Policy and practice Global eradication of polio: the case for “finishing the job” Chandrakant Lahariya a

Abstract While seven years have passed since 2000, the target set for the eradication of polio, success remains elusive. In 2006, despite coordinated international efforts, there was no major breakthrough in containing the polio virus, which persists in a few pockets in the four countries in which it is endemic. The polio eradication programme faces new hurdles such as importation, re- emergence and failure of political and community mobilization. The decreasing morale of health workers and volunteers, doubts about the efficacy of oral polio vaccine and ever-increasing programme costs and funding challenges are other issues to be addressed. This paper describes the ongoing conventional strategy adopted for polio eradication, then analyses existing challenges and some possible solutions. The author suggests that major modifications and additions to the ongoing conventional strategy are required in order to create a multi-pronged, area-specific strategy that can finish the job of polio eradication. This should include an area-specific approach, community dialogue, enhanced political advocacy and compulsory vaccination, as well as the use of inactivated polio vaccine in endemic countries even before the transmission of wild polio virus has been halted. This appears to be the best way to achieve eradication at the earliest opportunity.

Bulletin of the World Health Organization 2007;85:487–492.

الرتجمة العربية لهذه الخالصة يف نهاية النص الكامل لهذه املقالة. .Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español

Introduction cycle”; outbreaks of polio also occurred involves maintaining high coverage of in 1998 and 2002. It is now clear that vaccination with at least three doses of The reduction of the number of children polio will not be eradicated in 2007.8 live oral polio vaccine (OPV), providing affected by polio from 1000 per day1 in The number of cases reported globally supplemental rounds of vaccination, 1988 to about 5 per day 2 in 2006 is a no in 2006 was higher than in any of the establishing an effective mechanism for mean feat by any standard. However, the previous six years.9 In 2006, the number the surveillance of acute flaccid paralysis target established by the World Health of cases reported in India was higher (AFP), and house-to-house OPV “mop- Assembly 3 called for the eradication of than in any of the previous four years,2 up” campaigns carried out at the final polio by 2000, seven years ago. Globally, while the reported number of cases in stage in a limited geographical region. more than 10 million volunteers 4 have Afghanistan and Nigeria was the highest High-level political advocacy and administered about 10 billion doses of in the previous six years.9 The situation mass mobilization have been used to polio vaccine on hundreds of national calls for immediate action. optimum benefit in this programme. and subnational immunization days at The author searched and reviewed Simple management tools like nonmon- a cost of US$ 4.5 billion 5,6 since the the full text of the available published lit- etary incentives were used to a large World Health Assembly resolution of erature on polio eradication via PubMed extent. Polio eradication has been a dy- 1988.3 The initial success of the polio and examined Internet sources and the namic programme in which strategies eradication programme was remark- web sites of major international health have been frequently adapted and modi- able and many countries and continents agencies. In an effort to understand the fied to various extents. Supplementary were freed from infection and disease; current strategy for polio eradication immunization activities, house-to-house however, the scenario changed between and to identify the hurdles involved, the activities and enhanced surveillance were 2002 and 2005, when resurgence and 10 author suggests new approaches based later additions to the programme. The importation occurred in 21 countries.7 upon current experiences to eradicate administration of monovalent vaccine Since this time, success has been elusive polio as soon as possible. (which has enhanced efficacy, increasing and even in 2007 some pockets of wild the chances of seroconversion in immu- polio virus (e.g. in Moradabad, India, nized children by almost three times), and in Kano, Nigeria) give eradication The conventional strategy an increased number of supplementary experts cause for concern.8 The conventional four-pronged strategy rounds of vaccination and transit strate- The explanation for the outbreaks of has succeeded in eradicating polio from gies (vaccination at transit points, such as polio in 2006 is given by the “four-year a large part of the world. This strategy railway platforms and national borders)

a Department of Community Medicine, Lady Hardinge Medical College and Associated Hospitals, Connaught Place, New Delhi 110001, India. Correspondence to Chandrakant Lahariya (e-mail: [email protected]). doi: 10.2471/BLT.06.037457 (Submitted: 14 October 2006 – Final revised version received: 13 January 2007 – Accepted: 14 January 2007)

