《卫生经济学》课程参考文献（WHO年度报告）：World Health Report 2003_Shaping the Future_Chapter4 Polio Eradication：the final challenge

Chapter Four Polio eradication the final challenge As a result of the global polio eradication initiative. one of the largest public health efforts in history, the number of chil- dren paralysed by this devastating disease every year has fallen from over 350 000 in 1988 to as few as 1900 in 2003 the number of endemic countries has fallen from over 125 to seven. This chapter records the final phase of the campaign to eradicate one of the oldest known diseases the vision of a polio-free world is now within reach

Polio Eradication: the final challenge 57 Chapter Four Polio Eradication: the final challenge As a result of the Global Polio Eradication Initiative, one of the largest public health efforts in history, the number of chil￾dren paralysed by this devastating disease every year has fallen from over 350 000 in 1988 to as few as 1900 in 2003; the number of endemic countries has fallen from over 125 to seven. This chapter records the final phase of the campaign to eradicate one of the oldest known diseases. The vision of a polio-free world is now within reach

Polio eradication the final challenge In 1962, just 12 months after Albert Sabins widely hailed oral polio vaccine(OPv) was li- censed in most industrialized countries, Cuba began using the vaccine in a series of nation ide polio campaigns. Shortly thereafter, indigenous wild poliovirus transmission had been rrupted. In other words, no Cuban child would ever again suffer this devastating di as the result of a Cuban poliovirus. Seldom, if ever, had a new health technology been exploited so successfully and so early in its lifespan, to the benefit of so many people countries were to experience such early successes, however, as polio continued to paralyse permanently half a million people every year -even by the 1990s between 10 and 20 million people who had survived the acute illness were living with its debilitating and often painful consequences. For Sabin, however, Cuba's experience with mass campaigns had reaffirmed his conviction that polioviruses could be eradicated so completely that future generations would know polio paralysis only through history books. Sabin,'s way of shaping that future without polio was to donate his vaccine to the World Health Organization so that it might be made available to all peoples, everywhere. Forty years later, the world is on the verge of realizing Sabins global vision of a future with out polio. Through an extraordinary 15-year international effort, indigenous polioviruses have now been eliminated from all but seven countries, down from over 125 when the initia- tive began(1)(see Figure 4.1). This progress is the result of a unique partnership forged between governments, international agencies, humanitarian organizations and the private sector to take up three key challenges to reaching all children, everywhere: effective engage ment of political leaders, adequate financing, and sufficient human resources. Through this partnership, over 10 million volunteers immunized 575 million children against polio in 9 of the lowest-income countries in the world in the year 2001 alone. This experience, and the prospects for the completion of polio eradication, provide insights for scaling up access to other health interventions, a process that will be essential to achieving ambitious national and international health targets such as those adopted in the Millennium Development Goals( 2) A new kind of partnership As international interest in a global effort to eradicate polio began to build up 20 years ago, there was limited experience with large-scale international health initiatives and with part nerships. In the mid-1980s, however, as an increasing number of countries in South America most notably, Brazil-successfully applied the Cuban model of mass campaigns and height- ened surveillance to control polio, a new kind of partnership began to emerge with this common purpose

