Integration involves using polio tools, staff, expertise, and other resources to deliver important health interventions alongside polio vaccines – from measles vaccines and other essential immunizations to birth registration, counselling on breastfeeding, hand soap and more. It also includes incorporating polio vaccines into other planned health interventions when possible, delivering more services with fewer resources. 

There is no one-size-fits-all approach to integration. From the remaining endemic countries to countries affected by variant poliovirus outbreaks, activities must be country-driven and adapted to fit the unique challenges and needs of different communities.

Humanitarian engagement in Afghanistan: 

In Afghanistan, supplementary immunization activities are essential to vaccinating children. However, in the context of an unprecedented humanitarian crisis and extremely fragile health system, integrating polio efforts with other health services has helped the program reach even more children. 

Endemic transmission of WPV1 in Afghanistan has been restricted to the east region. Remaining pockets of inaccessible, unvaccinated children amid a broader humanitarian crisis pose challenges to stopping the virus for good. Today, more than two-thirds of the country’s population is in serious need of food, clean water, functioning sanitation facilities, and basic health services. 

WHO Representative in Afghanistan, Dr. Luo Dapeng, vaccinating children against measles in a mobile clinic in Baba Wali Village of Kandahar province. © WHO/Afghanistan

Building upon a strategy that has been in place for several years, ongoing collaboration with humanitarian organizations has demonstrated the value of integrating polio efforts with other health needs in the country. In 2023, the program began engagement with ten humanitarian partners operating in 12 high-risk provinces for polio across Afghanistan. Through these collaborations, the program and its partners have mapped and supported communities that lack basic health services, which has helped better identify and reach children still vulnerable to polio.  

Between January and October 2023, more than 1 million polio vaccinations have been delivered through the engagement with humanitarian partners. Through this effort, it’s estimated that more than 30,000 children have been vaccinated who would have otherwise remained inaccessible to the polio program during its standard campaigns¹.

The Far-Reaching Integrated Delivery partnership in Somalia: 

In Somalia, children are at high risk of encountering and spreading the poliovirus due to longstanding security challenges and a lack of health infrastructure, particularly in the south-central part of the country. As a result, the country has historically low routine immunization levels and faces the world’s longest-running outbreak of type 2 variant poliovirus

A health worker administers polio vaccine (nOPV2) drops to a child at Luley IDP camp during a door-to-door polio  immunization campaign in Kahda district, Mogadishu, Somalia on May 28, 2023. © Ismail Taxta/Getty Images
A health worker administers polio vaccine (nOPV2) drops to a child at Luley IDP camp during a door-to-door polio immunization campaign in Kahda district, Mogadishu, Somalia on May 28, 2023. © Ismail Taxta/Getty Images

To help address these challenges, in October 2022, the GPEI partnered with the World Food Program Innovation Hub, Save the Children, Acasus, and World Vision’s CORE group, amongst others, to launch the Far-Reaching Integrated Delivery (FARID) partnership. The partnership’s primary goal is to stop poliovirus transmission and reduce deaths from preventable diseases and malnutrition.  

To do this, the polio program and its partners have established a series of health camps across 20 districts in the country that provide families with vaccinations for polio and other infectious diseases, maternal health services, nutrition screening and supplements, and primary health consultations². These camps are tailored to address each community’s specific needs and aim to re-establish sustainable health systems that will continue providing primary health services on a routine basis. 

Between October 2022 and June 2023, FARID partners have visited 136 high-risk communities in Somalia, reaching almost 30,000 people; vaccinating more than 8,000 children, 6,000 of which had never received any kind of vaccine; and conducting over 10,000 maternal health and 4,000 nutrition consultations³. 

Read more about the polio program’s latest integration efforts here. 

Geneva, Switzerland, January 2024 Convening this week at the World Health Organization (WHO) headquarters, global health leaders and Ministers of Health at the WHO Executive Board (EB) reaffirmed their commitment to eradicate polio once and for all and use the polio investments to build strong, equitable and resilient health systems.

Opening the EB amid a wide array of public health topics on the agenda, WHO Director-General Dr Tedros Adhanom Ghebreyesus told assembled delegates:  “We continue to intensify our efforts to eradicate polio. Last year, six cases of wild poliovirus were reported in Pakistan, and six in Afghanistan, the second-lowest number of cases reported in a calendar year. Our target is to interrupt transmission of wild poliovirus this year.”

Member States noted the unique opportunity to eradicate remaining wild poliovirus type 1 endemic transmission, which is now limited to just a handful of areas of eastern Afghanistan and three districts of southern Khyber Pakhtunkhwa, Pakistan, and urged for continued intensified efforts to reaching all remaining un- or under-immunized children in those areas.  Delegates also reiterated the importance of intensifying efforts to combat variant poliovirus outbreaks (circulating vaccine-derived polioviruses), including through strengthened outbreak response and the continued roll-out of novel oral polio vaccine type 2, which became the first vaccine used under Emergency Use Listing (EUL) to be pre-qualified by WHO.  The engines of transmission for such strains are in clearly-identified and known most consequential geographies, namely north-western Nigeria, eastern Democratic Republic of the Congo, south-central Somalia and northern Yemen.

Speaking on behalf of WHO Regional Director for the Eastern Mediterranean Dr Ahmed Al Mandhari, Dr Hamid Jafari, Director for Polio Eradication in the Eastern Mediterranean said:  “In Afghanistan and Pakistan, the national programmes deployed innovative strategies and strengthened partnerships with humanitarian actors to reach more children. And across the region, the programme also identified pathways for sustaining essential polio functions, through integration with existing programmes. In particular, I am proud of the work of the Regional Subcommittee for Polio Eradication and Outbreaks that we started back in 2021. Their advocacy and support have successfully carved out clear pathways towards protecting children in the Region from polio and other vaccine-preventable diseases.”

Within this context, delegates thanked current Regional Director Dr Ahmed Al Mandhari, for his personal engagement and leadership in bringing the region to the threshold of success; and welcomed his successor, Dr Hanan H Balkhy, who committed to leading the region across the finish line.

“On behalf of the core partners of the Global Polio Eradication Initiative, Rotary International, the US Centers for Disease Control and Prevention (CDC), UNICEF, the Bill & Melinda Gates Foundation and Gavi, the Vaccine Alliance, we would like to thank all Member States for their tremendous efforts,” said Aidan O’Leary, WHO Director for Polio Eradication and Chair of the Global Polio Eradication Initiative Strategy Committee.  “Last year, thanks to your efforts, upwards of 800 million children were immunized, many in areas with protracted and complex emergencies.  The reality is that it is precisely in such areas of complex emergencies where polio persists, and unfortunately those emergencies are becoming even more complex.  We need the continued political will of Member States to overcoming whatever geo-political challenges might currently stand in the way of reaching that remaining last unreached child in these areas.  Be assured that together with our partners, we stand ready to support you in your incredible efforts.”  Underscoring WHO’s commitment to the effort, O’Leary reminded the EB that WHO now considered the effort to eradicate polio as its only Public Health Emergency of International Concern (PHEIC), under the International Health Regulations (IHR).

O’Leary also reminded delegates of our collective duty to prepare for a lasting polio-free world. He referenced specifically the new approach to polio transition, which draws upon lessons-learned, and puts countries at the forefront, as solutions need to be country-specific, tailored to each country’s own context.  Within that context, delegates emphasized the importance of implementing all activities to not only achieve a polio-free world, but also to sustain it through strengthening essential immunization, surveillance, integration and transition, reiterating their support and commitment to fully finance the Global Polio Eradication Initiative Strategy and the WHO base budget.

Speaking on behalf of Rotarians around the world and civil society as a whole, Judith Diment of Rotary International’s PolioPlus Committee, congratulated delegates on ongoing efforts to protect children from devastating diseases such as polio.  “The Global Polio Eradication Initiative is closing in on zero, with fewer cases in fewer places in 2023, reaching more children through tailored approaches to increase public demand and identifying missed children.  We applaud the use of targeted, integrated activities.”

The Global Polio Eradication Initiative has two goals laid out in its current strategy: to interrupt all remaining transmission of endemic wild poliovirus type 1 (WPV1) and to stop all outbreaks of variant poliovirus type 2 (cVDPV2). 2023 was a critical year for progressing on each of these, and while our urgent and diligent work to end polio must continue into 2024, the GPEI achieved incredible things in the past twelve months.

Continuing work in endemic countries

Despite significant geo-political and environmental challenges in the two remaining WPV1-endemic countries, Pakistan and Afghanistan, the polio programme has continued to reach greater numbers of children with polio vaccines.

WHO Representative in Afghanistan, Dr. Luo Dapeng, vaccinating children against measles in a mobile clinic in Baba Wali Village of Kandahar province. © WHO/Afghanistan

Wild polio transmission was beaten back to just a handful of districts in eastern Afghanistan and the southern area of Khyber Pakhtunkhwa province in Pakistan. In both countries, efforts are increasingly focused on reaching and vaccinating the last remaining ‘zero dose’ children – children who have received no vaccines of any kind. The number of these missed children continues to dwindle, with the success of improved collaboration with the national immunisation program, new efforts like Pakistan’s Nomad Vaccination Initiative and focused vaccination activities at border crossings between the two countries. Just one family of the virus remains endemic in each country, and coupled with this increasing geographic restriction, the situation resembles the end of wild polio eradication efforts in former virus hotspots like India, Nigeria and Egypt.

