
U.S. Government Funding
Total USG funding for polio has risen from $134 million in FY 2009 to $228 million in FY 2016 (see Figure 1).46 The President’s FY 2017 request for polio totaled $226 million, essentially matching the FY 2016 level. Most USG funding for polio is provided through CDC’s global immunization program (more than 70% in FY 2016). Additional polio funding is provided under the maternal and child health program at USAID.
Increased attention to polio, when coupled with global partnerships and the availability of effective interventions, offer a unique opportunity to eradicate an infectious disease affecting humans for only the second time in history. However, with continued insecurity in some of the remaining endemic areas and other ongoing challenges, concerns about how to not only sustain gains made but also eliminate the final reservoirs of the poliovirus exist. To achieve this vision, securing adequate funding for the final stretch of the GPEI will be important: Commitments of more than $4 billion from donors and governments were announced during the 2013 Vaccine Summit, and commitments of $1.7 billion have been made since, a significant step toward meeting the estimated $7 billion cost of carrying out the Polio Eradication and Endgame Strategic Plan and achieving eradication by 2019.47
GPEI, “History of Polio,” webpage, www.polioeradication.org/Polioandprevention/Historyofpolio.aspx.
2019 is the goal date for the certification of polio eradication; certification occurs after a sustained period of time with no transmission of WPV. Detailed criteria are described at: GPEI, “Certification,” webpage, www.polioeradication.org/Posteradication/Certification.aspx.
WHO, “Poliomyelitis,” fact sheet no. 114, April 2016.
In 1980, the World Health Assembly (WHA) accepted scientific certification that smallpox had been eradicated worldwide. WHO, The Global Eradication of Smallpox, 1980. Guinea-worm disease (a neglected tropical disease also known as dracunculiasis) could become the second disease eradicated; cases dropped from 3.5 million annually in the mid-1980s to 22 in 2015. WHO, “Dracunculiasis,” fact sheet no. 359, May 2016.
GPEI Independent Monitoring Board, “Letter to Margaret Chan dated Jan. 18, 2013,” www.polioeradication.org/Portals/0/Document/Aboutus/Governance/IMB/8IMBMeeting/8IMB_Report_EN.pdf.
White House, “Remarks by the President on a New Beginning,” Cairo, Egypt, June 4, 2009, www.whitehouse.gov/the-press-office/remarks-president-cairo-university-6-04-09.
The global goal of the Strategic Plan “is to complete the eradication and containment of all wild, vaccine-related and Sabin polioviruses, such that no child ever again suffers paralytic poliomyelitis.” GPEI: Polio Eradication and Endgame Strategic Plan, 2013-18, April 2013; Midterm Review, July 2015.
GPEI, “Polio this week – As of 25 May 2016,” webpage, http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx; WHO, “Poliomyelitis,” fact sheet no. 114, April 2016.
In 2015, all of these cases occurred in endemic countries (20 in Afghanistan and 54 in Pakistan).
In 2016, as of May 25, all of these cases occurred in endemic countries (5 in Afghanistan and 11 in Pakistan).
GPEI, “History of Polio,” webpage, www.polioeradication.org/Polioandprevention/Historyofpolio.aspx.
41st WHA, “Global eradication of poliomyelitis by the year 2000,” WHA 41.28, 1988.
Includes contributions and pledges through 2019. GPEI, “Contributions and Pledges to the Global Polio Eradication Initiative, 1985-2019,” as of 1 April 2016, www.polioeradication.org/Financing.aspx.
Duintjer Tebbensa, et al., “Economic analysis of the global polio eradication initiative,” in Vaccine, vol. 29, no. 2 (Dec. 16, 2010): 334-343.
These years represent the dates of regional certification of eradication. UNICEF, “The Story of the End of Polio,” www.unicef.org/immunization/files/The_Story_of_the_End_of_Polio.pdf; GPEI, “WHO South-East Asia Region Declared Polio-Free,” March 27, 2014, http://www.polioeradication.org/tabid/488/iid/362/Default.aspx.
It has been nearly three years since the last case of WPV3 was reported anywhere, leading to some hopes that this strain may soon be gone. However, the areas in which the strain may still persist without being reported are unstable security-wise, so undetected circulation has not been ruled out yet. GPEI, “A year without type 3,” news release, Nov. 13, 2013; WHO, “Wild Poliovirus 2010-2015,” as of 22 Sept. 2015, http://www.polioeradication.org/Portals/0/Wild_poliovirus_list_2010-2015_22SEP.pdf.
WHO, “Poliomyelitis,” fact sheet no. 114, October 2014; Global Certification Commission, “Declaration of WPV2 Eradication,” Sept. 20, 2015.
Sustained poliovirus transmission for over 12 months following importation is classified as re-established transmission.
GPEI, “Key countries,” webpage, http://www.polioeradication.org/Keycountries.aspx.
Most people infected with polio will have no symptoms, and those that do will usually experience minor symptoms that often resolve completely.
WHO, “Poliomyelitis,” fact sheet no. 114, April 2013.
Introducing IPV will help eliminate outbreaks caused by oral polio vaccine-derived polioviruses (VDPV), since OPV includes live, weakened poliovirus, while IPV does not. Polio Oversight Board, “Polio Eradication in Reach, with Renewed Commitment,” statement, Sept. 25, 2015.