Bulletin of the World Health Organization | June 2007, 85 (6) 487 Policy and practice Eradicating polio: “finishing the job” Chandrakant Lahariya became part of the programme as late could not be mobilized to bring their populations: in India almost two-thirds as 2005.11 children to the polio vaccination booths of cases still occur in children less than The number of countries in which on national immunization days,13 while two years old.13 polio is endemic has decreased from the Nigerian government succumbed to Country experts speculate that the 125 countries in 1988 to four countries pressure from religious groups to cease children affected may not actually have (Afghanistan, India, Nigeria and Paki- supplementary immunization activi- been immunized, although data to con- stan) in three WHO regions at the pres- ties (misbeliefs, held by certain religious firm this are not available. Indian agen- ent time. Nine other countries reported groups in some parts of India and Ni- cies claim that routine immunization importation of polio virus in 2006.2 geria, hold that vaccination with OPV coverage with three doses of OPV (an There is only one pocket – Moradabad can lead to sterility and death, and that important part of the strategy) in Uttar district in Uttar Pradesh, India – that is vaccination with OPV is being used Pradesh and Bihar has long been more continuously exporting wild polio virus as the means to reduce the number of than 90% and is under close scrutiny.13 to other countries. There is a funding believers in a specific religion). In India In contrast, international agencies such deficit of US$ 575 million to meet for and Nigeria, either coverage or turnout as the United Nations Children’s find 2007–2008.6 It is clear that sooner or on national immunization days was low, (UNICEF) have reported coverage with later the world will be able to eradicate allowing circulation of the wild polio three doses of OPV to be as low as 27% polio, but the current rate of progress virus. Poor community participation in Bihar, 38% in western Uttar Pradesh is very slow and is impeded by many and insufficient community ownership and 45% in eastern Uttar Pradesh, the hurdles. New threats still occasionally are factors that have contributed to the Indian states most severely affected by emerge that require immediate attention endemicity of wild polio virus in these polio.18 and urgent counteractive measures. two countries.13 Social mobilization can Surveys on immunization coverage be considered as important as political suggest that the countries in which polio The current challenges mobilization,14 and both need immedi- is currently endemic have always had low Political advocacy ate reinforcement. coverage with the third dose of OPV In the history of public health activities, in routine immunization; in increasing Volunteers it is likely that no effort has ever been order, the coverage was 39% in Nigeria, organized on such a wide scale as that of The role of volunteers in the eradica- 65% in Pakistan, 66% in Afghanistan polio eradication. Political advocacy tar- tion programme cannot be overlooked. and 70% in India. Moreover, national geted towards the participation of devel- These volunteers know the community, variation hides regional variations and its practices and beliefs, the terrain and considerable “immunity gaps” at subna- oping countries has been instrumental 11 in sustaining the programme, involving the language of the area in which they tional levels. The coverage on national volunteers and keeping vaccination cov- work, facilitating the job of administer- immunization days is always reported to 4 erage high. Societal and political factors ing the vaccine with a high coverage. be more than 90%, but in the present have always been thought of as deter- The efforts of hundreds of thousands situation this needs close monitoring as minants of disease eradication.12 The of people from different walks of life it is not logical that a vaccine that can importance of advocacy was highlighted have made many eradication activities be effective in one region cannot achieve when state authorities in Kano, Nigeria, successful. Can any health programme the same efficacy in another. These suspended supplementary immuniza- afford to recruit this many extra paid observations call for an immediate and tion activities between April 2003 and personnel? Definitely not. independent survey to be carried out in July 2004, resulting in a decrease in The recent repeated outbreaks and these areas to ascertain whether continu- OPV acceptance in all northern Nigerian frequent rounds of vaccination are ing outbreaks of polio can be attributed states.7 The subsequent importation and demoralizing for the volunteers and to vaccine failure or failure to vaccinate. re-emergence of polio is still haunting the inevitably lead to programme-related The past and present problems associ- world. The resumption of supplementary fatigue.15 If no corrective measure is ated with polio vaccine coverage are immunization activities there could only taken immediately the quality of im- managerial and not scientific.19 be achieved by high-level advocacy by munization coverage, and ultimately federal authorities, external partners the eradication programme, may be Threats of importation and and public health officials from affected adversely affected. re-emergence states. This example illustrates the fact When the history of polio eradication that the final stage of eradication needs Vaccine failure or failure to is written, the “Nigeria experience” 7 and sustained advocacy at the highest politi- vaccinate? the importation and re-emergence of cal level to maintain the tempo of the Reports of the occurrence of polio wild polio virus in 21 previously polio- programme; any deficit in this area may among children in India who had been free countries 7 will find a prominent delay achieving the target. previously vaccinated with more than place. Between September 2002 and four doses has raised doubts about the July 2005, type 1 wild polio virus trav- Social mobilization and efficacy of OPV.13,16,17 It has also been elled from country to country, causing community participation said that herd immunity (whereby vac- many outbreaks of polio. The number Where community involvement in the cination of a part of the population of cases ranged from 1 in Eritrea to 478 eradication programme has been low, provides protection to non-vaccinated in Yemen.7 These cases had originated OPV coverage has remained low, lead- individuals) is not being established in Nigeria and India. In 13 of 21 coun- ing to failure to eradicate polio. For with OPV; the age at which polio is ac- tries, there were repeated outbreaks; in example, in some states in India, people quired is not shifting upwards in some 8 of these 13 countries, transmission

