Polio Endgame Strategy 2019-2023

Developed in consultation with Global Polio Eradication Initiative (GPEI) stakeholders from around the world, the Polio Endgame Strategy 2019-2023 will guide the GPEI and its partners to overcome the final hurdles to polio eradication. Wild poliovirus (WPV) transmission continues in Afghanistan and Pakistan, and circulating vaccine-derived poliovirus (cVDPV) outbreaks are ongoing in several countries across Africa and Asia - this, despite the vision outlined in the 2013-2018 Strategic Plan (see Related Summaries, below). Building on all the knowledge, tools, and approaches the programme has built over the years, the new plan focuses on three key pillars: eradication, integration, and containment + certification, as well as enabling factors such as such as gender, governance and management, and research. For each pillar, the document outlines specific goals, challenges, and solutions.

The GPEI stresses that the primary underlying challenge in the last mile to WPV eradication is missing children in the delivery of polio vaccines. Reaching every child can be difficult due to geographical isolation; mobility and mass migration, particularly across borders, also confound the programme's ability to reach children during supplementary immunisation activities (SIAs) and through house-to-house campaigns. In Afghanistan, the programme encountered bans on house-to-house campaigns in 2018, and in Nigeria, areas of Borno state remain totally inaccessible to vaccinators due to conflict. However, even when the programme does have access, pockets of vaccine refusals are growing where, due to misinformation, mistrust, cultural beliefs, fatigue, or other priorities, caregivers turn vaccinators away at the door.

The GPEI will address the ongoing challenges that slowed progress towards interrupting WPV transmission by continuing the core strategies, building on best practices, and adopting further innovative approaches, with a concentrated geographic focus by individualising strategies for each at-risk subdistrict, community, and street levels.

Collaboration is one communication-related thread common among the GPEI outlines as key innovations to focus efforts on the endemic countries and provide support to prevent and stop outbreaks in the Eastern Mediterranean and African regions. Namely:

• Afghanistan-Pakistan hub: A partnership hub is being established to consolidate support to Pakistan and Afghanistan in their strategic planning and implementation of National Emergency Action Plans (NEAPs), working in close collaboration with the national and subnational emergency operations centres (EOCs). The hub will ensure enhanced coordination across the epidemiological block and within each of the countries.
• Expanded partnerships: For example, the programme will collaborate within and beyond the health sector through development efforts (e.g., health, nutrition, and water, sanitation and hygiene [WASH]) and civil society (non-governmental organisations [NGOs] and civil society organisations [CSOs]) to increase community demand for immunisation and provide broader health benefits to endemic areas.
• Rapid response teams: To increase the speed and effectiveness of response to polio outbreaks, the GPEI has established a global outbreak response team from the World Health Organization (WHO) and United Nations Children's Fund (UNICEF) in Geneva, Switzerland, and will set up a similar multi-agency Rapid Response Team (RRT) for Africa.

Other key activities that will be carried out as part of the endgame strategy include: improved campaign quality; dedicated action plans for high-risk subnational areas; updated management structure and expanded membership of the GPEI Polio Oversight Board (POB) with the inclusion of Gavi, the Vaccine Alliance; expanded use of polio vaccinators to strengthen demand for essential immunisation and other health services at the community level; and more contextualised strategies within NEAPs to focus proven strategies on specific local challenges.

Goal 1: Eradication - To achieve this overarching goal, the two core eradication objectives are:

• to interrupt transmission of all WPV; and
• to stop all cVDPV outbreaks within 120 days of detection and eliminate the risk of emergence of any further VDPVs.

Communication strategies are particularly at the forefront when dealing with the issue of vaccine refusals. Possible solutions include:

• better understanding the drivers for polio vaccine acceptance and increasing demand for immunisation by, for example, fostering coordination between operations and social mobilisation teams through engagement with CSOs, particularly women's groups and religious organisations (see the Enabling areas: Gender equality and equity section of the document);
• expanding convergence programming by supporting community-based vaccination workers (in Pakistan) and Immunization Communication Network (ICN) workers (in Afghanistan) in identifying young children, newborns, and pregnant women who require preventive or curative services and referring them to local health facilities;
• addressing basic needs in communities highly vulnerable to polio by, for example, engaging with local governments, development partners, and CSOs (particularly female-led) to identify other private and public non-polio resources that can be integrated and tailored to meet local needs; and
• collaborating with global and regional humanitarian and development partners to raise funds outside of the polio budget to directly target basic needs in communities at high risk of poliovirus transmission.

Goal Two: Integration

• Contribute to strengthening immunisation and health systems to help achieve and sustain polio eradication.
• Ensure sensitive poliovirus surveillance through integration with comprehensive vaccine-preventable disease (VPD) and communicable disease surveillance systems.
• Prepare for and respond to future outbreaks and emergencies.

To address one of the challenges associated with the goal of integration, the GPEI will work to increase the efficiency of the global polio information system (POLIS) and ensure alignment with comprehensive global reporting and monitoring networks for VPD and epidemic-prone diseases. POLIS will systematically evolve to openly communicate and share data with the new WHO immunisation information system (WIISE) that is being developed.

Goal Three: Certification and containment

• Certify the eradication of WPV.
• Contain all polioviruses.

The GPEI plans to directly tackle the communication issues surrounding global certification by coordinating and aligning clear, cogent messages that define the scope and programme implications of certification through a "VDPV communications plan", developed in close collaboration with regions and countries. In addition, advocacy among GPEI partners and governing bodies, global and regional committees, and the World Health Assembly and other convenings will be continued to increase awareness of the scope and magnitude of work involved in poliovirus containment.

One of the enabling areas covered in the document is gender equality and equity. Women now represent 99% of all frontline workers in Nigeria, 68% in Pakistan, and 34% in Afghanistan. In applying a gender lens, the GPEI has stepped up the collection and analysis of sex-disaggregated data and the use of gender analysis to guide programming, create opportunities for women's leadership, and affirm that all women, men, and people of non-binary gender identities have a right to equal, meaningful participation in polio eradication. According to the GPEI, gender-responsive strategies have been effective at addressing refusals, establishing trust, and reaching every last child. The GPEI will collaborate with broader health and immunisation communities to share lessons learned and ensure that special attention is paid to ensuring women's equal participation going forward. The GPEI is committed to reaching gender parity (50%-50%) in all governance, technical advisory, and oversight bodies by 2020.

To reach its goals and achieve eradication, the endgame strategy requires a US$4.2 billion budget, of which US$3.27 billion is to be raised by the GPEI. In support of the Strategy and to encourage additional commitments, a pledging event will be hosted in November 2019 at the Reaching the Last Mile Forum in Abu Dhabi, a gathering of leaders from across the global health space held once every two years.

As the GPEI advances towards each goal in the endgame strategy, a midterm review will take place in 2021 to assess progress and ensure smooth transition planning and deliberate inroads to the post-certification period.