The USAID Polio

Eradication

Initiative

1998 Reportto Congress

~ Progress and Partnerships·11111'

o•

POlio

Have You Se15 Ye en a Child

Pleasears cripPled th. less than

repOrt t IS Year?H 0 the .

ealth faCility.nearest

Take your child under1he ag

5 to the nearest centre.

JANUARY IS· IG

j

Thble of Contents

Executive Summary ii

Acronyms v

I. Introduction 1

A. Overview 1B. Polio Partners 2

II. The USAID Polio Eradication Initiative 4

A. The PEl Strategy 4B. PEl Results Framework 4C. PEl Funding 5D. 1998 Activities/Accomplishments 6

III. Partnerships and Progress 9

A. Overview '" 9B. Africa Shows Progress 13C. Asia and Near East: Progress Toward Eradication 17D. Operation MECACAR Moves Forward 19E. Latin America and the Caribbean 19E Western Pacific Region 19G. Global Projects 20

IV. Challenges in 1999 21

A. Challenges Ahead 21

AnnexTable 1:Table 2:Table 3a:Table 3b:Table 3c:Table 3d:

FY 1998 Budget by ResultsSummary Budget FY 1998Africa Region Funding FY 1998Asia Near East Region Funding FY 1998ENI Region Funding FY 1998USAID Funding for Global Activities FY 1998

Cover photo by Richard FrancolWHO

Executive Summary

The United States Agency for Interna­tional Development (USAID) is now in its thirdyear of support for the Polio Eradication Ini­tiative, an initiative launched in 1996 as partof the global effort to eradicate poliomyelitisby the year 2000. To carry out this initiative,USAID collaborated with its Polio Partners­the World Health Organization (WHO), Ro­tary International, U.S. Centers for DiseaseControl and Prevention (CDC) and UNICEF­in developing a strategic framework that buildson the lessons learned from the successfuleradication of polio in the Americas. Theselessons include the importance of workingclosely with donor partners, host governmentsand community organizations; establishing In­teragency Coordination Committees at coun­try and regional levels; the value of measuring

"I am very grateful for the extraordinarywork of Rotary International. Working togetherwith global partners-WHO, UNICEF, USAID,and CDC-its worldwide volunteers have im­munized over one billion children against po­lio. We can eradicate this disease by the year2000. And we can give the children of the 21stcentury a world without polio."

William J. Clinton,President of the United States

specific indicators of program success; andthe benefits of harnessing the enthusiasm andcommitment of those involved in eradicationefforts, including community members. Thisframework has proven to be effective and tre­mendous progress is being made. The strat­egy focuses on:

Building effective partnerships

Strengthening health systems and theroutine Expanded Program for Immuni­zation

• Ensuring effective supplemental polioimmunization through National Immuni­zation Days and mop-up campaigns,where polio vaccine is given to all chil­dren under five in two rounds, four to sixweeks apart, regardless of prior immuni­zation status

Improving acute flaccid paralysis (AFP)surveillance and laboratory capability toidentify cases of polio

Improving information collection and usefor continuous program improvement

Congressional support from 1996 throughfiscal year 1998 has provided a total of $70 mil­lion for the initiative. More than 85% of USAIDresources directly support country-level pro­grams; the remaining 15% support regional orglobal activities. A snapshot of recent accom­plishments follows:

Since the global eradication goal wasestablished a decade ago, the number ofreported cases of polio has declined bynearly 85%, from a high of 35,000 re­ported in 1988 to 5,673 confirmed casesin 1998.* More than half of all casesconfirmed are found in five countries inSouth Asia.

Steady improvements have been made inacute flaccid paralysis surveillance andreporting, especially in the South Asiaregion; however, improvements areurgently needed in the Africa region,where surveillance is not yet well estab­lished.

National Immunization Days (NIDs)reached more than 450 million children inmass immunization campaigns in 74countries in 1998. Many countriesreported that more than 95% of the

"'All statistics cited are from the World Health Organization and the Centers for Disease Control and Prevention.

11

eligible child population was reached;efforts are now underway to verify thesefigures. During a recent NID in India,two million volunteers were deployed toimmunize 130 million children in a singleday.

WHO assessed 112 laboratories in 1998,giving full or provisional accreditation to90. Laboratory capability is critical tothe eradication effort. The WHO GlobalPolio Laboratories Network (LABNET)consists of 133 national and regionalvirology laboratories that are or will becapable of confirming AFP and poliocases. USAID is the largest bilateraldonor to this global network.

The collaboration between USAID andthe Government of Japan under theU.S.-Japan Common Agenda for Coop­eration in a Global Perspective hasencouraged the Japanese government toincrease funding for polio and otherimmunization activities and has boostedits support of eradication in Africa.

The Voice of America (VOA) expandedits radio coverage on eradication activi­ties, and its partner, WORLDNETTelevision, joined the eradication effort.More than 900 VONWORLDNETbroadcasts supporting eradication havebeen heard in 22 countries. Thesebroadcasts include radio dramas, con­tests, polio fan club reporting and avariety of innovative features, all in locallanguages.

While major steps have been taken to­ward eradication, in much of the developingworld much more remains to be done. USAIDis working with its Polio Partners to addressthese challenges, such as the fundamental needto raise static or declining routine immuniza­tion rates. Surveillance and a functioning labo­ratory network are critical components in

III

achieving and documenting eradication. Theimmunization of children in war-torn areaspresents a challenge that must be met, espe­cially since movements of people escaping civilstrife can result in the virus being reintroducedin areas thought to be polio-free. USAID andits Partners are actively seeking "Days of Tran-

In Its third year of NIDs, India was able toImmunize 130 million children in December1997, and again in January 1998-the largestpublic health events in history.

PhcXobyJ.F. CretienlWHO

quility" to allow immunization to take place inthese troubled areas.

National commitment and funding sup­port must also be addressed. With many com­peting priorities, some countries are reluctantto continue support for more than three yearsof supplemental immunization activities. Inaddition, keeping countries focused on certifi-

cation-not just completing three years ofNIDs-is proving to be a greater challenge thanexpected. USAID and its Partners are advo­cating for increased local resources and com­mitment, both government and private, butfunding gaps remain. WHO estimates that anadditional $350 million is needed to cover thecosts of country-level eradication activitiesthrough 2001, and global and regional needscould widen the gap further. USAID intendsto continue support at $25 million annually in1999 and 2000, and will work with its Part­ners to advocate for funding from other donorsand private sector sources.

The Polio Partners collaboration is result­ing in significant achievement and is proof thatmajor improvements in global health are pos­sible when governments, institutions and indi­viduals work together to address common con­cerns. The collaboration is resulting in stronginteragency coordination that is strengtheningnational health systems at all levels. This is thelegacy that USAID hopes to leave for theworld's children: a legacy of a polio-free world,global cooperation, and strong and sustainablehealth systems to monitor and prevent thespread of disease.

ACRONYMS

AFP

ARCH

BASICS

BIMAA

CDC

CHANGE

CORE

DANIDA

ENI

EPI

FY

G/PHN

ICC

INCLEN

JOCV

LABNET

LAC

MECACAR

MOH

MOU

NGO

NID

NIS

OMNI

PAHO

PEl

PVO

SNID

TFI

UNICEF

UNFPA

UPHAAR

USAID

VOA

WHO

WHO/AFRO

WHO/EURO

WHO/EMRO

WHO/SEARO

WHO/WPRO

Acute Flaccid Paralysis

Applied Research on Child Health (USAID Project)

Basic Support for Institutionalizing Child Survival (USAID Project)

Bihar Immunization Acceleration Activity

U.S. Centers for Disease Control and Prevention

Behavior Change Innovations (USAID Project)

Child Survival Collaboration and Resources (USAID Project)

Danish International Development Assistance

Eastern Europe and New Independent States (USAID Regional Bureau)

Expanded Program on Immunization

Fiscal Year

Global Bureau, Center for Population, Health, and Nutrition (USAID)

Interagency Coordinating Committee

International Clinical Epidemiology Network

Japan Overseas Cooperation Volunteers

WHO Global Polio Laboratory Network

Latin America and the Caribbean (USAID Regional Bureau)

Middle East, Caucasus, Central Asia Republics

Ministry of Health

Memorandum of Understanding

Non-Governmental Organization

National Immunization Day

New Independent States

Opportunities for Micronutrients Initiative (USAID Project)

Pan American Health Organization

Polio Eradication Initiative

Private Voluntary Organization

Sub-National Immunization Day

Task Force on Immunization (in Africa)

United Nations Children's Fund

United Nations Fund for Population Activities

Uttar Pradesh Health Acceleration Activity and Review

United States Agency for International Development

Voice of America

World Health Organization

World Health Organization/Africa Regional Office

World Health OrganizationlEurope Regional Office

World Health Organization/Eastern Mediterranean Regional Office

World Health Organization/South East Asia Regional Office

World Health Organization/Western Pacific Regional Office

I. Introduction

The USAID Polio Eradication Initiative(PEl) is a vital component of the global polioeradication effort. In 1988, the U.S. govern­ment joined with other member nations of theWorld Health Assembly to adopt a global reso­lution to eradicate polio by the year 2000, inthe context of improving national immuniza­tion and disease control programs. USAID andits Partners are striving to ensure that polio­virus transmission can be interrupted by theend of the year 2000 or shortly thereafter.

