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

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

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

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

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

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

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

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

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

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

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

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

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

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

Egypt’s Minister of Health and Population, H.E Dr Hala Zayed, one of the elected co-chairs for the new subcommittee, making her interventions during the inaugural meeting on 16 March, 2021. © WHO/EMRO

The new Regional Subcommittee brings together ministers of health from Member States across the Eastern Mediterranean Region to tackle some of the persistent high-level challenges to polio eradication. Those include raising the visibility of polio eradication as a regional public health emergency and priority and mustering the political support and domestic financial support needed to finish the job.

During the inaugural meeting convened by the Regional Director, Dr Ahmed Al-Mandhari, two co-chairs were elected to drive the regional push: Egypt’s Minister of Health and Population, H.E Dr Hala Zayed, and the Minister of Health and Prevention of the United Arab Emirates, H.E. Abdul Rahman Mohammed Al Oweis.

H.E. Abdul Rahman Mohammed Al Oweis was represented at the meeting by Dr Hussain Al Rand, the Assistant Undersecretary for Health Centres and Clinics and Public Health, United Arab Emirates. Both Member States flagged the urgency of the state of polio transmission in the last polio-endemic region at present, but also the opportunity to leverage greater regional coordination to achieve eradication.

Polio eradicators around the world know that ours is, in many ways, a grassroots programme: we use microplans to work through neighbourhoods door to door, household to household. But big-picture solidarity is needed to maximize the success of our ground-level efforts.

Wild poliovirus transmission has spread beyond core reservoirs of polio endemic Afghanistan and Pakistan, infecting 140 children in 2020. Outbreaks of circulating vaccine-derived poliovirus type 1 (cVDPV1) paralysed 29 children in Yemen. Type 2 outbreaks spread across the Region in 2020, paralysing 308 children in Afghanistan, 135 in Pakistan, 58 in Sudan and 14 in Somalia. At a time like this, moving forward as a region and as blocs, rather than on a country-by-country basis, is critical.

One of the issues identified by Member States as critical to stopping transmission is the movement of people across borders, and ensuring that surveillance and vaccination efforts target the increasing number of people who regularly cross borders across the region – whether they are moving as a consequence of conflict, environmental crises or economic necessity.

Interventions were made by Afghanistan, Egypt, the Islamic Republic of Iran, Iraq, Oman, Pakistan, Saudi Arabia and the United Arab Emirates. All statements reaffirmed strong support for the establishment of the subcommittee under the Regional Committee Resolution on polio eradication adopted in 2020.

Members of the subcommittee were unanimous in their commitment to engage in coordinated action and support of regional polio eradication efforts in four strategic areas. These include raising the visibility of the polio emergency in the Region, pushing for collective public health action, strengthening efforts to transition polio assets and infrastructure and advocating for the mobilization of national and international funding to achieve and sustain polio eradication.

A theme that ran through all Member States’ interventions was the idea of maximizing the resources already in place – including the workers, the polio and EPI infrastructure a across the region, and the array of community leadership groups with which the polio programme has worked in past.

“Last year or the year before the year before there was a meeting in Muscat with religious leaders from different countries, and I think we need to capitalize on their support. We need to give them ownership,” said Dr Ahmed Al Saidi, Minister of Health, Oman.

The COVID-19 pandemic has had an outsized impact on polio programmes across the region. The four-month pause in vaccination, from March-July 2020, gave the virus a window to spread almost unchecked. While we are immensely proud to have shouldered much of the COVID response burden, with GPEI infrastructure still supporting that response, this has come at a cost: nearly 80 million vaccination opportunities were lost.

“But we are moving forward, making up lost ground and, through this new Regional Subcommittee, leveraging the credibility that the polio programme has built through its pivot to COVID-19 and back again to polio,” said Dr Hamid Jafari, Director of the regional polio programme and co-facilitator of the Regional Subcommittee.

That credibility is now the polio’s most valuable asset: the proof that polio programmes are not just a means to battle polio, but sophisticated, fast-moving public health assets skilled in pandemic response.