In addition, after a wild poliovirus outbreak that was confirmed in southeast Africa in early 2022, neither Malawi nor Mozambique has reported a WPV case since August 2022 thanks to a concerted subregional emergency response across five neighbouring countries. We are hopeful that this outbreak will be officially closed in the coming months, affirming that countries have what it takes to protect children from this devastating disease and keep wild polio out of Africa.

Progress on variant polio outbreaks

Thanks to the novel oral polio vaccine type 2 (nOPV2), strong political commitment and community-based efforts to reach more children with the vaccine, the number of cases of variant poliovirus type 2 (cVDPV2) continued to decline in 2023.

Nearly 1 billion doses of nOPV2, a comparably safe, effective, but more genetically stable version of the existing type 2 oral polio vaccine (mOPV2), have now been administered across 35 countries, protecting millions of children from illness and paralysis.

Emergency response to variant polio outbreaks is continuing, notably in the most consequential geographies for the programme—where children are at the highest risk of encountering and spreading poliovirus. In northern Nigeria, for example, variant polio cases have fallen by 90% since a peak in 2021, thanks to concerted commitment from government, unique community programs to improve the reach of vaccines and the extensive rollout of nOPV2. Across these consequential geographies, the programme will continue to focus on increasing access, acceptance and campaign quality, which have helped make incredible progress in Nigeria, and continue to innovate until we end polio for good everywhere.

Finally, In September 2023, after a massive vaccination response in the shadow of ongoing war, Ukraine officially stopped its outbreak of type 2 variant polio that began in 2021. New York, London and Jerusalem, where high-profile outbreaks began in 2022, have not detected the virus in recent months. Still, the emergence of polio in these areas is a reminder that as long as poliovirus exists anywhere, it is a threat to people everywhere.

nOPV2 Vaccination at Guilding Angel School Tunga, Minna, Niger. © WHO/AFRO

A global effort

Most importantly, thanks to the efforts of the GPEI and its partners, health workers vaccinated more than 400 million children in 2023, preventing an estimated 650,000 cases of paralysis from polio and saving the lives of up to 60,000 children. Building full, healthy futures was at the core of Rotary International’s mission when it began this fight to end polio for good in 1985, and when the GPEI was launched in 1988—35 years ago.

This year, the Independent Monitoring Board (IMB) conducted a rigorous mid-term review of the GPEI’s progress towards its strategic goals. This welcome counsel is already helping inform and guide the GPEI’s own ongoing analysis and strengthening of its strategic approaches to achieve a polio-free world, as the programme published its initial response to the mid-term review, under the guidance of the Polio Oversight Board (POB).

Achieving and sustaining a polio-free world has proven harder – and taken longer – than anyone could have imagined. But making history is never easy, and we are confident that together we can eradicate a second human disease from this earth, and build stronger, more resilient health systems along the way.

2023 has firmly set the stage for success. With the complexities of the world today, this programme still inspires to bring about the very best in our humanity.

Thank you to all who have contributed to this effort so far and continue to do so. Let us double down and make the dream of a polio-free world a reality.

Manzoor (second right, pictured here with his uncle, brothers and sisters) will make a full recovery from polio paralysis. ©UNICEF/Karimi

By Kate Pond, UNICEF Afghanistan

“Manzoor is our miracle child!” exclaims the young man, face shining. Two-and-a-half-year-old Manzoor is unmoved by his uncle’s excitement; he is busy eyeing the boiled sweet in the outstretched hand of a village elder on the other side of the room. The boy gets up decisively, and trots across the carpet. He grabs the candy in a pudgy hand and gobbles it down with relish.

Just a few months ago, Manzoor could not walk. His left leg was paralyzed by the polio virus.

In a neighbouring district, Saima, fidgets with her hennaed fingers while her father pours tea. Small for her 11 years, Saima still favours her right side, although the paralysis caused by the virus is easing. As her father tells the story of her recent illness, her grandfather puts his arm around the girl’s shoulders, embracing her warmly.

Polio is still endemic in Afghanistan – one of the last two countries in the world. Since the start of 2023, six children have been diagnosed with the disease, all of them in Nangarhar Province, a rural area in the east of the country. Saima and Manzoor are lucky: six months after the onset of symptoms, it looks like they will make a full recovery. Two of the six were not so lucky; one boy remains very weak in the limbs affected, and one girl died.

The national polio vaccination campaign, led by the National Emergency Operations Centre in coordination with UNICEF and WHO, is in full swing. Last year, 9.4 million children were vaccinated under the campaign, and the target for 2023 is 10 million. The monthly campaigns are boosted by educational campaigns for mothers and other caregivers, run by UNICEF and partners.

Saima and Manzoor received vaccine drops in recent campaigns, and their parents were well aware of the signs and symptoms of polio, how it is caught, and the importance of vaccination as the only preventative measure. In fact, the speed at which their parents acted to get tests and treatment for their children are testament to the commitment and hard work of over 30,000 polio social mobilisers and influencers building public trust in the programme, and the deep-seated desire of the Afghan community to eradicate the virus once and for all.

The combination of vaccination campaigns and regular routine vaccination is the gold standard to eradicate polio forever. Nangarhar ranks above the national average for full childhood vaccinations, with 27 per cent of children fully covered, although it is also slightly higher than average for children in the same age bracket to be unvaccinated (Ref: UNICEF MICS 2022-23). In each of the six new polio cases, the children had missed one vital vaccination – usually the intravenous jab given to babies and toddlers – which left a gap in their immunity, and the virus was able to break through.

Nothing happens in a vacuum. For a vaccine to work effectively, the child receiving it needs to be healthy, adequately nourished, and living in a sanitary environment. The polio virus is contracted from water sources that are contaminated by raw sewage infected with the virus. Wild polio is detected in the samples WHO collects in regions across Afghanistan, including in the east.

Less than half the population of Afghanistan has access to basic sanitation, and a third do not have access to clean drinking water. In rural areas, like Saima and Manzoor’s districts, the streams the children play in are often the same streams that household waste and effluent flow into. Nangarhar residents benefit from higher-than-average access to clean drinking water, but sanitation is considerably lower than average, and 20 per cent practice open defecation. In Manzoor’s district, for example, only 30 per cent of the population benefit from a piped water supply. Without the necessary infrastructure in place to provide these services, children will continue to be exposed to the virus in their living environment and run the risk of contracting the disease.

The polio vaccination campaign is striding forward in Afghanistan, and the virus is fighting to survive. But while the water in which children play is contaminated, the risk of them catching the virus hangs heavily over communities. Winning the battle involves recognizing the interconnectedness of health and nutrition, clean water and sanitation, community education and vaccination, and responding with a comprehensive package of services. As Saima’s father put it: “Mashallah my daughter is lucky. She will make a full recovery. But without better sanitation we will continue to live in fear of the virus.”

Dr Humayun Asghar. © WHO/EMRO

The vast machinery of the global polio eradication programme is much like the inner workings of a clock – a network of interconnected people, organizations and programmes that together are more powerful than the sum of their parts. Collaboration is foundational to eradication, and every eradicator plays a part in edging the programme closer to its goals.

But in some cases, individual eradicators develop capacities or practices that enable programmatic leaps. Dr Humayun Asghar is one of those outsize drivers of progress. His initiatives around early laboratory testing of stool samples of children with acute flaccid paralysis (AFP), his efforts to create  a cross-regional network of labs, and his efforts to set up a large pioneering network of environmental surveillance sites in Egypt are innovations that today power the programme’s surveillance capacity. We know where the virus is, even in the absence of paralytic polio cases, largely thanks to his work.

In 1988, when Dr Humayun joined the National Institute of Health (NIH) in Pakistan’s capital city of Islamabad, polio was paralysing more than 1000 children worldwide every day and the Global Polio Eradication Initiative (GPEI) was just being set up. Dr Humayun spotted an opportunity to stop the spread of poliovirus by tracking it – which meant identifying which children with AFP were infected with poliovirus and which children were experiencing paralysis for other reasons. In 1991, Dr Humayun began to contact pediatricians and, later, vaccinators, to collect stool samples from children who presented with AFP to test them for poliovirus infection. In a nod to the doctors’ and vaccinators’ contribution, Dr Humayun shared the results immediately with the reporting individual, regardless of their location.

The information filled a gap for physicians who wanted to know why their patients were unwell, and it provided a new level of detail on the virus’ whereabouts. Word got around and soon, more and more doctors started sending in their AFP patients’ stool samples. As the practice grew, processes needed to be formalized: Dr Humayun and his colleagues had to ensure stool samples were reaching them in the right conditions for testing, which led to the establishment of a set of criteria and standard operating procedures around the transportation of stool samples – something known today as the reverse cold chain.

The dawn of AFP surveillance in Pakistan

This new system unveiled the dawn of an era of detailed, systematic surveillance for AFP, the most common, tell-tale symptom of poliovirus infection. That it grew out of mutual trust and collaboration with focal points in the community reaffirmed Dr Humayun’s belief, “If you offer service to the community, the community serves you.”

Site selection during establishment of polio environmental surveillance in Pakistan. © WHO/EMRO

In their quest to fill in gaps in disease surveillance and formalize a practice of testing samples from AFP patients, Dr Humayun and his colleagues succeeded in establishing the first poliovirus laboratory in Pakistan.

