In 2004, the world has a one-time opportunity to stop the transmission of poliovirus. A rare confluence of factors, driven by the epidemiology of the disease, provides the world with a rare chance to end the crippling scourge of polio, thereby creating a legacy of a unique global public good from which all children will benefit.
The world has never had a better chance to end polio. It may also be the last chance. If the world does not seize the opportunity now, both risks and costs will increase dramatically. Failure to stop transmission in 2004 could squander a fifteen-year investment in polio eradication made by over 200 countries and 20 million volunteers at an international investment of more than US$3 billion. Governments in the six remaining endemic countries must act immediately, urgently and decisively over the next 12 months to stop poliovirus transmission in the remaining strongholds.
New opportunities: the best chance ever
Epidemiology: Success within reach in the remaining polio strongholds
Wild poliovirus now is endemic in only six countries – Nigeria, India, Pakistan, Niger, Afghanistan and Egypt – the lowest number in history since polio was first recorded.
Polio transmission is now primarily confined to a limited number of polio “hot spots" within these endemic countries. Five states and provinces within Nigeria, India and Pakistan are linked to more than 75% of all new cases of polio worldwide, and represent the key to stopping transmission globally. While intensifying immunization activities is essential wherever the virus still circulates, polio cannot be eradicated unless transmission is halted in these five hot spots.
In the late 2003 high season for poliovirus transmission, three key poliovirus reservoirs – India, Pakistan and Egypt - had the lowest levels of poliovirus transmission ever recorded. India, Pakistan and Egypt’s success sets the stage for stopping transmission there in the next six months.
Experience from every country in the world demonstrates that polio transmission can be stopped in 2004 -- but only if governments in the remaining endemic countries act immediately to ensure high quality vaccination campaigns reach every child in even the most densely populated or difficult areas.
While northern Nigeria had more cases than any other area in the world in 2003, experience in southern Nigeria demonstrates that with a sufficient number of high quality nationwide activities, transmission could be stopped within 12 months.
Campaign Quality: New Improvements to Combat Old Challenges
In India, for the first time, minority populations are being reached with a higher number of vaccine doses. In the key state of Uttar Pradesh, data show at least 87% of children from minority populations had received at least four doses of polio vaccine in 2003, compared to only 58% in 2002.
In Egypt, in the greater Cairo “megacity” (Cairo, Giza and Kalyoubia), improvements were seen in 2003 over 2002, as data show 65% of children had received at least 5 doses of polio vaccine in 2003 (versus 19% in 2002).
In Pakistan, vaccinators are gaining access to increasing numbers of households by employing female vaccinators who can enter every home to search and immunize previously unreached children.
Political Interest: Eyes now on the prize
Polio eradication is now a top line concern of leading international organizations, donors and multilateral institutions. Polio eradication was discussed at a number of key Summit meetings in 2003, including the African Union Summit, the Organization of the Islamic Conference Summit (OIC), and the G8 Summit.
Within each of the remaining polio-endemic countries – Nigeria, India, Pakistan, Egypt, Niger and Afghanistan – national and subnational leadership is now focused on the goal of stopping polio transmission by end-2004.
Significant risks: a last chance?
Epidemiology: Vulnerability to Poliovirus Importations
Polio knows no borders. The world’s few remaining reservoirs of poliovirus continue to pose a significant risk due to the threat of polio importations, which can spread rapidly and threaten millions of unprotected children. All countries – and all children - remain vulnerable to importations of the wild poliovirus until it is eradicated everywhere.
As a result of scarce financial resources, almost every polio-free country stopped their polio immunization campaigns in 2003, thereby leaving millions of children more vulnerable to poliovirus importations. In 2000, more than 100 countries conducted preventive immunization campaigns. In 2003, only 15 countries did so, with the result that children from Lebanon to Lagos were susceptible to poliovirus imported from the world’s remaining polio reservoirs.
The India epidemic of 2002 and the spread of the Nigerian virus in 2003 demonstrate the speed with which the virus will exploit this vulnerability. For example, importations from a polio hotspot in northern Nigeria (Kano) have now infected six neighbouring countries (Benin, Burkina Faso, Cameroon, Chad, Ghana and Togo) that were previously polio-free. Subsequent resulting mass immunization campaigns had to be organized in these countries, at an international cost of US$20 million.
Campaign Quality: A limited window for success
In all communities, the massive investment of health and civil administration resources will not be sustainable.
In India, upcoming national elections in November 2004 may seriously hinder or prevent civil administrators from lending their full support to vaccination activities.
In Pakistan, the use of female vaccinators may not prove sustainable were there to be a potential cultural backlash.
Political and Financial Support: Critical Need, Limited Duration
Commitment to polio eradication may not be sustainable beyond 2004 as other health, social and political issues clamour for the world’s attention.
The opportunity costs – as well as the financial, manpower and morale – of failing to stop poliovirus transmission grow significantly with each passing month. If transmission continues beyond mid-2005, costs to the program are estimated to increase by US$339 million (2005-06).
There is an ever-shrinking pool of international and national resources available for implementing polio eradication activities. Large-scale, costly efforts to halt the ongoing transmission of poliovirus beyond 2004 will be difficult to justify.
In 2004, the world now has its best -- and perhaps last -- chance to end polio. Now more than ever: end polio forever.