Some Lessons for Malaria from the Global Polio Eradication Initiative

"Thirty-two years of hard work against polio provide an array of lessons potentially useful to malaria and other disease eradication campaigns, building on the diversity of gains achieved and also the variety of setbacks encountered by the GPEI to date."

Acknowledging the deep differences between malaria and polio and the stages in their path towards eradication, this paper draws from the history of the Global Polio Eradication Initiative (GPEI) and highlights relevant insights into what it takes to eradicate a pathogen. It focuses on key questions of the GPEI whose answers may be of relevance to the malaria eradication effort, such as those around priority setting, global governance, strategy, community engagement, surveillance systems, and research. Above all, it shows the need for openness to change and adaptation, as the biological, social, and political contexts vary throughout the time an eradication campaign is ongoing.

The paper begins by describing the development of the Global Malaria Eradication Programme (GMEP), which the World Health Organization (WHO) initiated in 1955, as well as the WHO-led GPEI, which was launched in 1988. Analysing current trends and challenges on the prospects of malaria eradication was the task of the WHO Strategic Advisory Group on Malaria Eradication (SAGme), commissioned in 2016. SAGme stated in 2020 that in the context of more than 200 million malaria cases reported, eradication was far from reach in the near future and, therefore, efforts should remain focused on getting back on track to achieve the objectives set by the Global Technical Strategy against Malaria (2016-2030). SAGme began intently looking at lessons learned from other disease eradication efforts, including the GPEI, a massive effort that has led to only 2 countries (Afghanistan and Pakistan) still reporting wild poliovirus (WPV) in 2019. The Smallpox Eradication Programme, which was launched in 1960 (succeeding 20 years later, when smallpox was officially declared eradicated thanks to vaccination) is another example of an effort SAGme considered.

Having outlined some controversies around the launch and continuation of the GPEI, the paper looks at polio governance, describing, for example, elements such as the Rotary-supported National Polio Plus Committees, which contribute with health interventions alongside polio vaccination campaigns. Along those lines, there has been a shift towards increased integration of activities, which has been fostered by recognition of best practices throughout the implementation of the GPEI. For example, in Africa, polio eradication has been linked with other child survival strategies and support to coordination and communication, which has benefited both polio and other disease control programmes. To that end, in July 2020, the GPEI included the concept of integration among the priority issues to be improved when considering the initiative structure and decision-making processes, based on the results of a stakeholder survey.

Lessons have also been learned from polio eradication around importance of building and maintaining capacity for research, innovation, and epidemiological studies. For instance, environmental surveillance (ES) that detects wild poliovirus in sewage samples has been useful, as described here, in supporting the GPEI, particularly in high-risk countries. "Surveillance data have been critical to the ability redirect strategies and adapt them to changing circumstances, identify transmission routes in populations crossing borders and contribute to the development of vaccination strategies for migrant and mobile populations and other hard to reach target groups."

Community engagement and social factors are described here as crucial for success. The GPEI has faced some crises related to lack of trust, such as the 2003 stoppage of oral polio vaccination in Nigeria following rumours that oral polio vaccine (OPV) was contaminated with HIV and/or hormones to sterilise Muslim populations. One year after the interruption of vaccination in Nigeria, the number of cases doubled, re-infecting around 20 previously polio-free countries, including those affected by conflict, where organising vaccination campaigns was already challenging. In such places, access is the key challenge to vaccination, making high-level political negotiations to facilitate immunisation campaigns necessary. "Overall, the community's hesitancy to accept polio was fueled by genuine fear, internal rivalries and unattended health problems, such as malnutrition and malaria considered by the population and local leadership as more urgent than polio (and treated for a fee), that fueled the perception of polio eradication as an imposed, foreign agenda."

This example reinforces the importance of community engagement and involvement of religious leaders: "It took a site visit of a Nigerian team to a vaccine manufacturer in Indonesia (a Muslim country) along with unprecedented support from religious leaders, to restart the Nigerian vaccination programme the following year....Effective components of the strategy to overcome vaccine hesitancy included the formation of an Islamic Advisory Group for Polio Eradication, mass communication campaigns and Fatwas in support to polio vaccination by leading Islamic leaders."

All in all, the "GPEI developed a robust capacity for identifying communities with vaccine hesitancy and those not accessing immunization services due to logistics, culture, politics, ethnicity, gender, marginalization or security, developed context-specific communications strategies and social mobilization methods, and forged local partnerships with traditional, religious, and community leaders..."

The paper closes by reviewing overall lessons from the GPEI that may be useful for the malaria field; communication-related examples include:

• Challenges may come from a variety of sources, including mobile and migrant communities, which are likely to be key in sustaining transmission. These groups require targeted strategies, including cross-border collaboration and data sharing, as well as specific surveillance systems capable of providing data for real-time decision-making. Insecurity is also a fundamental factor affecting the capacity to reach intended populations.
• Different voices have emphasised the value of country-led governance, making coordination even more relevant. Independent bodies with a coordination role may be useful at the regional, national, and even sub-national levels (particularly to support implementation and community engagement), but may also create new challenges.
• The use of evidence for decision-making requires knowledgeable cadres in endemic countries capable of identifying problems, proposing solutions, and evaluating their own data. Relevant activities in this field include training and leadership programmes to enhance the capacity and to build bridges that allow different groups to listen to each other.
• "Acceptability and local ownership of the value of public health interventions are critical for the success of any eradication effort. Targeted research efforts are required to understand factors that contribute to or challenge acceptance of the relevant interventions, particularly those delivered as community campaigns, and to develop strategies to reach vulnerable and distant populations. The polio experience shows that sociocultural and political aspects need to be understood when designing strategies to overcome barriers to health campaigns, and provide important lessons on the role of community engagement and other social factors in eradication efforts."
• "When planning for the future, it should be remembered that community engagement is not just a matter of explaining the advantages of the proposed interventions or to deliver them with other health services that the community is more willing to accept, but to authentically acknowledge health priorities of specific contexts, and responding to them through strategies and packages of interventions that the communities themselves have contributed to shape. More specifically, malaria communications and community ownership will need to address the power of community interventions that can both directly and indirectly affect the community and individual risk of malaria."

In conclusion: "The need for parallel innovation, better use of data, inclusive governance, appropriate level of integration and, above all, flexibility and openness to change in all relevant areas, often not under the direct purview of the health community, are among the key lessons from GPEI to malaria."