488 Bulletin of the World Health Organization | June 2007, 85 (6) Policy and practice Chandrakant Lahariya Eradicating polio: “finishing the job” was later stopped. The countries that increase people’s participation in and approval from governments and com- succeeded in halting the transmission ownership of the programme. munities. This may be achieved by had a median coverage with three doses high-level advocacy among the target of OPV of 83%, compared with 52% What needs to be done groups and communities by experts and in the other 13 countries (P = 0.001).7 international leaders. This experience suggests that the debate immediately? about ineffectiveness of the OPV is not The area-specific approach and Compulsory vaccination and valid and points towards failure to de- community dialogue inactivated polio vaccine liver the vaccine as the reason for con- The four-pronged strategy described When polio importation occurred in tinued virus transmission. The response earlier should be credited with eradi- Saudi Arabia, a directive required a valid immunization was not initiated within cating polio from a large part of the certificate of polio vaccination in order the recommended period of 28 days world and causing it to retreat to a to enter the territory. Administration of in 6 of the 20 countries, and this delay few endemic pockets. In the last three OPV to all children aged less than 15 prolonged the duration of virus trans- to four years, we have seen that these years at the airport was also practiced.23 mission. The lesson from this experience pockets have different problems to be This approach could be emulated by was learned; in May 2006, the World addressed. In Afghanistan and Pakistan, other polio-free countries to prevent Health Assembly passed resolution 59.1 geographically difficult territories must future importation. concerning outbreak response in polio be negotiated by health workers.21 In two While the above methods are suited eradication.20 states in India, myths persist in a com- to the polio-free countries, countries in munity18 that has become non-receptive which polio is endemic should follow a The cost of eradication to vaccination in recent years, such that strategy based on compulsory vaccina- Cost–benefit analysis is always performed successive birth cohorts are not being tion.24,25 Compulsory vaccination does before embarking on any public health immunized. In Nigeria, the actions of not mean that all people should be vac- activity, including eradication. The cost the government and religious organiza- cinated with or without consent. There of polio eradication has now reached tions had an unfavourable effect on the is a provision whereby vaccination can US$ 4.5 billion, compared with the eradication programme, undoing gains be refused by legal declaration and after initial estimate of US$ 2 billion.5,6 The that had been acquired over years.7 Re- education about the possible benefits of programme needs an additional US$ cently, research has pointed towards the immunization. This approach has been 575 million for the coming two to three role of poor sanitation and hygiene in used in the United States of America years.5,6 Any eradication programme the spread of polio virus.22 Although the and the United Kingdom, and also for should be started with sufficient funds finding is noteworthy, it remains to be smallpox eradication in the past. The and financial backup from donors, as the explained why polio can be eradicated in challenge of achieving high coverage long-term challenge of fund-raising may some countries but not others in which could be ensured via extraordinary threaten the whole eradication effort, as sanitary conditions are similar or worse. legislation for compulsory vaccination happened in 1999 and 2003. In these areas in which polio still occurs, against polio in endemic regions. This the hurdles to be faced are all different, legislation might cease to function once New threats and eradication may not be achieved by polio is eradicated from that particular A new threat to the eradication pro- the same strategies. region. gramme emerged in Namibia early in Local and national experts need to The inclusion of inactivated polio 2006, when 20 cases of polio were re- identify and act on the problems in each vaccine (IPV) in eradication programmes ported in people aged 14 to 51 years.8 specific area. Instead of a national-level requires immediate consideration. That What if by immunizing all children we plan, we should prefer district-specific IPV has an important role in polio prevent childhood polio, and cases start or even subdistrict-specific plans. Each eradication is beyond doubt; once polio to occur in adults? Does the Namibia pocket needs to be dealt with individu- is eradicated, IPV is the only way of pre- experience have implications for when ally to stop the transmission of wild polio venting the circulation of re-emerging and how to stop vaccination with OPV? virus from that area.15 The area-specific polio viruses. IPV also provides collec- Is there a need to organize one or two approach plus community dialogue 8 tive and individual protection until the rounds of vaccination with OPV in the now seems to be appropriate. Commu- threat of resurgence of polio completely adult population before cessation of nity dialogue has a proven track record disappears. These facts call for use of IPV OPV in order to prevent circulation of in Nigeria and can also be applied in in endemic areas for eradication even polio virus in the adult population? other settings. The conventional eradica- before the disappearance of wild polio The persistence of myths about tion strategy needs to be supplemented virus from the community. There, the polio, particularly in endemic areas, according to local needs to make a multi- selected regions may opt for compul- can result in low participation and poor pronged, area-specific strategy that may sory vaccination with IPV by organizing cooperation. After almost 10 years of vary in different regions. special rounds. This can be supported running the eradication programme in by keeping the high OPV coverage in India, myths about the polio continue Political advocacy routine immunization. In areas in which to circulate among the general pub- The role of sustained advocacy12,14 has polio is endemic, three subnational im- lic.5,13 The solution may lie in including been highlighted in this paper. Continu- munization days could be organized to information on polio and vaccination ous advocacy to the local and national immunize all children with IPV, irre- in textbooks and curricula of school governments is more important now spective of their previous immunization and colleges to generate awareness and than ever, as new approaches require status. It would be most logical to initi-