A. Overview

WHO is divided into six regions, eachof which must individually certify their polio­free status. A country is free of polio whenthe wild poliovirus ceases to circulate and novirologically confirmed cases are found. Fora region to be certified as "polio-free," all coun­tries in the region must meet strict criteria forthree consecutive years. The criteria include:

the absence of confirmed polio casesand of detectable wild poliovirus

the presence of an adequate surveil­lance system

on-site evaluation by a national certifica­tion commission

establishment of appropriate measuresto handle importations

The Americas Region met these criteriain 1994. The WHO/Western Pacific Region(WPR) is approaching the necessary standardof surveillance and is preparing to submit itsfirst year of documentation for certification.It is hoped that all regions will gain certifica­tion status by 2003-05.

Much needs to happen before global cer­tification occurs. Health systems should striveto reach the 90% target level set by the globalExpanded Program on Immunization (EPI), thusassuring that children are fully immunized bytheir first birthday, and that populations are pro­tected against reimportation of the poliovirus.High quality National Immunization Days andmop-ups must continue in most countries forthe next several years to further boost popula­tion immunity and interrupt the chains of trans­mission. Surveillance systems must be in placethat can identify and report all remaining reser­voirs of the wild poliovirus, and the WHOLABNET system must be fully functional to ana­lyze and identify polio and AFP cases.

Transmission of wild poliovirus is now con­centrated in two major reservoirs in South Asiaand sub-Saharan Africa. Infection rates are high­est in the largest and most populous countries­Bangladesh, India and Pakistan in Asia, and the

What is polio? Polio is an infectious viraldisease that is spread from person to person, usu­ally through close (fecal) contact, with more than95% of cases occurring in children younger thanfive years of age. Transmission is most intense indensely populated areas with poor sanitation. Inone in 200 cases, the virus kills the nerve cellsthat activate the muscles. The dead nerve cellscannot be replaced; the result is usually lifelongparalysis or, in some cases, death.

Democratic Republic of Congo (DRC), Ethio­pia and Nigeria in Africa. High infection ratesare also found in a number of smaller countries,such as Angola. Each of these countries, withthe exception of the DRC, have initiated NIDsand especially in Asia, have succeeded in low­ering transmission rates.

\

Figure 1

much of the developing world much more re­mains to be done. USAID is working with itsPolio Partners to address these challenges, suchas the fundamental need to raise static or de­clining routine immunization rates.

USAID and its Polio Partners-WHO, Ro­tary International, UNICEF and CDC-areworking closely with host country governments

in Africa, Asia, Eu­rope and the New In­dependent States(ENI Bureau) regionsto promote andstrengthen eradica­tion efforts and im­prove links withother immunizationservices. Working to­gether, the Polio Part­ners monitor routineimmunization cover­age, provide techni­cal advice and reporton polio and EPIcoverage at country.regional and interna-

Surveillance and a functioning laboratorynetwork are critical components in achievingand documenting eradication. The immuni­zation of children in war-torn areas presents achallenge that must be met, especially sincemovements of people escaping civil strife canresult in the virus being reintroduced in areasthat were once polio-free. USAID and its Part­ners are actively seeking "Days of Tranquility"to allow immunization to take place in thesetroubled areas.

B. Polio Partners

Urutal Nations ChiJdrm ~ Fund

unicefe

, ,'••'1"

81'

:;j - i'l

• l79ji •

CDC

National Immunization Days, surveillanceand mop-up campaigns go hand in hand inthe eradication effort. NIDs are mass immuni­zation campaigns designed to stop the circula­tion of the wild poliovirus by immunizing ev­ery child under five in two rounds four to sixweeks apart, regardless of prior immunizationstatus. Three to five years of NIDs are usuallyrequired to eradicate polio, but in some coun­tries, where routine immunization levels are low,it can take longer.

While major stepshave been taken to­ward eradication, in

A strong surveillance system will identifywhere mop-up campaigns should take place.In the final stages of polio eradication, therewill be a few remaining areas where the polio­virus persists. These are likely to include urbanslums, where population turnover is high andhealth services inadequate, and where over­crowding and poor sanitation provide fertileground for disease transmission. The most vul­nerable population groups include minorities,nomadic groups, refugees and those who livein isolated or hard-to-reach areas. Surveillancedata are used to identify these geographicalareas, as well as the demographic characteris­tics of the high-riskgroups. Mopping-upimmunization is thencarried out in the de­fined areas. To ensurethat every child isreached, the vaccine iscarried and adminis­tered house to house.As with NIDs, twodoses are given amonth or so apart to allchildren under five, re­gardless of prior immu­nization status.

tional meetings. USAID is also supporting jointresearch on the impact of polio eradication ef­forts on health systems and is exploring cost­effective methods of providing supplementalimmunization.

USAID provides technical assistance andfinancial support for a variety of activities. TheAgency administers most of its support throughgrants to WHO and UNICEF. USAID also drawson the skills and experience of its technical staffand that of its cooperating agencies. Other im­portant polio partners are community groups.private and nongovernmental organizations(PVOs/NGOs), the Voice of America and otherbilateral donors, including the governments ofAustralia, Canada, Denmark, Japan, Swedenand the United Kingdom.

The Polio Partners provided an estimated$193 million in funding in 1998. Activities fo­cused on strengthening NIDs and mop-up cam­paigns, surveillance, the laboratory network andsocial mobilization, as well as the routine im­munization system. The Partners sponsoredand participated in regional and national ad­vocacy and planning meetings, all designed tostrengthen national systems, share informationand motivate participants.

Rotary International'sCommitment to Polio Eradication

Rotary International committed to polio eradi­cation in 1985, itsflrst global cause. Rotary hasraised more than $240 million in private donationsfor the initiative and has contributed more than$335 million through its 1.2 million members and23,000 clubs in 158 countries. The organizationexpects to spend nearly $500 million in total bythe time eradication is achieved. Rotary volun­teers help organize and participate in NIDs; theyare active in advocacy efforts and work with otherdonors and governments to support the initiative.Rotary plays an important advocacy role on Capi­tol Hill, regularly appearing before the U.S. SenateAppropriations Subcommittee to advocate for andpromDte polio eradication efforts.

,

.. .. ...liCK POLIO OUT OF

IMMUNIZE YOUR CHILD ONNOVEMBER 7 AND AGAIN ON DECEMBER 19. 1998.

