Polio update: Together, we end polio

Summary

Rotary Voices Podcast Summary Episode: Polio Update: Together, We End Polio
Release Date: October 24, 2024
Host: Nailah Boudu
Produced by: Rotary Magazine

---

Introduction

In this episode of Rotary Voices, host Nailah Boudu delves into the ongoing battle against polio, spotlighting recent outbreaks and the robust global response spearheaded by Rotary International and its partners. The discussion features insights from three distinguished experts: Dr. Hamid Jafre from the World Health Organization (WHO), Dr. Daniel Salas of the Pan American Health Organization (PAHO), and Dr. Varya Grabovok representing the Western Pacific region. Together, they explore the complexities of eradicating polio in regions where it has long been controlled and the vigilance required to maintain polio-free statuses globally.

---

Polio Outbreaks and Challenges

Guest: Dr. Hamid Jafre, Polio Eradication Director for the Eastern Mediterranean Region, WHO

Dr. Jafre discusses the alarming resurgence of polio in Pakistan and Afghanistan, highlighting the multifaceted challenges impeding eradication efforts.

• Epidemic Nature of Polio:
  “Polio is an epidemic-prone disease. If you do not interrupt its transmission, it will come back as an outbreak.” [01:48]

• Contextual vs. Programmatic Factors:
  As eradication efforts near completion, contextual factors like political stability become more critical than programmatic ones.
  “Progress is not really linear. You have these cycles until you sustain eradication efforts to a point that you can actually stop transmission.” [01:48]

• Primary Challenges:

  1. Insecurity:
     Conflict zones like Gaza, Sudan, Yemen, Somalia, and parts of Pakistan hinder access to vaccination.
     “Insecurity is a contextual factor because the program has some ability to mitigate, but it does not control insecurity and access.” [04:13]

  2. Social and Political Disconnect:
     Misinformation and unmet community needs lead to vaccine refusal and distrust.
     “Some services like roads are not there, schools are not there, health facilities are not there.” [04:13]

  3. Hard-to-Reach Populations:
     Mobile and migrant groups complicate vaccination efforts, exacerbated by cross-border movements.
     “Pakistan and Afghanistan both have extensive population movement, further complicated by extensive cross-border population movements.” [06:40]

  4. Programmatic Issues:
     Quality gaps in vaccination campaigns can lead to missed children and operational inefficiencies.
     “In the beginning, often the quality of the vaccination campaign is not that high and it takes some time to build to that level of quality.” [06:43]

• Genetic Clusters Explained:
  Dr. Jafre clarifies that polio viruses mutate and form clusters.
  “Polio viruses, as they replicate and spread, mutate and evolve into different families and then larger families become a cluster.” [06:43]

---

Case Study: Gaza Polio Outbreak

Guest: Dr. Hamid Jafre, WHO

The detection of poliovirus in Gaza Strip environmental samples and the subsequent case of a 10-month-old boy underscore the fragility of polio-free regions.

• Outbreak Response:
  Dr. Jafre details the rapid response and vaccination campaigns initiated in Gaza.
  “The first round has done better than our expectations. Micro planning was excellent by the teams on the ground.” [10:17]

• Community Engagement:
  Gaza's high health literacy facilitated a successful vaccination drive.
  “Overwhelmingly, the community was very, very avid in bringing their children to get the vaccine.” [10:17]

• Second Vaccination Round:
  Incorporation of additional health measures like Vitamin A supplementation enhances the campaign's impact without compromising quality.
  “The teams agreed to add Vitamin A to the polio vaccination campaign in the second round in Gaza.” [12:48]

• Regional Solidarity:
  Emphasizing a collective regional threat approach, neighboring countries like Jordan and UAE played supportive roles.
  “Regional solidarity is very important. Countries have demonstrated resilience and this support builds greater resilience across the region.” [12:44]

---

Lessons from India’s Eradication Effort

Guest: Dr. Hamid Jafre, WHO

Reflecting on India's successful polio eradication provides valuable lessons for ongoing efforts in Pakistan and Afghanistan.

• Non-Linear Progress:
  India experienced setbacks with periodic outbreaks before achieving eradication in January 2011.
  “Progress towards eradication is not linear. You go forward and then have a setback and then work through that again.” [16:04]

• National Commitment:
  Strong governmental dedication was pivotal in maintaining high vaccination standards and accountability.
  “The national commitment, the commitment of the government, is very important...” [16:04]

• Community Engagement and Rotary's Role:
  Engaging local communities and empowering Rotarians were crucial in overcoming resistance and logistical challenges.
  “The tremendous role that the Rotarians in India played... was crucial to get the elimination in the past.” [16:04]

• Inspirational Quote:
  Dr. Jafre cites Nelson Mandela to emphasize perseverance.
  “It always seems impossible until it's done.” [16:04]

---

Maintaining Polio-Free Status: Americas Region

Guest: Dr. Daniel Salas, Executive Manager, Comprehensive Immunization Program, PAHO

Celebrating 30 years without wild polio transmission, Dr. Salas underscores the necessity of sustained immunization efforts to prevent resurgence.

