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. 2025 Jul 11;122(14):393–398. doi: 10.3238/arztebl.m2025.0079

Achievements and Obstacles in the Late Phase of the Global Polio Eradication Initiative

Olaf Müller 1,2,*, Guangyu Lu 1,3, Peter Meissner 4, Lorenz von Seidlein 5, Albrecht Jahn 2, Oliver Razum 6
PMCID: PMC12571390  PMID: 40407715

Abstract

Background

The Global Polio Eradication Initiative (GPEI), founded in 1988, has contributed to a drastic reduction in the number of cases of wild poliovirus (WPV) infection. Progress has stalled for years, however, even though the GPEI has become a very costly global health program. Poliomyelitis is caused by WPV types 1, 2, and 3, as well as by mutated vaccine viruses.

Methods

This review is based on publications retrieved by a selective literature search relating to challenges that currently face the GPEI, with an emphasis on the situation in Germany, e.g., the problem of maintaining the high rate of vaccination coverage.

Results

WPV1 remains endemic in Pakistan and Afghanistan. In addition, outbreaks caused by viral mutants of oral live polio vaccines (OPV) have become a problem in countries with low vaccination coverage, with several thousand cases since 2000. Industrialized countries have also had rare cases of poliomyelitis in recent years, caused by mutated vaccine viruses, which often circulate undetected. Aside from the dysfunctionality of the health care systems of many countries, geopolitical tensions, international and civil wars, mass human migration, hesitancy and skepticism of the population about vaccination, and funding fatigue on the part of donor countries, there are a variety of technical problems confronting the GPEI in its quest for success.

Conclusion

Maintaining high polio vaccination rates may be a more realistic solution to the problem of polio than continuing to pursue the GPEI’s objective of putting all polioviruses out of existence. Doctors in Germany can actively contribute to the achievement of both these goals by checking the polio vaccination status of their patients, as recommended by the German Standing Committee on Vaccination (STIKO). This is especially important when doctors care for refugees and asylum-seekers who have arrived in Germany from abroad.

Information on CME

This article has been certified by the North Rhine Academy for Continuing Medical Education. The questions on this article may be found (in German) at http://daebl.de/RY95 (Deutsches Ärzteblatt’s CME portal). Their English translation may be found in the PDF version of this article. The closing date for entries is July 10, 2026.

Participation is possible at cme.aerztebatt.de

The eradication of a specific disease is defined as “the worldwide reduction of the incidence of an infection to zero by organized programs”. In contrast, elimination “refers to the reduction of the incidence of a specific disease in a defined geographical area below a predetermined threshold“ (1).

Seven eradication programs were started in the 20th century. The programs to eradicate hookworms (1909), yellow fever (1918), yaws (1952), and malaria (1954) failed because they were based on incorrect or unrealistic assumptions (e.g., that the pathogens only infect humans and that the majority of infections are symptomatic) (1, 2). So far, smallpox (1967) is the only human infectious disease that, according to the World Health Organization (WHO), has been eradicated since 1980 (e1). Two further programs have been active since the 1980s: the Guinea Worm Eradication Program (to eradicate dracunculiasis, a severe parasitosis) and the Global Polio Eradication Initiative (to eradicate poliomyelitis). While they have significantly reduce the number of cases, they have not yet been able to eradicate the pathogens due to unforeseen developments (e2, 3).

Poliomyelitis is primarily a disease caused by wild polio viruses (WPV) of the types 1, 2 and 3 (genus of enteroviruses, family of picornaviruses) (4, 5). The viruses are highly infectious and are primarily transmitted via the fecal–oral route. However, since the viruses initially proliferate in the pharyngeal epithelium, they can also be transmitted by droplet infection. Under the poor hygienic conditions prevalent in past centuries, an early infection, which was limited to the intestines, largely prevented full-blown polio disease and, in addition, ensured high levels of maternal immunity. Higher hygiene standards initially led to an increase in primary infections among older children, who were no longer protected by maternal antibodies, and thus to the clinical manifestation of polio disease (5). In most cases (90%-95%), the infection is asymptomatic or triggers unspecific symptoms of febrile infection after an incubation period of 1 to 2 weeks. Within one month, 0.1% to 1% of those infected develop the full clinical picture of the disease with often irreversible acute flaccid paralysis (AFP), typically affecting the lower extremities; the case fatality rate of 5% to 10% is due to acute central respiratory paralysis (5).

