GPEI-Serosurveys map child immunity in Afghanistan

Shokria, aged 4, displays her ink-stained finger to show that she has been vaccinated against polio. ©WHOEMRO 2016

In Afghanistan this year, staff from the non-governmental organization Care of Afghan Families collected 420 blood samples from children under 4 at the Mirwais Regional Hospital in Kandahar province. The aim? To find out whether polio vaccination campaigns have been reaching enough children, and whether the vaccines have been generating full protection against this paralysing disease. These ‘serosurveys’ showed that immunity in Afghanistan is high – and also identified where vaccination campaigns need to reach out further.

Whenever a polio vaccination campaign takes place, a purple dot of ink is painted onto the little finger nail of every immunised child to show that they have received the lifesaving vaccine. This data is collected and allows people to monitor the campaign and know exactly where children have been reached.

Now, with more children being vaccinated than ever before, the polio eradication programme needs to know more than how many children are being reached: we need specific data on where children are being missed.

Serosurveys testing for immunity

Serosurveys are simple tests of the serum in a child’s blood, which measures their immunity (or seroprevalence) to different diseases. The polio eradication programme uses this test to see what level of protection a child has against wild poliovirus types 1, 2 and 3, allowing them to assess whether the vaccination campaigns are reaching enough children, enough times, to give them immunity.

At the Mirwais Regional Hospital, the children tested were from a diverse range of provinces. Their results were sent to Aga Khan University for initial testing, and then sent for further analysis to one of the Global Polio Eradication Initiative partners, the US Centers for Disease Control and Prevention in Atlanta. Through mapping both where they live and their immunity results, scientists at both institutions helped polio eradicators to discover the areas where a child is at most risk of being missed by vaccination campaigns.

Serosurvey results can be crucial for planning campaign strategies – making sure that every last child is reached, no matter where they live.

Serosurveys help to map where at-risk children are living. ©WHOEMRO 2016

For Ondrej Mach, team lead for clinical trials and research in the WHO’s Polio Eradication Department, serosurveys “… are increasingly important for eradication efforts, allowing us to form an accurate picture of our progress so far, and the locations where we are being most effective.”

High immunity in Afghanistan

The Mirwais serosurvey proved that Afghanistan is closer than ever to eradicating polio, with more than 95% of children surveyed immune to wild poliovirus type 1, the virus type still circulating in some areas of Afghanistan, Pakistan and Nigeria, and more than 90% immune to type 3, which hasn’t been found anywhere in the world since November 2012. The tests also pointed to where gaps in immunity are, so that missed children can be found and protected.

These results are a strong reflection of the devoted work of polio vaccinators and community workers throughout the country, using their expertise to reach into every family, and spread awareness of the importance of polio vaccination.

Volunteer vaccinator Haji Mohammad inspects children from all over Kandahar, ensuring that no child is missed. ©WHOEMRO 2016

Using serosurveys in at-risk countries

As in Afghanistan, serosurveys are increasingly used in other countries where polio remains or poses a threat, to help identify the last remaining pockets of under-immunized children in high risk areas. This is especially important because with polio in fewer places than ever before, it is these unreached children that will take us over the finishing line.

By getting an increasingly accurate picture of where vaccination campaigns are operating successfully, as well as where the programme needs to renew efforts, we can move further towards the goal of reaching every child.

This helps us reach our ultimate goal – ensuring that every last child, everywhere, can be polio free.

© WHO Afghanistan/S. Ramo — © WHO Afghanistan/S.Ramo

Italy has provided €4.5 million to support efforts to reach and vaccinate all children under five years of age in Pakistan and Afghanistan – the only two countries worldwide that have reported polio cases this year.

In Afghanistan, the contribution will be used to support and train vaccinators and social mobilizers in generating demand for vaccination, the delivery of vaccines and monitoring whether vaccination activities are well-implemented. In Pakistan, the contribution will support vaccination campaigns in the most challenging areas of the country, as well as the immunization of communities that are at particularly high risk due to their mobility, through tactics such as giving vaccine established transit points.

The Bill & Melinda Gates Foundation have matched Italy’s contribution, doubling its impact to €9 million.

Polio is a highly infectious but entirely preventable disease which remains endemic in only three countries – Afghanistan, Pakistan and Nigeria. When the polio eradication effort was launched in 1988, there were 350,000 cases of polio every year across 125 polio-endemic countries. In 2017, there are 13 cases to date globally – 8 cases in Afghanistan and 5 in Pakistan, with Nigeria not recording any cases for more than 12 months.

This remarkable progress is thanks to the tireless work of committed front line health workers, governments and the five partners of the Global Polio Eradication Initiative: UNICEF, WHO, Rotary International, the US Centers for Disease Control and Prevention, and the Bill & Melinda Gates Foundation.

“The Italian Minister of Foreign Affairs, Angelino Alfano, underlined Italy’s commitment to a polio-free world for all future generations. “Italy is proud to support this immunization initiative which will not only rid the world of this devastating disease but improve children’s health and bring health returns and productivity gains for communities and countries’ economies,” Minister Alfano said.

UNICEF Director of Polio Eradication Akhil Iyer said that the funding would support efforts to generate community demand for vaccination and deliver vaccines in high-risk polio-endemic areas. “Italy’s contribution is critical in helping us to reach every last child in some of the world’s most challenging contexts, and to help us prove that we can live in a world where no child need be left behind,” Mr Iyer said.

WHO’s Director of Polio Eradication, Michel Zaffran, said new funding such as Italy’s was essential to ensure all children were covered during immunization campaigns. “As we reach the endgame of the polio eradication effort, the vaccination of what we call mobile populations – communities which are migrant or on the move – is essential to ensure all children are protected and the virus cannot spread from one area to another. This funding will directly help us reach and protect those most vulnerable populations,” Mr Zaffran said.

Abdullah Khalid marks a child’s finger with indelible ink at the Torkham border between Afghanistan and Pakistan in September 2017. © WHO/S.Ramo

Malik is one of the hardworking vaccinators making sure that even children on the move are protected against polio.

The poliovirus knows no borders, making children on both sides of the border between Afghanistan and Pakistan vulnerable to contracting the debilitating disease. This is why, placed strategically along the border, 19 WHO-supported vaccination posts reach children on the move as they cross between countries, ensuring that all children under the age of 10 receive two drops of the oral polio vaccine to protect them from polio.

One of these teams is led by Malik, who has worked for the polio eradication programme for 14 years.

“I wanted to join the eradication programme when I heard that polio is a contagious disease that affects children. I wanted to serve children and our community. I learned about polio on the TV and radio and the health workers who came to our home to share information about the virus.”

Protecting children on the move

Malik started working as a vaccinator and has now worked as a team supervisor for the past 10 years.

“I am proud when we can reach every child and when I see my team vaccinating children, making sure that no child is missed. This makes me very happy,” he says.

Cross-border vaccination teams are crucial in the fight against polio. The Torkham border between Afghanistan and Pakistan, in eastern Nangarhar province, is one of the busiest border crossings in Afghanistan. Currently 38 WHO-supported vaccinators work in three shifts, operating 24 hours a day, 7 days a week.

“Today I started my work at 5.30 am. When we arrive at work in the morning, I gather the team together and we go through any issues that arose in the previous shift. We revise the schedule of the day and I assign teams to their specific locations. We have three locations at this border where we vaccinate all children coming to Afghanistan and those who are leaving.”

Abdullah Khalid and his team approach a truck at the Torkham border vaccinate all children arriving to Afghanistan. © WHO/S.Ramo

Checking for signs of polio

Since January 2017, WHO and partners have vaccinated over 44 000 Afghan children under the age of 10 crossing the border to Afghanistan from Iran and Pakistan. Over 25 000 of these have been vaccinated at the Torkham border’s so called “zero point” – the first point where Afghan refugees and returnees returning from Pakistan arrive.

