A mother helps to reduce outbreak risk by allowing her child to be immunized. © WHO
A mother helps to reduce outbreak risk by allowing her child to be immunized. © WHO

“I was told that if the child was vaccinated against polio, he could one day become a great footballer like Drogba and Yaya Toure…Today, they have not yet become like Drogba and Yaya, but they are in good health.”

– Awa B., mother of five children, Côte d’Ivoire

Today, the countries most vulnerable to poliovirus outbreaks are those where the barriers to effective immunization are most acute. In high-risk countries like the Central African Republic and Côte d’Ivoire, populations are hard to access and persuading communities of the need to vaccinate can be difficult.

For polio workers in these countries, it is important to reduce outbreak risk through strategies that involve local people, and which are receptive to the local surroundings and culture. Not every child will grow up to be a champion footballer, but by persuading parents of the importance of immunization, they can grow up active and healthy, protected from the debilitating effects of polio.

The risk of polio outbreak

The Central African Republic and Côte d’Ivoire are both considered outbreak risk countries due to their difficult political and security situations, weak health-care systems, and regular cross-border population movement.

Geographically close to Nigeria, one of the last three polio endemic countries, the Central African Republic is currently at risk of virus spread from Borno state where there was a poliovirus outbreak in 2016. In 2011, Côte d’Ivoire experienced an outbreak of wild poliovirus type 3, also originating from Nigeria.

A child is vaccinated against polio in the Central African Republic. November 2017 © UNICEF CAR
A child is vaccinated against polio in the Central African Republic. November 2017 © UNICEF CAR

Outbreak prevention is a central part of the strategy to end polio, as the spread of the poliovirus through under-immunized populations could make eradication more of a challenge. In high risk countries where delivering vaccine can be difficult, different methods must be used to comprehensively immunize every last child.

Getting the local community involved

In Côte d’Ivoire, a round of National Polio Vaccination Days officially began on October 28th in Ebimpé, marked by a ceremonial gathering of vaccination partners alongside key members of the local community. Speaking at the event, the Minister of Health and Public Hygiene, Dr Raymonde Goudou Coffie, described the need to vaccinate every last child as a mission for everyone: “Traditional leaders, heads of households and communities need to be involved in this initiative.”

This is a powerful method of engagement – making sure that parents and local leaders, as well as health workers and volunteer vaccinators, are involved in the fight against poliovirus.

No one approach fits all

Vaccinators also understand that no single approach will fit every situation. Instead, the Global Polio Eradication Initiative partners and field workers must work hard to understand how best to communicate the risk of polio outbreaks to different communities.

For instance, to reach parents working in Nana Mambere prefecture of the Central African Republic, local radio station SIRIRI hosted a panel based radio discussion to mark the recent vaccination campaign. Featuring medical professionals and local politicians, the panel addressed community worries around vaccine, urging every parent listening to take their young children to be immunized.

The day before the October campaign in Côte d’Ivoire, an advance team of volunteer vaccinators in Grand-Bassam began vaccinating at the local weekly market. Knowing the routine of local women, they anticipated that there would be some children visiting the market with their mothers who might not be reached later in the week – making this gathering of the community too good an opportunity to miss.

Health workers mobilize communities in Côte d’Ivoire, September 2017. © Rotary International
Health workers mobilize communities in Côte d’Ivoire. September 2017 © Rotary International

Having an understanding of the communities targeted in campaigns, whether of their worries around vaccination, or even parents’ weekly schedules, is crucial to effectively reduce the risk of a polio outbreak.

Providing broader benefits

In Côte d’Ivoire, Dr Bamba Souleymane, Departmental Director of Health in Grand-Bassam, noted the quantity of different health interventions that his team was attempting to successfully deliver. Alongside the polio vaccine, the volunteers were distributing impregnated mosquito nets, de-worming medication, and vitamins.

Such combined efforts use the GPEI’s well-established infrastructure to deliver a variety of desirable health benefits in communities, not polio vaccine alone. In places where the health infrastructure can be weak, the polio programme’s ability to reach remote children can be a big advantage for many reasons.

For Awa, the dream of her son becoming a champion footballer was a persuasive reason to take him to be vaccinated. For others, receiving different health benefits or hearing information via radio are compelling reasons to vaccinate their children.

Lowering the chance of an outbreak is never a straightforward process, but instead requires understanding parents, children, and communities.

The best vaccinators and campaign planners are able to spot opportunities to keep campaigns relevant, access groups in different ways, and ensure that coverage is sustained.

This way, we can successfully protect every last child.


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.

More information

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.

© WHO/J-M Giboux

Following the recent detection of wild poliovirus in Nigeria, Ministers of Health from Cameroon, Central African Republic, Chad, Niger and Nigeria have declared the polio outbreak in Nigeria as a public health emergency for countries of the Lake Chad basin. The declaration, coming out of the 66th session of the World Health Organization Regional Committee for the African Region, demonstrates commitment from governments across the region to bolster momentum in the fight against the virus.

A regional response to a regional risk

The declaration requests that Nigeria and all countries of the Lake Chad Basin, as a matter of the utmost urgency, fully implement coordinated outbreak responses in order to quickly interrupt this outbreak before the end of 2016 and prevent international spread. It calls on all Member States of countries of the Lake Chad Basin to extend all possible support, including political advocacy and engagement at all levels, for successful coordination and implementation of synchronized polio vaccination activities across the countries of the Lake Chad sub-region. The declaration builds on the sustained commitment of member states across the region in the path towards polio eradication, highlighted at the African Union summit in June 2015 where African heads of state gathered to declare polio eradication a “historical legacy for future generations”.

Immediate action, challenging terrain

An immediate response was mounted by the Nigerian government following the outbreak by quickly declaring it as a public health emergency and mobilizing the needed resources, with a large-scale vaccination campaign implemented and further rounds planned across the Lake Chad sub-region.

While challenging terrain lies ahead in beating the poliovirus for good, in Nigeria, and in Africa – not least because of the grave humanitarian situation in many of the countries around Lake Chad – the declaration of a regional emergency provides an important foundation for action, including the mobilization of necessary financial, political and technical support from partners of the Global Polio Eradication Initiative and governments across the region.

Lake Chad public health emergency declaration
Nigeria declares polio outbreak as a national public health emergency


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.