Polio Eradication: the final challenge 59 4 Polio Eradication: the final challenge In 1962, just 12 months after Albert Sabin’s widely hailed oral polio vaccine (OPV) was li￾censed in most industrialized countries, Cuba began using the vaccine in a series of nation￾wide polio campaigns. Shortly thereafter, indigenous wild poliovirus transmission had been interrupted. In other words, no Cuban child would ever again suffer this devastating disease as the result of a Cuban poliovirus. Seldom, if ever, had a new health technology been fully exploited so successfully and so early in its lifespan, to the benefit of so many people. Few countries were to experience such early successes, however, as polio continued to paralyse permanently half a million people every year – even by the 1990s between 10 and 20 million people who had survived the acute illness were living with its debilitating and often painful consequences. For Sabin, however, Cuba’s experience with mass campaigns had reaffirmed his conviction that polioviruses could be eradicated so completely that future generations would know polio paralysis only through history books. Sabin’s way of shaping that future without polio was to donate his vaccine to the World Health Organization so that it might be made available to all peoples, everywhere. Forty years later, the world is on the verge of realizing Sabin’s global vision of a future with￾out polio. Through an extraordinary 15-year international effort, indigenous polioviruses have now been eliminated from all but seven countries, down from over 125 when the initia￾tive began (1) (see Figure 4.1). This progress is the result of a unique partnership forged between governments, international agencies, humanitarian organizations and the private sector to take up three key challenges to reaching all children, everywhere: effective engage￾ment of political leaders, adequate financing, and sufficient human resources. Through this partnership, over 10 million volunteers immunized 575 million children against polio in 93 of the lowest-income countries in the world in the year 2001 alone. This experience, and the prospects for the completion of polio eradication, provide insights for scaling up access to other health interventions, a process that will be essential to achieving ambitious national and international health targets such as those adopted in the Millennium Development Goals (2). A new kind of partnership As international interest in a global effort to eradicate polio began to build up 20 years ago, there was limited experience with large-scale international health initiatives and with part￾nerships. In the mid-1980s, however, as an increasing number of countries in South America – most notably, Brazil – successfully applied the Cuban model of mass campaigns and height￾ened surveillance to control polio, a new kind of partnership began to emerge with this common purpose

The World Health Report 2003 By 1988, the year in which the World Health Assembly voted to launch a global initiative to eradicate polio(3), four agencies had begun to form the core of the"polio partnership": the World Health Organization, Rotary International, the United Nations Childrens Fund (UNICEF)and the United States Centers for Disease Control and Prevention(CDC). Over the following 15 years, the polio partnership has grown to become an extensive network of national governments, international agencies, private corporations, foundations, bilateral do- nors, humanitarian organizations, nongovernmental organizations and development banks The work of the partnership continues to be governed by a common, multiyear strategic plan and overseen by international technical committees at the country, regional and global levels The close relationship between national health authorities and this international partnership was critical to the extremely rapid scaling-up of eradication activities in the mid-1990s, as the initiative began building on the early momentum in the Americas and the Western Pacific Region and extended its activities to all countries of all regions By the end of the decade, over 500 million children were regularly being reached with OPV through the efforts of 10 million volunteers in every low-income and middle-income country in the world. From the outset, this partnership sought to bring a new efficiency to international support for national health efforts. It relied heavily on strategies and management processes that had been established by the Pan American Health Organization(PAHO)in its work to achie regional elimination of polio. This goal was realized in 1991, when a young Peruvian boy named Luis Fermin Tenorio became the last child ever to be paralysed by a wild poliovirus in the Region of the Americas. The global partnership adopted PAHOs proven four-pronged strategy: high coverage with routine OPV immunization, national polio immunization days, surveillance and laboratory investigation of acute flaccid paralysis(AFP)cases, and massive house-to-house"mop-up"campaigns(4). PAHOs Interagency Coordinating Committee (ICC)mechanism brought together partner inputs at the country level to ensure sufficient resources, while promoting transparent budgeting and efficiencies. The ICCs, convened regu larly by national ministries of health, ensured that national authorities were always at the centre of key decisions on strategy implementation. The global partnership also emphasizes engagement at the highest political levels in both donor and endemic countries Effectively engaging political leaders The most visible element of the polio eradication initiative has been the National Immuniza- tion Days(NIDs), as they require the immunization of every child under 5 years of age(nearly 20% of a country's population)over a period of 1-3 days, several times a year for a number of years in a row. In many countries, the scale and logistic complexity of these activities were even greater than those of campaigns undertaken during the height of the smallpox eradica tion effort. Consequently, the commitment of political leaders has been central to their suc- cess.This support has been generated by actively and continuously advocating for such leaders to play a role in three key areas: oversight, access to non-health resources, and accountability. The oversight of polio activities by political leaders has often begun with their personal pa ticipation in highly visible events such as the launching of NIDs and, ideally, has continued with their monitoring of progress. Following the example of South America, most countries have had their NIDs launched by the head of state or other prominent political figure. For example, in China, President Jiang Zemin immunized the first child in the national polic campaign in 1993. In the same year, King Sihanouk played a similar role in Cambodia. In 1996, President Nelson Mandela of South Africa launched the "Kick polio out of africa campaign at the Organization of African Unity(OAU)meeting in Yaounde, Cameroon, and committed the oau to regularly monitoring progress(5). Among donor countries, polio has

