A child in west Africa receives polio vaccine. Photo: WHO.

More than 190 000 polio vaccinators in 13 countries across west and central Africa will immunize over 116 million children over the next week, to tackle the last remaining stronghold of polio on the continent.

The synchronized vaccination campaign, one of the largest of its kind ever implemented in Africa, is part of urgent measures to permanently stop polio on the continent.  All children under five years of age in the 13 countries – Benin, Cameroon, Central African Republic, Chad, Côte d’Ivoire, Democratic Republic of Congo, Guinea, Liberia, Mali, Mauritania, Niger, Nigeria and Sierra Leone – will be simultaneously immunized in a coordinated effort to raise childhood immunity to polio across the continent. In August 2016, four children were paralysed by the disease in security-compromised areas in Borno state, north-eastern Nigeria, widely considered to be the only place on the continent where the virus maintains its grip.

“Twenty years ago, Nelson Mandela launched the pan-African ‘Kick Polio Out of Africa’ campaign,” said Dr Matshidiso Moeti, WHO Regional Director for Africa.  “At that time, every single country on the continent was endemic to polio, and every year, more than 75 000 children were paralysed for life by this terrible disease.  Thanks to the dedication of governments, communities, parents and health workers, this disease is now beaten back to this final reservoir.”

Dr Moeti cautioned, however, that progress was fragile, given the epidemic-prone nature of the virus.  Although confined to a comparatively small region of the continent, experts warned that the virus could easily spread to under-protected areas of neighbouring countries. That is why regional public health ministers from five Lake Chad Basin countries – Cameroon, Central African Republic, Chad, Niger and Nigeria – declared the outbreak a regional public health emergency and have committed to multiple synchronized immunization campaigns.

UNICEF Regional Director for West and Central Africa, Ms Marie-Pierre Poirier, stated that with the strong commitment of Africa’s leaders, there was confidence that this last remaining polio reservoir could be wiped out, hereby protecting all future generations of African children from the crippling effects of this disease once and for all. “Polio eradication will be an unparalleled victory, which will not only save all future generations of children from the grip of a disease that is entirely preventable – but will show the world what Africa can do when it unites behind a common goal.”

To stop the potentially dangerous spread of the disease as soon as possible, volunteers will deliver bivalent oral polio vaccine (bOPV) to every house across all cities, towns and villages of the 13 countries.  To succeed, this army of volunteers and health workers will work up to 12 hours per day, travelling on foot or bicycle, in often stifling humidity and temperatures in excess of 40°C.  Each vaccination team will carry the vaccine in special carrier bags, filled with ice packs to ensure the vaccine remains below the required 8°C.

“This extraordinary coordinated response is precisely what is needed to stop this polio outbreak,” said Michael K McGovern, Chair of Rotary’s International PolioPlus Committee .  “Every aspect of civil society in these African countries is coming together, every community, every parent and every community leader, to achieve one common goal: to protect their children from life-long paralysis caused by this deadly disease.”

The full engagement of political and community leaders at every level – right down to the district – is considered critical to the success of the campaign.  It is only through the full participation of this leadership that all sectors of civil society are mobilized to ensure every child is reached.

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A child in northern Nigeria receives a dose of the oral polio vaccine. Vaccination teams are going to great lengths to protect every last child against polio. UNICEF/T.Moran

Experts from across the Global Polio Eradication Initiative (GPEI) partnership convened an emergency meeting in Abuja, Nigeria, from 3 – 5 November.  Led by senior epidemiologists from the governments of Nigeria and neighbouring countries, the group examined a detailed review of the current impact of the outbreak response, and identified area-specific challenges and prioritized operational plans accordingly.

The detection of new wild poliovirus type 1 (WPV1) cases in Borno, Nigeria, in August – the first detected on the African continent in more than two years – has prompted an unprecedented response.  The outbreak was immediately declared by both the Government of Nigeria and governments of surrounding countries to be national and regional public health emergency.  This opened the way for a regional outbreak response, mobilizing emergency resources from across the public and civil society sectors.