“We focus a lot of finding cases of acute flaccid paralysis, sudden onset of floppiness in the limbs that is a sign of polio. We check children in all the vehicles that arrive at the border and work hard not to miss any potential polio cases,” Malik says. “When the trucks park here, we talk to the parents and ask about any possible cases of paralysis in the family. We also educate them about the importance of vaccines and tell them about the routine immunization services that are available free-of-charge in Afghanistan’s health facilities.”

Building trust

Most caregivers crossing the border to Afghanistan accept the polio vaccine but challenges remain.

“Sometimes we see parents who refuse to vaccinate children. We try our best to convince them to vaccinate by telling them more about the benefits of the polio vaccine and how polio cannot be cured. Those who refuse to vaccinate their children often don’t understand what the vaccine is or how it is essential for protecting their children,” Malik says.

Despite difficulties and his demanding work in a challenging environment where the security situation can shift quickly, Malik and his team are determined to continue the fight against polio.

“Afghanistan is still polio-endemic and the virus is deadly,” he says as he leads his team to approach another truck that crossed the border into Afghanistan. “I want to deliver these crucial services, serve my community and protect vulnerable children.

Some of these girls have been practising for six years to master the skills they have. Being part of the circus enables them to also attend school. Children in the audience take great please watching other children perform with amazing skill. © UNICEF Afghanistan/Ashley Graham

“I am the king of this village! Every child belongs to me and I will spread my poison to a new person every day,” screams the snake, bursting onto the stage.

In the audience, children gasp and jump backwards, their eyes wide.

Hamid, clutching his precious box of vaccines, attacks the snake, managing to defeat him. The crowd cheers.

“Vaccinating your children will destroy this disease!” cries Hamid. “Make sure your whole village takes these droplets and you will see how strong you and your children can be.”

Clutching the precious box of vaccinations, the vaccinator (played by Hamid himself) finally manages to defeat the deadly polio threat. The crowd watches intently, you can see in their face that they are listening to the story about the danger of polio. © UNICEF Afghanistan/Ashley Graham

This poisonous snake – mor zaharia as it’s called in Dari – represents the dangerous threat of polio, a disease that Afghanistan is fighting hard to eradicate.

Hamid leads a touring youth circus group made up of children and teenagers from all across the capital, Kabul, who performs juggling, acrobatics and theatre routines for local audiences around the city and beyond.

Today the circus is in Qargha, Kabul, Afghanistan. It was started 14 years ago by Mobile Mini Circus for Children and is supported by UNICEF.

The circus enables the children who join – often from internally displaced communities around Kabul – to go to school every day and then practise circus skills at their centre after school and on weekends.

Part of their impressive performance includes passing on vital messages about healthcare and social issues to the audience, who may otherwise not have access to this information.

“Our circus is entertainment and it is so much fun for the performers and for the audience,” says Hamid.

The objective is to pass on a message about the importance of vaccinations against polio. “We pass on these important messages in a fun way which people listen to and they understand. Giving a message without fun means people will not take that message away,” says Hamid, who leads the circus. © UNICEF Afghanistan/Ashley Graham

“We pass on these important messages in a fun way which people listen to and they understand. Giving a message without fun means people will not take that message away.”

This is especially true of the children, who flock to the circus the moment they see youngsters their own ages pull out their juggling sticks and begin clowning around on the makeshift stage.

“We often perform in the internally displaced persons camps,” says Hamid. “These areas are not peaceful and the people have no proper shelters, no electricity and no running water.”

These conditions provide the perfect environment for communicable diseases like polio to spread; yet a simple oral vaccination, just two drops in the mouth, can bring a child closer to a life without polio. Children in Afghanistan will be vaccinated against polio multiple times, until the disease is stopped for good.

During the August and September 2017 National Immunization Days 9.9 million children under five across Afghanistan were targeted with repeat doses of the oral polio vaccine.

Afghanistan is closer than ever to eradicating polio. Through this photo essay, discover 10 innovative approaches that are bringing Afghanistan closer to ending polio, for good.

It’s a clear, summer day in Safdarabad, in the Punjabi province of Pakistan, and Mr. Patras Maseeh Bhatti and his colleagues have just arrived at “work” for the day. Surrounded by brick buildings instead of the inside of laboratory, they might look out of place in their attire. Dressed from head to toe in bio-hazard lab coats, long black rubber boots, and thick industrial gloves and armed with a bucket, their mission is to collect enough sewage from the selected sample site to be transferred in a separate container to the laboratory in Islamabad. Once there, the sample will be tested for poliovirus.

This sampling is part of a system of disease surveillance, which underpins the entire global effort to eradicate poliovirus. Without surveillance, it would be impossible to pinpoint where and how wild poliovirus is still circulating, or to verify when the virus has been extinguished from the wild.

Across the Eastern Mediterranean Region, disease detectives like Mr. Bhatti are becoming more and more important in the fight to end polio. In addition to surveillance for Acute Flaccid Paralysis (AFP), which involves the detection and reporting of children with rapid-onset ‘floppy’ limbs, environmental surveillance involves testing sewage or other environmental samples for the presence of poliovirus.

“This is the only mechanism where you will be able to detect viruses that are circulating with the absence of paralytic polio cases,” Dr Humayun Asghar of WHO’s Regional Polio Programme explains. “As we get closer to eradicating polio even with very high [vaccination] coverage in the population, the virus can still circulate undetected in under-immunized children.”

The growing network of disease detectives

Although AFP surveillance remains the gold standard for surveillance for polio, only one in approximately 200 cases of polio actually show symptoms of paralysis. The World Health Organization has been working closely with a number of countries within the Eastern Mediterranean Region to expand environmental surveillance networks and build capacity in field and lab staff. In endemic areas, environmental surveillance is providing critical supplemental information and data, enabling epidemiologists to tailor the eradication strategies even further. In other parts of the Region, it is proving a critical additional tool to mitigate the risks of a potential virus importation, particularly given the challenges that some countries face, including large-scale population movements, inaccessibility or insecurity.

“In these situations, any additional tools to supplement our AFP surveillance are critically valuable,” he says, “and we need a robust system in place for countries to be able to manage this network.”

In countries like Pakistan and Afghanistan, Dr Asghar says rapid and extensive population movement is the biggest risk for the virus spreading. “The virus moves with the people, so we cannot be sure that the virus is staying where we detect the cases. Here, environmental surveillance has proven extremely valuable because in the absence of many paralytic cases, we continue to detect wild poliovirus in the environment which tells us a lot about how and where the virus might be continuing to hide.”

The detection of poliovirus in countries not recording paralytic cases is also very useful, Dr Humayun says. During the polio outbreak in the Middle East in 2013-2014 this helped to inform partners carrying out the multi-country regional response where to further concentrate efforts in order to close the outbreak and ensure it did not spread further.

In both Pakistan and Afghanistan, environmental surveillance has been one of the key strategies for narrowing in on where the virus continues to circulate, and the lessons learned through the establishment of environmental surveillance in these countries is informing the expansion across the region.

In Lebanon and Jordan, where environmental sampling has been established in 2017, staff have been trained to collect samples from specified collection sites and to ensure the samples reach the laboratory in Amman in the right condition for processing.

Efforts to build on existing health infrastructure and disease surveillance systems in Iran, Sudan, Somalia, Syria and Iraq are underway, with plans for the expansion of environmental surveillance systems and lab networks in 2017.

Leaving a lasting legacy for health systems

Since the Global Polio Eradication Initiative (GPEI) began in 1988, the programme has mobilized and trained millions of community health workers and volunteers for surveillance. A standardized, real-time global surveillance and response network exists and is being put to full use.