• Achievement and Vigilance:
  “We managed to eliminate the wild polio transmission in the Americas 30 years ago... but it's difficult to keep this target because you need strong immunization programs.” [22:08]

• Challenges:
  Competing public health priorities and maintaining high immunization coverage amidst changing societal dynamics.
  “Some policymakers are not totally aware of the benefits... We need to reinforce the message that vaccines are safe and effective.” [23:37]

• Vaccine Hesitancy:
  Addressing misconceptions and ensuring communities understand the importance of timely vaccinations.
  “Still, most people trust in vaccines, trust in routine vaccines, and that's something we need to capitalize on.” [26:16]

• Urban vs. Remote Access:
  Strategies vary between urban and rural settings, including adapting vaccination schedules and leveraging electronic registries.
  “In metropolitan areas, adaptation is key, like adjusting vaccinators' working hours.” [27:53]

• Technological Integration:
  Utilizing AI and electronic registries to identify and reach under-vaccinated populations.
  “Having a nominal registry for every single person makes it much easier to be more efficient.” [30:20]

• Role of Education:
  Strong investment in education correlates with better health outcomes and vaccine uptake.
  “Education is crucial because educated people can understand preventive measures more easily.” [31:13]

---

Maintaining Polio-Free Status: Western Pacific Region

Guest: Dr. Varya Grabovok, Regional Laboratory Coordinator for Vaccine Preventable Diseases, Western Pacific Region, WHO

The Western Pacific region has upheld its polio-free status since 2000 through rigorous surveillance and immunization strategies.

• Sustained Efforts:
  Implementation of high routine vaccination coverage, supplementary immunization activities, and strong surveillance systems.
  “We have successfully maintained our polio-free status by increasing and sustaining high routine vaccination coverage.” [34:46]

• Challenges:
  Risks from circulating vaccine-derived polioviruses (CVDPVs), inadequate immunization in certain areas, and importations from neighboring regions.
  “Importation of wild poliovirus type 1 from endemic countries poses ongoing risks.” [34:46]

• Surveillance and Response:
  Robust environmental and acute flaccid paralysis (AFP) surveillance supplemented by a high-capacity laboratory network ensures rapid detection and response to any new cases.
  “Environmental surveillance was used successfully as a supplement to AFP surveillance.” [37:14]

• Risk Assessment:
  Continuous evaluation identifies high-risk countries, enabling targeted interventions and preparedness.
  “Updated Risk Assessment categorized three countries as high risk for poliovirus transmission.” [37:14]

---

Conclusion

The Rotary Voices episode underscores the relentless global effort to eradicate polio, highlighting both triumphs and ongoing challenges. Experts emphasize that while significant progress has been made, maintaining high vaccination coverage, addressing contextual barriers, and fostering regional solidarity remain imperative. Rotary International's pivotal role in community engagement and fundraising is recognized as essential in the final push towards a polio-free world. The collective commitment of health organizations, governments, and communities offers hope that polio eradication will soon be realized.

Notable Quotes:

• “Polio is an epidemic-prone disease. If you do not interrupt its transmission, it will come back as an outbreak.” – Dr. Hamid Jafre [01:48]
• “It always seems impossible until it's done.” – Dr. Hamid Jafre [16:04]
• “Most people trust in vaccines, trust in routine vaccines, and that's something we need to capitalize on.” – Dr. Daniel Salas [26:16]

---

Join the Fight to End Polio:
Visit www.endpolio.org to support and participate in eradication efforts.

Credits:
Produced by JP Swenson with assistance from Kristin Morris, edited by Wen Huang, and produced by Yoo Soo Kim. Special thanks to Sarah Tetzloff and Carol Pandak.

Transcript

[Nailah Boudu]

From Rotary magazine, this is the Rotary Voices podcast. I'm Nailah Boudu. In July of this year, poliovirus was detected in environmental samples from the Gaza Strip. In August, a 10 month old boy became the first confirmed case in Gaza in the last 25 years. This outbreak sparked urgent concern among global health organizations leading to an ongoing vaccination campaign in the Gaza Strip. These events and subsequent efforts highlight the importance of the Global Polio Eradication Initiative and its partners. In this episode we hear from three polio experts from around the world working in regions where wild polio has long been eradicated to the two countries where wild polio remains endemic, Pakistan and Afghanistan. Which brings us to our first guest, Dr. Hamid Jafre. Dr. Jofre is the Polio Eradication Director for the Eastern Mediterranean region of the World Health Organization. This region comprises 21 member states and Palestine with a population of nearly 679 million people. In this episode, Dr. Jofre discusses the importance of community engagement and vaccination campaigns, the first round of vaccinations in Gaza and the need for regional solidarity and eradication efforts. Dr. Hamid Jeffrey, welcome to the Rotary Voices podcast. Thank you for being with us.