60 The World Health Report 2003 By 1988, the year in which the World Health Assembly voted to launch a global initiative to eradicate polio (3), four agencies had begun to form the core of the “polio partnership”: the World Health Organization, Rotary International, the United Nations Children’s Fund (UNICEF) and the United States Centers for Disease Control and Prevention (CDC). Over the following 15 years, the polio partnership has grown to become an extensive network of national governments, international agencies, private corporations, foundations, bilateral do￾nors, humanitarian organizations, nongovernmental organizations and development banks. The work of the partnership continues to be governed by a common, multiyear strategic plan and overseen by international technical committees at the country, regional and global levels. The close relationship between national health authorities and this international partnership was critical to the extremely rapid scaling-up of eradication activities in the mid-1990s, as the initiative began building on the early momentum in the Americas and the Western Pacific Region and extended its activities to all countries of all regions. By the end of the decade, over 500 million children were regularly being reached with OPV through the efforts of 10 million volunteers in every low-income and middle-income country in the world. From the outset, this partnership sought to bring a new efficiency to international support for national health efforts. It relied heavily on strategies and management processes that had been established by the Pan American Health Organization (PAHO) in its work to achieve regional elimination of polio. This goal was realized in 1991, when a young Peruvian boy named Luis Fermin Tenorio became the last child ever to be paralysed by a wild poliovirus in the Region of the Americas. The global partnership adopted PAHO’s proven four-pronged strategy: high coverage with routine OPV immunization, national polio immunization days, surveillance and laboratory investigation of acute flaccid paralysis (AFP) cases, and massive house-to-house “mop-up” campaigns (4). PAHO’s Interagency Coordinating Committee (ICC) mechanism brought together partner inputs at the country level to ensure sufficient resources, while promoting transparent budgeting and efficiencies. The ICCs, convened regu￾larly by national ministries of health, ensured that national authorities were always at the centre of key decisions on strategy implementation. The global partnership also emphasizes engagement at the highest political levels in both donor and endemic countries. Effectively engaging political leaders The most visible element of the polio eradication initiative has been the National Immuniza￾tion Days (NIDs), as they require the immunization of every child under 5 years of age (nearly 20% of a country’s population) over a period of 1–3 days, several times a year for a number of years in a row. In many countries, the scale and logistic complexity of these activities were even greater than those of campaigns undertaken during the height of the smallpox eradica￾tion effort. Consequently, the commitment of political leaders has been central to their suc￾cess. This support has been generated by actively and continuously advocating for such leaders to play a role in three key areas: oversight, access to non-health resources, and accountability. The oversight of polio activities by political leaders has often begun with their personal par￾ticipation in highly visible events such as the launching of NIDs and, ideally, has continued with their monitoring of progress. Following the example of South America, most countries have had their NIDs launched by the head of state or other prominent political figure. For example, in China, President Jiang Zemin immunized the first child in the national polio campaign in 1993. In the same year, King Sihanouk played a similar role in Cambodia. In 1996, President Nelson Mandela of South Africa launched the “Kick Polio Out of Africa” campaign at the Organization of African Unity (OAU) meeting in Yaoundé, Cameroon, and committed the OAU to regularly monitoring progress (5). Among donor countries, polio has

Polio eradication: the final chall Figure 4.1 Endemic polio in 1988 and mid-2003 1988 Endemic >125 countrie Non-endemic 2003 Endemic 7 countries Non-endemic

Polio Eradication: the final challenge 61 Endemic Non-endemic 2003 7 countries Endemic Non-endemic 1988 > 125 countries Figure 4.1 Endemic polio in 1988 and mid-2003