Bulletin of the World Health Organization | June 2007, 85 (6) 489 Policy and practice Eradicating polio: “finishing the job” Chandrakant Lahariya ate compulsory immunization with IPV The use of monovalent and trivalent coverage, while all routine uses of OPV immediately on national immunization OPV in alternative rounds of national should be stopped once wild polio virus days, as coverage with three IPV doses immunization days is a good option; this is eradicated. In the final stages, the small will confer almost 100% immunity.26 would prevent sudden outbreaks of type number of children with compromised Compulsory vaccination with IPV has 3 that might spread silently in the com- immune systems need to be kept in the potential to eradicate polio earlier munity in the absence of vaccine against mind, and routine immunization of than could otherwise be expected. type 3 and that can arise suddenly, mon- these children with IPV can be consid- ovalent OPV giving protection against ered a viable approach. Live oral vaccine and/or type 1 polio virus only. This method Countries that have been polio-free inactivated vaccine? may work as a natural experiment to for at least two to three years may now Even with the eventual interruption document the probability of emergence decide upon a time frame to stop OPV of the transmission of wild polio virus, of circulating vaccine-derived paralytic use, using the next few years for mas- outbreaks of paralytic polio will continue polio (cVDPP) virus type 2 after the sive immunization campaigns to keep until the routine use of live vaccine is vaccine is discontinued,28 although that immunity high before discontinuation stopped.27 The public health benefits of would be of only theoretical significance and switching over to IPV. Alternatively, OPV continue to outweigh the risks at as vaccination with OPV has to stop OPV can be discontinued under an the present time.27–29 This situation will sooner or later when the wild virus has IPV “umbrella,” that is scaling down the reverse once transmission of wild virus been eradicated.30 If there is no evidence uses of OPV only when IPV coverage is interrupted and it will be very difficult for the occurrence of more than one type has reached a sufficient level to prevent 32 to eradicate polio using only OPV. The of virus in the community, monovalent circulation of vaccine-derived virus. administration of the number of doses OPV should be used and continued at – sometimes as many as 10 – required this stage. Re-emergence in the post- to confer the necessary immunity is a eradication era challenge,13,22 especially when parents’ Strengthening routine immuniza- International migration poses the threat and health workers’ motivation is likely tion and birth dose of OPV of re-emergence and importation in the to decrease. The polio eradication programme has post-eradication era. The lesson learned The possible solution may be that reportedly decreased routine immuniza- from outbreaks that occur while eradica- countries in which polio is endemic tion coverage, owing to the heavy work- tion efforts are ongoing can help should should organize three national immuni- load imposed on health workers also outbreaks occur after wild polio virus zation days with IPV with strategies like involved in eradication. On the contrary, has ceased to circulate. Countries need compulsory vaccination, which will give this opportunity should be used for to implement the necessary corrective almost 100% protection to the children strengthening routine immunization, as and preventive measures on an emer- gency basis in such circumstances,28 and vaccinated.27 This may be followed by once wild polio virus has been eradicated international experts and agencies need use of IPV in routine immunization pro- and the programme is in its final stages, to be prepared for such events. grammes to protect all successive birth a strong universal immunization system The current facilities for the produc- cohorts. The use of OPV in national will help other eradication efforts when tion of IPV are limited and might not and subnational immunization days to IPV needs to be given as the part of the be able to produce enough IPV when cover all the children routinely can be routine programme. countries are willing to use it in routine continued. IPV in routine immunization Other considerations immunization. Starting to produce IPV would protect individual children while in sufficient quantities should be a pri- circulation of wild polio virus will be Cessation of OPV strategy ority 21 to ensure that IPV is available stopped with high coverage with OPV The contribution of OPV to eradication from early 2008 for all countries that on national immunization days. This is beyond doubt, as is the fact that the might need it. approach is logistically feasible, as it does long-term global eradication of polio not require extra trained workforce. The will be impossible without IPV, seeing Other lessons for the future advantages are manifold; first, this will that use of IPV is the only way to pre- Firstly, eradication should always be address the current problem of occur- vent vaccine-derived paralytic polio 29,30 targeted to a shorter and stipulated time rence of polio in previously vaccinated in the future. For the well-described frame, as a long duration leads to fa- children (as IPV ensures almost 100% reason of reversion potential (reversion tigue and decreases the performance of protection after two doses). Second, it of a vaccinal strain to a wild-type virus), the people involved. Eradication pro- is easier to vaccinate a child with three the continued routine use of OPV is grammes should be likened to a military doses of IPV than with 10 doses of OPV. ultimately incompatible with the eradi- strategy and based on the “hit-and-run” However, the cost of IPV, sustained cation of polio.31 method. availability of vaccine and need for The recent outbreak of vaccine- Secondly, eradication should be an trained workforce to perform the neces- derived polio in Indonesia11 illustrates internationally coordinated effort and sary intramuscular injection are limiting the continued risk of emergence of most of the groundwork (including factors 29 in the use of IPV for national vaccine-derived polio virus in areas with funding support, workforce training, campaigns and in routine immuniza- low population immunity. It is im- sufficient availability of vaccine, infra- tion, and need to be addressed before portant to improve and maintain the structure planning, facilities for vaccine such decisions are made. highest possible routine vaccination delivery, political commitment, com-

