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2 Lessons from the Late Stages of the Global Polio Eradication Initiative R. Bruce Aylward Abstract Given the substantial influence that the Global Polio Eradication Initiative can be expected to have on future eradication initiatives, it seems increasingly important to identify and analyze lessons from each phase of this program. The protracted “tail” of the polio eradication initiative currently appears to be disproportionately influencing discussion of, and decisions on, future eradication efforts, particularly with respect to the potential merits of a future measles eradication effort. Consequently, for the purposes of this chapter the “late stages” of the polio initiative have been analyzed, with most attention to those geographical areas that have never interrupted wild poliovirus transmission and those which have been regularly reinfected. The major lessons that have been identified might be applied earlier in future eradication initiatives, ultimately increasing the prospects for their launch, early scale-up, and successful conclusion. The most pertinent lessons identified were in assessing operational feasibility, sustaining and applying research, conducting effective advocacy at the subnational level, operating in insecure areas, and anticipating and addressing vulnerabilities in areas with especially weak health systems. Introduction Launched in 1988 through a resolution of the World Health Assembly, the Global Polio Eradication Initiative (GPEI) has grown to become one of the most ambitious, internationally coordinated health initiatives in history (Fine and Griffiths 2007), and certainly the largest eradication effort to date. At its peak of field operations, the program directly employed over 4000 people globally, managed an annual budget of approximately USD 1000 million, and maintained active field operations in more than 75 countries (WHO 2003a). Each year, millions of people were engaged to vaccinate hundreds of millions 14 R. B. Aylward of children in multiple mass vaccination campaigns with oral poliovirus vaccine (OPV). Consequently, the GPEI may offer insights to facilitate the pursuit of future eradication initiatives, particularly against widespread, highly contagious but vaccine-preventable pathogens such as the measles virus. This article takes as its starting point the operational and technical challenges that the GPEI has faced since the year 2000, the original target date for interrupting wild poliovirus transmission globally (WHO 1988). Many of the lessons from the earlier launch and scale-up of the GPEI are either self-evident or documented elsewhere (Aylward et al. 2003; Aylward and Linkins 2005). Furthermore, lessons from the late stages of this initiative may have the greatest implications for improving the speed and efficiency of future eradication efforts, thereby avoiding the inevitable problems of fatigue and waning confidence associated with setbacks and missed milestones. This perspective also seemed most relevant to the international dialog on eradication at the end of 2010, as the GPEI’s “late stage” challenges appeared to be having the greatest influence, whether consciously or unconsciously, on that debate and especially in the context of a future measles eradication effort. Context Although the GPEI was launched in 1988, most polio-infected countries initiated eradication activities only in the mid-1990s, with the last two countries (Democratic Republic of the Congo and Sierra Leone) only beginning in 2000 (Figure 2.1). A combination of global, regional, and country-specific factors was responsible for the delays. Available financing was part of the equation, but in some areas there was simply a lack of sociopolitical “buy-in” to the global eradication goal, ranging from that of key health authorities to the broader sociopolitical environment. This reflected the lack of commitment to the fundamental eradication strategies by many public health officials and an insufficient understanding and acceptance of the enormity of the operational challenges to implement them globally (WHO 2008b). Thus the successful adaptation and implementation of the original PanAmerican Health Organization (PAHO) polio eradication strategies in the Western Pacific Region of the World Health Organization (WHO) was pivotal, as it provided the proof of “operational ” feasibility in large population countries (China) and fragile states (Cambodia in the early 1990s) that many decision makers seemed to require. As polio eradication efforts scaled up rapidly in other areas of the world, progress was dramatic (Figure 2.1). In contrast to the misconception that most countries have been trying to eradicate polio for over twenty years, the average time from strategy initiation to interruption of indigenous wild poliovirus was only two to three years (Figure 2.2). The few areas that remained “endemic” by the mid-2000s were the exceptions. However, it is these “exceptional” areas of [3...

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