Dr Humayun says that this investment in people and infrastructure is not only of benefit during the last mile of polio eradication, but will be a lasting legacy that the polio programme will leave behind for health systems of countries across the region.

“Polio surveillance methods, techniques, facilities and knowledge are our biggest assets, but they have applications beyond our programme. So, these laboratories can be of great value then to countries who need to develop their capacity in other diseases of public health importance,” he says.

Learn more about disease surveillance

The Afghanistan polio snapshot gives a monthly update on key information and activities of the polio eradication initiative in Afghanistan.

July updates include:

One new case of wild poliovirus was reported, bringing the total number of cases to 5 in 2017
Vaccination campaigns were carried out across 28 provinces, aimed at reaching 6.5 million children under 5 with oral polio vaccine OPV
Smaller campaigns aimed to reach 104,000 children with IPV & OPV in Kabul City and Khak-e-Safed district of Farah province, and 43,000 children with OPV in Paktika province

Acute flaccid paralysis (AFP) focal point Dr Siddiqui examines a child at Mirwais Regional Hospital in Kandahar. © WHO Afghanistan/S. Ramo

A strong surveillance system is the backbone of Afghanistan’s polio eradication effort. It ensures that every single poliovirus is detected and analysed, enabling a quick and effective response to stop every strain of the debilitating virus.

Afghanistan is closer than ever to stopping polio. The year 2016 ended with only 13 cases, down from 20 in 2015 and 28 in 2014. Most of Afghanistan remains polio-free, with transmission limited to the southern, eastern and southeastern parts of the country. Surveillance is key to ensuring that the virus is tracked and stopped wherever it circulates.

Together with partners of the Global Polio Eradication Initiative, WHO is further strengthening Afghanistan’s surveillance system to accelerate progress towards a polio-free Afghanistan.

Active volunteers track down the virus

Afghanistan currently has a network of 21 000 acute flaccid paralysis (AFP) reporting volunteers, including health workers in health facilities as well as community volunteers such as traditional healers, mullahs, shrine keepers and pharmacists, supported by over 700 AFP focal points. These volunteers actively find and report children who have symptoms that could be polio: floppy, rapid-onset paralysis with no apparent cause. Stool samples are collected from each child with suspected polio, and sent for further laboratory testing and analysis.

A child with AFP is examined at a health centre in Kandahar. © WHO Afghanistan/J. Jalali

“As a doctor I feel it is my responsibility to work for polio eradication in my country. Polio is a devastating disease that can cause permanent paralysis so everyone should play their part in ending this disease,” said Dr Saifurrahman, AFP reporting volunteer from Shah Wali Kot district of Kandahar. “When a patient with floppiness or paralysis comes to the clinic, I examine the child properly and if the signs point to polio, I immediately inform the Provincial Polio Officer, after which we’ll collect stool samples for further testing.”

In 2016, the polio surveillance network reported a total of 2903 AFP cases, of which 13 were confirmed polio cases and 2858 were discarded as non-polio AFP. As of mid-February, 31 cases are pending classification.

An external review conducted in 2016 concluded that Afghanistan’s polio surveillance surpassed global standards and the circulation of wild poliovirus is unlikely to be missed.

With the support of WHO, Afghanistan continues to step up its surveillance system. In last year alone, 458 new surveillance reporting sites have been introduced and the AFP reporting volunteer network expanded by 18%.

Dr Saifurahman works as an AFP reporting volunteer in Shah Wali Kot district of Kandahar where one polio case was reporded in 2016. © WHO Afghanistan/J. Jalali

When vaccinators go around communities during immunization campaigns and transit teams vaccinate children on the move, they also conduct active AFP case search to further boost AFP surveillance. Active AFP case search has also been incorporated into trainings led by the Ministry of Public Health and WHO ahead of every national immunization campaign.

Strong polio surveillance relies on Afghans who are close to their communities and trusted by them. Saheeb Jaan, a shrinekeeper in Bamyan province, has been a volunteer AFP reporter for 8 years.

“If I see a family come to the shrine with a sick child having weakness or paralysis, I report it to the doctors. WHO has given me a referral notebook so that I can get their information and convince them to call the doctors to make sure their child does not have polio,” she said. “I became a volunteer because it is a good cause and helps save children’s lives. I am happy and proud to be a part of the polio campaign.”

Every single AFP reporting volunteer receives comprehensive training from WHO at least once a year, reviewing key aspects of surveillance such as AFP case definition, clinical signs and symptoms of polio, proper check-up procedures and the protocol for notifying AFP cases to the focal point.

Stepping up environmental surveillance

Environmental sample collection from sewage water in Matun city of Khost province. © WHO Afghanistan/A.Zahed

Environmental surveillance, the collection and laboratory analysis of sewage samples, further increases the sensitivity of surveillance in critical areas.

Afghanistan’s environmental surveillance was set up in Kandahar City in 2013 and samples are now regularly collected from 17 active surveillance sites. WHO and partners conducted a thorough assessment of existing sites in December 2016, leading to three new additional surveillance sites being selected in Kandahar, Nangarhar and Khost, in addition to existing sites in Kabul, Kunar and Helmand. Environmental samples are collected monthly, but sampling frequency has recently been doubled in the south.

In 2016, two poliovirus isolates were reported from environmental samples, down from 19 in 2015.

The road ahead

Afghanistan’s strong surveillance system ensures that the programme continues to find every strain of the virus in its hiding places, accelerating the road ahead to a country free of polio.

Saheeb Jaan, a shrinekeeper from Bamyan province, is one of the 21,000 AFP reporting volunteers around Afghanistan. © WHO Afghanistan/R. Akbar

Vigorous training of AFP reporting volunteers and focal points remains crucial in order to guarantee that no AFP case is missed and that samples are collected, stored and transported properly. WHO continues to support the training and orientation of new and existing AFP focal points and volunteers to ensure each volunteer is trained at least once a year.

The programme is engaging more private health facilities to further strengthen the AFP reporting network. Currently almost 1400 private practitioners are involved as reporting volunteers around the country, making up 6% of the network, and the number is increasing. Engaging more private clinics will further improve the programme’s ability to find children with paralysis.

“Afghanistan’s surveillance system exceeds global standards but we must continue to stay vigilant and continuously review and expand the system where necessary,” said Dr Hemant Shukla, head of the polio programme at WHO Afghanistan. “Constantly improving the quality and sensitivity of the surveillance system is critical for securing a polio-free future for Afghanistan.”

WS20170207_Afghanistan — © WHO Afghanistan/ S. Ramo

Afghanistan’s long struggle to eradicate polio is showing strong signs that the country is closer than it has ever been to finally stopping the disease, once and for all.

The year 2016 ended with only 13 cases, down from 20 in 2015 and 28 in 2014. Notably, 99% of all districts ended the year polio-free, with transmission cornered in small geographical areas in the south, east and south-east of the country.

While Afghanistan this week will announce its first case of wild poliovirus for 2017 – an 11-month-old girl in Kandahar District of Kandahar Province – the country has made substantial gains that make eradication in the short term a realistic goal. Monthly campaigns will be held through the end of May during the traditional ‘low season’ for polio transmission, which provides the best opportunity to stop transmission country-wide.

Every last child vaccinated

There is reason to be cautiously confident about 2017. Last year saw notable improvements in the quality of immunization campaigns across the country – particularly in high-risk areas – with significantly more children being reached and protected than ever before. The proportion of areas achieving required coverage standards in post-campaign Lot Quality Assessment Surveys has increased over the 12 months to December 2016 from 68% to 93%. Concurrently, the quality of campaign monitoring has improved with new approaches including remote monitoring through mobile phone technology and independent third-party monitoring.

