This report provides a status update towards achievement of a lasting polio-free world, as at the end of 2020 and early 2021. It provides a summary of status against each main objective of the GPEI Strategic Endgame Plan 2019-2023, highlights remaining challenges to achieving success and proposes solutions for mitigating those risks.

Following the request by Global Polio Eradication Initiative (GPEI) stakeholders to update the monitoring framework for the GPEI Polio Eradication & Endgame Strategic Plan 2013-2018 (the Endgame Plan), the framework has been revised to conform with the results-based approach to polio eradication outlined in the Endgame Plan, and to ensure that progress against the Endgame Plan is reflected through programme indicators across all four of its objectives. The structure of this document includes a high-level summary, followed by a more detailed narrative for each of the strategic objectives, broken down by geography where appropriate. The narrative is followed by a series of annexes that contain the monitoring framework indicators for endemic countries, outbreak countries and high-risk countries, and global indicators. The data published in the first semi-annual status report, covering January to June 2014 (available at http://www.polioeradication.org) are helping to drive the refinement of strategic approaches at the regional and country levels. The analysed data are helping to shine a spotlight on the critical operational gaps that need to be filled and are enabling the development and implementation of corrective measures as appropriate.

Looking back on the second year of the Global Polio Eradication Initiative (GPEI) Strategic Plan 2010-2012, the scales are balanced between significant achievements on the one side and, on the other, some disappointing setbacks. Success in India was the most remarkable milestone, deemed "magnificent" by the Independent Monitoring Board (IMB) of the GPEI. Long considered one of the most challenging countries in which to eradicate polio, India accomplished what the IMB called the "systematic enforcement of best practice" to reach over 98% of children with polio vaccine. The country freed itself of endemic polio and finally laid to rest the question of whether polio eradication is technically feasible. Globally, polio cases fell to half the level of the previous year. In two of the four countries with re-established transmission of polio, no cases have been reported in the Republic of South Sudan and in Angola since June 2009 and July 2011, respectively. In the other two, Chad geographically restricted polio in the second half of the year and cases plummeted in the Democratic Republic of the Congo, after aggressive response to extensive outbreaks in early 2011. All of the eight outbreaks recorded in previously polio-free countries were successfully stopped, all but one within six months. On the other side of the scales, the three remaining endemic countries witnessed an unexpected and serious upsurge of polio. In Nigeria and Pakistan, the continued circulation of two wild poliovirus serotypes - and a vaccine- derived poliovirus in the former - had the ripple effect of international spread to two neighbours. In Afghanistan, the number of cases also increased, with the national programme unable to reach enough children to stop outbreaks in the insecure Southern Region. At the end of 2011, the three endemic countries were off-track for eradicating polio. The Independent Monitoring Board (IMB) warned in October 2011 that polio eradication would not be achieved on the programme's current trajectory. In November, an alarmed Strategic Advisory Group of Experts on immunization (SAGE) warned that failure to eradicate polio would constitute a failure of public health. By January 2012, the World Health Organization's (WHO) Executive Board had called for polio eradication to be declared a programmatic emergency for global health. Completing polio eradication is now a global emergency because of the clear - and, as stated by SAGE - "unacceptable" consequences of failure. The children of Nigeria, Pakistan and Afghanistan bear the brunt of current polio transmission, but the consequences reach much farther. In recent years, the international spread of polio has become deadlier. Recent outbreaks on three continents -Tajikistan, Congo and China, all far from polioendemic areas - paralysed mostly adults. In some of these outbreaks, half the affected adults died. When the virus affects adults who have grown up in previously polio-free countries and have received little or no vaccination, it kills far more frequently. These consequences have triggered emergency actions among countries and the international polio partners. The Global Polio Emergency Action Plan 2012_2013, and the revised national emergency action plans that underpin it, capture the fundamental changes that polio-affected countries and their partners are making in their approach and structure, to ultimately bring about polio eradication. Compounding this emergency is a 50% gap in financing needed to fully carry out the necessary activities in 2012_2013 (as of April 2012). In the first quarter of 2012, this has already dictated the scale-back of activities in 24 countries in Asia and Africa, increasing the risk of unchecked spread if poliovirus from endemic areas enters these countries. The emergency eradication programme is about speed, focus and most of all accountability. From heads of state to chiefs of multilateral agencies and donors, from parent to vaccinator, every link in the chain must be tempered and strengthened to bring about a polio-free world.

