T

he world — or the part that pays attention to polio eradication, anyway — has fixed its sights on zero, the nearly 30-year-old goal of stopping transmission of the paralyzing virus that causes polio. But as the finish line comes into view, officials are largely overlooking a big potential problem, a new report warned Monday.

The wind-down of the Global Polio Eradication Initiative and the roughly $1 billion a year it funnels into the World Health Organization as well as immunization efforts in a number of low-income countries is already underway.

Funding for the initiative is scheduled to be halved by 2019, and to cease after that, except in countries that are still battling polio then or at high risk of seeing the virus return. That will severely deplete the resources of a number of already cash-strapped countries, straining their capacity to continue to vaccinate against polio and other childhood diseases like measles and rotavirus, which causes severe and sometimes life-threatening diarrhea.

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It could also punch big holes in the surveillance network needed to ensure that polio and polio-vaccine viruses (which can also paralyze) are truly gone, the report suggested, noting that 70 percent of global funding for surveillance comes from the initiative.

“People need to start talking about this issue. Because it’s much wider than just polio and a polio-free world,” said Laura Kerr, who wrote the report. “It’s to do with immunization systems that could collapse.”

Kerr works for Results UK, an advocacy organization that works to influence political decisions on health, education, and economic opportunity.

Her report sounds an alarm about the state of planning for the end of the polio eradication effort, the largest health program ever to be wound down. The polio program — a partnership of the WHO; UNICEF, the U.N. children’s agency; Rotary International; the Centers for Disease Control and Prevention; and the Bill and Melinda Gates Foundation — has been battling polio since 1988, spending an estimated $15.5 billion so far on the effort.

Bill Gates recently said he hoped transmission would stop in 2017, though with a month and a half left in the year, that seems unlikely. There have been 14 cases so far this year, the lowest annual tally ever. All the cases have been in Pakistan (five) and Afghanistan (nine), where the most recent case was diagnosed in mid-October.

After transmission appears to have stopped, there will be a three-year period before eradication could be declared. That time lag is designed to ensure that the virus is actually gone.

The end of the polio program will place substantial economic pressure on the WHO, which gets about a quarter of its funding from the polio campaign.

The WHO’s member states are aware of this looming cash crunch. At the World Health Assembly in May, countries noted “with great concern” the agency’s reliance on funding from the polio initiative, and the ensuing risk that poses to its “capacity to ensure effective delivery in key programmatic areas and to maintain essential continuing functions.” They urged the new director-general, Tedros Adhanom Ghebreyesus, to find long-term funding to shield key programs and functions from the impact of the wind-down.

But Kerr said few people are talking about the danger the end of the initiative poses to the delivery of routine childhood immunizations, programs that in some low-income countries have piggy-backed off the polio program. For instance, polio money pays for staff who do other types of functions as well as their polio work; an assessment in 10 countries cited in the report revealed that nearly half of the work done by people whose positions were funded by the polio program related to other immunization goals.

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Until recently, the polio program has focused efforts on mass campaigns that send armies of workers and volunteers out to find children and squeeze a few drops of oral polio vaccine into the mouths of each. But that oral vaccine will need to be withdrawn from use after polio stops spreading; it contains live but weakened viruses that can regain the ability to paralyze if they spread in the environment.

Injectable polio vaccine — the type used in the U.S. — will take the oral vaccine’s place. The WHO is currently recommending it be used for at least a decade after eradication. But the injectable vaccine must be given by health care personnel, which requires a different delivery model — one that is more conducive to simultaneous delivery of other childhood vaccines.

The winding down of the polio eradication effort could provide an opportunity to refocus efforts on ensuring countries have the systems and capacity to vaccinate all children with the 11 vaccines the WHO recommends, Kerr said.

Dr. Seth Berkley agreed. Berkley is CEO of Gavi, the Vaccine Alliance, an international organization that helps low-income countries buy important childhood vaccines. “What we need to do is make sure that countries go back to focusing on strengthening routine [immunization] systems, which is exactly … what Gavi is trying to do,” he told STAT.

But if the necessary planning isn’t undertaken, the opportunity could be lost — or worse, the report warned.

It’s not clear all countries are in a position to make that delivery shift, especially at a time when resources will be decreasing. “A shift in focus from campaigns to routine immunization is not a simple one, and requires a fundamental change in service delivery,” the report said. Replacing the polio money with other sources of external funding won’t be easy.

“For donors, funding a disease eradication effort is much easier than funding all the different building blocks of routine immunization,” Kerr said. A discussion over what new funding will be needed can’t take place until people recognize the scale of the problem, she added.

Berkley said Gavi had hoped that by now there would have been a country-by-country assessment of polio program assets, so that the polio program and funding partners could figure out what needs to be retained and how to cover the costs of doing so.

“Unfortunately there has not been a full mapping and planning of this in all countries. And so that is a critical priority that has to happen and the report makes that point importantly,” he noted.

One of the concerns raised by Kerr’s report is that some of the countries that are about to lose polio program funding are also in the process of transitioning out of Gavi funding — a process that requires a country to eventually pick up the full cost of purchasing its vaccines. The report calls for the polio initiative and Gavi to coordinate their transitions. It suggests Gavi should factor the withdrawal of polio funding into transition assessments.

The report pointed to Sudan as an example of what could go wrong. The country currently has a high immunization rate — 93 percent — but its government only covers 9 percent of the cost of the program. Under its deal with Gavi, the government of Sudan must increase its share of vaccine costs from $3.3 million this year to $17.5 million in 2022 — at a time when it will also lose 70 percent of its polio initiative funding. The combination could put the country’s high vaccination rate in jeopardy, the report warned.

Kerr said people involved in the delivery of programs that use polio money have a sense of the looming problem, but most don’t have a full picture of the trouble that could be brewing. “All of that information needs to be pulled together urgently, so we can see the bigger picture and the full scale of the impact,” she said.

Correction: An earlier version of this story said the report used South Sudan as an example. It was in fact Sudan.  

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