Strategic district-specific plans for 2016-2017 are focused on 47 high-risk districts responsible for 84% of polio cases in the past 7 years. An intensified community engagement communication network has been established in these districts to ensure parents and caregivers are aware of the benefits of the polio vaccine and vaccinate their children during campaigns.

A National Islamic Advisory Group for Polio Eradication has been established in 2016 and Afghan religious scholars, the Ulama, issued a Declaration calling on all Afghans to vaccinate their children. Religious leaders are now strongly involved in supporting polio eradication efforts.

A strategy to revisit homes where children were missed was introduced in 2016. By the end of the year, in areas where the Immunization Communication Network was present, teams of mobilizers were successful in vaccinating 75% of missed children in very high-risk districts.

A single block

Afghanistan and Pakistan form one epidemiological block – reaching children on the move is another priority. Coordination and joint planning between the two countries is strong. Currently, 294 Permanent Transit Teams vaccinate children who travel in and out of security-compromised areas, special campaigns target nomadic populations and 49 cross-border teams at 18 cross-border vaccination points vaccinate children when they cross into or from Pakistan and Iran. In 2016, these border teams vaccinated over 122,000 returnee children with oral polio vaccine and over 32,000 with the injectable inactivated polio vaccine.

Surveillance is king

Underpinning all eradication efforts is a surveillance system which is able to pinpoint any virus. An external surveillance review concluded in 2016 that Afghanistan’s disease surveillance surpassed global standards and circulation of the virus is unlikely to be missed. In the past 12 months, an additional 458 disease surveillance reporting sites have been introduced and the number of reporting volunteers has increased by 18% to 21,000. Three additional environmental sewage surveillance sites have been added, in Kandahar, Nangarhar and Khost, and sampling frequency has been doubled in the south.

The road ahead: neutrality

Significant challenges remain: routine immunization coverage remains weak in many areas and insecurity and active fighting has hampered vaccination teams’ access. In this complex and challenging environment, the programme continues to maintain its neutrality. Maintaining dialogue with communities remains essential.

Now more than ever, Afghanistan has all the systems in place and tools it needs to achieve eradication: high-quality immunization campaigns, strong monitoring and supervision of vaccinators, vigorous communications platforms, a strong community engagement strategy creating an enabling environment for vaccination campaigns, national and regional Emergency Operations Centres to oversee and manage the programme, a supportive civil society, religious leadership and media and – most importantly – a committed network of local health workers who are trusted and supported by their communities.

In the coming months, Afghanistan has a unique opportunity to take the world over the finishing line for polio eradication. If all elements of the polio programme are accountable for reaching and immunizing every child in high-quality monthly polio vaccination campaigns, eradication is possible.

A child is given two drops of oral polio vaccine on a vaccination campaign in Afghanistan

Afghanistan is reaching over 5.6 million children with vaccines against polio during large-scale campaign starting in January.

On 30 January, the Ministry of Public Health, WHO and UNICEF launched the first polio immunization campaign of 2017. Targeting over 5.6 million children, the campaign will be delivering vaccines in provinces in the southern and south-eastern regions, most districts in the eastern region, as well as selected high-risk districts across the country, including Kabul city.

“The campaign will build on strong progress seen in 2016. Last year Afghanistan had only 13 cases of polio nationwide, down from 20 in 2015. This was made possible through hard work by thousands of frontline health workers and a renewed emphasis on monitoring and oversight,” said Dr Maiwand Ahmadzai, Director of the National Emergency Operations Centre for Polio Eradication at the Ministry of Public Health, speaking at a joint press conference held in Kabul.

This week’s campaign is carried out by over 31,000 trained polio workers. These vaccinators and other polio workers are trusted members of the community and they have been chosen because they care about children.

“We have seen significant progress in our polio eradication efforts over the past year. Most of Afghanistan is now polio-free, the circulation of the poliovirus is restricted to small areas in the eastern, southern and southeastern parts of the country and we have seen huge improvements in vaccination campaign quality,” said Dr Hemant Shukla, Director of the Polio Programme at WHO. “Our focus is now on reaching every single child during every vaccination campaign to stop the transmission of polio.”

More than 31,000 trained polio workers have been chosen to work on campaigns because they are trusted by their communities and care about protecting children against polio.

“With our collective efforts, we will be able to eradicate polio from the world. Vaccines are the right of every child and no child should be missed during polio campaigns,” said Ms Melissa Corkum, UNICEF Polio Director in Afghanistan. “Thousands of frontline workers visit every house in the country during campaigns. That’s not an easy task. Due to the hard work of these dedicated frontline workers, we are closer to polio eradication than ever.”

In 2016, new initiatives have been implemented to strengthen the polio eradication programme in Afghanistan. All polio eradication activities have been brought under one leadership as Emergency Operations Centres have been established at the national and subnational level. The surveillance system has been strengthened and the circulation of wild poliovirus is unlikely to be missed in Afghanistan. The quality of campaigns, routine immunization and rapid response to polio cases have improved tremendously over the past year.

In 2016, 13 polio cases were registered: 7 cases in Paktika, 4 cases in Kunar, one case in Kandahar and one in Helmand province. Afghanistan remains one of 3 polio-endemic countries together with Pakistan and Nigeria.

More than 65,000 dedicated frontline workers are working tirelessly to eradicate polio from Afghanistan

Feroza and over 65,000 dedicated frontline workers are at the heart of efforts to eradicate polio from Afghanistan.

Feroza is one of the more than 65,000 dedicated frontline workers who are working tirelessly to eradicate polio from Afghanistan. For the past year, she has been working as a volunteer polio vaccinator, vaccinating children in her community during immunization campaigns.

“Polio is a very dangerous disease and people often underestimate how important and effective the vaccine is in preventing the irreversible consequences of the disease,” Feroza says. “I joined the polio programme because I want to raise awareness about the polio vaccine and its benefits to children in my community.”

Most of Afghanistan remains polio-free with the circulation of the virus confined to small areas in the southern, eastern and south-eastern parts of the country. In 2016, 12 wild poliovirus cases were reported, down from the 20 cases reported in 2015 and 28 in 2014. One case has been reported this year.

A number of new developments were implemented in 2016 to accelerate progress towards stopping polio transmission. This included the training of all polio field workers with a new curriculum to boost their skills and ensuring that frontline workers are kept motivated and committed.

Dedicated and brave vaccinators like Feroza are at the heart of the polio eradication effort. Female polio workers are particularly important in building trust in their communities and encouraging vaccination, ensuring more children are reached with life-saving vaccines.

“The best thing about my work is helping women and children and spreading awareness about the problems that are caused if children are not vaccinated. Sometimes mothers try to convince us to give them the vaccine as well since we are praising it so much – this is always amusing,” says Feroza smiling.

During vaccination campaigns, Feroza and her team visit houses to vaccinate all children under the age of 5 with the oral polio vaccine (OPV). “We work long and hectic days during the campaigns but I enjoy it.”

The work of volunteers like Feroza is crucial to reducing the number of children missed during immunization campaigns.

Afghanistan has a well-informed generation of parents who accept the polio vaccine every time it is offered to them. According to a study carried out in 2016, nearly 90% of Afghans recognize that vaccination is a way of preventing polio and there has been a reduction in the belief in preventing polio by using traditional medicine.

“We generally don’t face any problems during campaigns as most families are familiar with the vaccine and want to vaccinate their children. If families are hesitant, we try to encourage them by giving them information about the benefits of the vaccine. If they still reject the vaccine, we ask our supervisors to come and help convince them. I have never met a family who refused the vaccine in the end,” Feroza says.

The border between Pakistan and Afghanistan is no barrier to the poliovirus. Close cultural and linguistic ties connect the two countries. Populations move fluidly across these borders. Each year, the virus moves with them.