Since the creation in 1988 of the Global Polio Eradication Initiative (GPEI), the incidence of polio has been cut by 99%. Between 2003 and 2006, polio eradication faced several serious challenges: four countries continued to have transmission of wild poliovirus; international spread from two of these countries resulted in the re-infection of previously polio-free areas; and both these developments generated questions about the feasibility of polio eradication. The year 2007 marked a turning point for the GPEI. Aided by the development of new-generation tools and tactics, an intensified polio eradication effort was launched, sequentially targeting type 1 polio-virus (the most paralytic), then type 3. By the end of the year, type 1 polio was reduced by 81% over 2006, the sharpest ever drop in a single year. The intensified eradication effort was the outcome of a consultation of GPEI stakeholders in February 2007 to determine the collective capacity of the international community to overcome the remaining hurdles to stopping wild poliovirus transmission globally. Engaging the Heads of Government and local leaders in polio-affected countries in a sustained dialogue, this intensified effort optimized the use of powerful monovalent oral polio vaccines (mOPV), enhanced social research and new, tailored tactics to ensure that all children were reached with the vaccines. Two of the key landmarks at the end of the year encapsulate more clearly than any other the recent progress and re-affirm the technical feasibility of polio eradication. In India, the western end of Uttar Pradesh state has been at the heart of polio outbreaks in that country since 2000 and is the only area which has never stopped wild poliovirus transmission. By the end of 2007, no cases of type 1 poliovirus had been reported from the core "polio-reservoir" districts of western Uttar Pradesh for over 12 months. On the international arena, six re-infected countries continued to report polio cases in the second half of 2007. In Afghanistan and Pakistan, creative local solutions in conflict situations helped vaccinators reach children in insecure areas. In Nigeria, the bundling of polio vaccine with other health interventions and improvements in campaign operations halved the proportion of children missed in the highest-risk areas during vaccination campaigns. Engagement from top political leaders, stronger local ownership and community involvement resulted in greater visibility of polio eradication efforts, re-energizing local workers and contributing to higher-quality immunization activities. The Director-General and Regional Directors of the World Health Organization (WHO) travelled to transmission hot-spots in all four endemic countries within 12 months of the stakeholder consultation and discussed polio eradication with Heads of Government and leaders in the highest-risk areas. The gains against polio were underpinned by intensified surveillance work at field and laboratory levels, particularly in areas with known gaps in surveillance sensitivity. Most notably, the number of laboratories capable of using the new specimen testing algorithm was doubled, allowing the Global Polio Laboratory Network (GPLN) to detect poliovirus twice as fast in 2007 as in 2006 and enhancing rapid response capacity. With the continued prospect of eradication, research to broaden the current knowledge base for post-eradication risk management was accelerated. To finance the intensification of polio eradication activities, contributions from traditional development partners were substantially complemented by domestic financing from the Government of India and an extraordinary re-programming of International Finance Facility for Immunization (IFFIm) funds previously earmarked for a post-eradication vaccine stockpile. Advances made in the course of the year catalysed a vote of confidence from Rotary International and the Bill and Melinda Gates Foundation, which in November 2007 announced a partnership to inject US$ 200 million into the GPEI over the next four years. At the request of stakeholders, the GPEI has published, for the first time, a five year budget (2008-2012), requiring US$ 1.8 billion. The 2008-09 funding gap is US$ 490 million (US$ 135 million for 2008), as of May 2008. In November 2007, the principal advisory group to WHO for vaccines and immunization, the Strategic Advisory Group of Experts (SAGE), reviewed the intensified polio eradication effort and affirmed that interruption of wild poliovirus transmission globally was possible, noting that northern Nigeria presented a risk to this goal In the same month, the Advisory Committee on Poliomyelitis Eradication (ACPE), the global body providing strategic guidance to the polio eradication effort, stated that the progress achieved during the year warranted an extension of the intensified activities. In 2008, GPEI focus is on stopping all transmission of type 1 polio, while controlling the upsurge of type 3 polio in India, before moving on to address remaining type 3 poliovirus in 2009. As of March 2008, the single greatest risk to the end-2008 goal appears to be the situation in northern Nigeria, where more than a fifth of children continue to be missed during vaccination activities in key areas, resulting in a new outbreak that threatens progress both in the country and globally. In each of the four countries, the continued assessment, refinement and introduction of a range of new innovations will be essential to improving operations and creating an optimal environment to interrupt the remaining chains of transmission. The impetus to create this environment must come from sustained political dialogue at all levels and local accountability for reaching all children. The world has a unique chance to deliver a public good--a polio-free world for future generations. The attainment of this public health goal can create momentum for the achievement of other important health initiatives and the Millennium Development Goals (MDGs). In 2007, 1310 children were paralysed by wild poliovirus. Millions more were protected by vaccination. More than five million children and young adults are walking today because of the polio eradication effort; future generations will join them only if the eradication of polio is realized, once and for all.