llQl Donated by ROTARY INTERNATIONAL andROTARY DlSI'RICT 5170

~~~-:--~~

Social mobilization - GhanaPhoto by Kwobello OforiNOA r-------~~~~~-~~~--"

II. The USAID Polio Bradication Initiative

A. The PEl Strategy

The Agency PEl strategy is designed toachieve the eradication of polio within the con­text of a strong and sustainable routine immu­nization and disease control system, an essen­tial foundation for basic primary health careservices in the developing world.

USAID assistance for polio eradication ini­tially focused on Latin America and the Carib­bean (LAC), where the Agency was the majorexternal donor (Figure 2). After the Americaswere certified polio-free in 1994, the U.S. shiftedits geographic focus. In 1996, with the encour­agement and support of the United States Con­gress, USAID launched the PEL The PEl strat­egy incorporated the many lessons learned fromten years of support to the LAC region. Theseincluded the importance of collaborating closelywith donor partners, host governments andcommunity organizations, establishing Inter­agency Coordinating Committees (lCCs) at

External Donor Contributions to Polio EradicationEfforts in Latin America, 1987-1996

country and regional levels, the value of mea­suring specific indicators of program success,and the benefits of building partnerships to har­ness the enthusiasm and commitment of allthose involved in eradication efforts, includingcommunity members.

The USAID PEl reflects a continuing po­litical commitment to polio eradication. As theyear 2000 approaches, USAID and its PolioPartners are accelerating eradication activities,with a strong focus on conducting high qualityNIDs and mop-up campaigns and strengthen­ing surveillance reporting and the laboratorynetwork.

B. PEl Results Framework

The five strategic elements (Figure 3) ofthe PEl Results Framework are:

1. Build effective partnerships

USAID supports partnerships at both theregional and national levels, including estab­lishing Interagency Cooperating Committeesto promote improved collaboration betweendonors and governments.

Fgve 2

Souce· PAHONet Rotary review ng ts flJrdi'1g rf til. or hiS tIme er d: II IS he evrd to beh',jher lhd' PAHO pert·<I ',~ures

Total expenditures lor the period: $69 million

2. Strengthen systems

USAID supports activities to enhance na­tional capacity to provide high-quality oral po­lio vaccine through routine and supplementalimmunization systems. This includes improvedtraining, supervision, logistics, planning, coldchain assessment and management, and pro­gram management for polio and other child­hood illnesses. Where feasible, USAID supportsincluding vitamin A in NIDs and EPI activities.

USAID

SpainCIDASweden

4

3. Ensure effective supplementalimmunization through ruos andmop-up campaigns

USAID resources are used in planning andimplementing strong supplemental polio immu­nization campaigns, including targeted mop-upactivities in high-risk areas.

4. Improve Acute Flaccid Paralysissurveillance and laboratoryinvestigation

USAID funds are used to strengthen ex­isting surveillance systems and to support thedevelopment of new surveillance systems todetect, report and respond to outbreaks of po­lio and other infectious diseases. USAID alsoprovides substantial support to the global WHOLABNET system.

5. Improve information collection anduse

USAID supports data and informationcollection to monitor, evaluate and continuallyimprove the quality of PEl activities.

c. PEl Funding

In FY 1996, with the support of the U.S.Congress, USAID allocated $20 million for thePEl, and in each fiscal year since an additional$25 million has been allocated, for a total of$70 million to date (Figure 4). This level ofsupport has provided USAID the opportunityto play an important role in the global eradica­tion effort. USAID resources have focused onAfrica, South Asia and the ENI region, areaswhere polio remains or was recently endemic.

USAIO Polio Eradication InitiativeFunds for FY 1996-1998

Global/PHN Center$12 million

Asia/NearEast Bureau$16 million

Total: $70 million

5,JUrl." . PO~ulatl(Jn, HI altt nl NL.tptlor Ctnter 1 9:

Figure 4

Results Framework for theUSAID Polio Eradication Initiative

~ I 1rBuild 2

Strengthen Support 3 4EffectiveI Partnerships

Selected Supplemental ImproveSystems Immunization Surveillance

Agency Goal

USAID·PEIStrategicObjective

Stabilize world population Iand protect human health

Support the global eradication of polio by the year2000 In selected countries and regions, In ways that

contribute to the development of sustainableImmunization and disease control.

5Improve

InformationCollection

and Use

Figure 3

5

In FY 1998, the USAID $25 million PElcontribution was allocated as follows:

• $16 million to the Africa Bureau forsupport to NIDs and surveillance viaWHO/AFRO, UNICEF and the USAID­funded BASICS project. Funds were usedto assist Ministries of Health to plan andstrategize for polio eradication activities.This included improving strategies forsocial mobilization, cold chain andlogistics management, program planningand evaluation. USAID funds wereessential in establishing AFP surveillancein West and Central Africa.

$5 million through the USAID/GlobalBureau Center for Population, Healthand Nutrition to WHO, VOA and severalUSAID-funded projects to fill countrylevel gaps and to support global, regionaland country eradication activities.

$4 million to the Asia and Near EastBureau for support to NIDs and surveil­lance, primarily through grants toUNICEF and WHO. The InternationalClinical Epidemiology Network (INCLEN)received limited support to continue post­NID assessments for program improve­ment in India, and Rotary/India contin­ued to receive funds for social mobiliza­tion and advocacy through UNICEF

Based on discussions with partner orga­nizations and regional need, the FY 1999 PElfunding of $25 million will follow the same dis­tribution pattern described for FY 1998.

Figure 5 illustrates the distribution of PElfunding for FY 1997 and FY 1998 by imple­menting organization.

Distribution of USAID PEl Funding by ImplementingOrganization FY 1997-1998 ($OOO's)

Total: 550 million

Source: USAID'Rotary India receives a sub-grant through UNICEF India

Figure 5

D. 1998 ActivitieslAccomplishments

The emphasis in 1998 focused onstrengthening key components of the PEl strat­egy, which in turn strengthened the foundationfor the final push toward eradication. NIDsreceived high priority, as did surveillance andestablishing the laboratory network. Significantprogress was made in these three areas. Atten­tion was also given to communication and so­cial mobilization efforts, especially in Africa.

The BASICS project, in collaboration withWHO/AFRO and UNICEF, facilitated three re­gional workshops, in West, Central and EastAfrica, to address communication and socialmobilization issues. A Social Mobilization Ad­visory Group meeting, held by WHO and in­ternational partners in Uganda in 1997, foundthat although social mobilization had made agreat contribution to the success of NIDs, it re­mained weak in supporting routine immuniza­tion and disease surveillance. Given the preva­lence of top-down communication in immuni­zation activities and the amount of attentionand resources increasingly diverted away fromroutine immunization to NIDs, a workshop ofcommunications practitioners was recom­mended to discuss possibilities for improvingoverall immunization through communicationefforts. These workshops were held late in1998; a fourth workshop will be held in South­ern Africa early in 1999. The purpose of theworkshops was to assist country teams in de­veloping and reinforcing strategic and inte­grated communication plans for the routine EPI,NIDs and surveillance, to be implemented in­country. This approach is part of a longer-termvision that should provide the impetus neededto rapidly address eradication priorities as wellas providing the foundation for a sustainablehealth infrastructure.

The latest partner in the PEl effort is theCORE Group of PVOs, a network organizationof 32 US-based PVOs with a history of suc­cessful USAID-funded projects in health andnutrition, and an established organizationalpresence in over 140 countries. The CORE fo­cus is to strengthen community-based surveil­lance in India, Ethiopia, Malawi, Mozambique,Tanzania and Uganda. CORE intends to ex­pand to other interested countries, once theseinitial programs are underway. CORE PVOswill also participate in ICCs and they plan toassist, where appropriate, in district-level plan­ning and training, monitoring and evaluation,social mobilization and advocacy.

USAID is also supporting ongoing re­search on a variety of topics. This includesuniversity-based research looking at polio vi­rus shedding in immune-compromised indi­viduals, the results of which will inform thedevelopment of end-stage strategies for theeventual cessation of immunization, and jointdonor-funded studies on the effects of eradi­cation efforts on national health systems. ThePartnerships for Health Reform project is look­ing at cost-effective approaches to supplemen­tal immunization strategies, and is assessing thefinancial implications of polio eradication onhealth systems.

The global eradication effort represents anenormous commitment of financial and humanresources, time and dedication from govern­ments, organizations and untold numbers ofindividuals. The examples cited below repre­sent a sampling of significant achievement in1998 and show steady progress toward achiev­ing polio eradication goals.

The number of cases of polio has de­clined by nearly 85%, from a high of35,000 cases reported in 1988 to 5,673confirmed in 1998. The increase from1997 is due to improved surveillance andreporting (Figure 6). More than half of

7

40,000

35,000

~ 30,000

l3 25,000

alI 20,000

ti 15,000

10,000

5,000

o

UI

• D'l

Global Annual Reported Polio Cases:1988-1999

+- 35,251

Figure 6

cases reported are found in five countriesin South Asia.