490 Bulletin of the World Health Organization | June 2007, 85 (6) Policy and practice Chandrakant Lahariya Eradicating polio: “finishing the job” munity mobilization and surveillance opportunity to eradicate polio? The to make the necessary modifications to networks) should be finished before polio eradication programme has greatly the strategy to design a multi-pronged embarking on any such activity. This contributed to a better understanding area-specific strategy with which to fin- was not the case with polio eradication, of the biological, socio-political and ish the job. This may require legislation as many countries started programmes economic complexities of eradication, for compulsory vaccination, addressing in their territory a long time after a large which will immensely benefit any fu- local needs and use of IPV in routine im- part of the world was polio-free. Had ture effort against other diseases. The munization in endemic countries even efforts been internationally coordinated unwanted delay in achieving the target before disappearance of wild polio virus. and synchronous, the situation could should now be used to benefit future Immediate action is needed to kick the have been different. public health efforts. First, once polio virus out and put polio into the history has been eradicated the world will have books. O Conclusions available an army of people who have been trained in public health and eradi- Acknowledgements The earliest possible time when we can cation matters and who will benefit the Special thanks go to Dr SK Pradhan expect zero cases of polio to be reported international community. Second, a and Dr Jyoti Khandekar at the Depart- is the end of 2007; this means that to be functioning network of laboratories, ment of Community Medicine, Lady sure of polio eradication, the world must surveillance systems, and convinced and Hardinge Medical College, New Delhi, continue to use OPV for another three motivated national governments and India, for their input. The author ex- years, until at least 2010. Theoretically, managers would be assets for nations, presses his gratitude to many people in this should be followed by use of IPV as would improved and more efficient the community, polio volunteers, health and continued surveillance for acute health systems. Third, thousands of staff at various health facilities in the flaccid paralysis for another seven to volunteers, proud to talk about their states of Uttar Pradesh, Madhya Pradesh eight years. This implies that the eradica- contribution to polio eradication, will and Delhi, and to the people involved in tion of polio in the truest sense cannot be there to prepare another generation of polio eradication in various capacities for be achieved before 2017. This era after volunteers to advocate for similar future sharing their ideas. The author would also the polio virus ceases to circulate will be efforts. Finally, the financial benefits are like to thank the three anonymous review- full of threats of outbreaks and uncer- clear. ers for their constructive comments. tainties. However, how could any major The traditional four-stage strategy Competing interests: None declared. health initiative ever be launched if the has done its work and polio is now world fails in or squanders this precious restricted to a few pockets. It is time

