Beyond Eradication: The United States' Role in Sustaining Public Health Gains Achieved Through Polio Programs

"Sustained investment and policy leadership by the United States will enable the eradication and certification of polio, harness its momentum for broader health gains, and foster tremendous impact on strengthening public-health systems globally to save lives."

This analysis from PATH provides policy recommendations for the United States (US) government (USG) to protect the public health gains made through Global Polio Eradication Initiative (GPEI), which is on the brink of achieving a polio-free world thanks in part to financial investments and technical support provided by the US Centers for Disease Control and Prevention (CDC) and the US Agency for International Development (USAID). The CDC serves as the lead technical agency together with the World Health Organization (WHO) in providing scientific, research, and programmatic leadership for GPEI. CDC and USAID coordinate efforts through regular meetings and informal communications as well as through host-country-led planning processes. The paper explores these roles and provides recommendations for each group going forward, as well as for USG political leadership.

To begin, the paper traces the roadmap to a polio-free world, noting that, to be certain of its eradication, polio will remain a mandatory reportable disease into the future. Beyond ensuring that polio eradication endures, the authors argue that opportunity exists to safeguard the broader public health gains achieved through eradication efforts. For example, in light of an imported case of Ebola in Nigeria in October 2014, GPEI-trained and/or -funded health workers undertook 19,000 contact-tracing visits and reached 27,000 households through social mobilisation, containing Nigeria's outbreak at just 19 cases.

To better understand how health systems might be impacted by winding down polio-eradication efforts, GPEI is working with countries to develop "transition plans". This paper argues that the USG must prioritise planning for these transitions with countries, identifying national and local stakeholders who will need to be trained and engaged to ensure the successful shift to long-term sustainability and country ownership. Namely:

• What CDC has contributed to the polio effort: Examples include using geographic information system tools and social-mapping techniques to improve immunisation coverage in countries such as Burkina Faso, Ethiopia, Kenya, and Nigeria and implementing the stimulate, appreciate, listen/learn, transfer (SALT) approach, which encourages the development of locally tailored, specialised communication strategies to increase polio vaccination acceptance in countries such as the Democratic Republic of the Congo (DRC). How CDC is contributing to the transition: CDC has established the Polio Legacy Transition Task Force, one of whose tasks includes development of detailed strategic materials for the maintenance of public health programmes funded through polio. CDC is also helping countries develop their own transition plans by encouraging their importance in bilateral diplomatic discussions.
• What USAID has contributed to the polio effort: USAID's polio-related efforts meet are done in conjunction with implementing partners through USAID's Maternal and Child Survival Program (MCSP), CORE Group Polio Project (CGPP), The Communication Initiative, WHO, and UNICEF. Polio funding supports endeavours such as communication and social mobilisation around vaccination, building public trust in immunisation, and engagement of international and local non-governmental organisation (NGO) networks that focus on cross-border, migrant, mobile, and hard-to-reach populations. USAID brings a community and capacity-building focus to its GPEI efforts. For example, as part of USAID's supports of the CGPP in India, CGPP tracked children under 5 years old in high-risk areas to discover the reasons they were not vaccinated and followed up by visiting homes, engaging influencers, and working with communities and schools. CGPP also gave further training to community mobilisers, launched mass media campaigns, developed communication materials, partnered with local health systems, and conducted other activities focused on building community trust. How USAID can contribute to the transition: "USAID must develop a plan, in consultation and coordination with host governments, for sustaining the gains achieved through its polio programs by cataloging its polio-specific efforts that must remain beyond eradication, identifying how to transition and build upon its assets, and documenting learning to support other vaccine-preventable diseases that build on the success of polio."

The authors also argue that political leadership will be needed, particularly in light of the newly elected presidential administration, which will be tasked with finalising budget requests for fiscal year (FY) 2018 and FY2019. "Advocates and technical experts must speak with a unified voice to ensure alignment within immunization priorities. Concentrated efforts to educate decision-makers about what is at stake as well as solutions to avoid health-system gaps are needed to ensure that the USG's valuable support continues to strengthen health systems and immunization services."