In 1838, the German orthopedist Jacob Heine described the clinical features of poliomyelitis and in 1884 the Swedish physician Oskar Medin discovered the contagious nature of this increasingly widespread disease which was approaching epidemic proportions at that time (6). Poliomyelitis became one of the most dreaded epidemics of the 20th century due to the long-term consequences for affected children, such as the need for prolonged ventilation in the “iron-lung”. In the 1950s, there were still 600 000 case of poliomyelitis per year in Europa and the USA; in 1961, the Federal Republic of Germany (FRG) suffered its so far last poliomyelitis epidemic with approximately 5000 cases, of which about 300 had a fatal outcome (6). It was during those years that the vaccines were developed that are still in use today. Salk‘s inactivated polio vaccine (IPV) became available in 1955. Sabin’s live oral polio vaccine (OPV) was rolled out in 1960 in the then German Democratic Republic (GDR); in 1962, it was introduced in the GFR, promoted with the catchy slogan “oral vaccination is sweet, polio is horrible“ (6). Polio vaccinations led to a rapid decline in the numbers of polio cases in industrialized countries. In Germany, the last WPV disease was recorded in 1990 and the last two imported WPV cases in 1992 (6) (Figure 1, e3).

Figure 1.

Figure 1

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Poliomyelitis in Germany, 1910–2020 (e3) (licensed under CC BY-SA 4.0, https://creativecommons.org/licenses/by-sa/4.0/) (Julius Senegal, “Poliomyelitis in Deutschland, 1910–2020“) – *Number of death multiplied by 5 for visualization.

Sources: 1910–1989: https://edoc.rki.de/handle/176904/161 (there page 70 f.); 1962: Introduction of live poliovirus vaccine (oral polio vaccine, OPV);

1990 onwards: 1990 last case; 1992 the last two imported cases; www.rki.de/DE/Content/Infekt/Jahrbuch/Jahrbuch_2020.pdf?__blob=publicationFile and also comparewww.rki.de/DE/Content/Infekt/Jahrbuch/jahrbuch_node.html; 1998: switch to IPV: Europe polio-free in 2002: www.impfen-info.de/impfempfehlungen/fuer-erwachsene/polio-kinderlaehmung

In 1988, the WHO initiated a worldwide program to eradicate poliomyelitis: the Global Polio Eradication Initiative (GPEI). Supported by national governments and currently six international partners (WHO, UNICEF, Centers for Disease Control and Prevention [CDC], Gates Foundation, Rotary International, and the GAVI Vaccination Alliance), it was originally planned to eradicate poliomyelitis by the year 2000 (3, 4). Our review article describes the developments, the epidemiological situation and the current challenges faced by the GPEI

Methods

In order to analyze the current challenges of the GPEI with special consideration of the situation in Germany, we carried out a literature search in the Medline database for the period from 1971 to September 2024, using the search terms “poliomyelitis“ and “disease eradication“. A total of 61 studies were included in the analysis. Since a part of the literature on a policy- and institution-led topic such polio eradication is published in the form of policy documents, these were researched on the relevant websites of the WHO and its partner organizations as well as with the help of the usual commercial search engines (e.g. Google Scholar).

Results

The history of the GPEI

As part of its Essential Program on Immunization [EPI], the WHO started in 1974 to protect children in developing countries against polio using OPV. Only after establishing the GPEI in 1988, the EPI program—frequently supplemented by measles vaccinations—achieved sufficiently high OPV vaccination rates (7, e4). While poliomyelitis was still endemic in 125 countries in 1988 and led to about 350 000 clinical cases per year, only a fraction of these disease numbers were recorded a few years later (Figure 2) (e5, 3). OPV is simpler to administer, leads to effective mucosal immunity and, at the same time, contributes to herd immunity due to its high infectivity, i.e., a significant proportion of immune individuals offers relative protection against infection to those in the population who are not immune. In industrialized countries, OPV was increasingly replace by IPV in the following years to prevent rare cases of vaccine-associated paralytic poliomyelitis (1 : 2.7 million) (3, 5).

Figure 2.