Dr Hamid Jafari, WHO Polio Director for the Eastern Mediterranean Region, says this contribution to eradication cannot be  overstated.

“Dr Humayun has sowed the seeds of AFP surveillance in Pakistan all through his own initiative and drive and nurtured and supported the lab network in the Eastern Mediterranean Region; as one of the architects of the regional and global laboratory network, he has contributed to building a great legacy.”

Advancing the Region’s work

Over the intervening decades, Dr Humayun has helped the Region’s laboratory network grow in size and skill, bringing in new practices such as testing for poliovirus in sewage water (environmental surveillance) and then harnessing this new practice to test for the presence of other diseases – most recently, COVID-19. He also took the practice out of the Eastern Mediterranean Region and into the African Region, supporting the polio laboratory in Nigeria to introduce environmental surveillance.

Collecting the first sample for polio environmental surveillance while training health workers, Nigeria. © WHO

Testing for and tracking the virus in stool samples and sewage water enabled the programme to identify different types of poliovirus, and by building on this, a practice was developed to conduct nucleotide sequencing, which provides a fuller picture of viruses’ lineage and allows scientists to identify which family any given poliovirus belongs to. Dr Humayun attributes these accomplishments to laboratory staff, who strengthened their own capacity to diagnose polio without waiting for results from other global specialized laboratories.

Supporting others to grow

Since he joined WHO’s Eastern Mediterranean Region in February 2002, Dr Humayun has served in several capacities – as Scientist Virologist, Regional Advisor for Public Health Laboratories, and finally as the Coordinator for the Region’s Poliovirus surveillance, Laboratory support and Data management. He credits two mentors in particular for inspiring his career – the late Dr Helmy Wahdan, former Polio Director for WHO’s Eastern Mediterranean Region, and Dr Olen Kew, a poliovirus scientist – and, over the course of his career, has tried to pay that inspiration forwards.

“Dr Humayun has mentored and supported young scientists and laboratory specialists across the Region to advance their skills and careers,” said Dr Nima Saeed Abid, WHO Representative for Sudan. “He has been a true leader in his field.”

Perhaps unsurprisingly, Dr Humayun believes one of the keys to eradicating polio lies not in the lab, but in people: in empowering and engaging the workforce by incentivizing them with education, training and promotion.

On the occasion of his retirement in May 2023, Dr Humayun expressed gratitude that he was able to witness and contribute to two important milestones: the eradication of wild poliovirus types 2 and 3.

And when the eradication of WPV1 does happen, he says, “I will be cheering from the sidelines, alongside so many other vital contributors to the programme’s legacy.”

©WHO

Global leaders and stakeholders have been unanimously declaring their solidarity to achieving a lasting world free of all forms of polioviruses.

Convening this week at the World Health Assembly in Geneva, Switzerland, Ministers of Health from around the globe evaluated the unique epidemiological opportunity which currently exists, in particular in eradicating all remaining chains of endemic wild poliovirus in a handful of districts of just two countries – Pakistan and Afghanistan.  As a record number of Member States and civil society partners took to the floor, key to success, all experts agreed, must be on adapting operations and reaching remaining un- or under-immunized children in just seven subnational most consequential geographies, with collectively account for 90% of all new polio cases, including in a gender-equitable and integrated manner.  To ensure lasting success, delegates urged country-specific solutions for polio transition.  In response to both a wild poliovirus outbreak in south-eastern Africa and multi-country circulating vaccine-derived poliovirus outbreaks, extraordinary special sessions were led by WHO and its Regional Office for Africa between affected Member States and partners, to discuss concrete steps to stopping all outbreaks affecting the Region by end of year.

The World Health Assembly comes on the heels of last week’s G7 Leaders and G7 Health Ministers meetings in Japan, where both meetings highlighted the urgent need to ensure a world free of polio can be rapidly achieved. Next week, Rotarians from around the world are convening at the Rotary International Convention in Melbourne, Australia, to ensure civil society support for the effort will go hand-in-hand with public sector engagement.

Speaking on behalf of both Pakistan and the entire Eastern Mediterranean, Mr A.Q. Patel, Pakistan Federal Minister for National Health Services, Regulations and Coordination, said:  “We are in the final leg of eradication and we are doing everything we have to do to achieve success.  The virus is restricted to its smallest-ever geographical footprint, and the (polio) programmes in both Pakistan and Afghanistan continue to vastly expand their hunt for the virus and mount robust campaigns to reach all children, not just with polio vaccine, but indeed other antigens as well.  We could not have come this far without the strong support and goodwill of all Member States, however there is still more to be done at the heart of all our work, and for the future of all generations of children.  We need continued and sustained financial and political support from all Member States and partners, in order to give every child, no matter where they live, the promise of a polio-free world.”

H.E. Dr Hanan Mohammad Al-Kuwari, Minister of Public Health of Qatar, and Co-Chair of the Eastern Mediterranean Regional Subcommittee for Polio Eradication and Outbreaks, commented:  “In our Region, we have made significant progress in both containing the spread of wild poliovirus and closing outbreaks of vaccine variant polio.  Afghanistan and Pakistan have restricted the virus to the smallest geographical footprint in history and are now doubling up efforts to fully interrupt the remaining transmission.  The engines fueling this progress are manifold, but the two most powerful, and the two I truly believe will get us across the line, are improved immunity and better surveillance. We are reaching and vaccinating more children, more often, and we are using the most sensitive and robust surveillance measures in history to ensure that if the virus is there, we are not missing it.  Excellencies, partners and colleagues, I ask this as clearly as I can: Stay the course. Dig deep to do what needs to be done. Stand with us and be part of history.”

Noting the global commitments being made, Jean-Luc Perrin, Rotary International’s Representative to the United Nations in Geneva, told the global health community at the Assembly:  “Polio eradication is a rare example of enduring, truly global collaboration toward a goal whose achievement will benefit all nations in perpetuity, while contributing toward broader global health priorities.  We cannot take progress or possible victory for granted. Let us make collective history and End Polio Now!”

In conclusion: global leaders continue to note the very real window of opportunity for success this year, but that this window will not remain open for long.  The virus will again gain in strength. Only collective and global collaboration will result in ultimate success, and delegates and leaders urge all stakeholders to keep the focus firmly on one overriding objective:  reaching remaining un- or under-vaccinated children in the most consequential geographies.  A collective responsibility, but if achieved, will result in success in 2023.

Additional quotes from the World Health Assembly:

“WHO and our partners remain steadfastly committed to finishing the job of consigning polio to history.  Last year, three million children previously inaccessible in Afghanistan received polio vaccines for the first time.  And in October, donors pledged US$2.6 billion to support the push for eradication.  At the same time, as part of the polio transition, more than 50 countries have integrated polio assets to support immunization, disease detection and emergency response.  We must make sure that the significant investments in polio eradication do not die with polio, but are used to build the health systems to deliver the services that these communities so badly need.”- Dr Tedros Adhanom Ghebreyesus, Director-General, World Health Organization

“Wild poliovirus transmission has been cornered to the smallest ever geographic locations in the Eastern Region of Afghanistan and seven districts in southern part of Khyber Pakhtunkhwa in Pakistan.  However, the last 100-metre dash presents its own challenges and we must do all we can to achieve success.” Dr Hamid Jafari, Director for Polio Eradication for the Eastern Mediterranean, on behalf of Dr Ahmed Al-Mandhari, Regional Director, World Health Organization Eastern Mediterranean Region

“The African Region, which was certified free of wild poliovirus in 2020, has set itself the objective of stopping the transmission of all types of 2 polioviruses by the end of 2023 and integrating polio assets into activities that strengthen broader disease surveillance. It is also deploying integrated public health teams to respond to other emergencies, building on experiences from past poliovirus outbreaks and leveraging the polio network and infrastructure for response activities.” – Delegation of Burkina Faso, speaking on behalf of the entire African Region.

WHO Representative in Afghanistan, Dr. Luo Dapeng, vaccinating children against measles in a mobile clinic in Baba Wali Village of Kandahar province. © WHO/Afghanistan

With more than twenty years’ experience on the ground in Afghanistan, WHO’s polio eradication programme continues to leverage its extensive operational capacity to deliver better health outcomes for all Afghans, including providing vital support to the recent nationwide measles vaccination campaign.

Measles outbreaks were reported across Afghanistan throughout 2022, with more than 5,000 cases and an estimated 300 deaths reported by November. Complications from the measles virus include severe diarrhea and dehydration, pneumonia, ear and eye complications, encephalitis or swelling of the brain, permanent disability and death. Most cases are children under the age of 5 years. There is no treatment for measles, the only reliable protection is vaccination.

While a series of sub national measles vaccination campaigns took place in 2022 reaching approximately three million children in 141 districts, the nationwide campaign from November 26 to December 5 represented the first national measles drive since the political transition in August 2021. The campaign covered 329 districts in all 34 provinces, vaccinating 5.36 million children aged between from 9 to 59 months against measles. 6.1 million children between 0 to 59 months received oral polio vaccine.

WHO’s polio eradication programme has significant reach in Afghanistan, with a presence in every district in the country. The polio programme leveraged this presence to recruit vaccinators, organize vaccination sites, and train campaign staff. With longstanding relationships with local authorities, the polio programme assisted in the selection of local schools, clinics, or mosques to serve as vaccinations sites. The programme’s established relationships with health institutions and communities enabled polio staff to recruit local health workers and other staff to fill the roles of measles vaccinators and provide training. Sharing their experience of implementing polio vaccination campaigns helped measles vaccinators prepare and plan for the task ahead.