The World Health Report 2003 received similar support -most noticeably when the G8 Heads of Government discussed their role in closing the funding gap for eradication activities during their meetings of 2002 and This high-level visibility has been critical to achieving the second, and perhaps most impor- tant goal of political advocacy: access to government and nongovernmental resources which lie outside the health sector. Because of the huge numbers of people and vehicles that are required to implement NIDs, such activities are beyond the logistic and communication capacity of the health sector in many countries. Consequently, countries have drawn heavily on ministries of information, transport, defence and others to help solve the challenge of rapidly reaching all children, in all corners of a country. Countries have also engaged the private sector, often on an extraordinary scale. In the Philippines, for example, more than 14 private companies have regularly donated personnel, vehicles, facilities and financial sup port. The effective mobilization of such support has been possible only when the highest political leadership, at both national and subnational levels, endorsed the initiative publicly and took the necessary steps to put these resources at the disposal of health authorities. Thus, the delivery of this health service became a government and societal responsibility, with the responsibility of the health sector moving from implementation to management and monitoring. This personal engagement of political leaders in the oversight and implementation of activi- ties leads naturally to the third goal of political advocacy: heightened accountability, both Box 4.1 Progress towards polio eradication in the Eastern Mediterranean All countries of the Eastern Mediterranean Region are rapidly progress. poliovirus, the certification of polio eradication and the development of on g towards the eradication of poliomyelitis. The number of cases has post-certification immunization policy decreased relatively regularly, as shown by the well-developed and effi National containment coordinators have been nominated in 19 of cient surveillance system. By the end of 2002, poliovirus transmission the 23 countries of the region, 16 of which have also established na- had been interrupted in 18 countries of the region for more than three tional containment committees. By the end of 2002, 18 countries had ars; in addition, Sudan has not reported a single polio case since April prepared a national containment plan; three of the remaining five coun- only four countries(Pakistan: 90: Afghanistan: 10: Egypt: 7; and Soma. has been successfully completed in seven countries and is currenty o 2001. During 2002, 110 confirmed cases of polio were reported from tries still have ongoing virus transmission. The first containment ph lia: 3). During the first eight months of 2003, 61 cases were reported ing implemented in another 11 (Pakistan: 57: Afghanistan: 2; and Egypt: 1); a further case, in Lebanon, All countries of the region except Somalia have established Na- proved to be imported and genetically linked to the virus strains from tional Certification Committees(NCCs) with appropriate membership. Eighteen countries with no viral circulation have submitted reports and Intensified national immunization days(NIDs)are continuing in national documentation to the Regional Certification Committee(RCC). 2003, with technical support from WHO, both in endemic countries which has already reviewed 15 of these reports and provided appropri- Afghanistan, Egypt, Pakistan and Somalia) and in Sudan which was ate feedback. The RCC is also reviewing annual updates provided by recently decared polio-free. All these countries conduct more than two countries whose initial reports were satisfactory. These annual updates NIDs and one or more rounds of sub-national immunization days(SNIDs) will be submitted annually until regional certification is achieved in high-risk districts each year, reaching all children through house-to. Despite the significant achievements in remaining endemic areas, house immunization. Acute flaccid paralysis(AFP) surveillance contin. the eradication programme still faces a number of challenges and con- ued to improve throughout the region. The non-polio AFP rate has further straints that must be overcome to reach the final goal. The main focus increased in 2003 to reach 2.39 per 100 000 children under 15 years of now is Pakistan, where several outbreaks occurred during 2002-2003 age, while stool specimen collection has reached 90% It seems that the youngest children in tribal and conservative populations As the polio eradication initiative moves into its final phase, tech- are likely to be missed if the vaccination team does not include a woman nical advisory groups for the priority countries regularly review the epi- In order to overcome these difficulties, the emphasis is on enlisting fed In addition, a regional technical advisory group was established to pro. target all transmission zones. New international staff are being mobi- vide leadership for eradication activities in the remaining polio-endemic lized in districts with no previously assigned consultants, to help provid countries and to advise Member States on other technical issues. In. the needed technical support to ensure high-quality performance in sur- creasing attention is being given to the laboratory containment of wild veillance in all areas

