WHO Board Looks Into Means To Reach Polio-Free World

Poliomyelitis, a highly infectious and sometimes debilitating viral disease, is about to be eradicated from the world. However, the last mile is the hardest, World Health Organization Director General Tedros Adhanom Ghebreyesus said last week at a member state discussion on polio eradication.

Beyond the direct eradication of wild polioviruses in the three last endemic countries, and the steady supply of affordable inactivated poliovirus vaccines, the WHO is called on to help countries keep the virus at bay, and implement a strategy to use polio-related structures to strengthen their national health systems, as polio funding is dwindling.

Inactivated polio vaccine

The 144th WHO Executive Board meeting is taking place from 24 January to 1 February. The 34-member Board took note of the two documents submitted, one on polio eradication, and one on polio transition.

Polioviruses: Wild and Vaccine-Derived

The world is on the verge of defeating poliomyelitis, but it still has to fight residual infections due to wild poliovirus in Afghanistan and Pakistan, and the additional threat of vaccine-derived poliovirus in several other countries.

According to a WHO Q&A, oral polio vaccine contains a weakened vaccine-virus, activating an immune response in the body. When a child is vaccinated with an oral polio vaccine, the weakened vaccine-virus replicates in the intestine for a limited period.

However, during that time, the vaccine-virus is also excreted and in areas of inadequate sanitation, this excreted vaccine-virus can spread in the immediate community, and poses a threat to under-immunised population. Sometime, the vaccine-virus can genetically change into a form that can paralyse, and this is what is known as a circulating vaccine-derived poliovirus, according to the Q&A.

According to the Board document [pdf] on polio eradication, there is an urgent need to eradicate wild polioviruses to prevent global re-emergence of such strains, and to enable the rapid cessation of oral polio vaccine.

“In 2018, four cases of paralytic poliomyelitis due to wild poliovirus type 1 have been reported in Pakistan (as at end-September 2018), compared with five for the same period in 2017; in Afghanistan, 15 cases have been reported, compared with six for the same period in 2017,” the Board document says. Wild poliovirus type 1 is also endemic in Nigeria.

According to the meeting document, the declaration in 2014 of the international spread of wild poliovirus as a public health emergency of international concern and the temporary recommendations promulgated under the International Health Regulations (2005) remain in effect.

Inactivated Poliovirus Vaccines: Supply, Price Issues

Switching to inactivated poliovirus vaccine (IPV) appears to be a challenge for some countries.

Gabon for the African region asked for continued financial support until countries are certified polio-free and beyond, and that needs for IPV are covered in all parts of the world. Vietnam said the supply of doses does not meet country needs, and Colombia also voiced concerns about the risk of lack of supply of IPV, and said shortages require short, mid- and long-term planning. China concurred and called for sufficient supplies of IPV to avoid gaps in immunisation.

India said increased IPV production and vaccine security have not been ensured before the mandatory use of IPV, which has resulted in price hikes and shortage crises. The Indian delegate added that those inflated prices result in financial burden in low and middle-income countries, impacting their other health agendas. India urges global market shipping of IPV to control “unprecedented price hike” so as not to endanger the world eradication of the vaccine.

According to Russia, the Board document is “too optimistic” regarding the supply of IPV, despite the fact that the transition from oral vaccine has been ongoing for three years. Some countries, the delegate said, still only have oral vaccines, maintaining a risk of transmission. Russia called for a careful assessment of global needs for vaccines to ensure that the supply is really meeting the needs and financial possibilities of all countries to purchase the vaccines, the delegate said.

Mexico brought attention to the need for the strategy 2019-2023 to be fully funded and there is a need for innovative financing sources. Monaco also mentioned the need for financial and human resources to implement the strategy.

Director of WHO/Polio Michel Zaffran said supply is improving and there is now enough supply to support routine immunisation in all countries. The supply is however fragile, he added.

Dr Tedros announced that Gavi, the Vaccine Alliance, was invited to join the Rotary Club, the US Centers for Diseases Control, the Bill and Melinda Gates Foundation, UNICEF, and the WHO on the Oversight Board of the Polio Global Eradication Initiative.

Gavi said it committed additional support in June 2018 for IPV in priority countries until 2021.

A draft strategy covering the period 2019-2023 considering the actions of the Polio Global Eradication Initiative is expected to be presented to the World Health Assembly in May, according to the Board document.

Polio Transition, How to Use Polio-Related Structures

Successfully defeating polio means resources that were deployed to fight the disease are no longer necessary. However, keeping polio at bay for good is an ongoing challenge, which will need planning, and expertise and infrastructures deployed to fight polio could be reassigned to help strengthen health systems in countries.

The WHO has established a strategic action plan on polio transition, according to the Board document [pdf]. The plan includes identification of the capacities and assets, in particular at country level that are required to sustain progress in other polio-funded programmatic areas and to maintain a polio-free world after eradication.

Japan last week advised to increase collaboration with UNICEF and Gavi to maintain regions polio-free. The Japanese delegate also said polio legacy should contribute to strengthen national health systems and health security management in each country.

However, the Japanese delegate said, all functions of the WHO polio programme should not be automatically kept, and WHO should identify which functions should be kept and which should be terminated. Australia also called for preserving essential functions at country level as polio resources decline.

The United States delegate called on WHO to work with stakeholders on the financial implications of maintaining essential polio functions after the eradication of wild polio.

Country Ownership, National Health System Strengthening

At the close of the discussions, Dr Tedros said eradication should remain the focus and transition should not be allowed to affect eradication. He added that transition should be owned by countries and support should be tailored to their status and situation.

A successful polio transition means a transformation of polio-related structures into general structures as part of domestically-financed national health systems and not only structures necessary for keeping the world free of polio, Germany said last week. The German delegate said polio transition is one of the WHO’s key institutional challenges for the next few years.

As part of the transition issues, the German delegate underlined the pay gap between “relatively well-paid” polio workers compared to counterparts in the rest of national health systems. He stressed the importance of national ownership and long term funding of currently polio-funded structures.

However, national transition plans are a financial challenge for many developing countries, as underlined by Gabon for the African region.

Iran, a non-EB member, said “polio staff,” assets, and experience should move into the 13th General Programme of Work (GPW13) and key staff and assets should serve to help strengthen surveillance and immunisation in priority countries.

Answering member state concerns, Ranieri Guerra, WHO assistant director general for special initiatives, said no polio functions will be dismantled but will be integrated and transformed into health system blocks.

 

Image Credits: Flickr – Sanofi Pasteur.

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