National Immunization Days (NIDs)reached more than 470 million childrenin mass campaigns in 74 countries in1998. Many countries reported that morethan 95% of the eligible child populationwas reached; efforts are now under wayto verify these figures: During a recentNID in India, two million volunteers weredeployed to immunize 130 millionchildren in a single day.

Steady improvements have been made inacute flaccid paralysis surveillance andreporting, especially in the South Asiaregion (Figure 7). This is evidenced bythe increase in numbers of AFP casesreported, from roughly 17,000 in 1997 to25,000 in 1998. A growing number ofsurveillance systems are integrated, whichmeans they are capable of detecting casesand outbreaks of vaccine-preventablediseases other than polio.

WHO assessed 112 laboratories in 1998,giving full or provisional accreditation to90. The WHO Global Polio LaboratoriesNetwork consists of 133 national andregional virology laboratories, all of whichwill soon be capable of identifying and

AfR AM R EM R EUR SEA WPR

Non-Polio AFP Rate by WHO Region, 1996-1998*

Polio eradication was a highlight of the agendaat the March 1998 U.S.-Japan Common AgendaOpen Forum and September 1998 U.S.-Japan Sum­mit. At the March meeting agreements were reachedto maintain or increase funding for polio and EPl;shift funding resources to Africa to better meet PElneeds; increase human resources through JapanOverseas Cooperation Volunteers (JOCV) and U.S.Peace Corps volunteers; and increase participationat key meetings. At the September summit, Presi­dent Clinton and Prime Minister Obuchi praised thiscollaboration and announced their commitment topolio eradication.

U.S./Japan Common Agenda

tests, polio fan club reporting and avariety of innovative features, all in locallanguages.

The BASICS project produced twoimportant technical reports that areexpected to have a wide distribution andinfluence on social mobilization and theroutine EPI: The Polio Eradication Initia­tive: Monitoring Service Delivery duringNational Immunization Days and Assess­ing Local Capacity to Strengthen DiseaseSurveillance, and CommunicationHandbook for Polio Eradication and EPI.

USAID supported the development of thevaccine vial monitors, which are now acomponent part of all polio vaccine vialsused in the PEL These monitors changecolor when the vaccine has been exposedto heat and indicate when the vaccine isno longer potent. This simple tool hasalready reduced wastage and has thepotential to save millions of dollars in

vaccine costs. Other USAID-supportedresearch has resulted in a cost-savingswitch to more efficient droppers that willalso reduce vaccine wastage.

Rapidly rising AFP RatesIn Endemic Areas

.1997 01998iii 1996

confirming AFP and polio cases. Thenational laboratories process stool speci­mens and identify serotypes from AFPcases, while regional laboratories identifythe type of poliovirus and determinewhether it is wild or vaccine-derived.USAID is the largest bilateral donor to theglobal laboratory network.

The collaboration between USAIDand the Government of Japanunder the u.s. -Japan CommonAgenda has encouraged theJapanese government to increasefunding for polio and otherimmunization activities and hasboosted its support of eradicationactivities in Africa. USAID has alsoencouraged the collaboration ofJapan Overseas CooperationVolunteers and U.S. Peace Corpsvolunteers in case detection andreporting at the community level.

The Voice of America expanded itsradio coverage on eradicationactivities, and its partner, WORLDNETTelevision, joined the eradication effort.More than 900 VONWORLDNETbroadcasts supporting eradication havebeen heard in 22 countries. Thesebroadcasts include radio dramas, con-

Failing AFP Rates In1.40 , Polio-free Areas

1.20

1.00 ......-......j~-I----~H;-+lHTARGET

0.80

0.60

0.40

0.20

o.00 l-A.--l....,-L---'--r-'-"--II...-J-........--'-r-"~-'--r----II-J....,

sc.-. WO"cll""~r_ 1l91li

'Ootu ..ol"~'"'

III. Partnerships and Progress

Within this collaborative context, USAIDhas gained recognition as a strong technicalresource and has been increasingly called uponto provide technical expertise and to facilitatecollaborative activities. USAID and cooperat­ing agency staff actively participate in key in­ternational and regional meetings, on interna­tional surveillance reviews and on monitoringand observational visits. Below are three ex­amples of successful partnerships:

A. Overview

The year 1998 saw significant improve­ments in the quality of NIDs and in surveillanceand reporting of suspected AFP cases. The geo­graphic distribution of poliovirus continues toshrink. Reducing the number of cases furtherwill require increased attention to reaching chil­dren not yet immunized and continuedstrengthening of surveillance and the labora­tory reporting network. To accomplish this, allpartners will need to collaborate and closelycoordinate activities and resources to achievemaximum impact.

The following section highlights specificexamples of 1998 accomplishments within thecontext of the PEl results framework.

National Immunization Day - NigeriaPhoto by Ellyn ()gd,m,!Jl!iAID

1. Build Effective Partnerships

In 1998, strong consensus and teamworkwere in evidence among the Polio Partners andother groups and organizations involved in theeradication effort. At the country level Inter­agency Coordinating Committees began tak­ing a more proactive approach by identifyingareas to be strengthened and targeting resourcesto those areas.

•

In the Democratic Republic of the Congo,USAID forged a partnership and signedan MOU with the Ministry of Health(MOH), WHO, UNICEF and BASICS tocoordinate polio eradication activities.Although NIDs were postponed becauseof civil strife and international staff weredispersed to safer areas, USAID contin­ued to coordinate with the Ministry andICC through telephone and e-mail. As aresult, when the political situation stabi­lized, USAID and its partners were able toquickly organize and conduct Sub­National Immunization Days (SNIDs) inareas considered safe. USAID also helpeddraft a recommendation at the recentAfrica Task Force on Immunization (TFI)meeting, requesting that WHO andUNICEF seek assistance from the Organi­zation of African Unity, United NationsHigh Commission on Refugees, orultimately the United Nations SecretaryGeneral, to intercede on behalf of theeradication program and ensure that theremaining areas of the country are able toparticipate in the proposed 1999 NIDs.These avenues are being pursued as thisreport goes to press.

In India, USAID worked closely with theBihar state government, WHO, Rotary,UNICEF and more than 30 NGOs toestablish the BIMAA, the Bihar Immuni­zation Acceleration Activity. As thesecond most populous state in India,

Bihar has 25 million children under agefive. Routine immunization coverage isan unacceptable 5% and NID coverage isaround 80%-far short of what is neededto eradicate polio or protect against otherchildhood diseases. The MOU thatestablished BIMAA was signed in October1998, with all signatories agreeing towork closely to coordinate and improveall NIDs, mop-up and surveillance activi­ties. Most important, agreement wasreached to ensure year-round routineimmunization services. Although opera­tional for only a few months, early resultsare impressive. Bihar immunized over

Immunization in Jinja, UgandaPhoto by Richard Franco WHO

90% of eligible children during theDecember 1998 NID. USAID was able tofacilitate a similar MOU in the neighbor­ing state of Uttar Pradesh, with an evenlarger under-five population and routineimmunization coverage of around 40%.

• A July 1998 visit to Nigeria by the USAIDWorldwide Polio Eradication Coordinatorprovided the catalyst for developing anMOU between the government, WHO,UNICEF, USAID and its NGO cooperat­ing agencies. Since USAID cannot workdirectly with the government in Nigeria,establishing a formal framework with

10

NGOs for PEl coordination was anessential step. The collaboration resultedin the development of Nigeria's PElstrategy and focused on identifying andresolving constraints, and improvingcoordination and planning between thepublic and private sectors. Nigeriaachieved 100% coverage in both roundsof the 1998 NIDs, a significant improve­ment from 1997. Over 100 NGOsparticipated in the NIDs.

2. Strengthen Systems

Strengthening health systems and boost­ing routine immunization through the EPI hasbeen a central topic at recent regional ICCmeetings. The Africa ICC is beginning to seeintegrated national budgets for routine immu­nization, NIDs and surveillance activities. Thetwo MOUs in India each give increased atten­tion to linking polio eradication to stronger EPIsystems. Continued investments in cold chainand logistics management, the laboratory net­work, integrated surveillance and communityparticipation are all intended to build nationalcapability to both prevent and respond to dis­ease outbreaks on a sustainable basis.

USAID and Japan have shared a con­tinuing dialogue on both immediate and long­term regional cold chain needs, with the resultthat Japan is now planning to increase its sup­port for cold chain equipment through its ChildHealth Grants under the U.S.-Japan CommonAgenda.

Strengthened routine immunization sys­tems that result in increased coverage for allvaccine-preventable diseases should also re­duce the incidence of measles. The skills learnedthrough the PEl experience in logistics and coldchain management and planning, vaccine fore­casting and advocacy can be utilized in improv­ing the routine EPI system. The Agency en­courages ICCs to emphasize the importance of

VOA reporter talks to children inSenegal

Pharo by Maimouno Mi/lsiVOA

high routine measles coverage, and to facili­tate EPI outreach activities in hard-to-reachpopulations and areas where the health infra­structure is weak.