Thousands of health workers across the region have been mobilized and trained, and in Borno alone more than 1.7 million children have been vaccinated.  But many more continue to be un- or under-immunized, either due to operational deficits in outbreak response implementation, hampered access due to insecurity or large-scale population movements within countries.

Unless these missed children are rapidly reached, the risk remains that the current outbreak could spread further, including internationally, and cause more preventable, incurable paralysis.


Access and reaching populations everywhere

Insecurity, geographical challenges and difficulties with communication in some of the hardest to reach areas are providing barriers to reaching all children. Internally displaced persons (IDPs), refugees and nomads are particularly vulnerable groups, with insecurity blocking transit routes and the ability to accurately predict population size ahead of vaccination campaigns reduced. Due to population displacement, detailed micro-plans are frequently disrupted.

Children across northern Nigeria and other countries in the Lake Chad region must be protected rapidly against polio to end the outbreak. UNICEF/T.Moran

Cross-border coordination, embedding the response within the broader humanitarian emergency context, and innovating rapidly to adapt strategies to local challenges is what has stopped similar outbreaks with similar challenges elsewhere in the world.

Yet despite these challenges, the GPEI can draw on a vast array of experience from running outbreak responses in similar settings, most recently in the Middle East, Central Africa and the Horn of Africa from 2013-2015. These existing, proven strategies are rapidly adapted to the evolving environment. Permanent vaccination teams are now in place, as and when an area becomes accessible, to rapidly implement ‘mini’ vaccination campaigns in between larger-planned activities. Such teams are also critical to reach populations as they leave inaccessible areas. Children in both formal and informal IDP camps are a particular focus for the delivery of the polio vaccine alongside other humanitarian and basic health needs.
Assuming that many children living in conflict-affected areas will not have been vaccinated for several years, the target age group has been raised to protect children over 5 years of age.

The Volunteer Communication Network of vaccination advocates within communities has been expanded to cover Internally Displaced Populations living in camps and host populations, while Koranic School teachers have been engaged to address non-compliance and the mobilization of women and youth to ensure local protection for vaccination teams.

Volunteer community mobilizers wearing distinctive blue hijabs are working in IDP camps and host communities to identify unvaccinated children, pregnant women and those with severe acute malnutrition. UNICEF/T.Moran

Coordinating across borders

While cases of polio have only been found in Borno, extensive population movement, insecurity and previous cross border population movements require the outbreak response to cover the entire Lake Chad region. Cameroon, the Central African Republic (CAR), Chad, Nigeria and Niger are working together to track population movements and addressing the challenges inherent in accessing some hard-to-reach areas in each country, including sourcing communication equipment to operate where there is a lack of telecommunication network, closed borders in some places and language barriers. Efforts are being intensified to map out the seasonal movement of nomads, identifying resting places and water points with the support of nomadic community leaders in order to improve micro-planning to inform the response. In Chad, vaccination campaigns are providing livestock vaccines alongside polio vaccines to children in order to increase uptake in nomadic communities.

It is not insecurity alone that leads to hampered access. Sometimes it is simply a more natural phenomenon: the rains! The rainy season in the region typically runs from June to mid-October. Some areas are completely cut off from roads and other transport networks as a result of the associated flooding. With the rainy season now over, many areas and populations will be able to be reached with polio vaccine and other urgent health services.

Stopping outbreaks in such challenges settings is possible

There is no doubt that running an outbreak response with such challenges is far more complex, dangerous, costly and slower than under normal circumstances. However, what is equally clear is that the plans being intensified and implemented across the region are having an impact, and will continue to have an impact. Cross-border coordination, embedding the response within the broader humanitarian emergency context, and innovating rapidly to adapt strategies to local challenges is what has stopped similar outbreaks with similar challenges elsewhere in the world.