The detection of measles cases and collection of data by WHO’s extensive polio surveillance network also played a crucial role in providing evidence-based planning for the campaign. WHO’s polio programme also provided logistical support, transporting measles and polio vaccines, ensuring the cold chain was maintained and vaccines were delivered to every district. Polio staff played additional roles in campaign monitoring and supervision.

“Measles is a highly contagious disease. WHO Afghanistan is very proud of its work immunizing and protecting children against both measles and polio in this campaign,” said Dr Luo Dapeng, WHO Representative in Afghanistan. “I am very grateful to all health workers, partners and donors who made this possible.”

Addressing social norms

Dr Amira Zaghloul ©WHO/Pakistan

Giza, Egypt, is home to the ancient world-renowned pyramids and a medical marvel of the modern age — the accredited Polio Regional Reference Laboratory (RRL) at the Egyptian Holding Company for Biological Products and Vaccines (VACSERA). Director of the polio regional reference laboratory,

Amira Zaghloul oversees five different departments, working closely with her 25-member team. They regularly conduct poliovirus diagnostic tests on stool samples obtained from children as well as sewage samples from Egypt. Additionally, they carry out sequencing of samples that have been identified as positive for polio in Egypt, Iran, Iraq, Jordan, Sudan, and Syria, which determines if the polioviruses confirmed are related to any other ones. Their goal is to meet tight deadlines, to swiftly respond to any detection of the poliovirus.

Like her counterparts across the Region, Ms Zaghloul and her colleagues rely on the latest laboratory and digital technology. With support from partners, they regularly upgrade their technology and skills to ensure the shortest possible time between sample collection and churning out results. Soon, for example, Ms Zaghloul and her team will acquire the next generation of sequencing technology – that will help test the entire genome of a virus, or genetic materials that make up a virus, and identify any mutations. This will also help to determine the origin of detected polioviruses, and track epidemiological patterns of spread.

Her work doesn’t come without challenges though. When she first took on this role, Ms Zaghloul faced negative social perceptions of being a female leader of a mixed team of men and women. To address this, Ms Zaghloul introduced rules and regulations that apply to all, regardless of age and gender.

People working in health should exemplify a spirit of perseverance, devotion, hope and ambition – regardless of their gender – she emphasizes.

Negotiating to receive samples for polio tests

Dr Hanan Al Kindi ©WHO/Pakistan
Dr Hanan Al Kindi ©WHO/Pakistan

When Dr Hanan Al Kindi finally settled on what to study − over virology, medicine or business — she had no idea she would need negotiation skills in her job. As the head of nine polio and measles laboratory departments that test samples from Bahrain, Qatar, United Arab Emirates and Yemen for polioviruses, Dr Al Kindi ensures everything runs like clockwork.

At times, this involves thinking out of the box. After noting huge time lags in the delivery of stool samples – used to test for polioviruses – from Yemen to Oman, Dr Al Kindi rolled up her sleeves and got to action. She learnt that after driving through mountains and deserts to reach Oman’s borders, the refrigerated trucks that transport stool samples were kept at the border for hours of inspection. Dr Al Kindi and her team got the contacts of officials at the border and invited them over for a chat.

Her determined negotiation skills and ability to read the room – to understand when peripheral stakeholders such as officials at the border and couriers needed more context about the laboratory’s role in saving children from polio — eventually helped reduce the red tape at the border. This means Dr Al Kindi and her team can test for polioviruses and turn over their results to the polio programme in Yemen in less time than before. This steers timely and appropriate outbreak response activities, including polio immunization campaigns to protect children from polio.

Working in an equitable environment

Dr Nayab Mahmood ©WHO/Pakistan

Dr Nayab Mahmood plays a vital role in ensuring samples are tested for poliovirus as swiftly as possible for timely interventions in Afghanistan and Pakistan – the only two countries left with naturally occurring poliovirus.

Dr Mahmood is a virologist serving the polio programme of the Regional Reference Polio Laboratory at Pakistan’s National Institutes of Health in Islamabad. Her role involves intricate technical procedures, including molecular diagnostics, and genetic sequencing of the poliovirus genome. This work helps to determine how wild polioviruses are spreading across both endemic countries.

Being part of an emergency programme means that Dr Mahmood and her colleagues need to be available 24 hours a day – a pace that is impossible to maintain without feeling an impact in one’s personal life. She feels that the best way to maintain a work-life balance is for each member of a team to communicate their needs with each other, which further helps the programme’s leaders like her to shape policies and programmes that enable a good work-life balance.

Grateful that she hasn’t had to challenge any stereotypes related to gender dynamics in her role,
Dr Mahmood credits this to directives in her workplace that support gender equality, and to the culture of her individual team. These attributes have blended to create an equitable environment where everyone can use their abilities.

Sharing rare, much-needed skills

Professor Henda Triki ©WHO/Pakistan

Chief of the Laboratory of Clinical Virology in the Pasteur Institute of Tunis, Professor Henda Triki makes a concerted effort to share her knowledge with others. Her altruistic spirit goes beyond her laboratory, especially as her specialty of work is still rare in North Africa: She teaches virology at the Faculty of Medicine of Tunis, and constantly keeps an eye on how best to upgrade her team’s skills and technology at work.

Professor Henda Professor Triki has a collaborative leadership style at work, which results in her sharing her team-building skills with her colleagues – which has helped them address challenges many times before, including during the COVID-19 pandemic. Amidst the chaos and anxiety during the pandemic, Professor Triki and her team had strong moments of solidarity and collaborative work.

Professor Triki wants her fellow female colleagues to be proud of working for the polio eradication programme, as it offers great opportunities. It has allowed women to distinguish themselves from others by acquiring skills that other laboratories do not have. She is pleased to note now that there are many women who are the face of specialized laboratory work in the Eastern Mediterranean Region.

This year, the UN’s theme for International Women’s Day is ‘DigitALL: Innovation and technology for gender equality’.

Originally published here.

©WHO
©WHO

Acknowledging that our common goal is to attain ‘Health for All by All’, which is a call for solidarity and action among all stakeholders;

Noting the progress achieved globally in eradicating wild poliovirus transmission since 1988, with endemic wild poliovirus transmission restricted to just two countries – Afghanistan and Pakistan;

Recalling that 2023 is the target year for interrupting all remaining poliovirus transmission globally, as per the Global Polio Eradication Initiative Strategy 2022–2026: Delivering on a Promise;

Appreciating the recent, intensified efforts made by both Afghanistan and Pakistan, resulting in a unique epidemiological window of opportunity to achieve success in 2023, as characterized by:

the geographic restriction of wild poliovirus transmission in 2022 to eastern Afghanistan and a few districts of north-western Pakistan;

the absence of any wild poliovirus case since September 2022;

the significant decline in genetic biodiversity of wild poliovirus to just a single lineage in each country; and

the successful interruption of circulating vaccine-derived polioviruses;

Emphasizing that the opportunity to interrupt wild poliovirus transmission must be seized now, given the unprecedented epidemiological progress and the inherent risks of delays in stopping polio, which would likely result in resurgence of polio;

Underscoring the ongoing risk of  transmission of wild poliovirus, with detection of wild poliovirus from environmental samples in both countries since January 2023,  confirming cross-border transmission ;

Highlighting that the key to success lies in reaching remaining zero-dose children (children who are un- or under-immunized) with oral polio vaccine in the most consequential geographies,1  operating within a broader humanitarian emergency response, including increasing access to all populations in some areas;

Underscoring the importance and heroic work of health workers at the forefront in insecure settings, especially women, whose support and participation is critical to the eradication effort;

Recognizing the sustained commitment by leaders at all levels, notably by political leaders and law enforcement agencies, community and religious leaders, civil society, Global Polio Eradication Initiative partners, especially Rotary International, parents, caregivers and all health workers;

Recalling that the international spread of poliovirus constitutes a Public Health Emergency of International Concern under the International Health Regulations (2005);

Appreciating the support provided by the GPEI in responding to the devastating floods affecting Pakistan and the tragic earthquake affecting Afghanistan in 2022;

Appreciating the commitment of the United Arab Emirates through the initiative of His Highness Sheikh Mohamed bin Zayed Al Nahyan, President of UAE, to promote and support polio eradication in Pakistan through the UAE Pakistan Assistance Programme;

Recognizing the longstanding support of donors like Rotary International and acknowledging the historical financial support of other Member States to the eradication effort, including the Kingdom of Saudi Arabia, Kuwait, Oman and Qatar;

Appreciating and supporting the decision of the WHO Regional Director for the Eastern Mediterranean to formally grade all polio emergencies and to apply relevant emergency standard operating procedures to WHO operations to address polio emergencies;

We, Member States of the Regional Subcommittee for Polio Eradication and Outbreaks for the Eastern Mediterranean,

DECLARE THAT:

1. We will focus all efforts on reaching remaining missed children with oral polio vaccine, within a broader humanitarian response context in the remaining most consequential geography of eastern Afghanistan and in north-western Pakistan;

COMMIT TO:

2. Mobilizing all necessary engagement and support by all political, community and civil society leaders and sectors across the Region, to fully achieve interruption of wild poliovirus transmission in the Region;

3. Facilitating the necessary support to fully implement all aspects of the Global Polio Eradication Initiative Strategy 2022–2026, including by ensuring rapid detection of and response to any poliovirus from any source, and implementing high-quality outbreak response;

4. Fostering coordination with other public health efforts, to ensure closer integration in particular with routine immunization efforts;

REQUEST THAT:

5. The international development and humanitarian communities and donors strengthen their support for full implementation of the National Emergency Action Plans to Eradicate Polio in Afghanistan and Pakistan; and

6. The Regional Director continue his strong leadership and efforts to achieve a Region free of all polioviruses for good, including by advocating for all necessary financial and technical support, reviewing progress, planning corrective actions as necessary and regularly informing Member States of the aforementioned and of any further action required through the World Health Organization Executive Board, World Health Assembly and Regional Committee for the Eastern Mediterranean.

