10 years polio free
Dr Oblapenko joined WHO/Europe in 1990 as a medical officer in the area of poliomyelitis (polio) elimination. On retiring in 2000, he was given a special year-long assignment as coordinator of the process to certify Europe as polio free. In this role, he worked with a range of partners and the European Regional Commission for the Certification of Poliomyelitis Eradication (RCC) to reach certification in the European Region on 21 June 2002. On the tenth anniversary of that momentous accomplishment, he reflects on achieving and maintaining polio-free status.
It took tremendous effort to get the Region to the point of being certified polio free; what was the biggest challenge along the way?
There were quite a few challenges. First, at the time we started the certification process, polio was still coming and going in the Region, affecting different countries. WHO had clear strategies for interrupting polio transmission including: reaching 90% immunization coverage; mass vaccination campaigns, called national immunization days, and mop-up campaigns, where appropriate; and surveillance for acute flaccid paralysis (AFP) [surveillance for poliovirus begins with testing every person with AFP, which may indicate polio]. But many countries did not have national plans that used these strategies. So that was an initial challenge: getting all countries to accept them.
Second, many countries did not value the achievement of polio-free certification. Some countries hadn’t seen polio in years, so it was difficult to mobilize them to do what they had to do, for example, introduce surveillance so they could prove there was no poliovirus circulating. But, of course, we had outbreaks in all different parts of the Region; we even had an outbreak in the Netherlands in the 1990s. So we knew we needed the political commitment of all countries.
And that was, in fact, the third challenge. In 1990 there were only 31 countries in the European Region. With the dissolution of the USSR in 1991, there were suddenly 15 new countries in the Region, each with brand new ministries of health. Many of these new countries required technical and financial assistance, and this was a challenge because our biannual budget for regional polio eradication was only USD$ 10 000. So you can see that we faced many challenges in terms of commitment and resources. But we still found ways to move forward and make it work.
What achievement during the certification process stands out for you?
Everything was exciting about the years leading up to polio-free certification, but, if I had to pick a particular achievement I would have to single out Operation MECACAR. This name stood for Mediterranean, Caucasus and central Asian republics, and sometimes MECACAR Plus, to include the Russian Federation. The idea was to synchronize mass vaccination campaigns among neighbouring countries and within subregions, to improve the chances of successfully suppressing polio transmission in these areas.
The idea for Operation MECACAR was actually born during a routine meeting of the global polio team in June 1994 in Atlanta, Georgia, United States of America. I can clearly remember that one of the presentations was about genetic analysis of polioviruses and it showed that many endemic viruses actually came from India and Pakistan. This led to a discussion about how countries and subregions couldn’t hope to interrupt polio transmission alone; they would be much more effective working together and synchronizing activities.
The discussion at this initial meeting led to a plan to coordinate activities in 10 countries in the European Region and 7 in the Eastern Mediterranean Region, to get agreements to schedule a first round of national immunization days for polio vaccine. We hoped to schedule the first round on (or near) 7 April 1995, World Health Day, and had an appropriate theme that year of “a polio-free world”. After the technical group endorsed our proposal, Rotary International generously promised US$ 5 million. Understandably, they wanted to hold the funds until we could demonstrate that countries were really going to move forward with this plan.
We had extremely strong support from the Centers for Disease Control and Prevention (CDC), in the United States, the United Nations Children's Fund (UNICEF) and the United States Agency for International Development (USAID) on this project, but we were getting to the last days of January and we needed to secure the Rotary funding. Our colleagues at UNICEF, in particular, had to purchase vaccine for the planned April activities. I remember going down to see the UNICEF procurement officer, and he was calculating down to cubic centimetres how most efficiently to ship the vaccine to countries. It was at that time that Rotary confirmed that it saw uniformity and enthusiasm among all countries, and gave the cheque to UNICEF the next morning, so we were able to proceed with Operation MECACAR. Immediately, we had staff head out to the countries to develop action plans for the campaigns. That was an especially exciting time.
What do you remember as being the most exciting part of the signing ceremony in 2002?
The most exciting part actually didn’t happen during the official ceremony. The day before there was a closed-door meeting of the RCC where its members had to decide whether they trusted the information that countries had provided. Would they certify the Region as polio free? There were various criteria and preconditions for certification, and the RCC had to carefully consider whether countries had met all of them. So, the meeting before the ceremony was where the nitty-gritty work took place. The RCC reviewed very precise documents from 1992 to 2002 and there was a lot of discussion and evaluation.
The night before the ceremony, we got the news that the RCC had accepted the evidence and would certify the Region polio free. And it really was a joyful evening. A group of us, including the RCC members and WHO staff, went to a restaurant for a small celebration; the next day we were ready for a larger, more formal celebration. I really couldn’t sleep much that night because I was too excited. I kept thinking back about past activities, about what had happened and what we had accomplished. It was just such a feeling of achievement.
What is the bottom-line value of polio-free status? What does it mean in practical terms for health in the European Region?
This is a difficult question in many ways. I remember that, when smallpox was eradicated, now more than 30 years ago, the WHO Director-General commented that this achievement was so important that, though we couldn’t fully appreciate it at the time, we would one day recognize it as being on par with spaceflight and putting a man on the moon. He said that smallpox eradication helped human beings finally understand what we can do when we join our efforts. I think it is fair to say that the achievement of reaching polio-free status is similar, albeit on a regional level. We estimate that approximately 1500 cases of paralysis have been averted in the past decade. Perhaps we can’t feel this; we can’t point to specific children and say they were saved from paralysis, but this is still a major achievement.
A more tangible benefit to the Region is the AFP-surveillance system that was put into place as part of the push to stop indigenous transmission of poliovirus in the European Region. There were no AFP surveillance systems when we started, and between 1996 and 2000 these systems were established and the polio laboratory network was established as part of eradication activities. It has been a model for other laboratory networks – for the surveillance of measles and rotavirus, for example. I think its establishment helped everyone in the public health sector recognize that, to achieve disease control, you need good laboratory support for surveillance. We now have high standards and clear results from our labs, and this is thanks to our regional polio-eradication activities.
After all your work, what did you think when the Region had a large polio outbreak in 2010?
I was disappointed. Having experienced importations before certification, into places like Bulgaria, Georgia and the Netherlands, I was aware that sooner or later it would happen. But I was still disappointed, because we created a good system for surveillance and this should have allowed us to detect importations quickly.
I cannot say that we won’t have another outbreak in the Region. The outbreak in Tajikistan, while it was disappointing, demonstrated that countries that are doing well with their surveillance can control outbreaks quickly. We saw this in Kazakhstan and the Russian Federation, countries that only had a few cases, primarily among migrants. But we had a saying when the Region received polio-free certification and I believe it is still valid today: “It’s not over until it’s over”. To me, this means that we have to continue immunizing children; we have to continue conducting surveillance; we have to detect the disease and stop it. We cannot say, “We are polio-free”, and then think we are finished and stop working.