Afghanistan and Pakistan have seen significant progress in the last 18 months in their efforts to stop polio. But both countries have been close before, and have been thwarted: the virus has found pockets of unvaccinated children where it can hide, regroup, and stage a comeback. Despite historically low levels of polio over the last few months, cases of paralysis and positive samples found through environmental surveillance show us that the virus has not yet been stopped.

A new approach

Armed with this knowledge, Pakistan and Afghanistan have taken a new approach. Since June 2015, the two have been coordinating major programme activities, as success in one country depends on success in the other. Monthly polio immunization campaigns have been synchronized so that no child on either side of the border can fall through the cracks, the Emergency Operations Centres (EOCs) of each country – which house the government and partners of the Global Polio Eradication Initiative to coordinate eradication activities – interact with one another on a weekly basis, and the highest level political and administrative leadership meet face to face every six months, to resolve challenges and to develop plans to address the remaining hurdles.

A common communications strategy has synchronized messaging at the border and – with radio being the main source of news for 70% of Afghans and 50% of Pakistanis in border areas – the programme has coordinated radio programming on the leading border channels, producing weekly health shows and using popular soap operas to create Pashto-language programming on polio and children’s health.

This innovative approach is paying dividends. The polio eradication programmes in both countries are working closely together to coordinate vaccination campaigns, surveillance, and to track population movements.

The three ‘corridors’ of polio transmission

Three ‘corridors’ are serving to allow the virus to travel with population movements between countries: via the Torkham border crossing from Peshawar and Khyber in Pakistan to Nangarhar, Kunar and Laghman in east Afghanistan, and via the Friendship Gate border crossing from Pakistan’s Quetta Block to the Greater Kandahar area in south Afghanistan. Population immunity in these transmission corridors have been gradually improving in the last year, shown by the vaccination status of non-polio AFP cases.

Wild polio increasingly seems to be travelling down a central corridor between southern Khyber Pakhtunkhwa and the Federally Administered Tribal Areas in Pakistan travelling across rugged, smaller border crossings to Paktika, Paktia and Khost provinces in the south east of Afghanistan.

Mobile populations

At the most recent Inter-Country Coordination Meeting in Islamabad, Pakistan, the Afghanistan National EOC Director underscored the importance of reaching and vaccinating populations on the move, whether at formal or informal locations.

While Torkham in the northwest and Friendship Gate in the south are the main border crossing points between the reservoirs – with more than one million children under 5 crossing these points each year – the smaller informal crossings are considerably more challenging to reach and vaccinate children.

Pakistan and Afghanistan are working to strengthen coordination on the communities moving through these locations, to ensure that all children under 5 are vaccinated wherever they are. The programmes are strengthening their disease surveillance at community level, mapping out mobile groups and ensuring they’re included in immunization microplans, and working with leaders and influential figures to understand their movements better.

Stronger together

The new polio cases in the central corridor have reinforced the idea that neither Pakistan nor Afghanistan can eradicate polio alone, with the virus travelling between the two. At the Islamabad meeting, the National EOC coordinator for Pakistan highlighted the fact that neither programme was where it intended to be by this time in 2016, and these strategies tailored to addressing specific challenges were essential to end the virus for good.

Two vaccinators climb onto a truck to deliver polio vaccines to a family travelling across Torkham border into Afghanistan. © WHO/S. Ramo

The significant improvements in the programme quality in the southern and eastern corridors can be attributed to a relentless focus on improving campaign quality and the innovative approach of the two countries working as one team across the border.

Pakistan and Afghanistan are learning from the programme’s experiences in other countries. If this progress can be maintained in the traditional corridors between the long-time polio reservoirs, and the programme can move quickly to rapidly increase immunity in the new, central corridor, the programme has the opportunity to strike out polio in two countries with one blow, working together to ensure that no poliovirus can find a hiding place along the porous border between them.

The Global Polio Eradication Initiative (GPEI) is highlighting the innovations that are helping to bring us closer to a polio-free world. Find out about other new approaches driving the polio eradication efforts by reading more in the Innovation Series.

The polio eradication programme is using technology in innovative ways to map the activities of polio workers on the ground, and ensure that expertise and support is getting to the areas where it is most needed.

More than 300 international consultants are deployed by the partners of the GPEI in some of the countries most vulnerable to polio. By strengthening surveillance, tracking the virus, identifying immunity gaps and supporting vaccination campaigns to fill them, these consultants provide an important boost to capacity in polio-affected or vulnerable countries. By using new technologies, the programme is mapping the activities of all consultants to capture the range of locations they travel to and the activities they carry out. These innovations ensure that countries receive the best support from these consultants, and that they are working where the need is greatest.

Survey 123

The introduction of this new technology means that each week, no matter where they are in the world, international consultants report on their activities using a smartphone application called Survey123. The report only takes a minute to complete, works offline and captures their location at the time of reporting. By answering questions on what activities and diseases they have been working on that week, this tool enables the GPEI to capture data in real-time and ensure international consultants are being efficiently deployed in high risk polio areas and being used to their greatest advantage.

In the below snapshot from the first week of October, reports from the consultants can be seen in Guinea, the Lake Chad region, Madagascar, Somalia, Afghanistan and Pakistan – the areas that are most vulnerable to the virus.

Getting people where they are most needed

Survey123 is also enabling the GPEI to identify changes in deployment over time. The recent notification of wild poliovirus in the Lake Chad region demonstrated the use of this clarity, by showing the movement of consultants into and around the Lake Chad region, despite insecurity and inaccessibility.

In depth analysis such as this provides greater clarity on what additional human resources are needed to respond to outbreaks or newly recognised risk areas, and indicates how rapidly GPEI resources can be used to fill important needs.

Following cases of polio being found in Nigeria in July 2016, Survey 123 was able to show the movement of international consultants into the affected areas to strengthen the response effort.

The broader benefits of polio eradication

Due to the scale of polio eradication activities even in the most remote and vulnerable areas to reach every last child, international consultants are sometimes present where other health infrastructure is weak. The capacity of the polio programme in these vulnerable areas is sometimes used to support other health initiatives, including improving routine immunisation, measles activities, communication for development and emergency response.

Analysing the collected reports from Survey 123 is giving us greater insight into the extent to which consultants are supporting other health programmes. The support provided to other health programmes shown in the map below highlights the continued benefits of the polio eradication infrastructure to other public health initiatives, giving the donors to the GPEI more bang for their buck when investing in polio eradication. The information gathered from this new technology is helping to inform transition planning efforts, providing information needed to country governments and GPEI partners as they look ahead to what should happen to the polio eradication infrastructure once the goal of a polio-free world has been achieved.

International consultants working on polio are also helping to support other health programmes. This map shows the amount of time in the different WHO Regions being spent on both polio and non-polio activities.

The Global Polio Eradication Initiative (GPEI) is highlighting the innovations that are helping to bring us closer to a polio-free world. Find out about other new approaches driving the polio eradication efforts by reading more in the Innovation Series.

The Afghanistan polio surveillance review that took place in June commended the progress made in achieving strong surveillance networks throughout the country.

Afghanistan constitutes part of the final frontier in the fight to eradicate polio, as one of two remaining polio endemic countries alongside neighbouring Pakistan. Surveillance is key to eradication efforts: it is not just vaccinating every last child but being able to trace every last virus that will take us over the finishing line.

Highly sensitive surveillance is more important now than ever, as wild poliovirus transmission drops to very low levels – six cases have been reported through the surveillance system in Afghanistan in 2016. Strong surveillance enables the Global Polio Eradication Initiative to quickly identify outbreaks and helps guide a targeted, rapid outbreak response.

Strengthening Surveillance in Afghanistan

An external review of the Acute Flaccid Paralysis (AFP) surveillance system for polio eradication was conducted from 19 – 24 June 2016 in the eastern, southern, central and western regions of Afghanistan. Review teams consisted of polio eradication experts from WHO, UNICEF and Bill & Melinda Gates Foundation, facilitated by in-country staff from the Ministry of Public Health, WHO and UNICEF country teams. The review teams assessed surveillance records, health facilities, surveillance activities and the quality of case investigation.