@WHO

In October 2022, the Technical Advisory Group (TAG) for Afghanistan and Pakistan met in Muscat, Oman, to conduct a thorough review of ongoing polio eradication efforts in the remaining polio endemic countries. During the 6-day meeting they also provided strategic technical guidance on steering efforts towards successful interruption of the poliovirus in both countries in 2023.

Polio programmes make significant progress, despite challenges

The TAG recognized the accomplishments of the polio programmes despite longstanding humanitarian crisis in Afghanistan and unprecedented levels of flooding across Pakistan that affected almost 33 million people. The progress comes due to concerted efforts by all stakeholders across all levels, intense vaccination schedule, timely programmatic pivots to changing epidemiology and the full support of law enforcement and security agencies in implementation of polio vaccination campaigns.

Members noted the high level of sustained political commitment to polio in both countries. In Afghanistan, since the political transition, nationwide campaigns have allowed the polio programme access to almost 10 million children, 3.5 million of whom were previously inaccessible. In Pakistan, intensified vaccination activities and strategic approaches were used to reach missed children.

The TAG also acknowledged the strategic role played by the Emergency Operations Centres (EOCs) in strengthening coordination and providing programmatic oversight at the national and regional levels.

Promising epidemiological trends provide a window of opportunity

Remarkable improvements in epidemiology in Afghanistan and Pakistan provide a window of opportunity for interrupting transmission of wild poliovirus. In Pakistan, the virus is endemic only in the southern districts of Khyber Pakhtunkhwa province, and in Afghanistan both cases have been reported from the eastern region. However, no cross-border transmission was recorded in 2022.

In addition to the limited geographical spread, the biodiversity of the genetic clusters is also at an all-time low: down from 8 in 2020 to 2 in 2022 in Afghanistan and from 11 in 2020 to one in 2022 in Pakistan.

Moreover, there has been no detection of circulating vaccine-derived poliovirus type 2 (cVDPV2) in either country in the last year. The last cVDPV2 case in Afghanistan had onset of paralysis on 9 July 2021, and the last cVDPV2 case in Pakistan had onset of paralysis on 23 April 2021.

Given the promising epidemiological trends seen in 2022, the TAG noted the possibility of full interruption of polioviruses this year. However, for the 2 programmes to succeed, the TAG proposed major strategic shifts in categorization of risks based on the epidemiological trends. The group of experts’ recommendations include context-specific tactics and technical guidance on activities to prioritize until mid-2023, when the TAGs for Afghanistan and Pakistan will meet again.

This new categorization redefines and re-demarcates the endemic zones in Afghanistan and Pakistan from the outbreak districts and the rest of the country where it is important to maintain children’s immunity. Additionally, it identifies highly vulnerable and consequential areas that are an additional risk category for Pakistan, where historically core reservoirs may play a role in establishing circulation in an event of reinfection.

The TAG also endorsed the 2023 polio supplementary immunization activities’ calendars for Afghanistan and Pakistan and emphasized continued cross-border coordination between the 2 countries, particularly in the key corridors. Finally, the TAG encouraged the continued use of strategies to integrate gender and social behavioural change communication into the programme’s activities, to reach every last child.

To read the reports from the Technical Advisory Group meeting on Afghanistan and Pakistan, click here.

“The mother was complaining that her son was weak and that the weakness had happened suddenly, so I examined his leg,” said Spogmai. “I saw that the limb was paralysed and immediately notified the clinic’s AFP focal point.”

AFP stands for Acute Flaccid Paralysis. Surveillance for AFP – keeping an eye out for the signs of paralysis among children – is the cornerstone of polio eradication in one of the last countries where the virus is endemic. To eradicate polio, every last child must be vaccinated and, importantly, every last virus must be traced. A sign that the virus may be circulating in the community, every case of AFP is tested to confirm or rule out presence of poliovirus.

Details of all AFP cases are copiously recorded in Surveillance Registry books. © WHO/AFG

Afghanistan is closer to interrupting polio transmission than ever before. In 2020, 56 children were paralysed by the virus, to date in 2022, the number has been reduced to two. Vigilance is key and highly sensitive surveillance enables the polio programme to quickly detect presence of polio and guide rapid targeted responses.

Like all staff at the clinic – doctors, nurses, cleaners, guards, administrative staff – Spogmai was trained to look out for signs of the virus.

“I had never seen a case of polio before, but I know how to watch out for it because I was trained to detect these things by the clinic’s medical officer. We have refresher training regularly to make sure we know.”

Orientation sessions for AFP surveillance are straightforward: what are the signs of polio, what to look for and what to do next. Participants form part of a vast jigsaw of community-based surveillance across Afghanistan. Beyond the clinic’s doors is a network of more than 46,000 volunteers comprising of religious leaders, hospital staff, private practitioners, physical rehabilitation centres, mid-level health workers, community health workers, community volunteers, traditional healers, pharmacists, drug store staff and others working in health care, all looking out for signs of paralysis in children in their communities.

“Sudden onset paralysis in cases is more compatible with polio,” says WHO’s Dr Khushhal Khan Zaman, Medical Officer, Polio. “We don’t want any case of polio to be missed and spreading the virus. Every case of AFP is notified, investigated, followed up and documented.”

The local Provincial Polio Officer visits Spogmai’s clinic regularly to check on documentation and discuss cases with clinic staff. Details of all AFP cases are copiously recorded. Binders line the shelves of the surgery, holding details of cases going back more than a decade.

The scene in Paghman is repeated across the country in all of Afghanistan’s 34 provinces, all part of the network of surveillance across the country. Spogmai’s clinic is a ‘CHC Plus’ (a comprehensive health centre that provides additional services) and serves a large population in the district. Other health facilities such as Basic Health Centres are smaller but regardless of their size, all staff are trained to look out for AFP cases and to report them to the designated focal point for further investigation.

Afghanistan’s AFP surveillance network was established in 1997 and the system is complemented by an environmental surveillance network consisting of 32 sites across the country. In June, the first review of the polio surveillance system in six years took place with WHO hosting a 16-strong team of national and international experts who visited 76 districts across 25 provinces. The review determined the likelihood of undetected poliovirus transmission in Afghanistan to be low. Recommendations, including upscaling surveillance in the country’s south and southeast, are being implemented.

For Spogmai’s young patient, the next steps involved collecting two stool samples 24 hours apart which were sent to a WHO accredited polio laboratory for testing. The results were negative for polio and the young boy is living a healthy life with his family in the community, that same community that continues to ensure cases of AFP are spotted, recorded and tested.

Examining Terms of Reference for AFP Focal Points. ©WHO
Examining Terms of Reference for AFP Focal Points. ©WHO

Monday 6 June

Arrive Kabul at 9.30am, my first visit in two years and the city has lost none of its bustle.

A review team last visited here in 2016 but access was limited. Much has changed – both within Afghanistan and for polio – since then. The programme now has access across the country and the epidemiological picture has changed dramatically. In 2020, 56 children were paralysed by the virus. So far this year only one child has been paralysed giving Afghanistan its strongest chance yet of interrupting polio transmission.

Surveillance underpins the eradication of any virus. For polio, it consists of monitoring for signs of Acute Flaccid Paralysis or AFP in children under 15 years, and collecting samples of sewage, what we call environmental surveillance, to check for the presence of the virus in the community.

We’re here to apply a magnifying glass to Afghanistan’s surveillance system, to see if there’s anywhere the virus might still be hiding and recommend adjustments to make sure the system is capable of catching it.

If polio surveillance is about gathering data and documenting it meticulously, it’s even more so for a surveillance review. Our job includes checking documents and records, interviewing health workers and families of children with AFP, reviewing guidelines and standard operating procedures – checking and rechecking data.

Wednesday 8 June

Dr Abdinoor reviewing documents at a health facility. All major health facilities in Afghanistan have an AFP focal point who acts as the link between the facility and the broader polio surveillance system. © WHO
Dr Abdinoor reviewing documents at a health facility. All major health facilities in Afghanistan have an AFP focal point who acts as the link between the facility and the broader polio surveillance system. © WHO

After meetings yesterday, including briefing the National Emergency Operation Center (EOC), the operational heart of the polio programme here, I head to Herat in the country’s west where my first stop is the WHO office. I meet the polio team before moving on to the Regional EOC where we discuss the objectives of my mission. I review records before checking the cold room where vaccines are kept. There’s a corner for stool specimens that come in from the western region. Part of the process of checking children with signs of AFP is collecting stool samples that are then sent to the regional laboratory in Pakistan for testing. Reviewing the collection, storage and shipping of these samples is part of my remit as a reviewer.