Figure 2

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Paralytic polio cases since 1980, by WHO region (e5) (licensed under CC BY-SA) (Max Roser, “Paralytic polio cases since 1980, by world region”)

Source: Global Polio Eradication Initiative (2023). Multiple sources compiled by World Bank (2024). With major processing by Our World in Data. OurWorldinData.org/global-fight-polio (accessed on 13 April 2025)

Worldwide, EPI and GPEI have already prevented more than 1.5 million deaths and approximately 16 million cases of paralytic poliomyelitis; GPEI continues to pursue the eradication of all polioviruses and, once this is achieved, the discontinuation of polio vaccinations (3, 8, 9). In 2015 and 2019, the WHO announced the eradication of WPV2 and WPV3 (10). In 2000, however, first cases of acute flaccid paralysis were discovered that were caused by circulating vaccine-derived poliovirus [cVDPV]) 11). cVDPVs are caused by reverse mutations from OPV back to WPV in areas with low vaccination rates. It is not possible to differentiate between disease caused by cVDPV and disease caused by WPV based on clinical findings (3, 10). A further challenge is posed by the low effectiveness of OPV in countries with high population density and a lack of hygiene (9). Nevertheless, poliomyelitis was successfully eliminated in India in 2014. The subsequent global switch from trivalent to bivalent OPV resulted in a higher than expected rise in cVDPV2 cases in Africa and Asia (12, 13). In 2020, the WHO region Africa was certified as polio-free and the GPEI staff was reduced which contributed to rising case numbers (9). In 2014, the WHO declared the spread of poliovirus a Public Health Emergency of International Concern (PHEIC) (3, 9).

The GPEI ‘s Polio Eradication Strategy 2022–2026 renewed its goal of interrupting polio transmission worldwide by the end of 2023, but had to extend the timeline needed to 2029 (14). While point 1 of this strategy—WPV1 eradication—is primarily based on programmatic improvements in Afghanistan and Pakistan, point 2—the prevention of cases caused by vaccine-derived viruses—focusses on the use of an improved oral polio vaccine (14–16). The first version of this novel OPV (nOPV2) has already been used in vaccination campaigns in 23 countries and led to a significant reduction in polio outbreaks (e4). Even though nOPV2 is considerably more stable compared to OPV2, neurovirulent mutations have developed in nOPV2 too, but cases are few (e6, 15, 17–19).

Epidemiological developments

Following the elimination of poliomyelitis in Nigeria, Afghanistan and Pakistan are now the last two countries with endemic WPV1 transmission (13). In 2019/2020, the two countries reported the highest number of WPV1 cases since 2014 as well as cVDPV2 outbreaks (e7, e8). The biggest obstacles to the GPEI in this region still are political changes, persistent security problems, weak healthcare systems, high cross-border mobility, and widespread vaccine skepticism (9, 20, 21).

Since 2010, a total of 3798 cases of paralytic poliomyelitis have been reported (20). Inadequate preparation for the global switch from trivalent OPV to bivalent OPV1+2 in 2016 led to reduced immunity to WPV2 und subsequently to cVDPV2 outbreaks (20, 22). Then, from 2020, the COVID 19 pandemic has led to further disruptions to the vaccination programs (23, 24). In 2022, 676 cVDPV2 and 187 cVDPV1 cases as well as 1 cVDPV3 case were reported (15). cVDPV outbreaks are primarily observed in the Democratic Republic of Congo, Nigeria, Somalia, and Yemen (20).

The detection of cVDPV2 in wastewater and the subsequently in 2024 identified poliomyelitis case in Gaza gave rise to fears of a polio epidemic (25), aggravated by the war-related destruction of infrastructure and the catastrophic sanitary situation. In response, the United Nations (UN) implemented two nOPV2 vaccination campaigns for children (25).

In recent years, rich countries have also reported poliomyelitis cases and the spread of polioviruses (26). In 2022, an unvaccinated man in an orthodox Jewish community in the State of New York developed paralytic poliomyelitis. Furthermore, cVDPV2 was detected in the sewage system of New York City (27). Genetic analyses showed that these isolates were related to cVDPV2 isolates from London/UK, Quebec/Canada and Jerusalem/Israel (15). Wastewater samples have already demonstrated the silent circulation of cVDPV2 in Israel since 2021 and in London from February to November 2022 (15).