WHO/GPEI: “Planning for IPV Introduction: FAQs,” March 2014; “Preparing for the withdrawal of all OPVs,” OPV Switch Briefing Note, Feb. 2015.
Herd immunity is the resistance to an infectious agent of an entire group or community (and, in particular, protection of susceptible persons) as a result of a substantial proportion of the population being immune to the agent. See CDC, “Glossary of Epidemiology Terms,” webpage, http://www.cdc.gov/OPHSS/CSELS/DSEPD/SS1978/Glossary.html#immunityHerd.
Surveillance efforts include monitoring for cases of acute flaccid paralysis (AFP), an early sign of possible polio.
According to GPEI, “Priority areas include those where polio cases have been found over the previous three years and where access to health care is difficult. Other criteria include high population density, high population mobility, poor sanitation, and low routine immunization coverage.” GPEI, “Targeted mop-up campaigns,” webpage, www.polioeradication.org/Aboutus/Strategy/Targetedmopupcampagins.aspx.
The GPEI Independent Monitoring Board monitors progress toward GPEI milestones, examines key challenges, and makes recommendations accordingly; see www.polioeradication.org/Aboutus/Governance/IndependentMonitoringBoard/Reports.aspx.
65th WHA, “Poliomyelitis: intensification of the global eradication initiative,” WHA 65.5, 2012.
WHO Executive Board, Poliomyelitis, Report by the Secretariat, EB136/21, Jan. 16, 2015; GPEI, “Polio Public Health Emergency,” webpage, http://www.polioeradication.org/Keycountries/PolioEmergency.aspx.
GPEI: Global Polio Emergency Action Plan 2012-2013, 2012; Polio Eradication and Endgame Strategic Plan, 2013-2018, April 2013; Midterm Review, July 2015.
Decade of Vaccines Collaboration, website, www.dovcollaboration.org/.
The Decade of Vaccines Collaboration grew out of Bill and Melinda Gates’ initial call for the next ten years to focus on helping “to research, develop, and deliver vaccines for the world’s poorest countries.” See Gates Foundation, media release, 2010, www.gatesfoundation.org/Media-Center/Press-Releases/2010/01/Bill-and-Melinda-Gates-Pledge-$10-Billion-in-Call-for-Decade-of-Vaccines and www.gatesfoundation.org/Media-Center/Press-Releases/2010/12/Global-Health-Leaders-Launch-Decade-of-Vaccines-Collaboration.
Gates Foundation, media release, 2010, www.gatesfoundation.org/Media-Center/Press-Releases/2010/01/Bill-and-Melinda-Gates-Pledge-$10-Billion-in-Call-for-Decade-of-Vaccines and www.gatesfoundation.org/Media-Center/Press-Releases/2010/12/Global-Health-Leaders-Launch-Decade-of-Vaccines-Collaboration; KFF analysis of funding through 2015 based on data in GPEI, “Contributions and Pledges to the Global Polio Eradication Initiative, 1985-2019,” as of 1 April 2016, www.polioeradication.org/Financing.aspx.
Formerly known as the Organization of the Islamic Conference. White House, “Remarks by the President on a New Beginning,” June 4, 2009, www.whitehouse.gov/the-press-office/remarks-president-cairo-university-6-04-09.
State Department, “United States Support for Polio Eradication,” fact sheet, Oct. 7, 2010, www.state.gov/e/oes/rls/fs/2010/149227.htm.
USAID: Acting on the Call: Ending Preventable Child and Maternal Deaths, June 2014; Ending Preventable Maternal Mortality: USAID Maternal Health Vision for Action, June 2014; Working Toward the Goal of Reducing Maternal and Child Mortality: USAID Programming and Response to FY08 Appropriations (Report to Congress), July 2008; Two Decades of Progress: USAID’s Child Survival and Maternal Health Program, June 2009.
Committing to Child Survival: A Promised Renewed, website, http://apromiserenewed.org/.
CDC provides virological surveillance expertise (genetic fingerprinting) to investigate polio cases, identify the strain of poliovirus involved, and pinpoint genetic and transmission linkages. KFF communication with CDC, May 2013.
CDC, “Polio,” webpage, www.cdc.gov/polio/.
CDC, CDC Global Health Strategy, 2012-2015, 2012.
USAID, Global Health and Child Survival: Progress Report to Congress, 2010-2011, 2012.
The last case in Latin America occurred in 1991, and the region was certified polio-free in 1994.
USAID, Polio Eradication Initiative Mission Information Kit, 1999.
State Department, “United States Support for Polio Eradication,” fact sheet, Oct. 7, 2010.
KFF analysis of funding through 2015 based on data in GPEI, “Contributions and Pledges to the Global Polio Eradication Initiative, 1985-2019,” as of 1 April 2016, www.polioeradication.org/Financing.aspx.
The USG provided support for polio activities prior to FY09; however, total funding amounts are not available. KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, Congressional Appropriations Bills, and U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov.
Cost of eradication activities during 2013-2019. WHO, “Poliomyelitis: intensification of the global eradication initiative,” A66/18, March 28, 2013; GPEI: Financial Resource Requirements 2013-2019, as of 1 April 2016; “Summary of confirmed funding against the Global Vaccine Summit commitments,” as of 1 April 2016; “Financing,” webpage, www.polioeradication.org/Financing.aspx.