The PEl communications strategy pro­motes health issues and the mobilization ofcommunities to participate in immunizationand surveillance efforts. The BASICS projectwork in 1998 has strengthened this effort enor­mously. The Voice of America has also greatlyenhanced community participation and in­volvement through its ability to reach even iso­lated areas and communities through its radionetwork. Highlights of its contribution, andthat of its WORLDNET Television partner, aredescribed below.

Communication Uighlights:

The Voice of America is influential inreaching large segments of the popula­tion. VOA reporters participate in NIDsby conducting live interviews with re­spected authorities, local doctors andpolio survivors, which help to counterrumors, myths and misinformation aboutimmunization. The scripts and materialsproduced by VOA are available toaffiliates and others free of charge, thusfurther expanding the potential audience.

II

A VOA listener from Nigeria wrote: "Withsincere appreciation for the good workundertaken by your organization inrecent times ... My radio dial is alwaystuned to the VOA Africa Service for newsupdates and more information on 'childhealth care' programs. Please keep it up!"

In August 1998, WORLDNET Television,the U.S. Information Agency's globaltelevision network, introduced "HealthWatch," an interactive health program,with an hour-long feature on polio andpolio eradication.

VOA Listeners' Contest Draws aLarge and Enthusiastic

Response

The VOA Urdu Language Service re­ceived more than 6,000 entries to its May1998 contest on polio. Many contestants in­dicated that, when polio questions were toodi.f1icult, they sought help from local physi­cians and friends, broadening the program'saudience. Most entries camefrom small townsand villages, particularly from north Pakistanwhere the incidence of polio has been veryhigh. As one listener in Thatta noted, "If chil­dren can be saved from this disease throughyour efforts, we should all be grateful to you."And a listener from the Punjab wrote, "Thepolio contest has become the talk ofour town.. . . This is a topic which will really do a lot ofgood In our community."

• The VOA website (http://www.ibb.gov/polioerad/index.html) now providespolio program information, digitizedaudio from many of its language pro­grams, links to the Polio Partners, andaccess to the Child Survival BroadcastingScript Delivery System.

The US Pharmacopeia is producing apolio monograph series. One monographaddresses superstitions and myths aboutpolio vaccine and immunization that are

prevalent in developing countries. TheVOA and other health journalists will usethis information to develop messages todispel such misinformation. The messageswill be targeted to specific areas andpopulations where these beliefs prevail.

Virological confirmatIon of laboratoryspecimens, Polio Enterovirus Laboratory ­Lucknow, India

Photo by Ellyn Ogden USAID

USAID is supporting the WHO poliowebsite, a site which currently receivesover 300 hits per day. USAID also sup­ports the WHO global newsletter, "PolioNews," which has a global distribution of2,000, and regional publications such asthe EURO Polio Page and weekly surveil­lance reports, SEARO AFP weekly report,the Indian AFP Alert, and the AFROmonthly surveillance report. (WHO Poliowebsite~ http://whqsabin.who.int:8082.)

3. Bnsure Bffective SupplementalImmunization Through NIDs andMop-up campaigns

A record number of supplemental immu­nization activities took place in 1998. The num­ber of countries reporting such activities to dateis 97 broken down into 74 NIDs, 16 SNIDs andseve~ mop-up campaigns. USAID participatedon several international observation teams tomonitor the quality and effectiveness of NIDs.

12

Recommendations from these site visits havebeen incorporated into the planning of subse­quent NIDs.

4. Improve AfP Surveillance andLaboratory Investigation

Progress in improving AFP surveillanceand laboratory investigation worldwide is evi­dent in the increasing number of AFP cases thatare reported. Since the deployment of 60 sur­veillance medical officers in India in late 1997,the number of reported AFP cases tripled; andof those cases, two-thirds were confirmed aspolio. Pakistan experienced a similar increasein AFP cases and confirmed polio when sur­veillance improved. Improved surveillance isidentifying cases that were previously missed.The CHANGE Project is developing an infor­mation kit to assist PVOs and volunteers withsimple instructions for AFP case detection andreporting. Continued high quality NIDs thatreach the entire eligible child population willresult in a reduction of both AFP and poliocases, but meanwhile surveillance is doing itsjob, and these skills will transfer to the identifi­cation of other disease outbreaks.

The laboratory network confirms the pres­ence or absence of polio in specimens collectedand provides supporting data necessary for cer­tification. Since AFP can be caused by agentsother than polio, stool samples must be collectedfrom each reported case, transported to andexamined by an accredited virological labora­tory. Improved surveillance has resulted in anincreased workload for the laboratory system,with the number of reported AFP.cases triplingin 1998. Intense efforts are underway tostrengthen the laboratory network, and alreadygreat strides have been made in the ability toanalyze and respond to the field in a timelymanner. Of the 133 laboratories in the WHOLABNET system, more than 100 are accred­ited.

o raJ mobilization - AfricaPhoto by Richard Franco WHO

The BASICS Project played a vital role incommunications and social mobilization work­shops in Africa in 1998. With UNICEF andWHO/AFRO, BASICS contributed to the de­velopment and field testing of the WHO/AFROCommunications Handbook for Polio Eradica­tion and Routine EPI for program officers andothers engaging in polio and EPI country-levelactivities. BASICS also produced The PolioEradication Initiative: Monitoring Service De­livery During National Immunization Days andAssessing Local Capacity to Strengthen DiseaseSurveillance. The Handbook and accompany­ing training manual (available in French andEnglish) were used in the regional communi­cations and social mobilization workshops de­scribed earlier. With immunization and com­munications experts from 33 African countriesin attendance, the workshops provided guid­ance to country teams on integrated planningand design for communications activities forEPI, NIDs and surveillance activities.

To improve the quality of NIDs and mop­up campaigns, the USAID-funded Applied Re­search on Child Health (ARCH) Project is con­ducting research on improving social mobiliza­tion messages and AFP case reporting, and isidentifying barriers to immunization participa­tion. The project is collaborating with the Min­istry of Health, UNICEF, WHO and local USAIDmissions and is working in urban areas of Benin,Gambia and Mali.

USAID grants provide funding to WHOand UNICEF for monitoring and evaluationactivities. Post-NID assessments, conveniencesamples, exit interviews and other survey meth­ods are being used to document and evaluatethe effectiveness of NIDs. Surveillance reportsprovide timely data for program managers anddonors. Several USAID projects are focusingon improving information collection and use.The Center for International Health Informa­tion project is documenting lessons learned,evaluating communications activities, and hasinitiated the development of a community sur­veillance tool to be used in PEl information kitsfor PVOs and Peace Corps volunteers. CIHI alsoproduced an advocacy document for WHO/AFRO in support of the PEl. The MEASUREproject will be helping VOA review su :vey dataon the reach and effectiveness of its radio pro­grams.

B. Mrica ShowsProgress

5. Improve Information Collection andUse for Continuous ProgramImprovement

By the end of 1998, all countriesin Africa, with the exception of theDemocratic Republic of Congo and Si-erra Leone, had conducted at least one com­plete round of NIDs. The first round of NIDs inSierra Leone was interrupted by an upsurge infighting but managed to reach 350,000 chil­dren in 70% of the country under governmentcontrol; the second half of the NID was can­celled. With low routine immunization levelspersisting in many countries, additional roundsof NIDs and mop-up campaigns are urgentlyneeded.

Eradication efforts in Africa have beenhampered by the frequent postponement ofNIDs due to civil strife. The immunization ofchildren in war-torn areas presents a challengethat must be addressed, especially since move­ments of people escaping civil unrest can resultin the virus being reintroduced in areas onceconsidered polio-free. Conducting immuniza­tion campaigns in the Democratic Republic ofCongo is a top priority for the global eradica­tion program.

Local Hero Helps 3.5 Million Children inthe Democratic Republic of Congo

When fighting broke out in August 1998 in theDRC, NIDs were delayed and expatriate health staffwere evacuated. At great personal risk, a localBASICS consultant, Dr. Michel Othepa, ensured thatthe polio vaccine was in a safe and secure location,with functioning generators to maintain the coldchain, until the situation stabilized in December. Dr.Othepa dodged security forces and checkpoints toguarantee vaccine safety. His bravery, courage andextraordinary efforts ensured the potency of thevaccine for the December SNID, and resulted in theeffective immunization of 3.5 million children and asaving of millions of dollars.

Recent AFP data indicate improved sur­veillance and reporting in some countries, butAfrica in general has a long way to go, since inmany countries, surveillance has only just be­gun. Surveillance presents special challengesin politically unstable areas.

USAID.funding: USAID provided fund­ing to WHO/AFRO, UNICEF and the BASICSProject to strengthen partnerships and immu­nization and surveillance systems; provide tech­nical assistance for planning; training andsupplemental immunization; improve socialmobilization and information collection; andprovide program support in 22 countries.

I ~

1. Mrica ICC and TFI Meetings Focus onAccelerating Eradication Efforts