Thursday 9 June

At a hospital in Herat city, I meet with the AFP focal point – a pediatrician. All major health facilities have an AFP focal point who acts as the link between the facility and the broader surveillance system. I ask him about his background, the facility’s stool handling, preparation and shipment, and the work of the hospital.

In the afternoon, I examine two children affected by AFP earlier in the year. I talk to their parents and ask them the same questions they were asked by the initial investigating surveillance officer. I do this to check the accuracy of the information collected during the original case investigation and to see if there are any discrepancies.

Friday 10 June

Friday – the only holiday of the week. I spend it at the WHO office going through documents including AFP case files and data. It’s also a good opportunity to enter all the information I collected over the previous two days into the online tool developed specifically for this review.

Saturday 11 June

We set out early to a district near the border with Iran, two hours’ drive away. First stop is a very busy Comprehensive Health Center (CHC). It’s reported six out of the eight AFP cases from this district this year. I meet with the director, doctors, nurses, and other staff. Beneath their facemasks, their smiles are beaming. They speak with pride of their clinic and, like all the health facilities I visit, it’s spotlessly clean.

In the afternoon, I meet with the community health supervisor who oversees 16 community health workers (CHWs) working in village health posts nearby. Village health posts play an important role in community-based polio surveillance.  I review the curriculum and training agenda to check what information is captured.

Sunday 12 June

I spend the day in the districts surrounding Herat city. My meetings include a visit to a traditional healer who fixes broken bones among other ailments, and a CHW who is an imam at a local mosque. Both are reporting volunteers in the 46,000-strong community-based surveillance network that keeps an eye out for polio among their communities.

Going through referral notes. The 16-strong review team visited 67 districts in 25 of Afghanistan’s 34 provinces, checking documents and records, interviewing health workers and families of children with AFP, and reviewing guidelines and standard operating procedures. © WHO
Going through referral notes. The 16-strong review team visited 67 districts in 25 of Afghanistan’s 34 provinces, checking documents and records, interviewing health workers and families of children with AFP, and reviewing guidelines and standard operating procedures. © WHO

Monday 13 June

I visit an environmental surveillance site in Herat city. Samples are taken from sewage on a regular basis and shipped to the lab in Pakistan to determine the presence of poliovirus.  I assess the site to see if it meets quality standards, check its location to make sure it’s in the right place to catch a good enough sample, the flow of the water and its appearance. I watch as trained staff from the local municipality collect a sample to determine whether the SOPs are adhered to.

Tuesday 14 June

To neighbouring Farah province, a round trip of about eight hours. At a CHC, a boy is brought in who was referred by a local faith healer. I observe the staff examine the child, and then visit the faith healer who tells me he inherited the knowledge of healing from his father and has been doing it now for over 20 years. It was heartening to hear him talk of his collaboration with the polio team for both AFP surveillance and immunization campaigns.

Wednesday 15 June

Last day in Herat city and I debrief the team in the REOC. Our flight back to Kabul departs late and we stop in Bamyan in the central highlands to collect two other passengers, including my fellow reviewer assigned to the Central Region.

The rest of the review team makes its way back to Kabul in the remaining days. We’ve all been doing the same thing – verifying, checking, interviewing, collating data. Our next task is to compile our report and provide any recommendations to the programme to make sure Afghanistan’s polio surveillance system catches every last virus, no matter where it may be hiding.

 

A child is vaccinated during a nationwide vaccination campaign in Jabuary 2022. Seven national and one sub national campaigns have taken place since 15 August last year. © WHO/Afghanistan
A child is vaccinated during a nationwide vaccination campaign in Jabuary 2022. Seven national and one sub national campaigns have taken place since 15 August last year. © WHO/Afghanistan

Wild poliovirus transmission in Afghanistan is currently at its lowest level in history. Fifty six children were paralysed by wild polio in 2020. In 2021, the number fell to four. This year to date, only one child has been paralysed, giving the country an extraordinary opportunity to end polio.

The resumption of nationwide polio vaccination campaigns targeting 9.9 million children has been a critical step. Since 2018, local-level bans on polio vaccination activities in some districts controlled by the Taliban had significantly reduced the programme’s ability to vaccinate every child across the country. With access to the entire country following the August transition, seven nationwide vaccination campaigns took place between November 2021 and June 2022, and a sub national campaign targeting 6.7 million children in 28 provinces took place in July. Of the 3.6 million children who had been inaccessible to the programme, 2.6 million were reached during the November, December and January campaigns. With improved reach to previously inaccessible children throughout the February to July campaigns, the number children has been reduced to 0.7 million. Further campaigns are planned for the remainder of the year.

With Afghanistan and Pakistan sharing one epidemiological block, the two countries continue to coordinate cross border activities. December and May’s campaigns were synchronized with Pakistan’s national campaigns, focusing on high risk populations including nomadic groups, seasonal workers and communities straddling both borders.

Improved access also had a significant impact on polio surveillance activities. Afghanistan’s surveillance indicators remained above global standards throughout the transition. With access to all districts since August, the quality of activities has improved significantly including early case detection and reporting.

In June, the first review of the polio surveillance system in six years took place with WHO hosting a team of technical experts including epidemiologists and virologists. A small team visited in 2016 but insecurity and lack of access to much of the country limited the visitors’ movements to Kabul, Herat, Kandahar, Jalalabad, Mazar-e-sharif and Kunduz. This year, the 16-strong team visited 76 districts across 25 of the country’s 34 provinces. The review determined the likelihood of undetected poliovirus transmission in Afghanistan to be low. Recommendations, including upscaling surveillance in the country’s south and south east, are being implemented.

With more than twenty years on the ground in Afghanistan, the polio programme continues to leverage its extensive operational capacity to deliver better health outcomes for all Afghans. In the face of an unprecedented humanitarian crisis, in addition to day-to-day polio activities, polio staff continue to regularly monitor the functionality of health facilities across the country as well as support ongoing vaccination campaigns including measles and COVID 19. WHO’s polio team in the southeast were among the first responders following the devastating earthquake in Paktika and Khost provinces in June. In addition to providing critical health care, the team’s experience working among local communities provided the foundations of an assessment tool that mapped affected communities and ensured accurate data guided a focused response in the immediate aftermath.

Although the number of children paralysed by polio has reduced significantly in Afghanistan, the threat is far from gone and the programme faces significant challenges. While access has improved across the country, accessing every child though house to house vaccination remains a challenge in some areas leaving immunity gaps and, with them, children at risk.

On 24 February, eight polio workers were killed in targeted attacks in the country’s north, not the first time polio workers had come under attack in the course of their life saving work. Four of those killed were women. Female polio workers play a critical role in the programme, building community trust and reaching all children.

The sharp rise in the number of wild polio cases in Pakistan is a cause for concern, and the detection of one case each in Malawi and Mozambique is a reminder of the continued risks of poliovirus and the urgencyrequired to permanently interrupt transmission in both Afghanistan and Pakistan.

While the polio programme has made important progress in the last 12 months, sustaining those gains with high quality campaigns that vaccinate all children and build enough immunity to end circulation of the virus for good is critical. A polio free Afghanistan is within reach – but there is still a long way to go.

Development and Health Ministers of the G7 countries met in Berlin, Germany, last week to hold urgent joint consultations on “supporting vaccine equity and pandemic preparedness in developing countries”.  The joint group highlighted the need to accelerate equitable and sustainable access to vaccines everywhere, and to strengthen pandemic preparedness and response in low- and middle-income countries.  At the same time, however, the meeting cautioned against letting global crises interfere with other development and public health priorities and urged continued support for existing efforts, including global polio eradication.

The global effort to eradicate polio is a clear and concrete example of the value of working in close integration with other development and public health efforts, and contribute to global pandemic preparedness and response.  Polio staff continue to contribute to the COVID-19 pandemic response and immunization recovery efforts, together with the introduction and roll-out of COVID-19 vaccines. 

In April 2022, GPEI partners, led by WHO Director-General, launched the ‘Investment Case for Polio Eradication’, the sister document to the Polio Eradication Strategy 2022-2026, which lays out the economic and humanitarian rationale for investing in a polio-free world, as well as the broader benefits of polio eradication.

In October 2022, Germany will generously co-host a global pledging moment, giving the international development community the opportunity to publicly re-commit to this effort, including to support a stronger and sustainably-funded WHO, so that the organization can maintain its capacity to support countries in achieving and sustaining polio eradication, and continue to benefit broader public health efforts, including support for pandemic preparedness and response.

In this two-part video series, we chat with Dr Ananda Bandyopadhyay, Deputy Director of Polio Technology, Research & Analytics, BMGF, about the new tool in GPEI’s kit to combat cVDPV2: novel oral polio vaccine type 2 (nOPV2).

 

GENEVA, 26 April 2022

Today, the Global Polio Eradication Initiative (GPEI) announced that it is seeking new commitments to fund its 2022-2026 Strategy at a virtual event to launch its investment case. The strategy, if fully funded, will see the vaccination of 370 million children annually for the next five years and the continuation of global surveillance activities for polio and other diseases in 50 countries.

During the virtual launch, the Government of Germany, which holds the G7 presidency in 2022, announced that the country will co-host the pledging moment for the GPEI Strategy during the 2022 World Health Summit in October.