Challenges facing the GPEI

In addition to the above mentioned problems in Afghanistan and Pakistan as well as the intensifying conflicts and wars in Africa and the Middle East, the GPEI faces further challenges today (9, 20):

  • The global phasing out of OPV requires the universal introduction of IPV. A first IPV dose has already been introduced in all 126 countries where OPV was still used in 2019. However, many countries are experiencing IPV shortages. For example, the IPV vaccination rate is only 5% in parts of Nigeria and Pakistan (9, 28).

  • The multitude of vaccine stocks and the unknown number of laboratories storing poliovirus-containing fecal specimens complicate the destruction of non-essential WPV and OPV stocks (9).

  • It is difficult to identify chronic poliovirus shedders with primary immunodeficiency and there is a lack of effective antiviral agents for this group (9).

  • Even in technologically advanced countries, such as the Netherlands, polioviruses can escape from IPV-producing facilities (29).

  • After the discontinuation of polio vaccination programs, polioviruses synthesized in laboratories with terrorist intent could be used to cause poliomyelitis epidemics (3).

  • After almost 40 years since the start of the GPEI, the willingness to fund an expensive (costs of about 1 billion US dollar per year) and foreseeably never-ending program could wane. The current geopolitical crises and the policy of the new US government will further aggravate the financial situation (3, 9).

Polio in Germany

In Germany, poliomyelitis is a notifiable disease and must be reported in the event of suspicion, illness or death (30). In 1990, the last case of WPV acquired in Germany was recorded and since 1998 no vaccine other than IPV has been administered (31). If high vaccination rates are not sustained in the long term, there could be poliomyelitis cases again in Germany too. Ongoing monitoring of the infection situation is also crucial, for example by means of poliovirus surveillance in wastewater. Since September 2024, circulating, vaccine-derived type 2 poliovirus (cVDPV2) has been detected in wastewater in five European countries (Spain, Poland, United Kingdom, Finland, Germany) in altogether 14 cities; these viruses were brought in from countries where OPV is used and are genetically related to the cVDPV2 from Nigeria (32). At the end of 2024, the Robert Koch Institute (RKI) confirmed the detection of cVDPV2 in Munich, Bonn, Cologne, and Hamburg (33). In order to protect the population, the German Standing Committee on Vaccination (STIKO, Ständige Impfkommission) continues to recommend three doses of the vaccine (at 2, 4 and 11 months of age), at the age of 9–17 years a booster and further boosters only prior to trips to high-risk countries or upon exposure (30). Immigrants and asylum seekers, especially if they are accommodated in shared accommodation, as well as persons who have entered the country from high-risk areas should be vaccinated for pragmatic reasons if no vaccination documents are available (30).

In Germany, the office of the National Commission for Polio Eradication is located in the RKI. In 2006, AFP Surveillance was replaced by the Enterovirus Surveillance. In Germany, the polio vaccination rate for three vaccinations at the age of 15 months (international polio surveillance indicator) was with 90 % for the 2019 birth cohort significantly below the 95% target of the WHO; in addition, there are major regional differences (34–36). For example, the Stade district in Lower Saxony achieved a vaccination rate of 90%, the Donau-Ries district in Bavaria only 43% (complete polio vaccination; birth cohort 2021; as of 12/2024 [37]). The social debate on vaccinations has been further intensified and polarized by the COVID-19 pandemic.

Discussion and outlook

Its high manifestation rate and its unique signs and symptoms created ideal conditions for the eradication of smallpox. In addition, a stable and highly effective vaccine was available (3). This is not true for poliomyelitis (3–5): The infection is frequently asymptomatic, most of the time the pathogen has already spread before cases are diagnosed, and the available vaccines are neither optimally effective nor genetically stable.

Since 1988, the international community has supported the GPEI with public and private funds of approximately 20 billion US dollar (3). Further 5 billion US dollar are allocated for the period 2022–2026 (14). This does neither include the costs for the provision of IPV by GAVI nor the costs of national polio vaccination programs (21).