At the fifth meeting of the Africa RegionalICC in December 1998, WHO/AFRO presentedits revised three-year action plan for polio eradi­cation, which included extra rounds of NIDs,SNIDs and mop-up activities. While progresswas evident in 1998, additional work and re­sources are needed in social mobilization, com­munication, AFP surveillance and the regionallaboratory network. TFI meeting participantsvoiced their strong support of the global eradi­cation effort and commended member coun­tries for their achievements. An independentreview of the regional EPI supported a renewedfocus on improving routine immunization cov­erage as a means to accelerate polio eradica­tion.

2. Progress in the Democratic Republicof Congo (DRC)

After months of postponement, SNIDswere finally held in December 1998 and Janu­ary 1999 in six southern and western provincesunder government control, including Kinshasa.While this is only a portion of the country, theestimated coverage in these six provinces was91 %for the first round. Coverage was between92% to 95% for the second round, which alsoincluded vitamin A supplementation. In antici­pation of a UN-negotiated truce, full NIDs areplanned for August and September 1999. AFPsurveillance was introduced nationwide earlyin 1998, following a series of advocacy andtraining activities. Four full-time surveillanceofficers are in place and AFP reporting is ex­pected to improve.

3. Ethiopia Conducts Successful NIDs

Ethiopia conducted NIDs in Novemberand December of 1998, reaching more than98% of eligible children. Vitamin A was addedin the second NID, as was measles vaccine inseven urban cities. The nomadic nature of the

populations in sparsely settled regions poses amajor problem in reaching all children, and thePolio Partners in Ethiopia are seeking ways toaddress the issue. Surveillance is also recog­nized as an important area needing to bestrengthened. Partnerships were key to thesuccess of the 1998 NIDs, which were greatlyfacilitated by USAID collaboration with CDC,WHO and UNICEF

4. Liberia Collaborates for a Successfulfirst Round of NIDs

Liberia's seven-year civil war destroyedhealth clinics, roads and much of the country'sinfrastructure. Although NIDs were considereda priority, political tensions in 1998 forced theirpostponement until January 1999. At the NIDslaunching ceremony, the Liberian president toldthe crowd that his sister is partially crippled asa result of polio. VONWORLDNET reportedthat during the NIDS, there were "hundreds ofpeople at each vaccination site. Moms, Dads,Grandparents, they all came out to get the vac­cine for their children . . . A caravan of volun­teers traveled to a coastal fishing village to de­liver the vaccine. A helicopter was used to reachvery remote regions." The NIDs were a suc­cess, with the first round reaching more than580,000 children out of an estimated 600,000.The Minister of Health sent a personal letter toUSAID to thank them for their funding andsupport.

5. Local Support and Partnerships Movethe PEl Ahead in Zambia

Zambia NIDs received support from theWHO/AFRO grant, USAID/Zambia, theBASICS and OMNI projects, and for the firsttime, the U.S.-Japan Common Agenda.BASICS and USAID staff helped developstrategies to strengthen AFP surveillance.BASICS also provided funds to print anddisseminate NID guidebooks; OMNI developedstrategies and communication materials andsupported distribution of vitamin A capsules

IS

Not/ona/Immunization Day IndiaPhoto by Richard Franco WHO

during one NID. A joint U.S.-Japan ProjectFormulation Mission in late 1998, under theU.S.-Japan Common Agenda, identifiedpriorities for joint support over the comingyears. Top priorities were strengthening the coldchain and improving AFP surveillance.

6. Mozambique NIDs Benefit fromImproved Planning and SocialMobilization

The BASICS/Mozambique EPI Advisorand the USAID Rational Pharmaceutical Man­agement Project worked with the Ministry ofHealth and the ICC to bolster 1998 NID plan­ning and surveillance and to improve socialmobilization, at the same time working tostrengthen routine immunization service deliv­ery. The 1998 NIDs were successful, with 97%coverage reported in the first round and 112%in the second (indicates an underestimation ofthe under-five age group, but can also resultfrom the immunization of children over five).In late 1998, an independent review ofMozambique's routine EPI recommended theneed to strengthen immunization campaignsand the surveillance system. Logistics trainingand cold chain management also need im­provement.

7. Increasing Polio Coverage andImproved Surveillance in Ghana

The Ghana ICC reported excellent cover­age for the 1997/98 NIDs, with rates close to or

Carrying vaccine to Grand KruCountry, Liberia

Phoro by Richard Fi

above 100%, reflecting improved planning,adequate resources and improved technicalsupport. USAID/Ghana contributed $740,000through WHO/AFRO for NIDs and surveillancewith another $100,000 above the directive t~UNICEF for social mobilization, improved coldchain equipment and vaccine distribution. Amajor objective of the USAID Mission is to iden­tify and support ways to boost routine immu­nization, as less than 60% of Ghanaian chil­dren are fully immunized by one year of age.

8. Low Coverage in Kenyan NIDsAttracts USAID Support

UNICEF/Kenya received USAID grantfunding for disease surveillance and prepara­tory activities for Kenya's 1999 NIDs. The ICCis overseeing an intensive NID planning pro­cess. This is in response to WHO/AFRO's strongrecommendation for continued and improvedNIDs due to inadequate surveillance, declin­ing routine immunization coverage, and cov­erage below 80% in its two previous NIDs. NIDswill be held in October and November 1999.

16

9. Strong Leadership and PartnershipsUighlight Madagascar's SuccessfulNIDs

The Government of Madagascar launchedits second year of NIDs in September 1998 withthe Prime Minister, U.S. Ambassador and otherimportant officials in attendance. Immunizationcoverage was over 100% of the 2.5 millionchildren targeted. The NID success is attribut­able to strong MOH leadership, and the col­laborative efforts of BASICS, CDC, UNFPA,UNICEF, USAID, WHO and the Embassy ofJapan. Vaccine forecasting, planning, trainingand distribution were well coordinated at alllevels, and extensive social mobilization activi­ties helped make the NIDs one of the biggestnational events in the past 50 years. The gov­ernment plans to utilize the PEl communica­tions and community mobilization channels tobolster other priority health programs, such asadding vitamin A to the second round of NIDs.USAID provided about $754,000 throughWHO AFRO, with additional support providedlocally through the BASICS project.

10. Private Sector Fully Involved in MaliNlDs

The social mobilization required for thesuccess of the Mali NIDs, held in Novemberand December 1998, resulted in an unprec­edented level of private sector involvementparticularly in the areas of financing, logisticalsupport and mobilization of volunteers. Theprivate organizations involved included coop­eratives, private industries, commercial estab­lishments, private press and agricultural orga­nizations. The NID was launched by the Presi­dent of Mali, ensuring high level governmentcommitment. More than 100% of the targetpopulation was reached, indicating an under­estimation of the population of eligible children.USAID/Mali provided bilateral funds throughUNICEF and has been involved in all phasesof NID planning and implementation.

Photo by Ellyn Ogden/USAID

c. Asia and NearEast:ProgressTowardEradication

Afghanistan, Bangladesh, India, Nepaland Pakistan constitute a major poliovirus res­ervoir in Asia, accounting for more than half ofall confirmed cases of polio in 1998. Improvedsurveillance, especially in India, is responsiblefor more accurate reporting and for the increasein numbers of both AFP and polio cases. WHO/SEARO reports a doubling of AFP cases from1997, from approximately 5,000 to 11,000cases. USAID funds are supporting SurveillanceMedical Officer (SMO) positions in Bangladesh,India and Nepal; the officers already in placehave had a significant impact. The quality ofsample collection has also improved dramati­cally. A network of 16 WHO-accredited labo­ratories is conducting poliovirus isolation andAFP classification in the region.

Because of the continuing exportation ofpolioviruses from Afghanistan into neighboringcountries, Afghanistan, Iran, and Pakistan con­ducted coordinated, cross-border immunizationactivities in 1998. These will be repeated in1999.

Afghanistan and Myanmar concludedthree years of NIDs; Bangladesh, India andNepal four years; and Pakistan five years.

USAID funding: Grants were providedto WHO, UNICEF, Rotary and INCLEN tostrengthen partnerships, planning, surveillance,laboratory and immunization systems; conductNIDs and mop-up campaigns; provide train­ing; improve social mobilization and informa­tion collection; and provide country-specific

"

program support in Bangladesh, India, Indo­nesia and Nepal.

1. Bangladesh Conducts Its fourth Yearof NlDs

BASICS continued to assist theBangladesh national immunization program inits fourth cycle of NIDs (December 1997 andJanuary1998) in allurban areas.BASICS pro­vided techni­cal input onnational ad­vocacy andplanning,supply andlogistics man­agementandfield monitor­ing. Cover­age for theseNIDs ranged from fair (78%) to good (90%).BASICS also assisted the national program indeveloping an urban surveillance system, or­ganizing surveillance workshops in district andmedical college hospitals, and prodUcing thequarterly Diseases Surveillance Bulletin.USAID/Bangladesh provided $600,000 forsurveillance in FY 98; this was in addition tothe $125,000 provided by the Global Bureau.While few virologically confirmed polio casesare reported from Bangladesh, surveillance re­mains below standard.

2. Egypt Conducts a Successful NIDcampaign