[Dr. Hamid Jafre]

It's a pleasure to be with you today. Thank you.

[Nailah Boudu]

When we look at where we are this year compared to last year, there have been quite a few challenges with polio eradication. So I wanted to just start and ask you what's top line when it comes particularly to your region and new polio cases.

[Dr. Hamid Jafre]

I think there are certain principles that we have learned over these decades of polio polio eradication. I think it boils down to two fundamental factors. One is that polio is an epidemic prone disease. And what that means is that if you do not interrupt its transmission in a country or in a region, it will come back as an outbreak. So repeated outbreaks is just a characteristic. That's how the virus behaves. So if you don't succeed in eliminating the virus, it will come back, it will resurge. So that's one thing, and we've seen that repeatedly. I think the second thing is that the increasingly as you get towards the end of an eradication effort, the contextual factors become much more important than the programmatic factors. And so progress is not really linear. So you have these cycles until you actually sustain eradication efforts to a point that you can actually stop transmission. And that's how the five of the six regions of WHO became free of polio. So I think those are the two things to keep in mind and so what has happened in the last 12 months is that we have seen a resurgence of polio in Pakistan and Afghanistan after a period when we thought that we were very, very close. And I think that's where these are extremely complicated and difficult political and security and conflict contexts. And so the kind of what we call last mile issues that we are facing in Pakistan and Afghanistan are, I usually put them into four categories. The first is insecurity, which creates difficulties for accessing children with vaccination. Right. In fact, the countries where we are facing polio outbreaks, most recently Gaza, are places that have prolonged emergencies and prolonged conflict. That's Sudan and that's Yemen, Somalia and most recently Gaza. And we have parts of Pakistan, particularly where there is insecurity, you know, rising militancy, and that makes access to children extremely difficult.

[Nailah Boudu]

So insecurity, is that a contextual factor?

[Dr. Hamid Jafre]

Yeah, absolutely. Contextual factor because the program has some ability to mitigate, but it does not control insecurity and access. You know, it's not in the direct control of the program. The second area is when there is a social and political disconnect between the program and the communities, right. When there is certain population subgroup that either because of some belief or because of misinformation around vaccine that they refuse vaccination, Right. Or these are extremely deprived communities, deprived of essential social and civic services, who then see that the government is really keen to eradicate polio. And there is a lot of effort. Polio vaccination teams come repeatedly to vaccinate their children. But some services like roads are not there, schools are not there, health facilities are not there. And they figure out that maybe we could boycott the vaccination campaign to negotiate for other services. Nothing to do with polio, nothing really to do with health, but it becomes a bargaining tool. I think the third is now we are starting to get into programmatic sort of factors. There are always populations that are very hard to reach. The hardest populations to reach are mobile and migrant populations. So even in the final years of polio eradication in India, for example, polio virus was over represented in migrant and mobile communities in India. And Pakistan and Afghanistan both have extensive population movement. And then that's further complicated by extensive cross border population movements. Now coming back to what has happened recently, Pakistan was making very, very strong progress and in fact Pakistan eradicated that virus that was endemic to Pakistan. It was a particular genetic cluster of polio virus. Similarly, a genetic cluster was on the Afghanistan side. Now Pakistan has eradicated that cluster, but on the Afghanistan side that didn't happen. And last year there was just unprecedented population movement because of forced repatriation of Afghan citizens back to Afghanistan. That led to extensive population movement both across the borders and within Pakistan. So the cluster that was surviving in Afghanistan probably infected border communities living in the bordering districts of Pakistan and then spread across Pakistan.

[Nailah Boudu]

Dr. Joffre, can you explain what you mean by genetic cluster?