A Strong Framework

The review concluded that surveillance in Afghanistan is strong and the circulation of wild poliovirus is unlikely to be missed. The network of sentinel sites to detect and report cases of ‘acute flaccid paralysis’ (AFP – the lead symptom of paralytic polio) was deemed appropriate, with adequate documentation of AFP data and excellent ongoing data analysis.

In their summary conclusions and recommendations, the review team emphasised the vital role played by health professionals and volunteers across the country both for polio immunisation efforts and in maintaining effective surveillance for AFP cases. Review teams found evidence for high levels of awareness of the concept and practice of AFP surveillance among health workers in the country. Both key indicators of AFP surveillance quality – the annual rate of reporting of AFP among children aged under 15, and the percentage of AFP cases for whom adequate stool specimens for lab analysis are taken – were found to meet international standards in all visited Regions. In addition to surveillance for AFP, the country also maintains a system of regular environmental surveillance, with collection and lab analysis of sewage samples, to further increase the sensitivity of surveillance in critical areas.

Admission log books are used by active surveillance workers to scan for patients having symptoms of acute flaccid paralysis (WHO/R.Tangermann)

Looking Forward

While commending the Government of Afghanistan and partners for their work in securing progress in the last year, the review team also provided some recommendations to further strengthen the surveillance system.

To ensure that all avenues are explored to detect the presence of polioviruses, the review recommended that private health facilities must be further integrated in the AFP surveillance system. This will improve the programme’s ability to find children with paralysis, regardless of their background. The review also highlighted the importance of comprehensive training for surveillance staff, emphasising the need to utilise existing hospital infrastructure to spread awareness about concepts and practice of AFP surveillance.

Further progress towards interrupting poliovirus transmission in Afghanistan requires that even more children are reached and vaccinated against polio, and that the quality and sensitivity of surveillance for poliovirus remains strong and is further improved. A sustained focus on improving surveillance efforts remains paramount to eradication.

The external AFP review team commended overall surveillance efforts of the Ministry of Public Health and partners. The Global Polio Eradication Initiative would like to thank Rotary International, USAID, and the Canadian and German governments for their continued support in the fight to eradicate polio in Afghanistan. Bolstering and extending surveillance networks across the country is essential in order to secure a polio-free future in Afghanistan.

Strengthening Surveillance in Afghanistan

An external review of the Acute Flaccid Paralysis (AFP) surveillance system for polio eradication was conducted from 19 – 24 June 2016 in the eastern, southern, central and western regions of Afghanistan. Review teams consisted of polio eradication experts from WHO, UNICEF and Bill & Melinda Gates Foundation, facilitated by in-country staff from the Ministry of Public Health and from WHO and UNICEF country teams. The review teams assessed surveillance records, health facilities, surveillance activities and the quality of case investigation.

A Strong Framework

Admission log books are used by active surveillance workers to scan for patients having symptoms of acute flaccid paralysis (WHO/R.Tangermann)

Looking Forward

To deliver a polio-free world, every child in the remaining polio reservoirs- Pakistan and Afghanistan – must be vaccinated. The purple ink dot on this babies’ finger shows that they have received the oral polio vaccine. – © WHO

World Health Organization’s (WHO) World Immunization Week 2016 kicks off this week with the aim of raising international awareness on the critical importance of full immunization from childhood through to adulthood. One of the campaign’s major focuses is the crippling poliovirus; incurable, but preventable with a simple vaccine. World Immunization Week is an opportunity to celebrate the progress marked by the drop in cases by 99.9% in the last three decades; but it also calls for increased momentum for the final push to overcome the last remaining pockets of the virus and wipe out the disease.

This World Immunization Week, experts are cautiously optimistic that we could see the end of the virus very soon. In 2015, a total of 74 cases of polio were reported in Afghanistan and Pakistan, the only two remaining polio endemic countries, down from 334 cases worldwide in 2014.

“We’ve come a long way since the establishment of the GPEI in 1988, from 125 polio-endemic countries to just two,” said Chris Maher, manager of WHO’s regional polio eradication unit in Amman, Jordan. “We are at the final frontier of eradication. A lot of work is still needed, but if we can stop polio transmission in Afghanistan and Pakistan by the close of 2016, the whole world will finally be free of wild poliovirus.”

As pressure mounts around achieving this historic goal – the second of its kind since the eradication of small pox almost three decades ago – the world spotlight shines hot on Afghanistan and Pakistan as these countries work to take the world across the finish line.

Driving demand for polio vaccine at the community level

In both countries, the redoubling of anti-polio efforts has seen some impressive gains. However, challenges remain. In spite of regular mass vaccination campaigns in both countries, reaching persistently missed children with oral polio vaccine (OPV) and delivering quality health services remain big challenges. In Afghanistan, conflict, difficult terrain and insecurity continue to hamper access, creating and sustaining reservoirs of poliovirus transmission, yet the programme maintains its neutrality to ensure the support of all key actors and to achieve the best results for children. In Pakistan, high population movement into areas where the virus remains and pockets of under-immunized children also continue to pose risks for viral transmission.

To improve the quality of campaigns and the public acceptance of the importance of vaccination, WHO and the partners of the GPEI – UNICEF, Rotary International, the Centres for Disease Control and Prevention and the Bill and Melinda Gates Foundation – are working closely with both national governments and community leaders to boost demand for OPV, and dispel false rumours surrounding the vaccine.

Parents have a crucial role to play in securing polio eradication, by seeking out opportunities to get them vaccinated. © WHO

“The polio programme is not only engaging health officials and professionals, but also rallying the support of senior, influential religious scholars to reach out to communities,” said Dr Richard Peeperkorn, WHO Representative in Afghanistan. “A recent Ulama conference in Kabul brought together religious leaders from around Afghanistan, resulting in a public declaration encouraging caregivers to vaccinate children against polio and other vaccine-preventable diseases. Ulama conferences will be organised in five regions in the coming months to further strengthen the advocacy role of religious leaders in the fight against polio,” he explained.

WHO, along with partners, currently supports the training of 65,000 Afghan frontline polio workers on a newly-revised curriculum to enhance their skills in vaccination, surveillance for cases of acute flaccid paralysis, campaign monitoring and inter-personal communications. Frontline workers are trusted community members who care about the children in their communities, maximizing their ability to play a crucial role in the final push to eradicate polio.

In Pakistan, publicity campaigns to foster community trust and protection for polio vaccinators is helping to improve coverage in areas with clusters of refusals. “Although refusals are not a widespread issue in Pakistan, overcoming them where they are a problem is necessary for eradication,” said Dr Michel J. J. Thieren, WHO Representative in Pakistan. “WHO is supporting the Government of Pakistan and other partners to show that vaccinators are at the heart of every community and eradication efforts. Vaccinators are trusted and accepted by their community, which is helping the polio programme to encourage the vaccine seeking behaviour of parents,” he said.

Logistics key to reaching more children

In addition to advocacy and community outreach, WHO and partners in both countries are working constantly to fine-tune logistics to reach more children in campaigns. Revisions to Afghanistan’s ‘revisit strategy’ and the installation of fixed vaccination teams at Afghanistan-Pakistan border crossing points has helped to reach children on the move.

“Vaccination teams are re-visiting households with absent children at the end of every campaign day. There is also a revisit day at the end of each vaccination campaign on Fridays to reach out to families at picnics, public markets and mosques, to give OPV drops to children who may not have been at home when the teams first visited,” said Peeperkorn. “This type of ‘mop-up’ activity has been very effective in reducing the number of missed children,” he said.