The groundwork set by this first phase of the outbreak response has set for reaching previously missed children in late 2016 and throughout 2017.

With continued leadership of political, health and community leaders at the local, national and regional levels alongside the international development community, this outbreak will be stopped and children across Africa protected against polio.

Children in Equatorial Guinea proudly show the dot of ink on their finger that demonstrates they have received a dose of oral polio vaccine.
Children in Equatorial Guinea proudly show the dot of ink on their finger that demonstrates they have received a dose of oral polio vaccine. ©UNICEF/Equatorial Guinea

This week, 18 countries across western and central Africa have been holding synchronised polio immunization campaigns to reach nearly 94 million children with oral polio vaccine (OPV). This is a monumental coordination effort, incorporating strong governmental commitment, global support from international organisations such as the World Health Organization and UNICEF and the motivation of members of communities themselves to mobilize their friends and neighbours to ensure every child is protected.

National Immunization Days in Angola, Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Cote d’Ivoire, the Democratic Republic of the Congo, Equatorial Guinea, Gabon, Gambia, Ghana, Guinea Bissau, Mauritania, Niger, Nigeria, the Republic of the Congo and Senegal are working to build immunity across western and central Africa. Each child needs at least 3 doses of OPV to build immunity and end the transmission of the virus, making it crucial that campaigns such as this reach every child.

Africa is closer than ever before to achieving eradication, with only 22 cases across the continent to date in 2014 compared to 232 by the same point in 2013. This decrease of over 90% in one year is due to increased commitment from the governments of the last remaining endemic country in Africa, Nigeria, and the sites of current outbreaks in Cameroon, Equatorial Guinea, Somalia and Ethiopia.

Nigeria saw only 6 cases in 2014 compared to 53 in 2013 by this date. This dramatic improvement can be attributed to measures put in place to avoid missing children from campaigns, and to a surge in staff to the country to support Emergency Operations Centres. The international spread of polio, affecting Cameroon, Equatorial Guinea, Somalia and Ethiopia as well as countries in the Middle East, lead to the declaration of polio as a Public Health Emergency of International Concern (PHEIC) in May 2014 by the Director General of the World Health Organization. With temporary recommendations to stop the international spread of polio, the PHEIC is another step towards ensuring a polio-free Africa.

Through these measures – improved surveillance, innovative community engagement strategies and a surge in staff to affected areas – the past year has seen gains in the eradication effort that must be protected. Synchronized campaigns such as this bring us ever closer to the important milestone of ending transmission in Africa.
These synchronised campaigns demonstrate the commitment of the governments of countries across central and western Africa to ending the transmission of polio once and for all, despite the increased focus on Ebola prevention and response in 2014. In some cases, polio resources are being utilized to strengthen the Ebola response, demonstrating the Global Polio Eradication Initiative’s commitment to securing the polio infrastructure for a polio-free world.


Immunisation specialist Dr Deo delivering vaccines to a community in the Central African Republic. UNICEFCA/Matas

An emergency response strategy has been introduced across central Africa to stop the transmission of poliovirus by the end of September 2014, in line with the goals set by the Polio Endgame Strategic Plan 2013 – 2018.

This drive comes with the onset of two cases of wild poliovirus type 1 (WPV1) reported in Cameroon’s Est province on the 1st and 9th of July 2014, close to the border with the Central African Republic where there has been conflict and insecurity throughout 2014. The 5-year old girl and 20-month old boy affected are both refugees from the Central African Republic who had been living in Cameroon for the past three months. Both children had been immunized with two doses of OPV, so had not yet developed full immunity. These are the first cases in Cameroon since January 2014.

These cases highlight the threat of cross-border transmission in Central Africa, where ten cases have now been found in Cameroon and Equatorial Guinea since the onset of the outbreak in October 2013. Due to the circulation and influx of vulnerable refugee populations from the Central African Republic, the risk is seen to be particularly high in Cameroon.