[Dr. Hamid Jafre]

Yeah. So this is the naturally occurring polio virus. You know, there are three types of naturally occurring polio virus, what we call wild poliovirus, and they were type 1, type 2 and type 3. Type 2 and type 3 wild polio viruses have been eradicated and certified as eradicated globally, everywhere. Only type one is surviving. And this type one virus is surviving in only Afghanistan and Pakistan. And the genetic element that I'm talking about, polio virus, is in RNA virus, just like COVID virus. And you've heard about the variants of COVID virus, right? So polio viruses like that also, as it replicates, as it spreads, it develops, it mutates and evolves into different families and then larger families become a cluster. So Pakistan and Afghanistan had more than 12 clusters around 2019, 2020. They reduced them to one in Pakistan and one in Afghanistan. Pakistan eradicated the cluster that was endemic in Pakistan. What we are seeing in Pakistan and Afghanistan now is the spread of the cluster that survived in eastern Afghanistan. So that's what researched. So then hard to reach populations, particularly migrant and mobile populations, is the third factor. The first was conflict, insecurity and inaccessibility. Second was a social and political disconnect. Third are these hard to reach populations and migrant and mobile populations foremost among them. And fourth, of course, is where just the quality of our work is not good enough, that there are gaps in our planning, there are operational quality gaps. We miss children, teams miss houses. And so both Afghanistan and Pakistan programs, and in many parts of the world, the general quality is good. Now, when you have a polio outbreak in a country that has been polio free for many years, it takes them a while to get it all, you know, put it all together to do the micro planning again, which means that, you know, where are the children? How many teams are needed? Are the houses listed? Do we know how many children live in the area? It takes some time for them to get up to speed. So there, I think in the beginning, often the quality of the vaccination campaign is not that high and it takes some time to build to that level of quality. We still have pockets in Pakistan, Afghanistan, where this quality is suboptimal. And the program has to constantly work at it. So I don't want to convey the message that our program is perfect and it's only the outside factors. No, that would be misleading. I think it's a combination. And we also shape the contextual factors. We have extensive experience globally to negotiate access. In Afghanistan, for decades we've negotiated with the Taliban authorities when they were in opposition. And now of course, it's their government in Afghanistan, wherever families live, wherever women and children live, you can always find interlocutors to negotiate access. And so we've been able to stop outbreaks of polio. The last cases of Nigeria were in Borno, in the northeast region where the Boko Haram was. There was extensive militancy in that setting. That transmission was stopped. We've stopped wild polio virus outbreaks in Somalia, in Sudan and repeatedly in Syria. So we have experience. And most recently we were able to work together with the Ministry of Health and unicef, who with of course support from Rotary International, we were able to mount a very rapid response to the detection of poliovirus in Gaza Strip.

[Nailah Boudu]

I was going to ask you about Gaza. When you talk about all of the factors that we were just talking about, can you explain the Gaza story and how that relates?

[Dr. Hamid Jafre]

After the start of the war, the surveillance for polio virus was also disrupted. And there are two ways we do surveillance for polio virus. The gold standard is detecting and reporting and then investigating any cases of acute flaccid paralysis and to test them whether their reason of paralysis due to polio virus. And the other, is that what we call environmental surveillance where you do sewage testing? And so Gaza had both of those, but both of those got disrupted. But in June, samples were collected from a few sites in two different governorates of Gaza and they were positive. And then a 10 month old child got paralyzed by polio virus. And so very rapidly risk assessments were done as part of the standard response for a polio outbreak in a polio free country. Rapidly, micro plans were developed and then there were extensive negotiations with the authorities in Israel about these humanitarian pauses. And the important thing is that I think there was no debate about the need to stop this outbreak and prevent its international spread. A lot of the negotiation was how best to do that. So I think the first round has done better than our expectations. So micro planning was excellent by the teams on the ground of Ministry of Health, unurva, who, unicef. They did a fantastic job of planning the implementation. But I think the overarching factors for success were first that all the parties Adhere to these humanitarian pauses because that is something that could have very quickly disrupted the whole thing. You know, if there would have been an incident, unfortunately, then the workers would have gotten very nervous and most importantly, families would not have felt confident to bring their children up. Right. And the second, and an equally important factor was the enthusiasm with which the families brought their children out. Now, Gaza population is a very highly health literate population. You know, before the start of the war, the vaccination coverage of children in Gaza was around 99%. Right. So when the campaign was organized, they came out in droves to get their children vaccinated. So what we had working for us here, none of that vaccine hesitancy or refusal, I mean, they were just minor pockets of that. But overwhelmingly the community was very, very avid in bringing their children to get the vaccine.

[Nailah Boudu]

And what would that second round involve this time?

[Dr. Hamid Jafre]

