Published on Investing in Health

Routine Immunization: A Systemic Approach to Polio Eradication

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Since 1988, when the World Health Organization,  Rotary International, CDC and UNICEF launched the Global Polio Eradication Initiative (GPEI) more than US$ 8.2 billion has been invested in polio immunization and surveillance. It’s an investment that has paid off: The number of polio cases worldwide decreased by more than 99%, from 350,000 in 1988 to less than 650 cases in 2011, while the number of polio endemic countries (those with ongoing domestic transmission of the virus) decreased from over 125 to just three: Afghanistan, Nigeria and Pakistan. 

The world has made tremendous progress, but in our push toward eradication, it’s easy to forget a basic truth: The first step in ending polio is stopping endemic transmission of the virus, through routine immunization.

Although routine immunization is the first pillar of the World Health Organization strategy to end polio, it doesn’t get the attention it deserves, relative to other pillars more likely to make news. These include campaigns, normally organized as national and sub-national immunization days; active surveillance for wild poliovirus through case reporting and laboratory testing; and targeted "mop-up" campaigns once wild poliovirus transmission is limited to a specific limited area.

Normally, immunization is an integrated part of a broader package of mother and child health services. High infant immunization coverage through routine immunization delivers four doses of polio vaccine in the first year of life. However, immunization campaigns for polio carried out in a vertical approach using the health care system have been disruptive for the delivery of other basic services.

At a time when the world is approaching (we hope) the goal of eradication, polio campaigns have become so frequent that there is hardly any space left for basic routine health programs in the last endemic countries. In an environment of constrained resources, health workers are taken away from their routine daily activities—including immunization—to work on the campaigns.

A strong routine country immunization system is essential to achieve and sustain polio-free status. Three trends provide evidence for this:  1) In all three of the last remaining countries with endemic polio (Afghanistan, Pakistan and Nigeria), full, age-appropriate coverage of routine immunization services is low. 2) The last few years have seen outbreaks of polio in 12 countries that already had been declared polio-free, due to virus reintroduction from endemic countries. Those countries which had a strong routine immunization program with high coverage were able to quickly bring polio transmission under control. 3)  Most countries with high coverage of routine immunization never needed campaigns to eliminate polio from their territories.

The World Bank has been supporting polio eradication through targeted efforts in a number of countries including Nigeria, Pakistan and Afghanistan, as well as through broader health programs in countries like Yemen and India. The disease disproportionately affects poor regions and countries with limited fiscal space for disease control programs.  Investments in polio are demonstrably pro-poor, but eradication will benefit all future generations in all countries, rich and poor. There’s no question it would be a global public good.

The costs of stopping polio are substantial—more than should reasonably be borne alone by those countries where the epidemic persists. This requires a more holistic approach, ensuring that systems are in place that can ensure delivery of basic health services, including immunizations. Strengthening health systems and supporting routine immunization, the neglected pillar of GPEI, should both be a high priority.


Kees Kostermans

Lead Public Health Specialist

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