“A strong and fully funded polio programme will benefit health systems around the world. That is why it is so crucial that all stakeholders now commit to ensuring that the new eradication strategy can be implemented in full,” said Niels Annen, Parliamentary State Secretary to the Federal Minister for Economic Cooperation and Development, Germany. “The polio pledging moment at the World Health Summit this October is a critical opportunity for donors and partners to reiterate their support for a polio-free world. We can only succeed if we make polio eradication our shared priority.”

Wild poliovirus cases are at a historic low and the disease is endemic in just Pakistan and Afghanistan, presenting a unique opportunity to interrupt transmission. However, recent developments, due in part to impacts of the COVID-19 pandemic, underscore the fragility of this progress. In February 2022, Malawi confirmed its first case of wild polio in three decades and the first on the African continent since 2016, linked to virus originating in Pakistan, and in April 2022 Pakistan recorded its first wild polio case since January 2021. Meanwhile, outbreaks of cVDPV, variants of the poliovirus that can emerge in under-immunized communities, were recently detected in Israel and Ukraine and circulate in several countries in Africa and Asia.

The investment case outlines new modelling that shows achieving eradication could save an estimated US $33.1 billion this century, compared to the price of controlling polio outbreaks. At the launch event, GPEI leaders and polio-affected countries urged renewed political and financial support to end polio and protect children and future generations from the paralysis it causes.

“Despite enormous progress, polio still paralyses far too many children around the world – and even one child is too many,” said UNICEF Executive Director Catherine Russell.  “We simply cannot allow another child to suffer from this devastating disease – not when we know how to prevent it. Not when we are so close. We must do whatever it takes to finish the fight – and achieve a polio-free world for every child.”

“The re-emergence of polio in Malawi after three decades was a tragic reminder that until polio is wiped off the face of the earth, it can spread globally and harm children anywhere. I urge all countries to unite behind the Global Polio Eradication Initiative and ensure it has the support and resources it needs to end polio for everyone everywhere,” said Hon. Khumbize Kandodo Chiponda MP, Minister of Health, Malawi.

The new eradication strategy centres on integrating polio activities with other essential health programs in affected countries, better reaching children in the highest risk communities who have never been vaccinated, andstrengthening engagement with local leaders and influencers to build trust and vaccine acceptance.

“The children of Pakistan and Afghanistan deserve to live a life free of an incurable, paralyzing disease. With continued global support, we can make polio a disease of the past,” said Dr Shahzad Baig, National Coordinator, Pakistan Polio Eradication Programme. “The polio programme is also working to increase overall health equity in the highest-risk communities by addressing area needs holistically, including by strengthening routine immunization, improving health facilities, and organizing health camps.”

The investment case outlines how support for eradication efforts will enable essential health services in under-served communities and strengthen the world’s defences against future health threats.

Since 2020, GPEI infrastructure and staff have provided critical support to governments as they respond to the COVID-19 pandemic, including by promoting COVID-safe practices, leveraging polio surveillance and lab networks to detect the virus, and assisting COVID-19 vaccination efforts through health worker trainings, community mobilization, data management and other activities.

“The global effort to consign polio to the history books will not only help to spare future generations from this devastating disease, but serve to strengthen health systems and health security,” said Dr. Tedros Adhanom Ghebreyesus, WHO Director-General.

Additional quotes from the GPEI Investment Case:

“We have the knowledge and tools to wipe polio off the face of the earth. GPEI needs the resources to take us the last mile to eradicating this awful disease. Investing in GPEI will also help us detect and respond to other health emergencies. We can’t waver now. Let’s all take this opportunity to fully support GPEI, and create a world in which no child is paralyzed by polio ever again,” said Bill Gates, Co-chair, Bill & Melinda Gates Foundation.

“An investment in polio eradication goes further than fighting one disease. It is the ultimate investment in both equity and sustainability – it is for everyone and forever. An important component of GPEI’s Strategy focuses on integrating the planning and coordination of polio activities and essential health services to reach zero-dose children who have never been immunized with routine vaccines, therefore contributing to the goals of the Immunization Agenda 2030.” said Seth Berkley, Chief Executive Officer, Gavi, the Vaccine Alliance.

“Twenty million people are walking today because of polio vaccination, and we have learned, improved and innovated along the way. We are stronger and more resilient as we enter the last lap of this marathon to protect all future generations of the world’s children from polio. Please join us; with our will and our collective resources, we can seize the unprecedented opportunity to cross the finish line that lies before us,” said Mike McGovern, Chair, International PolioPlus Committee, Rotary International.

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Media contacts:

Oliver Rosenbauer
Communications Officer, World Health Organization
Email: rosenbauero@who.int
Tel: +41 79 500 6536

Ben Winkel
Communications Director, Global Health Strategies
Email: bwinkel@globalhealthstrategies.com
Tel: +1 323 382 2290

Sabrina Sidhu
UNICEF New York
Email: ssidhu@unicef.org
Tel: +19174761537

April 2022 – Convening this month in Geneva, Switzerland, the Strategic Advisory Group of Experts on immunization (SAGE), the global advisory body to the World Health Organization (WHO) on all things immunization, urged concerted action to finish wild polioviruses once and for all.

The group, reviewing the global wild poliovirus epidemiology, highlighted the unique opportunity, given current record low levels of this strain. At the same time, it noted the continuing risks, highlighted in particular by detection of wild poliovirus in Malawi in February, linked to wild poliovirus originating in Pakistan.

On circulating vaccine-derived poliovirus (cVDPV) outbreaks, SAGE expressed concern at continuing transmission, in particular in Nigeria which now accounts for close to 90% of all global cVDPV type 2 cases, as well as the situation in Ukraine, and its disruption to health services, urging for strengthening of immunization and surveillance across Europe.  It also noted the recent detection of cVDPV type 3 in Israel in children, and in environmental samples in occupied Palestinian territories, and urged high-quality vaccination activities and strengthened surveillance.

Preparing for the post-certification era, the group underscored the importance of global cessation of all live, attenuated oral polio vaccine (OPV) use from routine immunization, planned one year after global certification of wild poliovirus eradication.  To ensure appropriate planning, coordination and implementation, the group endorsed the establishment of an ‘OPV Cessation Team’, to consist of wider-than-GPEI stakeholder participation and ensure leadership on all aspects of OPV cessation.

SAGE will continue to review available evidence and best practices on a broad range of GPEI-related programmatic interventions, including as relevant the increasing role of inactivated polio vaccine (IPV), including in outbreak response and effects of novel oral polio vaccine type 2 (nOPV2), as part of global efforts to secure a lasting world free of all forms of poliovirus.

After the safe and successful rollout of nationwide polio campaigns since November 2021, we have received tragic news that 8 health workers at the forefront have been killed this morning in a series of shootings in Takhar and Kunduz in northeast Afghanistan.  The vaccination campaign has been suspended in both provinces.

A statement has been issued by the Regional Director of WHO’s Eastern Mediterranean Region, Dr Ahmed Al-Mandhari, as well as by the United Nations in the country, condemning these attacks, expressing condolences to the families and underscoring that the provision of health and the safety of healthworkers at the forefront are paramount, and must be kept neutral to any geo-political situation anywhere.

Our thoughts and prayers are both with the families and our teams on the ground at this time.

Cairo, 10 February 2022 – The fourth meeting of the Regional Subcommittee on Polio Eradication and Outbreaks was convened on Wednesday 9 February, by WHO’s Regional Director for the Eastern Mediterranean Dr Ahmed Al-Mandhari. The meeting was attended by health ministers or their representatives from Djibouti, Egypt, the Islamic Republic of Iran, Pakistan, Qatar, Saudi Arabia, Sudan, United Arab Emirates and Yemen.

The Subcommittee declared the ongoing circulation of any strain of poliovirus in the Region to be a regional public health emergency and called on all authorities to enable uninterrupted access to the youngest and most vulnerable children through the resumption of house-to-house vaccination campaigns. It issued statements on wild poliovirus circulation in Afghanistan and Pakistan and on the circulation of vaccine-derived poliovirus strains in Yemen, where limits on house-to-house vaccination are preventing access to the most vulnerable children.

The spread of polio in the Eastern Mediterranean Region is a pressing emergency and it remains a Public Health Emergency of International Concern (PHEIC) under the International Health Regulations (IHR 2005).

Members noted a sharp decrease in cases of wild poliovirus in Afghanistan and Pakistan in 2021 but warned against complacency.

“Wild poliovirus transmission is at a historic low in the endemic countries of Afghanistan and Pakistan. The progress is remarkable, but it is fragile. The opportunity to end polio is knocking at our door, and we must seize it,” said Dr Al-Mandhari.

Speaking to the progress made in the last year, the Special Assistant to the Prime Minister on Health, Dr Faisal Sultan, assured members that the programme in Pakistan was leaving no stone unturned in the pursuit of zero polio transmission.

“We have intensified efforts in the hardest districts and core reservoirs and we are closely monitoring transmission across the border in coordination with Afghanistan, taking measures to respond to outbreaks if they occur and making every effort to ensure that the virus doesn’t spill over in either direction. To boost the confidence of marginalized communities, we are also providing essential services and vaccination of other antigens and diseases,” he said.