If the GPEI were successful, this financial effort could be considered cost-effective, because more money would have to be spent on continuous polio prevention programs in the long run. It was possible to discontinue vaccinations and surveillance in the smallpox eradication program and achieve a high eradication dividend thanks to resource savings. Even if the polio eradication initiative were successful, it would still be necessary to continue vaccinating for an indefinite period due to the high risks of new outbreaks discussed above; thus, there is no comparable savings potential (3) (eSupplement).

eSupplement. Would a change of strategy from polio eradication to polio control bring about cost savings?

The question arises as to whether a change of strategy from polio eradication to polio control by means of routine vaccination programs would lead to financial savings. With no reliable pertinent data available as yet, we can only present fundamental considerations in the following.

Previous modeling has arrived at the conclusion that the eradication of polio leads to cost savings in the medium term. However, these models were based on two assumptions:

  • First, that polio eradication would be successfully completed within a few years

  • Second, that routine polio vaccination could subsequently be discontinued (e10).

In this scenario, most of the ongoing costs for eradication would be saved (in the period 2003–2022, these amounted to approximately 1 billion US dollar per year on average; see eFigure), as only low costs for maintaining the eradication status would be incurred. In addition, there would be no more expenses for routine polio vaccination (e11). Zimmermann et al. estimated that from 2032 (confidence interval 2027–2051) the cumulative expenditure for polio control would be higher than the cumulative expenditure for successful polio eradication, thus savings would be made from this point onwards.

However, given the repeated delays in reaching the eradication goal, among others due to the COVID-19 pandemic, other authors arrived only a short time later at a less optimistic assessment of the cost savings or cost efficiency of eradication (e12). Two recent developments increase cumulative expenditure and further erode the cost efficiency of the strategy:

  • First, at end of 2024, the GPEI once again delayed the time of reaching the eradication goal, among others due to problems with cVDPV2, this time from 2026 to 2029 (https://polioeradication.org/wp-content/uploads/2024/11/GPEI-Strategy-extension-20241113.pdf; accessed on 20 March 2025).

  • Second, immediately after President Trump took office in January 2025, the USA threatened to withdraw from the WHO and almost completely stopped funding the development aid organization USAID. This is likely to create an acute funding gap for polio vaccines and GPEI of 131 million US dollar and lead to further delays (e13) (https://borgenproject.org/global-polio-eradication/; accessed on 20 March 2025). Thus, the expenditure for eradication will have to be funded for an even longer period than assumed by the earlier models, albeit possibly at a reduced level.

In our article, we argue that the assumptions underlying the two eradication scenarios (successful eradication and subsequent discontinuation of routine vaccination) are likely not correct. If the eradication attempt would now be aborted and the strategy would change to a scenario of polio control by routine vaccination programs, the financial consequences would probably be as follows: The vast majority of the expenditure for eradication would be eliminated, which would amount to an average saving of about 1 billion US dollar per year (eFigure), with a currently slight downward trend (e11). The expenditure for routine polio vaccination would remain unchanged. However, these expenses would decrease over time since the vaccine (in particular IPV) is going to be available at increasingly lower prices (e10).

Neither of the two scenarios takes into account the continued need for expenditure on surveillance and disease control programs not directly related to poliomyelitis, which have so far been covered by funding for polio eradication (39). These costs would continue in both scenarios and would need to be covered by other funding sources.

In summary, there are currently no reliable studies available that quantify the cost savings arising from a change in strategy from polio eradication to polio control. Models that postulate the cost efficiency of polio eradication as compared to polio control are based on assumptions that increasingly need to be questioned. Thus, it cannot be ruled out that a control strategy will be the more cost-effective option in the long term too.

In light of these challenges, doubts are growing as to whether the GPEI should be continued in its current form (3, 8, 10, 13, 38, 39). To put an end to poliomyelitis as a public health problem by indefinitely maintaining high polio immunity rates could be a more realistic solution than continuing a global program with the goal of eradicating polio (3, 10, 40, e9). Physicians in Germany—especially those involved in pediatrics, in the public health service and in the care of refugees—can actively contribute to this approach: They should always highlight the importance of polio vaccination and regularly check the vaccination status and, if necessary, administer a catch-up vaccination, even though there currently are no known polio cases in Germany (35).

eFigure.

eFigure

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Financial contributions toward polio eradication (e14) (licensed under CC BY-SA, https://creativecommons.org/licenses/by/4.0/) (Saloni Dattani, “Financial contributions toward polio eradication”) Contributions from donor institutions to the Polio Eradication Initiative (in USD, adjusted for inflation).