Résumé Eradication de la poliomyélite à l’échelle mondiale : il faut « finir le travail » Le terme fixé pour l’éradication de la poliomyélite, à savoir l’année solutions pour y répondre. Selon l’auteur, il serait nécessaire de 2000, est dépassé depuis sept ans et l’objectif est encore hors de modifier et de compléter de façon conséquente cette stratégie pour portée. En 2006, malgré les efforts internationaux coordonnés, en établir une nouvelle, intégrant plusieurs volets et s’adaptant aucune avancée majeure n’a été enregistrée dans l’endiguement spécifiquement aux différentes zones touchées, de manière à du poliovirus, qui se maintient dans quelques poches d’endémie pouvoir finaliser l’oeuvre d’éradication. Les modifications et les de quatre pays. Le programme d’éradication de la poliomyélite doit apports à la stratégie d’éradication pourraient donc comprendre faire face à de nouveaux obstacles : importation et réémergence de une adaptation à la zone d’intervention, un développement du la maladie, échec de la mobilisation politique et communautaire. Il dialogue avec les communautés, un renforcement des actions faut aussi surmonter le découragement des professionnels et des de sensibilisation politique, une mise en œuvre plus poussée volontaires dans le domaine sanitaire, les doutes quant à l’efficacité de la vaccination obligatoire, ainsi que l’utilisation du vaccin du vaccin antipoliomyélitique oral, l’inflation permanente des coûts antipoliomyélitique inactivé dans les pays d’endémie avant programmatiques et les difficultés grandissantes pour financer même l’interruption de la transmission du poliovirus sauvage. Ces les interventions. améliorations constitueraient, d’après l’auteur, le meilleur moyen Le présent article expose la stratégie actuellement appliquée d’atteindre le plus tôt possible l’éradication. pour éradiquer la polio, puis analyse les problèmes existants et les