A Permanent Transit Post team working at the Kohat Tunnel in Khyber Pakhtunkhwa province flag down cars to vaccinate children towards Afghanistan. © WHO

“The proximity of the two countries makes polio importation a constant challenge,” said Thieren. “There is a large population of children under five that travel across the border which has led to shared WPV circulation in the two corridors with a Ping-Pong phenomenon between the bordering areas of the two countries. One of the strategies to reduce cross-border transmission by high risk mobile populations is to ensure vaccination teams are positioned in areas where there is huge population movement,” he added.

Afghanistan is also revising its microplans to obtain critical data on the size and location of target populations in different areas. Revised and accurate microplans are the backbone of successful polio vaccination campaigns as they determine the amount of vaccines that is needed, the number of health workers required and transportation needs, ensuring that every single child is reached by the polio vaccination teams.

Keeping up the pressure

Despite the gains, there is still much to be done, not only in Afghanistan and Pakistan but also in countries with declining immunization rates. So long as polio continues to circulate anywhere, children everywhere are at risk.

“We cannot afford to take our foot off the pedal now,” said Maher. “WHO and the GPEI partners will continue to support these two countries to get the job done. The broader support of the international community must also not waver,” he added.

Afghanistan and Pakistan will hold their next national vaccination campaigns in May. This year, there have only been 12 cases of polio, down from 23 cases in the same period for 2015.

World Immunization Week will take place between 24 – 30 April with the theme “Close the Immunization Gap”.

A child is vaccinated with an oral poliovirus vaccine. WHO/Afghanistan — A child is vaccinated with an oral poliovirus vaccine.
WHO/Afghanistan

What is the switch?

Between 17 April and 1 May, approximately 150 countries will switch from the trivalent oral poliovirus vaccine (tOPV) to bivalent oral poliovirus vaccine (bOPV). This represents the largest withdrawal of one vaccine, and associated roll out of another vaccine in history.

Polio is a debilitating and crippling disease, which can result in incurable, lifelong paralysis. The extensive use of trivalent OPV around the world has been largely responsible for reducing the number of cases of wild poliovirus from over 350,000 in 1988 to just 74 in 2015. In the same period, the number of countries endemic to polio has decreased from 125 to just 2. Now only Afghanistan and Pakistan remain endemic to wild poliovirus.

If tOPV has been so successful in reducing paralysis, why is it being withdrawn?

While many people believe that polio is a single disease, it can actually be caused by three very closely related viruses, types 1, 2 and 3. Immunity against one serotype of poliovirus does not induce immunity against the other types of virus.

In September 2015, the Global Commission for the Certification of Eradication of Poliomyelitis confirmed the eradication of wild poliovirus type 2, the last case of which was recorded in India in 1999, and has not been detected in humans or in the environment since.

The trivalent oral polio vaccine contains live, attenuated (weakened) virus of all three serotypes, and is administered orally. The virus is able to replicate in the gut, during which time the individual is able to mount an immune response.

In exceptionally rare circumstances, if too few people in a community are vaccinated, the vaccine-virus may begin to circulate, and if continued uninterrupted over many months, the vaccine-virus may reacquire neurovirulence, and cause cases of paralysis. This is known as a circulating vaccine-derived poliovirus (cVDPV). However, if enough people are vaccinated during immunization the vaccine-virus will die out before it is able to revert to a neurovirulent form. As such, cVDPVs are not a problem of the vaccine – they only occur in communities in which coverage is low.

The risks of cVDPVs are well known and accepted. In the last 10 years, vaccination against poliovirus has averted more than 5 million cases of paralysis. In the same period, only 725 individuals have been paralysed by a cVDPV.

While the wild poliovirus type 2 has been eradicated, it is the type 2 component in tOPV – now essentially redundant – which has been responsible for more than 90% of the cVDPV cases in the last ten years. However, while tOPV is still in use, there is the continued risk of reintroduction of cVDPVs. As such, polio can only be eradicated if all OPV is eventually withdrawn. The withdrawal of the type 2 component in April 2016 is the first stage of this withdrawal.

Why does the switch have to be synchronised around the world?

Use of trivalent OPV after the switch could jeopardize polio eradication by generating type 2 cVDPVs. The switch must be globally synchronised to ensure that no country is put at risk of importing a type 2 cVDPV from another country that continues to use tOPV.

The same reasoning holds for why countries are advised not to switch before April 2016, as use of bOPV while tOPV is still being used would put the country at risk.
With the globally synchronised cessation, the type 2 vaccine-virus in the environment should die out before a new birth cohort introduces new susceptible individuals for the virus to persist within.

What happens after the switch?

A stockpile of monovalent oral polio vaccine type 2 (mOPV2) which only contains attenuated type 2 virus will be mobilised in the event of any cVDPV type 2 outbreak, that started circulating prior to OPV2 cessation.

Wild poliovirus type 3 has not been detected in the wild since 2012, raising hopes that this serotype has also been eradicated. Following the interruption of transmission of wild poliovirus type 1, the program will eventually withdraw the bivalent oral poliovirus vaccine. In the future, the inactivated poliovirus vaccine (IPV), which does not pose any risk of generating cVDPVs, will be used in place of OPV.

Laboratory and research facilities must ensure any potential sources of poliovirus are contained to prevent accidental release into the environment. The polio programme will transition the infrastructure developed and lessons learned to contribute to broader health outcomes.

If progress is maintained, poliovirus can be the second-ever human disease in history to have been eradicated. This will represent a remarkable achievement and will protect all future generations from the devastating effects of poliovirus.

What is the switch?

If tOPV has been so successful in reducing paralysis, why is it being withdrawn?

Why does the switch have to be synchronised around the world?

What happens after the switch?

When we look back on 2015, it may well be seen as the year the tide irreversibly turned on polio. Wild poliovirus is more geographically constrained than it has been at any point in recorded history. As of 10 December 2015, 66 wild poliovirus cases have been reported from the only two remaining polio endemic countries, Pakistan and Afghanistan, compared to the 324 cases found in nine countries during the same period in 2014.

From Nigeria being removed from the list of polio endemic countries to the declaration of wild poliovirus type 2 (WPV2) eradication to the closure of several outbreaks, progress against polio has accelerated in its remaining strongholds. We are rapidly closing in on the finishing line.

While we saw important steps forward this year, we also faced challenges which we must address in 2016 to achieve a polio-free world.

Nigeria polio-free

In 2015, the three remaining polio endemic countries were reduced to two.
After many years of determination and hard-work, Nigeria reached one year without polio on 24 July, and was removed from the endemic country list in September. With large populations in remote, hard-to-reach areas, as well as regional insecurity, success in Nigeria was thanks to renewed political commitment and attention to detail at every level of the programme. August 11 marked one year without any wild poliovirus across the entire African continent. The hard work must continue if Africa is to be declared polio-free; in Nigeria and other at risk countries in Africa, the focus must shift from stopping transmission to building resilience. Three years with no case of wild polio are needed for the WHO Africa Region to be declared polio-free.

Progress in Afghanistan and Pakistan

Cases in Afghanistan remained low in 2015, with a total of 16 cases compared to 21 by this time in 2014. While in 2014 most cases in Afghanistan came from cross border transmission from Pakistan, this year saw endemic cases in areas of the south and east. Security threats continued to pose a threat to reaching children with vaccines in some areas of the country; but healthcare workers and volunteers continued to work tirelessly to protect children everywhere, as can be seen in this photo story.

Vast improvements have been seen in Pakistan, with more than 80% fewer cases in the country than in 2014. In part, this is thanks to the establishment of the Emergency Operations Centre (EOC), which serves as a platform for increased government ownership of the polio programme. The EOC has played an important role in the implementation of new strategies such as health camps, which have reached almost 350,000 people in high-risk areas, with additional health services alongside polio vaccines this year. Encouragingly, the number of inaccessible children has declined to just 35,000 in comparison to 300,000 in 2014. While this gives much cause for optimism, environmental surveillance shows widespread transmission continues in several provinces. Pakistan must leverage the low-season to the best of its ability if we are to be successful in eliminating transmission in 2016.