Egypt's 1998 NID campaign-with immu­nization coverage exceeding 99%-was inau­gurated by the First Lady of Egypt and is con­sidered one of the country's most successful.The Minister of Health and Population person­ally contacted relevant ministries and governors

to ensure full participation. The social mobili­zation campaign used the media to its fullestextent. In addition to the NIDs, eight millionchildren were immunized in three targetedsupplemental campaigns in high-risk areas.High quality surveillance in 1998 confirmed 12polio cases. Additional NIDs rounds areplanned for the spring of 1999 with mop-up inthe autumn. USAID/Egypt provided $600,000in bilateral support for polio activities, over andabove the directive.

An unusual side benefit of the NIDs wasits impact in resolving a longstanding feud be­tween two families in Upper Egypt. When a caseof polio appeared in 1997 in this community,the families decided to end their animosities andwork together with the government on polioeradication activities.

Social Mobilization - New Delh.Photo by Richard FrancO/WHO

IX

3. India Makes Unprecedented Progressin Surveillance

Recognizing the need to establish an ef­fective surveillance system early in the Indianeradication program, tremendous effort wasinvested to ensure that AFP cases were foundand data used immediately to drive programdecisions. What took the Americas over fouryears to accomplish, India accomplished in one.USAID and DANIDA are coordinating andfunding Surveillance Medical Officer posts inIndia in 1999. In addition, USAID staff partici­pated in the International Review of the IndiaPolio Surveillance System, acted as interna­tional observers to the NIDs, and conducted asite visit with a Japanese Embassy official dur­ing the NIDs.

Rotary's PolioPlus Program in India heldseveral workshops with doctors, health work­ers and local NGOs to improve AFP surveil­lance in high-risk areas. Rotary also collabo­rated with an Uttar Pradesh NGO, Progress Al­ternatives, that trained girls to ensure that allchildren in their villages were immunized. Theresults were excellent; the villages had 100%coverage during the 1998 NIDs. As a result,this NGO has been asked to generate a 1999awareness campaign that involves puppetshows and other community events to high­light the need for children to be immunizedduring NIDs.

UNICEF conducted a successful trainingfor health workers on how to use the vaccinevial monitors that were introduced for the firsttime during the 1998 NIDs.

4. Indonesia Sustains Bxcellent PolioSurveillance Achievement

Despite a severe economic, social andpolitical crisis, Indonesia has shown sustainedquality AFP surveillance and consistent highquality case investigation and laboratory per­formance. Wild poliovirus was last isolated in

Indonesia in June 1995. These results andcontinued high routine coverage provide strongevidence that Indonesia is polio-free. USAIDfunds were used to improve intersectoral co­operation in surveillance and case investiga­tions by district health officers. USAID fundsalso supported national laboratory strengthen­ing and community-based AFP surveillancetraining for village midwives and a local NGOin East and West Java.

5. Strong Partnerships UnderscoreMorocco's Successful NIDs

The Government of Morocco's annualNIDs were considered a great success. Fundsfrom the government, USAID PEl and bilateralfunds from USAID/Morocco, and support fromthe ruling family, community groups and indi­viduals at all levels helped achieve the cam­paign goal. The NIDs reached 2.7 million chil­dren under the age of five, 98% of the targetgroup. USAID funding was used primarily foradvocacy and social mobilization efforts.

D. Operation MECACARMoves Forward

Routine immunization coverage in mostof the USAID/ENI region (WHO/EURO andWHO/EMRO regions) is quite high, yet peri­odic outbreaks have occurred in several coun­tries in recent years, including Turkey andTajikistan. More attention needs to be given tosurveillance before the region can initiate certi­fication procedures. Most MECACAR countriescompleted a fourth year of NIDs in 1998; in1999, "Operation MECACAR Plus" will con­duct NIDs and mop-up campaigns in selectedhigh-risk areas.

USAID funding: WHO/EURO received$600,000 in 1998 to improve the cold chain,

I )

surveillance systems, donor coordination andinformation dissemination. In addition, USAID/ENI funded UNICEF to strengthen AFP surveil­lance, produce training manuals, and con­duct surveillance, monitoring, supervisionand social mobilization activities in Armenia,Azerbaijan and Georgia.

E. Latin America andthe Caribbean

Although the LAC region was certi­fied polio-free in 1994, USAID has con­tinued to provide limited non-PEl fund­ing through a grant to the Pan American HealthOrganization to improve measles control andto maintain polio surveillance. Key polio sur­veillance indicators have recently slipped, andthis is being closely monitored. It may be nec­essary for the Americas to "re-certify" prior toglobal certification.

t: WesternPacific Region

The last polio case was con- -',firmed in the WPR two years ago, inMarch 1997. The level of AFP surveillance inthe WPR is approaching WHO standards, andthe region is preparing to submit first-year docu­mentation toward the certification process nextyear, with the hope of achieving certificationby 2003. No PEl funds are provided to theregion. USAID is working closely with WHO/WPRO on global assessment studies being con­ducted by two USAID projects, and is also co­ordinating with WHO and other donors oncross-border issues in Southeast Asia. Cam­bodia, where the last case of polio was found,

is making a concerted effort to ensure that allpockets of unimmunized children are reached.The USAID Mission channels funds through itsgrantees to both strengthen the national healthsystem and to support NIDs.

o survIVor - IndiaPhoto by Ellyn Ogden USA/D

G. GlobalProjects

USAID's Global Bureausupports a range of activitiesthat impact the global and regional programs.These activities include research, communica­tions, regular reports, provision of cell lines andreagents to laboratories, and support to com­munities primarily through PVOs and second­arily through UNICEF. These activities are de­scribed elsewhere in this document.

~ Challenges in 1999

Major achievement toward eradicationhas taken place in 1998, but many challengesremain. USAID is working with its Polio Part­ners to address these challenges, such as thefundamental need to raise static or decliningroutine immunization rates. Surveillance anda functioning laboratory network are criticalcomponents in achieving and documentingeradication. The immunization of children inwar-torn areas presents a challenge that mustbe met, since the virus can continue to circu­late in unreached areas and populations. Com­munities must be mobilized and understand theneed to support both routine and supplemen­tal immunization efforts. The challenges of 1998are thus the challenges of 1999 and beyond.

A. Challenges Ahead

1. Reaching the Unreached

To achieve the eradication goal, USAID isfocusing on achieving high quality NIDs tomake "every round of NIDs count" and "reachthe unreachable." By linking communicationsystems with disease control activities, theAgency hopes to reach those who have notparticipated in NIDs. The Agency will continueto work with its Polio Partners to ensure thatPEl participating organizations improve theirplanning capabilities and build strong public­private partnerships. USAID will continue todraw on its own technical expertise and that ofits cooperating agencies to support the Initia­tive.

2. Accelerating Surveillance

USAID will continue to support commu­nity and facility-based surveillance. USAID­funded surveillance officers are having an im­mediate positive effect on improving both the

_I

quality and quantity of surveillance reporting.USAID is working with the CORE Group ofPVOs, UNICEF, Peace Corps and the JOCV toimprove AFP case detection and reporting. ThePeace Corps and the JOCV will promote andstrengthen community-based participation andensure that potential AFP cases are reported ina timely manner to designated facilities, in sup­port of national surveillance systems.

3. Static and Declining RoutineImmunization Coverage

Many countries are experiencing analarming decline in routine immunization rates,even as successful rounds of NIDs are con­ducted. Underfunded and neglected for manyyears, the health infrastructure and EPI pro­grams in many countries are struggling to pro­vide the most basic services, with the effect thateradication efforts are forced to add costly ex­tra rounds of NIDs and extensive mop-up as ameans of compensating for the poor routinecoverage. USAID is monitoring the situationto identify and address barriers to routine im­munization, and continues to work with its part­ners to find ways to further support and boostroutine immunization coverage. USAID con­tinues to promote the right of every child to befully immunized before the first birthday.

The importance of routine immunizationand AFP case reporting are being promotedduring NIDs and through social mobilizationefforts in most countries, and ICCs are expand­ing their scope to coordinate support tostrengthen the routine system.

4. War-torn and Conflict Areas

War and civil unrest destroy health sys­tems and infrastructure, resulting in declines inroutine immunization coverage and creatingfertile ground for disease transmission. WHO,UNICEF and Rotary have brokered cease-firesand truces in several countries to allow polio

5. Sustainability

6. Political and Financial Commitment

Political and financial commitment re­mains weak or inconsistent in a number ofcountries where polio transmission persists.With many competing priorities, some coun­tries are reluctant to continue support for morethan three years of supplemental immunizationactivities. In addition, keeping countries fo­cused on certification-not just completingthree years of NIDs-is proving to be a greaterchallenge than expected. Although most coun­tries have borne a significant percentage of polioeradication costs, virtually all the supplemen­tary costs need to be financed by externalsources, especially in the poorest countries.New partners continue to join the effort, butfunding levels from current Polio Partners havestayed constant or declined.