Data source: Global Polio Eradication Initiative (2023); Multiple sources compiled by World Bank (2024)

NGO, non-governmental organization; USD, US dollar

Questions on the article in issue 14/2025:

Achievements and Obstacles in the Late Phase of the Global Polio Eradication Initiative

The submission deadline is 10 July 2026. Only one answer is possible for each question.

Please select the most appropriate answer.

Question 1

In which year was the oral polio live vaccine (OPV) introduced in the Federal Republic of Germany?

  1. 1950

  2. 1955

  3. 1962

  4. 1971

  5. 1979

Question 2

The abbreviation IPV stand for which vaccine?

  1. Intravenous Sabin vaccine

  2. Inactivated Salk vaccine

  3. Intravenous Behring vaccine

  4. Inactivated Sabin vaccine

  5. Inactivated Calmette-Guérin vaccine

Question 3

Which statement about Sabin vaccine is not true?

  1. The vaccine is administered orally.

  2. The vaccine was first introduced in the GDR and then in the GFR.

  3. The vaccine was the first available polio vaccine.

  4. Since 1974, it has been increasingly used in developing countries for mass vaccination campaigns.

  5. It achieves effective mucosal immunity.

Question 4

How are polioviruses classified taxonomically?

  1. Genus: lentiviruses; family: retroviruses

  2. Genus: aviadenoviruses; family: adenoviruses

  3. Genus: vesiculoviruses; family: rhabdoviruses

  4. Genus: enteroviruses; family: picornaviruses

  5. Genus: Marburgviruses; family: filoviruses

Question 5

Which two countries are the last to have endemic transmission of wild poliovirus type 1 (WPV1)?

  1. Nigeria and Algeria

  2. Morocco and Tunisia

  3. Sudan and Egypt

  4. Iraq and Iran

  5. Afghanistan and Pakistan

Question 6

Which statement about circulating vaccine-derived poliovirus (cVDPV) is the most appropriate?

  1. cVDPVs result from reverse mutation of inactivated Salk vaccine to wild polioviruses in areas with high vaccination rates.

  2. The clinical features of polio disease caused by cVDPV differ significantly from those caused by WPV.

  3. Disease caused by cVDPV is harmless and does not constitute an epidemiological problem.

  4. cVDPVs result from reverse mutation of oral polio vaccines to wild polioviruses in areas with low vaccination rates.

  5. cVDPVs were intentionally produced to accelerate vaccination coverage.

Question 7

What is the current target year of the Global Polio Eradication Initiative (GPEI) for achieving interruption of poliovirus transmission worldwide?

  1. 2026

  2. 2029

  3. 2036

  4. 2040

  5. 2043

Question 8

Many countries use wastewater surveillance to monitor emerging polio infections. Which poliovirus strain was detected in wastewater in five European countries in September 2024?

  1. WPV3

  2. cVDPV1

  3. WPV2

  4. WPV1

  5. cVDPV2

Question 9

According to the article, which of the following is not one of the challenges facing the GPEI in its efforts to eradicate polioviruses?

  1. The instability of the IPV vaccine which can lead to reverse mutations back to the wild type.

  2. It is difficult to identify chronic poliovirus shedders.

  3. There is an unknown number of laboratories that store poliovirus-containing fecal specimens.

  4. Polioviruses can escape from IPV-producing facilities.

  5. The willingness to fund the eradication program decreases in times of geopolitical crises.

Question 10

The article provides complete vaccination rates for the 2021 birth cohort as at December 2024 as an example. What were the complete polio vaccination rates among children in the districts Stade (Lower Saxony) and Donau-Ries (Baviara)?

  1. 65% and 95%, respectively

  2. 85% and 98%, respectively

  3. 95% and 65%, respectively

  4. 90% and 43%, respectively

  5. 99% and 87%, respectively

Acknowledgments

Translated from the original German by Ralf Thoene, M.D.

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Footnotes

Conflict of interest statement

OR is the Vice-Chairman of the National Verification Commission for Measles/Rubella (Nationale Verifizierungskommission Masern/Röteln, NAVKO) at the RKI. He is a member of the RKI’s Scientific Advisory Board.

The remaining authors declare no conflict of interest.

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