There's been a lot of discussion that given the success of the first round, what else can be added to deliver to these children that are so deprived and have so many health risks? But the operating environment is extremely complex there and if you add anything, you can risk the quality of the polio campaign. So after a lot of discussion, the teams agreed to add vitamin A to the polio vaccination campaign in the second round in Gaza. And this is really about working together in 2021 as a result of a regional committee resolution. Regional committee is a committee of ministers of health of the region. Among many things that need to happen in polio eradication. They said that there will be a ministerial regional subcommittee for polio eradication and outbreaks in our region. And this is these ministers of health. It's currently co chaired by the Minister of Health of Qatar and uae and ministers participate. And it is a tremendous forum of developing regional solidarity and regional resource mobilization and regional commitment. So the countries that are dealing with polio outbreaks and Pakistan and Afghanistan, it's about how do you look at this as a regional challenge, a regional threat rather than an individual country issue? And they have been fantastic in mobilizing regional solidarity, regional commitment, so that every country is even prepared to maintain high surveillance for polio virus. And if polio virus comes in, they're prepared to respond to the outbreak. And this Gaza situation exemplified that, that this was seen as a regional threat with a regional response. For example, Jordan opened up its lab for testing samples from Gaza. United Arab Emirates pledged funding for the outbreak response there. And all the countries of the region were saying, we are ready to assist. Tell us what needs to happen, what we need to do. And so this regional solidarity is very important. And many of these ministers, they are available to the program for a lot of back channel advocacy, what we call track two. There are things they can say openly, but then there are things they can communicate bilaterally with certain countries or they help us collectively to address some very gnarly challenges of access and other complicated politics that are affecting polio eradication. And these ministers are doing amazing work behind the scenes in helping us solve those problems. So this working together in our region has really brought out great support across the region because the countries have demonstrated resilience and then this support builds greater resilience across the region.

[Nailah Boudu]

I appreciate you saying that because I feel like I'm covering all the news of everything every day. And I'm thinking of how difficult it is just to cooperate on so many things. But it sounds like at least for polio, that was a bridge that people could build together. Dr. Jafre, you were a key part of India's eradication efforts. People said before that it happened that that would be impossible. So I wonder what lessons other countries can take from what India accomplished. In terms of what we've been talking about here, particularly in regards to Pakistan and Afghanistan.

[Dr. Hamid Jafre]

I think that's a great question. You know, we also had repeated outbreaks of polio in Uttar Pradesh and Bihar that then used to spread from there to other states of India. And until the whole program was able to stop the transmission of wild polio virus in India, we faced periodic outbreaks in India as well. So that again, to reinforce that progress towards eradication is not linear. You go forward and then something happens and then you have a setback and you see a polio outbreak and then you work through that again, learn lessons from it, you fix those issues. It is amazing to reflect back now that the last case of polio in India occurred in January of 2011. In the year 2009, there were 741 cases of paralytic polio in India. We had a massive outbreak in 2009 and we went through 2010 with fewer cases. And then the last case occurred in January. Boom, it was done right. And so when you look at Pakistan and Afghanistan, I think once we can maintain quality across the board and have access across the board on both sides of the country. The key here is what is different from India is that Pakistan and Afghanistan and all the hotspots within have to succeed concurrently. What we've had is that most areas succeed, or one or two, the virus survives in one area, then it comes back and then infect all those areas again. Right. So this is what we are trying to avoid, sort of after this resurgence, to avoid another cycle and really kill it, kill the virus, you know, in the next 12 to 15 months. So that's one critical lesson from India. Second, very important lesson from India is the national commitment, the commitment of the government. And that's very important because if the government is wishy washy and not fully committed, then it's very, very difficult to get the quality of work you need on the ground and the kind of accountability, the monitoring, corrective actions that are needed just to maintain excellence of vaccination operations. I think third is the community engagement. We went through a very difficult period of a lot of community resistance to polio vaccination in India. And it took a lot of effort to get communities on board, get the communities to own the program, get workers from the community to vaccinate their own communities. I would say that the tremendous role that the Rotarians in India played and the Rotarians are playing now to support the program in both Pakistan and Afghanistan, their civil society voice as Rotarians in Pakistan, the kind of work that the Pakistan Polio plus committee chair is doing in terms of political advocacy, working with the communities, establishing clean water sources for the most deprived communities, doing health camps, providing vaccination sites at major border crossings and highways, Very, very important work Rotary is doing in Pakistan and of course, the funding support for both Afghanistan and Pakistan that Rotary International provide. So I think, I mean, India, there were so many times when we thought we were stuck and the Rotary leadership in India came to our rescue and they opened doors that we thought, thought we could never open. My favorite quote is from Nelson Mandela that it always seems impossible until it's done. It seemed impossible. So many people told us in India that you're delusional, that how can you get rid of polio virus from 1 billion people, many of them living in very crowded and unsanitary conditions? It's impossible. So the India program was a huge technical challenge. People challenged the biological feasibility of eradication in India and it was done.

[Nailah Boudu]

So it sounds like you have a lot of hope for the future.

[Dr. Hamid Jafre]

We have no choice but to have a hope. Look where we are. I mean, we are more than 99.9% of the way. We have demonstrated success, of course, after a lot of effort in situations that were considered completely impossible. I mean, who would have thought that we could implement a campaign in Gaza or stop an outbreak in Syria in the height of the civil war there in 2013. But you know, it's working together. It's working with communities, it's partners working together. It's Rotary's leadership in this. And it's very, very important that Rotarians stay with us in this last journey. There is a reason why these countries are the last countries that still are struggling with polio. It's not that everything is equal. It's a level playing field and they are just laggard countries. That's not the case. I mean, the social political security context is extremely complex and the way people are moving is extremely complicated.

