The last mile of a long fight to eradicate poliomyelitis
Despite decades of vaccine development, smallpox remains the only disease to have been completely eradicated by vaccination. By the end of 2026, the Global Polio Eradication Initiative hopes polio will be added to this short list.
Poliomyelitis, more commonly known as poliomyelitis, is a highly infectious virus that can cause paralysis or death in infected people. Clinically identified in 1789, there is no cure for poliomyelitis and the only hope for containment lies with vaccination.
Since the launch of the Global Polio Eradication Initiative in 1988, polio cases worldwide have dropped by approximately 99% and two of the three wild virus varieties have been eradicated. Southeast Asia and Africa have been declared polio-free and there are only two countries left where the virus remains endemic: Afghanistan and Pakistan.
Cases in both countries have increased since 2014, compounded by conflict and security concerns, natural disasters and COVID-19, all of which have undermined community immunization efforts. In Afghanistan, there were 56 officially reported cases in 2020 (and likely many more that went unreported), up from 29 the previous year. In 2020, Pakistan recorded 84 cases of poliomyelitis, and 20 cases have already been detected this year, mainly in the virus hotspot of Khyber Pakhtunkhwa.
The failure to control and eradicate endemic poliomyelitis in these two countries poses a health threat far beyond their borders.
Three challenges must be overcome if poliomyelitis is to follow smallpox to extinction. First, at the global level, donors need to increase their financial commitment to the initiative. Second, national – and especially subnational – government institutions need to better coordinate and prioritize efforts to reach all communities. The final, and most important, challenge is to reduce community mistrust and reluctance to vaccinate in places like Afghanistan and Pakistan.
At the World Health Summit in Berlin last month, donors pledged $2.6 billion – including $1.2 billion from the Bill and Melinda Gates Foundation – to fund the five-year polio eradication strategy of the Global Polio Eradication Initiative. However, that leaves a significant shortfall of almost $1.9 billion. In the current climate of global and financial instability, donors may be reluctant to intervene. For example, the UK was heavily criticized for cutting its funding for polio eradication by 95% last year.
This makes the role of regional donors more important. The United Arab Emirates, for example, has long supported eradication efforts, particularly in Pakistan. Abu Dhabi has given the country more than $200 million since 2014 to pay for 600 million doses of the vaccine, protecting more than 100 million children. Amid the international shortfall, donors in the Middle East could find themselves under increased pressure to provide more funding.
International funding is important, but commitment and support at national and district levels are also critical to the success of polio campaigns. Governments must ensure both adequate infrastructure and safe access for health workers. District-level governments, however, often suffer from a lack of resources and struggle to juggle multiple and sometimes competing priorities.
In Pakistan, recent floods have diverted attention and spending from other programmes, but disasters have also presented opportunities: as part of humanitarian responses, emergency health facilities have been used to deliver vaccinations of routine, including polio, to affected children.
Eradication efforts in Afghanistan are even heavier. Prior to 2021, several Taliban-controlled district administrations banned local polio campaigns. Since taking control of the central government last August, the Taliban have revived the national agenda. But remote areas have less infrastructure, are difficult to access and are often governed by local authorities who can provide less support. An estimated 700,000 Afghan children cannot be reached by vaccination teams.
The biggest challenge is overcoming vaccine hesitancy in communities deeply suspicious of health campaigns. Parents may refuse to have their children vaccinated and health workers may face threats of violence. Not only does this put these communities at significant risk, but it also creates pockets of virus reservoirs, from which a wider regional and even global resurgence could occur.
To eradicate poliomyelitis, vaccination coverage must be high. The most common vaccine uses a weakened but still living form of the virus. In well-vaccinated communities, this weakened virus — which is shed and therefore can be transmitted — is harmless. But in places where large parts of a community remain unvaccinated, the vaccine can mutate into strains that can create symptomatic polio, including paralysis.
This form – known as circulating vaccine-derived poliovirus – has grown globally over the past decade, with recent outbreaks in parts of Africa eradicating wild poliovirus. Increased efforts to engage and work with communities are essential if vaccination is to be successful and all forms of the virus are to be wiped out.
Vaccine hesitancy is not just a matter of mistrust and ignorance. In February, eight polio workers were murdered in northern Afghanistan. It shows how local, national and even international politics and tensions can create distrust and suspicion around vaccination campaigns, undermining efforts to control the virus.
Increased efforts to engage and work with communities are essential for immunization to succeed.
After the United States allegedly used a fake vaccination campaign as part of its effort to capture al-Qaeda leader Osama bin Laden in Pakistan in 2011, anti-vaccine campaigns and attacks on vaccinators escalated. , leading to a marked decline in vaccination rates in some parts of the country.
The next four years are an opportunity to eradicate poliomyelitis once and for all. But this will require coordination to ensure that global, national and local challenges are addressed. Failure to secure full funding, improve coordination and gain the trust of communities would be a missed opportunity with devastating consequences.
- Michael Jennings is Professor of Global Development at SOAS University of London, where he works on issues related to global health as well as the politics and history of global development. Copyright: Syndication Bureau
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