Lessons from Smallpox Guide Polio Endgame

The world is closer than ever to eradicating polio. With only 223 wild poliovirus cases in five countries in 2012, the paralytic disease has been knocked down to just a handful of small reservoirs. Recognizing this historic opportunity to achieve eradication, we have enthusiastically joined more than 400 scientists from 80 countries to sign the Scientific Declaration on Polio Eradication.

Through the declaration, we are endorsing a clear path?not just an aspiration?to bring an end to polio: the new Eradication and Endgame Strategic Plan. This plan, developed by polio partners, donors and other stakeholders under the auspices of the Global Polio Eradication Initiative (GPEI), is a comprehensive strategy to reach and sustain eradication. Scientists signing the declaration are uniting behind GPEI?s plan, urging its full funding and implementation.

What gives us confidence that this plan will work? For both of us, the proof is personal: we served more than three decades ago on the team that eradicated smallpox, the only other human disease to be wiped from the planet. We see in the polio endgame plan the same hallmarks of success that guided smallpox eradication to completion.

The first ingredient for success is a relentless focus on pulling out the roots of the disease, no matter how challenging the circumstances. The smallpox effort required rooting out the disease amid major floods, famines and civil war. In recent years, similar focus has enabled huge obstacles to be surmounted for polio. Notably, India has now gone two years without a new wild polio case, despite a large population, inconsistent infrastructure and hard-to-reach migrant groups.

Over the next few years, the GPEI strategic plan calls for focusing polio efforts on the three countries where the disease remains endemic: Afghanistan, Nigeria and Pakistan.¹ All three countries have already launched emergency action plans on polio, and have made remarkable progress toward stopping transmission.

The second ingredient for success is creative problem-solving. For smallpox, the value of creative and flexible approaches was demonstrated in Nigeria in 1966, when the country faced a smallpox vaccine shortage just as the disease broke out in an isolated village in Ogoga province. An unconventional plan to vaccinate only those at highest risk of contagion proved pivotal. Vaccinators identified these individuals by working with community members and tracking the daily routines of villagers, such as visits to markets. This catalyzed a revolutionary ?surveillance and containment? strategy that is now used to fight other infectious diseases.

The polio program itself has spawned spectacular innovations. As with smallpox, vaccination is the main tool against polio, and reaching underserved and migrant children who are perpetually missed during vaccination campaigns is one of the program?s biggest operational challenges. In response, new tools like GIS mapping technology have been employed, and polio vaccinators carry GPS-equipped cellphones that quickly identify missed areas. Critically important genomic meta-data is mapped to each new outbreak, creating an innovative ?marriage? of epidemiology and genetic detective work.

A third ingredient for success is learning from setbacks. We are encouraged that the polio effort is taking a page from smallpox by continually reviewing where past approaches have been insufficient. GPEI?s plan outlines new approaches to ensure vaccination campaigns are not interrupted by political instability and insecurity. The plan also includes a careful timeline for withdrawing versions of the polio vaccine that, in very rare cases, can lead to paralysis ? a critical final step toward achieving eradication.

Perhaps the most important way in which polio eradication builds on smallpox is by following up after a country eliminates the disease by building systems for other national health priorities. When the smallpox campaign entered its final stages, those of us involved were keenly aware of our responsibility to contribute to the fight against other diseases. In the same way, the plan for polio eradication looks beyond polio. The future holds promise for the transfers of resources for delivering polio vaccines ? including health workers, surveillance systems and community relationships ? directly to other health priorities.

Polio eradication has never been closer. Now, the global community must meet its collective responsibility to ensure implementation of the plan, including fully funding it upfront and promoting shared accountability. By working together, we will soon relegate polio ? alongside smallpox ? to the history books.

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¹ Although in 2012 there were wild poliovirus cases in five countries, the disease is endemic in only three countries. Endemic countries are defined as those that have never stopped indigenous wild poliovirus transmission.

Images: top: Independent Monitoring Board report, October 2012; bottom: World Health Organization.

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