[Nailah Boudu]

The World Health Organization's Dr. Hamid Joffrey, polio eradication Director for the Eastern Mediterranean Region. Thank you for being with us.

[Dr. Hamid Jafre]

Been a pleasure. Thank you so much.

[Nailah Boudu]

Thank you again to Dr. Jafre for joining us. Now it's time to look to the past. Our Next guest is Dr. Daniel Salas, the executive manager of the Comprehensive Program on Immunization for the Pan American health organization, or PAHO. Wild polio was eradicated in the Americas 30 years ago, but Dr. Salas says it's important to maintain strong immunization programs to prevent the virus from resurging. He explains how PAHO's work sustains these programs, discusses the role of organizations like Rotary and reflects on the region's 30 year milestone of being wild polio free. Dr. Daniel Salas is the executive manager for the Comprehensive Immunization Special Program. Thank you for being here. Welcome.

[Dr. Daniel Salas]

Oh, it's my pleasure to have this opportunity.

[Nailah Boudu]

Earlier in this episode, we spoke to Dr. Jofre about conditions across the Eastern Mediterranean region where we're seeing wild polio cases in Pakistan and Afghanistan rising. Can we start with what the situation looks like in the Americas?

[Dr. Daniel Salas]

Well, we managed to eliminate the polio of the wild polio transmission in the Americas 30 years ago. Actually, we're having the anniversary this year of this milestone that was truly celebrated across all the continent. And of course it has been difficult to keep this target because you need to have strong immunization programs. But I would say that there's lately a lot of competing priorities, probably more than ever. So that can really deviate the attention of the immunization program. It is a challenge that we need to face to continue positioning the immunization as a public good in the Americas. Some of the policymakers are not totally aware of the benefits of all the things that are not happening in our society because we have managed to keep strong immunization programs. The other part is to have human resources well trained, well motivated to understand which are the dynamics of population so that we can cope with their needs. We have still the challenge of understanding what is the perception of people. I mean, what are they thinking about vaccination? Are they receiving enough information to make decisions to be totally sure that vaccinations or vaccines are safe enough or effective enough? I mean, that's something that we need to reinforce, to continue working to get that message.

[Nailah Boudu]

Clearly to Dr. Salas, congratulations, first of all on 30 years. And it sounds like you're saying that in some ways, because There has been 30 years of this milestone, it may be hard to understand what's actually been accomplished.

[Dr. Daniel Salas]

Yeah, because 30 years ago you used to know people with poliomyelitis. So that's something very impacting to see a person that can walk. Some of the people that got complications with polio, they ended up not being able to breathe by themselves. So that's something that you are not seeing anymore. People of course tend to forget or even the newer generations didn't see any kind of effect of polio in other side vaccines is one of the most important inventions in public health during the previous century. That effect of prevention, of not having devastating effects in our society, that's something that is worthy to continue reinforcing those effects.

[Nailah Boudu]

For the people listening, what do you want them to be thinking about in the context of not just achieving but maintaining these milestones?

[Dr. Daniel Salas]

I would say that Rotary, for example, can really help us address their concerns in a more effective way. To be close to the communities, to make them feel cared, to make them feel that there is a real interest on them. That's truly important. Because if you let those coverages go down, if you let those surveillance indicators go down, then you're not going to be able to keep the milestones of the elimination of some of these diseases. We know that when we achieve the eradication, which is a global phenomena, we are not going to have to vaccinate with polio or measles anymore. But at this time and at this point of the history, we haven't achieved that yet. So there is this risk of having importations and if we don't have strong vaccination coverages, then those importations can reignite an outbreak that can be sustained and then we're going to have polio or measles again. We know that there is still transmission of via polio in Pakistan and Afghanistan and there are even transmissions of vaccine derived polio viruses in some instances. So that's something that we need to understand. We are not at that point of settle down and Say we should not sustain those goals that we have achieved in the past.

[Nailah Boudu]

How specifically are you addressing vaccine hesitancy? Because particularly with COVID 19, I don't know if you would say that was a setback worldwide for vaccine hesitancy because of the pockets of people who were resistant to a COVID vaccine.