The continuation of the outbreak implies that there are significant gaps in the surveillance system, which has been hampered by the rise in armed conflict in the Central African Republic. As most individuals show no symptoms when infected by the poliovirus, these cases imply that undetected circulation in both Cameroon and the Central African Republic cannot be ruled out.

To address the risk, the ten countries within central Africa are working together to stop transmission. At the beginning of July, the Technical Advisory Group met in the Democratic Republic of the Congo, bringing together experts on epidemiology, public health and communications to produce an emergency action plan to address the challenges currently faced to preventing transmission in this sub-region.

Central Africa poses a distinct threat to eradication efforts due to low population immunity, conflict and insecurity, poor surveillance, population movements across borders and low quality immunization programmes. The emergency action plan outlines the steps interrupting WPV1 transmission by the end of September by identifying and maximising opportunities for immunization, reducing the risk of spread, and maintaining immunization, surveillance and importation preparedness plans.

Despite difficulties in accessing children for immunization in the Central African Republic, the emergency action plan outlines the aim to create a buffer zone’ of immunity along the border with Cameroon to prevent further spread of the virus with population movements. With a further 30,000 refugees expected to enter Cameroon in the coming months, this is crucial to protect these people who have received very little support since the worsening of the conflict in December 2013. Mop-up immunization activities are being finalized to deliver short interval additional doses, a pioneering strategy which allows children to be protected in a matter of days rather than the standard 4 weeks. There will also be work to sensitize communities on the need for immunization, active detection and reporting.

During September and October there will be synchronized immunization activities across West and Central Africa. The wide scope of these plans will enable a much more comprehensive coverage of children, especially those made accessible as they cross borders to avoid conflict. In both Cameroon and the Central African Republic, strong coordination with NGOs and health organisations has made all the difference to enabling campaigns. These relationships will continue to be strengthened in the coming months.
With immunization activities globally being reinforced wherever access to children is possible, the stemming of the central African outbreak is crucial to enabling the end of WPV1 on the continent by the end of 2014. With only 5 cases in Nigeria this year compared to 35 by August in 2013, and most cases in Afghanistan coming from population movements from Pakistan, the impact that global efforts are having is notable. However, while polio remains in enclaves in conflict affected areas, eradicating the risk of outbreaks will be a major challenge; one that the Global Polio Eradication Initiative remains committed to meeting head on.


21 November 2013 – Two children have been paralyzed by wild poliovirus type 1 (WPV1) in the West Region of Cameroon during the month of October. This indicates that wild poliovirus is present in the country, presenting a high risk that the virus will spread.

Genetic sequencing indicates that these viruses are linked to WPV1 last detected in Chad in 2011.

An emergency outbreak response plan is now being finalized, including at least three national immunization days (NIDs), the first of which was previously conducted on 25-27 October 2013. Subnational Immunization Days (SNIDs) will be implemented in December 2013, followed by two subsequent NIDs in January and February 2014. Routine immunization rates are reported to be approximately 85.3% for OPV3. A response in neighbouring countries is also being planned, notably in Chad and Central African Republic.

Surveillance activities across the country and the region are being analyzed to find any gaps.

Given the history of international spread of polio from northern Nigeria across West and Central Africa and subnational surveillance gaps, the World Health Organization (WHO) assesses the risk of further international spread across the region as high.

In 2013, Cameroon also reported four cases due to circulating vaccine-derived poliovirus type 2 (cVDPV2) in the Far North region, linked to circulation in Chad and also detected in Nigeria and Niger. In response, several large-scale supplementary immunization activities (SIAs) had been conducted during the months of August and September, followed by the full NIDs in October. Circulating VDPVs are indicative of poor immunity in the population.

It is important that all countries, in particular those with frequent travel and contacts with polio-affected countries and areas, strengthen surveillance for AFP cases in order to rapidly detect any new virus importations and to facilitate a rapid response. Countries, territories and areas should also maintain uniformly high routine immunization coverage at the district level to minimize the consequences of any new virus introduction.