Resumen Erradicación mundial de la poliomielitis: argumentos para «acabar el trabajo» Aunque han transcurrido ya siete años desde 2000, año fijado nuevas dificultades, como la importación y la reaparición del virus y como meta para erradicar la poliomielitis, el éxito de ese empeño el fracaso de la movilización política y comunitaria. La menguante sigue sin concretarse. En 2006, pese a la coordinación de los moral de los trabajadores sanitarios y los voluntarios, las dudas esfuerzos internacionales, no se registró ningún avance destacable sobre la eficacia de la vacuna antipoliomielítica oral y los cada de las actividades de contención del virus poliomielítico, que vez mayores costos de los programas y problemas de financiación persiste en unos cuantos focos de los cuatro países en los que es son otras cuestiones a abordar. endémico. El programa de erradicación de la poliomielitis afronta En este artículo se describe la estrategia convencional puesta

Bulletin of the World Health Organization | June 2007, 85 (6) 491 Policy and practice Eradicating polio: “finishing the job” Chandrakant Lahariya en marcha para erradicar la poliomielitis y se analizan los retos comunidades, mejoras de la sensibilización de la clase política y existentes y algunas soluciones posibles. El autor sugiere que la vacunación obligatoria, y uso de la vacuna antipoliomielítica es necesario introducir importantes modificaciones y nuevos inactivada en países endémicos antes incluso de la interrupción elementos en la actual estrategia convencional a fin de desarrollar de la transmisión del poliovirus salvaje. Este planteamiento es una estrategia amplia y propia de esta área para poder acabar probablemente el más idóneo para lograr la erradicación lo antes el trabajo de erradicación de la poliomielitis. Ello debería incluir posible. un enfoque específico para este problema, diálogo con las

ملخص استئصال شلل األطفال من العامل: حالة )) استكامل املهمة (( بعد مرور سبعة أعوام عىل عام األلفني، وهو العام الذي سبق أن حُدِّد العتامدها الستئصال شلل األطفال، ثم تقدم تحليالً للتحديات الراهنة وبعض الستئصال شلل األطفال، اليزال النجاح غري واضح للعيان، فلم تُحَقَّق إنجازات الحلول املمكنة. ويقرتح املؤلف إدخال بعض التعديالت واإلضافات الكبرية هامة عام ألفني وستة رغم الجهود الدولية املنسَّ قة الحتواء فريوس شلل األثر عىل االسرتاتيجية املعهودة، وأن ذلك رضوري لخلق اسرتاتيجية متعددة األطفال، فاستمر رسيانه يف جيوب قليلة يف أربعة بلدان يتوطن فيها. ويواجه األبعاد وخاصة بكل مجال من املجاالت عىل حدة، وميكنها أن تستكمل مهمة برنامج استئصال شلل األطفال عقبات جديدة مثل وفادته وانبعاثه والفشل استئصال شلل األطفال. وينبغي أن تشتمل هذه االسرتاتيجية عىل أسلوب يف استنهاض السياسيني واستنهاض املجتمع. ويلقي تضاؤل الحامس لدى خاص بكل مجال من املجاالت عىل حدة، والتحاور مع املجتمعات، وتعزيز العاملني واملتطوعني الصحيني بظالل الشك حول نجاعة اللقاح الفموي املضاد الحمالت الدعائية بني أصحاب القرار السيايس، والتطعيم )التلقيح( اإلجباري لشلل األطفال وحول ما تفرضه الربامج من تكاليف تتزايد دون توقف، وحول إىل جانب استخدام اللقاح املعطّ ل لفريوس شلل األطفال يف البلدان التي التحديات يف التمويل، وهي من القضايا التي ينبغي التصدي لها ومعالجتها. يتوطن فيها املرض، وذلك حتى قبل إيقاف رساية الفريوس الربي؛ فذلك قد وتقدم هذه الورقة وصفاً لالسرتاتيجية املعهودة التي يجري العمل يكون أفضل الطرق لتحقيق استئصال شلل األطفال يف أقرب فرصة ممكنة.

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