[Dr. Daniel Salas]

It is important to understand always what are the conceptions of people. You have to implement some kind of research to understand which are the social drivers of immunization. And of course, if we're talking about different target populations, those perceptions are going to be different. And even among countries, even among, you know, inside a territory, we're going to find different perceptions and at the same time to really try to convince them that vaccines are important, but from their perspective, not from ours. So I could say that still most of people trust in vaccines, trust in the routine vaccines, and that's something that we need to really capitalize to continue doing all what is needed. In the case of The Americas in 2023, the coverage report has indicated that we are recovering. Comparing 2019, which was the year previous to the COVID 19 pandemic. I mean, we have two years in a row that we have positive results, and that's something that should be encouraging. But we are not at the level of settling down and say this is an automatic process and we're going to continue improving. We need to get to the last mile, because at the end, going from the 88% of DPT3 and get to the 95%, which is the standard for the Americas, it's something difficult. It's going to take a lot of extra efforts to get to all the populations and make the vaccination a reality.

[Nailah Boudu]

So obviously we're talking about a huge geographic region. You were talking about the differences even within countries. How different does that look for urban versus remote areas when we're thinking about access?

[Dr. Daniel Salas]

Well, I would say that there are challenges in both of them. For example, in the rural areas, we have people that in some cases live really far away from the vaccination centers. And that's a barrier that we need to address. And in rural areas, it is very important to have that kind of social participation and to really identify social leaders at a community level to be champions and to engage all of the different social stakeholders. That can really help to increase the coverages and to identify which are the differentiators, because we can't generalize and say that rural areas are all the same. Even among rural areas, you have a lot of differences that you need to read the Context. And of course, we're talking about the metropolitan areas. There are places that have low security, and it is important to take advantage of every kind of contact, even outside the health sector, to try to offer that vaccine to population. Another important thing we have seen in the metropolitan areas is adaptation, being able to adapt the strategies to get those people vaccinated. For example, you adapt the working hours of our vaccinators to work after 4, 5pm Some days, not every single day. We're living in 2024. It is important for the national programs on immunization to move forward with having electronic nominal registries to detect every single person that has been vaccinated. Because in some countries still they are counting the vaccine supplied, not the people that are being vaccinated. So that makes a huge difference. If you have that data and you know that a child was born two years ago, and you can identify electronically on the screen that that child hasn't received the third polio, for example, dose, you can make a plan application and then you start to identify that there are several children in that area where that child lives that hasn't received the third dose of polio. So you can identify that those children doesn't have access to a closed vaccination center. So you need to adapt that strategy to have that nominal electronic registry for the countries.

[Nailah Boudu]

As we're talking about technology, I'm curious about the role AI and how this could play into all of this. Because it sounds like you need the data before that could even be helpful.

[Dr. Daniel Salas]

Exactly. We are working now with some. It's a model that is called the asymmetric populations, and it uses AI to try to understand where are the people that hasn't received the vaccines and what are, for example, the schools, the vaccination centers, the roads that you have there. And then you can make a plan to address that population more easily. But of course, it's something that we need to really understand. But what I can say is that having that kind of nominal registry for electronic for every single person, that's going to make it much easier to be more efficient.

[Nailah Boudu]

As you talk about countries and investment, your home country is Costa Rica, which of course is renowned for the amount of money that gets invested in education and the health system, which is considered one of the best in the world. How important is that to everything that we have been talking about?

[Dr. Daniel Salas]

Well, I would say that education, it is crucial because if you combine the access to health and educated people can understand more easily how to take care of themselves, how they need to take preventive measures to avoid any kind of disease. And I'm not talking just about communicable diseases, but now we're having a huge prevalence of non communicable diseases. And if you have educated people, it is going to be a lot easier to work with them to understand the measures they must take. They can understand better why these kind of regulatory measure has been taken to help them get better health conditions. This is not something that you're wasting money. It's the opposite. If you are investing more in education and in health, you're going to have more progress as a society, more development, you're going to have healthier workforce, you're going to have more tourism. It adds up in terms of all the benefits that you get for the whole society.

[Nailah Boudu]

Dr. Salas, we've talked about so many important things today. What do you want Rotarians in particular to be thinking about to know about the work that you are doing?

[Dr. Daniel Salas]

Well, I would say that first of all we achieved that milestone of eliminating the polio transmission in the Americas thanks to a joint work. And Rotary was there to say we would like to be a social stakeholder to get this elimination milestone. And Rotary was there. I know that Rotary continues to work on sensitizing the communities about the importance of having timely detection of possible polio cases or to get the vaccination on time. That role, it's going to be very important in the future, not just for polio because at the end we are still trying to, for example eliminate cervical cancer. Now we have a very effective vaccine. We are going to have a lot more milestones to achieve in the future. So this kind of support, this kind of self motivation that I have seen in Rotary that was crucial to get the elimination in the past is still important. So Rotary has this advantage of working very close to communities. Rotary have presence everywhere. So that kind of coordination, that kind of alignment, pursuing the same goal is going to be very important to achieve more milestones and to keep the ones that we have already achieved. So it's a win win relationship. When Rotary and the health authorities and organizations as the World Health Organization or PAHO in the Americas can really have this kind of relationship that can be.