62 The World Health Report 2003 received similar support – most noticeably when the G8 Heads of Government discussed their role in closing the funding gap for eradication activities during their meetings of 2002 and 2003 (6). This high-level visibility has been critical to achieving the second, and perhaps most impor￾tant goal of political advocacy: access to government and nongovernmental resources which lie outside the health sector. Because of the huge numbers of people and vehicles that are required to implement NIDs, such activities are beyond the logistic and communication capacity of the health sector in many countries. Consequently, countries have drawn heavily on ministries of information, transport, defence and others to help solve the challenge of rapidly reaching all children, in all corners of a country. Countries have also engaged the private sector, often on an extraordinary scale. In the Philippines, for example, more than 140 private companies have regularly donated personnel, vehicles, facilities and financial sup￾port. The effective mobilization of such support has been possible only when the highest political leadership, at both national and subnational levels, endorsed the initiative publicly and took the necessary steps to put these resources at the disposal of health authorities. Thus, the delivery of this health service became a government and societal responsibility, with the responsibility of the health sector moving from implementation to management and monitoring. This personal engagement of political leaders in the oversight and implementation of activi￾ties leads naturally to the third goal of political advocacy: heightened accountability, both Box 4.1 Progress towards polio eradication in the Eastern Mediterranean All countries of the Eastern Mediterranean Region are rapidly progress￾ing towards the eradication of poliomyelitis. The number of cases has decreased relatively regularly, as shown by the well-developed and effi￾cient surveillance system. By the end of 2002, poliovirus transmission had been interrupted in 18 countries of the region for more than three years; in addition, Sudan has not reported a single polio case since April 2001. During 2002, 110 confirmed cases of polio were reported from only four countries (Pakistan: 90; Afghanistan: 10; Egypt: 7; and Soma￾lia: 3). During the first eight months of 2003, 61 cases were reported (Pakistan: 57; Afghanistan: 2; and Egypt: 1); a further case, in Lebanon, proved to be imported and genetically linked to the virus strains from India. Intensified national immunization days (NIDs) are continuing in 2003, with technical support from WHO, both in endemic countries (Afghanistan, Egypt, Pakistan and Somalia) and in Sudan which was recently declared polio-free. All these countries conduct more than two NIDs and one or more rounds of sub-national immunization days (SNIDs) in high-risk districts each year, reaching all children through house-to￾house immunization. Acute flaccid paralysis (AFP) surveillance contin￾ued to improve throughout the region. The non-polio AFP rate has further increased in 2003 to reach 2.39 per 100 000 children under 15 years of age, while stool specimen collection has reached 90%. As the polio eradication initiative moves into its final phase, tech￾nical advisory groups for the priority countries regularly review the epi￾demiological situation and national plans and provide technical advice. In addition, a regional technical advisory group was established to pro￾vide leadership for eradication activities in the remaining polio-endemic countries and to advise Member States on other technical issues. In￾creasing attention is being given to the laboratory containment of wild poliovirus, the certification of polio eradication and the development of post-certification immunization policy. National containment coordinators have been nominated in 19 of the 23 countries of the region, 16 of which have also established na￾tional containment committees. By the end of 2002, 18 countries had prepared a national containment plan; three of the remaining five coun￾tries still have ongoing virus transmission. The first containment phase has been successfully completed in seven countries and is currently be￾ing implemented in another 11. All countries of the region except Somalia have established Na￾tional Certification Committees (NCCs) with appropriate membership. Eighteen countries with no viral circulation have submitted reports and national documentation to the Regional Certification Committee (RCC), which has already reviewed 15 of these reports and provided appropri￾ate feedback. The RCC is also reviewing annual updates provided by countries whose initial reports were satisfactory. These annual updates will be submitted annually until regional certification is achieved. Despite the significant achievements in remaining endemic areas, the eradication programme still faces a number of challenges and con￾straints that must be overcome to reach the final goal. The main focus now is Pakistan, where several outbreaks occurred during 2002–2003. It seems that the youngest children in tribal and conservative populations are likely to be missed if the vaccination team does not include a woman. In order to overcome these difficulties, the emphasis is on enlisting fed￾eral, provincial and local political leaders and expanding the SNIDs to target all transmission zones. New international staff are being mobi￾lized in districts with no previously assigned consultants, to help provide the needed technical support to ensure high-quality performance in sur￾veillance in all areas