Political commitment

In May, the sixty-eighth World Health Assembly adopted a landmark resolution to finish polio once and for all. This puts into place all the necessary building blocks to complete the polio endgame and urges all member states to fully implement and finance it.

Securing a polio-free world

The switch

To make the world polio-free, we must stop all kinds of poliovirus. While wild poliovirus cases are at an all-time low, circulating vaccine-derived polioviruses (cVDPVs) are taking on an increasing significance in the eradication endgame. In 2015, more countries were affected by cVDPVs than by WPVs, giving them a greater precedence and illustrating how important the trivalent to bivalent OPV switch will be in 2016.
In 2015, WPV2 was declared eradicated with no case since 1999 in northern India.
This was one of the factors that enabled the Strategic Advisory Group of Experts on immunization (SAGE) to give the go-ahead for the globally synchronised trivalent to bivalent oral polio vaccine (OPV) switch in April 2016. This will play an important role in preventing the emergence of cVDPVs.
This year saw six countries affected by cVDPV outbreaks: Guinea, Lao People’s Democratic Republic, Madagascar, Myanmar, Nigeria and Ukraine. This is far less than in 2015, but the fact that any cases continue to be found underlines the fact that children are still under-immunized.
Ahead of the switch, all we are focused on fully stopping residual cVDPV2 transmission everywhere. By the close of 2015, 83% of the global birth cohort will be receiving a routine dose of the inactivated polio vaccine, which will boost immunity against all polioviruses and provide a base-layer of protection against type 2. This includes all of the highest risk countries that have reported cVDPV2 transmission since 2000 or that are endemic for wild polio.

The polio legacy

Countries and partners have also continued to ensure that the polio infrastructure continues to pay dividends for other health programmes once polio has been eradicated. In the last 26 years, the GPEI has mobilized and trained millions of health workers and volunteers, accessed households untouched by other health initiatives and established a global surveillance and response capacity which has huge potential to contribute to future health objectives. Countries with a strong polio eradication presence have begun to plan for the transition of the polio infrastructure to other programmes; but at the same time, the polio infrastructure is already strengthening routine immunization, reaching remote children with other health services and was also integral in fighting Ebola in western Africa.

Looking ahead

As we enter the home stretch, it is more important than ever that we maintain the momentum that has brought us this far. In order to fully eradicate poliovirus, and remove the burden of polio from all future generations, high coverage of immunization is essential. Surveillance must be improved yet further to ensure polio is rooted out from all existing reservoirs. Funding must continue until every last case is found.
2015 has been a great year in the fight against polio. With continued drive and commitment we can make 2016 even better.

20 September, Bali – In an important step towards a polio-free world, the Global Commission for the Certification of Poliomyelitis Eradication (GCC) today concluded that wild poliovirus type 2 (WPV2) has been eradicated worldwide. The GCC reached its conclusion after reviewing formal documentation submitted by Member States, global poliovirus laboratory network and surveillance systems. The last detected WPV2 dates to 1999, from Aligarh, northern India.

This announcement marks a major landmark in the global efforts to eradicate all three wild poliovirus serotypes: WPV1, WPV2 and WPV3. WPV3 has not been detected globally since November 2012 (in Nigeria); the only remaining endemic WPV1 strains are now restricted to Pakistan and Afghanistan.

The timing of this declaration of WPV2 eradication is also a significant step in preparation for the phased removal of oral polio vaccines (OPVs), beginning with the removal of type 2 oral polio vaccine requiring a switch from using trivalent OPV (containing all three serotypes) to bivalent OPV (containing only type 1 and 3 serotypes, but not type 2) in OPV-using countries, planned for April 2016.

Meeting one prerequisite for the switch.

OPV contains attenuated (weakened) polioviruses. On extremely rare occasions, use of OPV can result in cases of polio due to vaccine-associated paralytic polio (VAPP) and circulating vaccine-derived polioviruses (cVDPVs). For this reason, the global eradication of polio requires the eventual cessation of all OPV. With WPV2 transmission already having been successfully interrupted, the only type 2 poliovirus which still, on very rare occasions, causes paralysis is the type 2 serotype component in trivalent OPV. The continues use of this vaccine component is therefore inconsistent with the goal of eliminating all paralytic polio disease.

The continued occurrence of polio cases caused by type 2 vaccine-derived poliovirus is the reason to implement the switch from trivalent OPV to bivalent OPV in routine immunization programmes, even before the remaining strains of wild poliovirus are eradicated. Following WPV1 and WPV3 eradication, use of all OPV in routine immunizations will subsequently be stopped. Recent new cVDPV outbreaks in Ukraine (type 1 cVDPV) and the Guinea/Mali border area (type 2 cVDPV) this year further underscore the need for the phased removal of OPVs beginning with type 2 next year.

The switch is expected to be associated with significant public health benefits. More than 90% of all cVDPV outbreaks are caused by the type 2 component of trivalent OPV. Also, up to 38% of all VAPP cases are estimated to be caused by this component. The disease burden due to type 2 vaccine viruses is expected to drop to zero after the planned switch is implemented globally.

To prepare for the switch in April 2016, a number of criteria must be met, as guided by the Strategic Advisory Group of Experts on immunization (SAGE), the independent expert body advising the World Health Organization (WHO) on all matters relating to immunization. These criteria include:

introducing inactivated polio vaccine (IPV) in all routine immunization programmes to maintain immunity levels to type 2 polio (IPV is a trivalent vaccine manufactured from all three inactivated/killed vaccine strains, which are not associated with vaccine-associated paralysis);
securing access to bivalent OPV licensed for use in routine immunization in OPV-using countries (bivalent is currently licensed primarily for supplementary immunization activities);
ensuring global outbreak response capacity, including through a global stockpile of monovalent OPV type 2 (mOPV2), to rapidly enable a response should any vaccine-derived type 2 poliovirus still emerge following the switch;
securing all WPV2 and Sabin type 2 viruses remaining in a small number of essential facilities under appropriate biocontainment levels to minimise the risk of re-introduction into a type 2 polio-free world; and,
declaration by the independent Global Commission that WPV2 has been eradicated globally.

This week’s declaration has satisfied the fifth criteria outlined above, removing a major hurdle and further paving the way for the trivalent OPV to bivalent OPV switch next year, as planned. SAGE will convene at end-October in Geneva, Switzerland, to further review countries’ preparatory plans for next year’s switch and offer additional guidance as needed. In the meantime, a major step towards securing a lasting world free of all polio paralysis, has been taken.

Country: Afghanistan

Serosurveys testing for immunity

High immunity in Afghanistan

Using serosurveys in at-risk countries

The growing network of disease detectives

Leaving a lasting legacy for health systems

Learn more about disease surveillance

Active volunteers track down the virus

Stepping up environmental surveillance

The road ahead

Every last child vaccinated

A single block

Surveillance is king

The road ahead: neutrality

A new approach

The three ‘corridors’ of polio transmission

Mobile populations

Stronger together

Strengthening Surveillance in Afghanistan

A Strong Framework

Looking Forward

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Driving demand for polio vaccine at the community level

Logistics key to reaching more children

Keeping up the pressure

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What is the switch?

If tOPV has been so successful in reducing paralysis, why is it being withdrawn?

Why does the switch have to be synchronised around the world?

What happens after the switch?

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Nigeria polio-free

Progress in Afghanistan and Pakistan

Political commitment

Securing a polio-free world

The switch

The polio legacy

Looking ahead

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