[Nailah Boudu]

Of benefit to Dr. Danielle Salas. Thank you for being with us.

[Dr. Daniel Salas]

Oh, my pleasure.

[Nailah Boudu]

Thank you again to Dr. Salas. Similar to America, the western Pacific region of the World Health Organization has maintained its polio free status since 2000. The region has still experienced several outbreaks over the years, all of which were rapidly stopped. This is the result of preventative actions including those strong immunizations programs and risk assessments that Dr. Stalis mentioned. We reached out to Dr. Varya Grabovok, a regional laboratory coordinator for Vaccine Preventable Diseases in the Western Pacific region. First, we wanted to know what the current status of polio is in the region and what challenges they're facing in maintaining their polio free status.

[Dr. Varya Grabovok]

The Western Pacific region has been declared polio free in 2000 and since then the region has successfully maintain its polio free status by implementing a range of activities including increasing and sustaining high routine vaccination coverage, addressing immunity gaps with supplementary immunization activities, implementing strengthening surveillance for poliovirus, implementing annual risk assessment and polio laboratory containment. Currently, there is no ongoing outbreaks of CVDPVs in the region. There are some challenges in the region, some related to emergence and outbreaks of type 1 and or type 3 CBDPVs in countries with inadequate routine immunization levels with oral polio vaccines combined with subnational gaps in surveillance in several countries Cambodia, Lapidia, Malaysia, Philippines, Papua New Guinea, Vietnam Also challenges with importation of wild poliovirus type 1 from endemic countries importation of CVDPV2 from countries with confirmed outbreaks in other regions Close proximity of prolonged outbreak of CVDPV and VDPV in neighboring Indonesia is posing increased risk of polio importation, especially for Papua New Guinea, Malaysia and the Philippines because of very easy sea crossing, population movement, migrant workers, undocumented population existing there. Also risk of importation of CVTPV1 and CVDPP3 from from countries with confirmed outbreaks in the last two years importation of Sabine like type 2 polio virus from countries that responded to type 2 outbreaks with either MOPV2 or NOPV2 and finally circulation of any poliovirus due to containment breach in countries with polio essential facilities such as Australia, China, Japan and Republic of Korea.

[Nailah Boudu]

We also asked Dr. Grebevock what measures are in place to quickly detect and respond to new cases should they arise in the region.

[Dr. Varya Grabovok]

In November 2023 at its 29th meeting of the Regional Commission for Certification of Polio Eradication, it was confirmed that the Western Pacific region remained free of indigenous and imported wild poliovirus transmission. The RCC noted the apparent absence of circulating vaccine derived poliovirus transmission in the region. Most member states were able to maintain more than 90% coverage with three doses of polio vaccine in routine immunization at the national level and most member states were able to maintain the key IP surveillance indicators at the required level. Environmental surveillance was used successfully as a supplement to AFP surveillance to monitor circulation of poliovirus that may not be captured with AFP surveillance. Currently we have eight countries with more than 170 active sites. High quality polio laboratory network has been maintained since 1992 and today we have 43 network laboratories with capacity for virus isolation. 42 out of 43 laboratories have capacity for intratypic differentiation. 6 laboratories have capacity for sequencing with 2 additional laboratories building capacity for sequencing of portiovirus. We have established excellent referral system in the region where countries without adequate national capacity are able to quickly send the samples to regional reference or global specialized laboratories for timely confirmation and further characterization of poliovirus. This referral system was tested in real time during the outbreaks of CVDPV1 and CVDB2 that occurred in the last eight years in Lao PDR, Papua New Guinea, Malaysia and the Philippines. All laboratories in the regional network are continuously monitored for their proficiency in virus isolation, ITD and sequencing while participating in external quality assurance programs and through accreditation system. Updated Risk Assessment Assessment was done last year and categorized three countries as a high risk for poliovirus transmission La pdr, Papua New guinea and the Philippines. The risk assessment is updated annually in close collaboration with priority countries.

[Nailah Boudu]

Thanks so much to Dr. Varya Grebovak and all of our guests for joining us on the Rotary voices podcast. Visit www.endpolio.org to join the fight to end polio. This episode of the Rotary Voices Podcast was produced by JP Swenson with help from Kristin Morris and edited by Wen Huang. Production by Yoo Soo Kim. Special thanks to Sarah Tetzloff and Carol Pandak for helping us research and produce this episode. I'm Naila Budu. If you enjoyed the show, please rate us five stars on Apple Podcasts and Spotify and share it with your friends. The Rotary Voices Podcast is produced by Rotary Magazine, the official monthly publication of Rotary International. Thanks for listening.