Outbreaks of circulating vaccine-derived polioviruses type 1 (cVDPV1) and type 2 (cVDPV2) continued to emerge and spread in the Region in 2021. As of February 2022, Afghanistan, Djibouti, Egypt, Pakistan, Somalia, Sudan and Yemen are responding to transmission of vaccine-derived polioviruses.

“The increasing outbreaks of circulating vaccine-derived poliovirus type 2 in the Eastern Mediterranean Region and neighbouring countries of Africa are deeply concerning and must be stopped rapidly. To do so, we need to ensure that we are creating an enabling environment for health workers to reach children with those two drops of polio vaccine,” said newly nominated co-chair H.E. Dr Hanan Mohamed Al Kuwari, Minister of Public Health of Qatar.

During the meeting, Djibouti’s Public Health Minister, Dr Ahmed Robleh Abdilleh, shared plans for vaccination campaigns and increased surveillance in response to the transmission of cVDPV2, recently detected through the newly launched environmental sampling programme.

Reflecting on the work of the Subcommittee, co-chair and Minister of Health and Prevention of the United Arab Emirates H.E. Abdul Rahman Mohammed Al Owais urged members to sustain the commitment seen in in 2021.

“We have together advocated for an increase in domestic funds, we have driven collaborative public health action in our own countries, and collectively pushed for a regional response to address the regional public health emergency of the poliovirus. But these things alone will not end transmission,” he said.

Dr Al-Mandhari expressed appreciation for Egypt’s role as the first country in the Region to roll out a nationwide vaccination campaign using the novel poliovirus vaccine, and Chris Elias, Chair of the Polio Oversight Board, praised the remarkable progress made in polio eradication in Pakistan with support of the United Arab Emirate’s Pakistan Assistance Programme.

“This regional solidarity and commitment we have seen, through this Subcommittee, is something I am proud of. It is this commitment to the end goal that will help push us over the last mile,” said Dr Hamid Jafari, director of the regional polio programme and co-facilitator of the Regional Subcommittee.

Vaccination team crossing river in West Garo Hills of Meghalaya. ©WHO

With the ongoing COVID-19 pandemic, continued wild polio transmission in the remaining endemic countries and spreading outbreaks of circulating vaccine-derived polioviruses type 2 (cVDPV2), this year began with many challenges facing polio eradication efforts. But amid this new reality, countries and partners of the Global Polio Eradication Initiative (GPEI) intensified their efforts to protect children from lifelong paralysis.

In June, the GPEI launched the new GPEI Strategy 2022-2026, which lays out the roadmap to achieving a lasting world free of all forms of polioviruses through stronger community engagement, a renewed focus on gender equity and the rollout of new tools and technologies. These new tools include the novel oral polio vaccine type 2 (nOPV2), which began deployment under Emergency Use Listing (EUL) as part of the GPEI’s broader polio vaccine repository to curb cVDPV2 transmission. In August, the WHO African Region celebrated one year since it was certified wild polio-free, and countries recommitted to strong cVDPV2 outbreak response across the continent with the support of the GPEI.

Further critical progress took place in Afghanistan – one of two final countries endemic for wild poliovirus, along with Pakistan. For the first time in more than three years, nationwide polio immunization campaigns resumed across Afghanistan reaching 8.5 million children, including 2.4 million children who were previously inaccessible.

At the same time, polio programme health workers at the forefront continued to support global COVID-19 response efforts by delivering vaccines, mobilizing communities, and countering misinformation among other activities. The use of GPEI infrastructure for health emergency response has provided critical lessons for integrating polio resources into broader health systems as more countries work towards transition and the post-certification period.

Containment area monitoring in India. ©WHO

Following dire predictions issued at the end of 2020, the polio programme once again proved its ability to adapt to programmatic, epidemiological and political developments. Entering 2022, there is much cause for cautious optimism – wild poliovirus transmission has slowed drastically, and cases of cVDPV2 have also declined compared to last year.

Importantly, commitment to achieving a lasting polio-free world is evident at all levels: by core GPEI partners, including among the Polio Oversight Board, which travelled to Pakistan twice in 2021; by health workers, communities and parents; and by country leaders worldwide who helped champion this year’s milestones. With the new strategy, new tools and adapted approaches, the stage is set to achieve lasting success.

To stop all forms of polio for good, the GPEI aims to capitalize on the positive epidemiological situation leading into 2022. A key opportunity to kick-start the year will be the WHO Executive Board meeting in January, where Member States plan to discuss building on the successes of this past year by fully implementing and financing the programme’s new strategy. Rotary and other key global GPEI partners are planning a renewed and intensified outreach across the broader international development community to secure the necessary financial resources to achieve success. Polio immunization campaigns will also continue in full force in both endemic and outbreak countries.

Twelve months ago, the programme was in a much different place, as WHO and UNICEF launched an Emergency Call to Action to draw attention to the need for renewed commitment. A year later, thanks to a strengthened and unified response, the GPEI is meeting the moment and is more committed than ever to end all forms of poliovirus, once and for all.

©WHO Afghanistan/RaMin Afshar

25 August 2021 – “Poliovirus circulation does not stop during conflicts, it does not stop during emergencies. If anything, it makes children and families even more vulnerable by adding a layer of risk”, says a Polio Provincial Officer from Balkh province.

Despite risks and challenges due to the recent insecurity, the polio programme is staying and delivering for the children of Afghanistan. Our 315 staff and more than 70,000 polio health workers across the country remain firm in their resolve to eradicate polio. Their work ensures that critical polio activities continue while adapting to the rapidly changing situation and carry on even when hostility levels are high.

In 2021, one wild poliovirus type 1 (WPV1) and 43 circulating vaccine-derived poliovirus type 2 (cVDPV2) cases have been confirmed in Afghanistan. All cases have been reported in areas of the country that have for years been inaccessible for door-to-door vaccination campaigns, which left at least 3 million children repeatedly deprived of polio vaccination. Population displacement brought about by the current situation could further impact the programme’s access to children and increase immunity gaps against polio, triggering a rise in transmission. It is also feared that the mixing and movement of unvaccinated populations due to the upheaval faced by thousands of Afghans may spur polio transmission.

“We are working with all actors, to ensure there are no delays or disruptions to polio vaccination campaigns and overall routine immunization. Gains of the past twenty years cannot be lost. Children need immunization now, they must not bear the brunt of conflict and instability. We are calling for unimpeded access to all children,” says Dr. Dapeng Luo, WHO Representative in Afghanistan.

Pre-planning and resilience measures

While the current situation is a challenge, it is by no means the first the polio programme has faced. Using its wealth of knowledge from many years of operating in complex environments, the programme has invested in robust, pre-emptive contingency planning to be able to adapt and continue delivering. Regular monitoring of the security situation has allowed for nimble decision making.

The programme has moved swiftly to ensure safety and security of its staff. Its international staff footprint has been significantly reduced and vulnerable national staff and their dependants have been temporarily relocated to Kabul. Flexible working arrangements and salary advances have been provided to cover urgent needs of staff and polio health workers, who are the backbone of polio operations.

Around eighty percent of polio staff remain at their field locations and working to maintain essential polio services, supported remotely by colleagues who have needed to relocate.

“I am filled with pride for my team and their strong resolve, courage and passion. They are the heroes children of Afghanistan need right now. Thanks to their efforts, Acute Flaccid Paralysis (AFP) and environmental surveillance never stopped.  Except for a few locations that experienced temporary disruptions last week, stool sample collection, visits to active health facilities, case investigation, the shipment of samples to Pakistan for laboratory testing, and the collection and transport of sewage samples for polio environmental surveillance remain unaffected. COVID-19 surveillance, which the polio programme has been supporting since last year, has also continued,” says Irfan Elahi Akbar, Polio Team Leader, WHO Afghanistan.

©WHO EMRO

Vaccination continues

Polio vaccinations are continuing through permanent transit teams in most regions and at cross-border sites, including Friendship Gate (between Afghanistan and Pakistan).

After a brief pause, the National Emergency Operation Center is back up-and-running and undertaking planning needed to implement future campaigns. Discussions are ongoing with local authorities to safeguard the resumption of critical immunization activities across the country. The programme remains optimistic that polio vaccination campaigns planned for later this year can go ahead, however, is maintaining a flexible approach.

“The safety and security of staff and polio health workers is our top priority. Their commitment to ending polio is nothing short of inspirational. I stand ready to support their critical work in any way I can. I say this with absolute conviction: We will achieve a polio-free world,” said Dr. Hamid Jafari, Director of Polio Eradication, WHO Eastern Mediterranean Region.

See link to story on WHO EMRO’s website.

The Global Polio Eradication Initiative (GPEI) is closely monitoring developments in Afghanistan. GPEI partners and staff are currently assessing immediate disruptions to polio eradication efforts and the delivery of other essential health services, to ensure continuity of surveillance and immunization activities while prioritizing the safety and security of staff and frontline health workers in the country.

The polio programme in Afghanistan has operated for many years amid insecurity and conflict, and will continue working with all actors, agencies and organizations who enable delivery of immunization as well as deliver humanitarian assistance to populations in need across the country. The GPEI remains steadfastly committed to protecting all children from polio and supporting the provision of other essential immunizations and health services.

We strongly believe that the delivery of health care – including polio vaccination – is essential to prevent diseases and safeguard communities. Together with our partners, the people of Afghanistan, national and provincial authorities, we will do everything in our power to continue this critical work.