and most regions do not expect to be certifiedpolio-free before 2003. WHO estimates thatthe earliest global certification can be achievedis 2005. Containment of laboratory stocks ofpoliovirus, as well as other factors, will deter­mine when to recommend cessation of immu­nization.

immunization cam­paigns to take place.These efforts willcontinue whereverand whenever nec­essary.

Many of themost difficult coun­tries to reach arethose that USAID isnot currently sup­porting, such as Af­ghanistan, Burundi,Myanmar, SierraLeone, Somalia andSudan. USAID andits Polio Partners areexploring alterna­tives to support po-lio eradication inthese and other criti­

cal areas where the virus continues to circu­late, including working with local partners andNGOs.

Child with polIo CambodiaPholO by UN1Cl F

The PEl focus on strengthening the rou­tine immunization system, surveillance and thelaboratory network is a deliberate strategic ap­proach that it is hoped will lead to the estab­lishment of sustainable national health systemsand the consequent improvement of globalpublic health. This could ultimately be the mostimportant potential long-term legacy of the en­tire polio eradication effort.

The success achieved to date establishesthe technical feasibility of polio eradication.Despite certain obstacles, it now appears thatmost chains of transmission will be interruptedby the year 2000 if current levels of participa­tion are maintained or, in some cases, acceler­ated. Surveillance continues to lag in Africa,

USAID and its Partners are advocating forincreased local resources and commitment,both government and private, but funding gapsremain. WHO estimates that an additional$350 million is needed to cover the costs ofcountry-level eradication activities through2001, and global and regional needs involvingcertification will widen the gap further. USAIDintends to continue support at $25 million an­nually in 1999 and 2000.

The challenges are significant, but thebenefits are many. Polio eradication will elimi­nate the disease and wipe out the wild poliovi­rus forever. It will also eliminate the social andcultural ostracism experienced by crippled chil­dren, as their families attempt to provide edu-

cation, arrange marriages and find meaningfulemployment for them, often to be rebuffed intheir efforts. When global certification isachieved and immunization is no longer nec­essary, WHO estimates the global savings couldequal $1.5 billion per year, most of which willaccrue to industrialized countries. The UnitedStates will save an estimated $230 million peryear in vaccine costs alone.

The Polio Partners collaboration is proofthat major improvements in global health arepossible when governments, institutions andindividuals work together to address common •

National Immunization Day - AfricaPhoto by Maimauna Mills/VOA

concerns. The collaboration is resulting instrong interagency coordination which isstrengthening national health systems at all lev­els. This is the legacy that USAID hopes toleave for the world's children, a legacy of apolio-free world, global cooperation, and strongand sustainable health systems to monitor andprevent the spread of disease everywhere.

SOcial Mobilization - New DelhiPhoto by Richard Franco WHO

Annex to the PolioEradication Initiative

1998 Report to Congress

• Table 1: USAID Polio Eradication Initiative - fY 1998 Budgetby Results

• Table 2: USAID Polio Eradication Initiative - Summary BudgetfY 1998

• Thble 3a: USAID Polio Eradication Initiative - Africa RegionFunding fY 1998

• Thble 3b: USAID Polio Eradication Initiative - Asia Near EastRegion Funding fY 1998

• Table 3c: USAID Polio Eradication Initiative - ENI RegionFunding fY 1998

• Thble 3d: USAID Polio Eradication Initiative - USAID Fundingfor Global Activities fY 1998

Table 1: USAID Polio Eradication Initiative - FY 1998 Budget By Results($OOO's)

Africa ANE G/PHN Total

WHOI BASICSt UNICEFI Other Subtotal WHOI UNICEFI INCLEN Other Subtotal WHOI WHOI WHOI WHO/SEA G/PHN Subtotal FY 98 PElAFRO AFR AFR India India" HQ EURO SEARO Countries t Projects Funds

Result 1: 250 250 90 250Partnerships

Result 2: 1,533 445 1,978 100 100 90 100 300 450 2,528StrengtheningImmunizationSystems Planningand Training

Result 3: 7,445 1,550 1,775 300 11,070 900 650 600 2,150 100 100 1,100 800 14,020EffectiveSupplementaryImmunization,Social

Result 4: 2,182 370 2,552 2,000 100 200 600 2,900 375 350 300 375 1,500 2,900 8,352Surveillance

Result 5: Use of 250 250 50 50 100 70 50 850 1,150Information

Total 11,660 1,550 2,590 300 16,100 2,950 850 200 1,200 5,200 575 600 500 375 2,950 5,000 26,300·

• Total reflects additional funding ($1,300,000) over and above directive ($25,000,000)••• Includes $400,00 for Rotaryflndiat Bangladesh, Indonesia, Nepal

Table 2: USAID . Polio Eradication Initiative Summary Budget FY 1998

By Region and Major FY 98 PEl Funds Additional FY 98 Total FY 98 FundsPartners Bilateral Funds

AfricaWHO/AFRO 11,660,000 11,660,000UNICEF 2,590,000 2,590,000BASICS 1,550,000 1,550,000OTHER 200,000 200,000

Subtotal 16,000,000 *100,000 16,100,000

Asia & Near EastWHO/India 2,950,000 2,950,000UNICEF/ India 850,000 850,000INCLEN/lndia 200,000 200,000

Subtotal 4,000,000 **1,200,000 5,200,000

Global/ PHNWHO/ SEARO 500,000 500,000WHO / Bangladesh 125,000 125,000WHO / Indonesia 125,000 125,000WHO / Nepal 125,000 125,000WHO/EURO 600,000 600,000WHO/ HQ 575,000 575,000G/PHN Projects 2,950,000 2,950,000

Subtotal 5,000,000 5,000,000

Total 25,000,000 1,300,000 26,300,000

* Ghana** Bangladesh: $600,000; Egypt: $600,000

Table 3a: USAID Polio Eradication Initiative - Africa Region Funding FY 1998~

WHO UNICEF PEl Olrectlve Additional Total PEl

Country NIOS Surveillance NIOSSocial Planning & Manit. & Surveillance BASICS OTHER Total Bilateral Funding

Mobilization Training Evai.Angola 1,200 100 50 1,350 1,350

Benin 194 173 367 367

Chad 20 20 20

Cote O'ivoire 300 20 320 320

OR Congo 400 1,000 600 2,000 2,000

Eritrea 110 345 35 5 5 500 500

Ethiopia 2,000 821 2,821 2,821

Ghana 487 254 741 100 841

Guinea 200 211 411 411

Kenya 65 50 60 100 275 275

Liberia 589 589 589

Madagascar 528 226 80 20 854 854

Malawi 25 142 167 167

Mali 187 171 30 389 389

Mozambique 500 50 40 35 625 625Nigeria 400 200· 400 400

Rwanda 270 270 270

Senegal 46 20 66 66

Tanzania 50 15 5 30 100 100Togo 187 74 261 261

Uganda 30 30 30Zambia 331 50 35 15 431 431

Subtotal 7,444 2,182 1,345 430 215 120 250 1,000 200 13,187 13,187

Regional Office 2,033 230 550Support (inclUdes 13% admln costs) (Includes 3% admin, costs/Total 11,660 2,590 1,550 200 16,000 100 16,100

*Johns Hopkins University/PopulatIOn Communications Services (JHU/PCS)

Table 3b: USAID Polio Eradication Initiative - Asia Near East Region Funding FY 1998"T" - - - -,

WHO UNICEF Rotarv Via UNICEF INCLEN PEl Directive Additional Total PElCountry NIDS Soc. Plan. & Manit. &

Surveillance NIDS Soc Plan. & Manit. &Surveillance

SoclalNIDS

Total Bilateral Funding

Mop Up Mob. Trng Eva!. Mop Up Mob. Trng Eva!. MoblhzallonBangladesh 125 125 "600 725Egypt """600 600India 900 2,050 280 70 100 300 100 ·"200 4,000 4,000Indonesia 125 125 125Nepal 125 125 125WHO/SEARO 100 100 50 250 500 500Subtotal 900 100 100 50 2,675 280 70 100 300 100 200 4,875 1,200 6,075Total 3,825 850 200 4,875 1,200 6,075

" Surveillance"" Monitoring and Evaluation""" NIDSI Social Mobilization

Table 3c: USAID Polio Eradication Initiative - ENI Region Funding FY 1998

WHOfEURO" TOTAL

Surveillance, Plannina,Traimna,Monitionna I 600,000

Total I 600,000 600,000

• Includes ENI Countries: Russia, Moldova, Ukraine, Kazakstan, Kyrgystan, Uzbekistan, Tajikistan,Turkmenistan, Georgia, Armenia

Table 3d: USAID Polio Eradication Initiative - USAID Funding for Global Activities FY 1998

Global Child Health Research Voice Of

Projects WHOfHQ BASICS ARCH JHU America CHANGE CORE TOTAL

Amount 575,000 500,00 200,000 50,000 350,000 350,000 1,500,000Total 3,525,000

IIDRlIIG I =:l\'~-{"E.\.~

" thr end nr can say Ihal: A tm/J hralthJ person Is a happ.J and actl.r.

for CI good hralth wr nlllst rat good food and nr should r\rrcisr rwryda.• brcallsr r\rrcisr hrlp,o;liS 10 brralhr drrpl,r and allows bellrr cIrclllation of blood In Ihr bod.•.

I ha.r to IIIrntion lIlai prrforlllancr of Ihr .accination of polio arc nrcrssary 10 br donr on tllllr.

1I"lI11h Is vrry Imporlan, In ollr lifr and hrallh Is a stall" of doJlJ or IIIrnial nell brIng. Unlrss ourbotllrs Clrr In good hrallh "r arr not able to function proprrly in ollr e.rryday lI.rs. for bodi(.hrllllh. CI nrl/ balance dIrt, clranllness. r\rrcJse and rrst arr r.'.srntlal.

Only for prrventlon of all dlsrase... to Aerp clran our cllJ em1ronmrnt. The polio Is .rry' dangrTOusdlsrasrs and 10 prr.rnl up br prolecte from dl!~rasr wr IIIUSt .acclnr on tlmr.

Name: Mllstaf" "nassry" Class: rlghl 81hf: lValllr: Khalil M. "Nas,o;ry"School: MalalJ

January 1998

AlwaJs proplr should cart'flll for our hrallh. If nr don'I careflll for ollr hrallh It r[frcl otht'r p,'oplr

I wOllld firsl of allllAe 10 e\prrss my profound thanks and apprrclatlon 10 ,Jourt'Ihrral and optimistic campaign lo"ards polio 10 rradlcate by thr ,.rar 2000.

ltIagnlloqurallJ, , allrsl that in m,v homr town Ihe campaign agalnsl polio nas .erysllt't'rssflli. Thr children Inoculalrd at dl[frrrni .acclnatlons posts and comlllendidthr actl.r participation b,J Ihr communltlrs on lI,r normal st'hrdules. I prrsonall,Ju'rp mJ fingrr crossrd for such and Ihr rrst world-""dr campaign IOU performed.

GUDUNMAWA

ullltrlorlettrtalJOftJllltalthbdormbOll

This document was produced for theU.S. Agency for International Development by the

Center for International Health Information1601 N. Kent Street,Suite 1014

Arlington, Virginia 22209e-mail: info@cihLcom • website: www.cihLcom