The subcommittee will report its progress to WHO’s governing bodies meetings, including the World Health Assembly and the Regional Committee for the Eastern Mediterranean.

The Secretariat, which is made up of the office of the Regional Director and members of the regional polio eradication programme from WHO’s Eastern Mediterranean Region, will support the subcommittee to develop a programme of work based on the key outputs of the group.

Press Statement following inaugural meeting.

During polio vaccination campaigns in big cities such as Cairo, Egypt, vaccinators go above and beyond to find millions of doors to knock upon to find children who need to be vaccinated. © GPEI

Rising up into the sky, a tower block’s outline trembles in the heat haze, even in the early morning. It’s hard to count the number of floors from the ground as the concrete block stretches up so high. Inside the door, you look around for an elevator – but there is none. Taking a deep breath and hoisting the vaccine carrier higher onto your shoulder, you begin the long climb up the stairs through the heat. At the top, many pauses for breath later, you knock on the first door. As a mother holding her baby opens it, your work for the day really begins – but there is a long way to go. To vaccinate every child in the city against polio, you and your fellow vaccinators must knock on every door in this building; on this street; in this neighbourhood; and across the entire city. It is a monumental task – and one you take on several times a year.

Cities: Uniquely challenging environments

Often it is the ability of polio vaccinators to reach the most remote and inaccessible villages, hampered by challenging weather or conflict, that is the biggest challenge to eradication. But big cities, while more easily accessible, can pose an equal challenge.

Dr Mohammed Sibak Abouzeid, has been working to stop polio in Egypt since 1999, planning and organising polio eradication campaigns and evaluating whether enough children were reached in each campaign so that the next one can be better. Over 40% of Egypt’s population lives in urban environments.

“While my colleagues in the countryside are battling challenging terrain, weather and long journeys, we have a different set of barriers: slums, high rise buildings, marginalised communities and big populations that can change overnight,” says Dr Mohammed. “But our goal is the same: to reach every single child, no matter where they live.”

One critical tactical shift to ensure all floors of a tower block were covered was to ensure vaccinators first walked to the top floor, and then knocked on every door coming down, rather than the other way around, which meant the very top floors were missed.

A playground for polio

Cities provide an easy environment in which for polio to spread. The poliovirus spreads between humans through faeces, so wherever sanitation systems or hygiene practices are poor, or many people live in close quarters, the virus is able to spread rapidly.

Vaccination teams go door to door in urban slums such as this. This location is also used to collect sewage water which is tested for poliovirus as part of the country’s environmental surveillance network. UNICEF/S. Biswas

The city of Karachi is one of the remaining strongholds of the virus. People move in and out of Pakistan’s biggest city constantly:  these ever changing populations make it difficult to know how many children need to be vaccinated and where they live. Many children are born every day, giving the virus many opportunities to hide in the unvaccinated guts of infants who have not received at least three doses of polio vaccine. Given the informal nature of many of the slums within this city, the lack of infrastructure such as health care centres can make it especially difficult to get vaccines to every child.

Slums have another consequence for polio eradication; with high levels of poverty, malnutrition and diarrhoea are regular threats. Malnutrition can damage the immune systems of children, meaning that even if they receive the vaccine, it might not be able to kick start the process of generating protection against the virus. Diarrhoea can lead to the vaccine leaving the body too quickly for it to begin creating antibodies; but it also can act as a vehicle to cause the poliovirus to spread further and faster.

Stopping polio in cities

Stopping polio even in these challenging environments takes ingenuity and creativity. Luckily, people like Dr Mohammed have the experience necessary to make a difference.

The city of Dhaka, Bangladesh, stretches off as far as the eye can see, hiding from view the millions of children who need to be vaccinated against polio. © Gavi

“To stop polio in urban environments, you need to train all vaccinators incredibly well, and give them the motivation they need to work in difficult environments. But the most important thing is to come to understand the networks that city inhabitants are a part of so that you can engage them, involve them in vaccination campaigns and find the right influencers from local communities to encourage parents to vaccinate their children.”

In cities like Cairo in Egypt and Mumbai in India, once thought to be the hardest places in the world to stop polio, such tactics were instrumental in stopping poliovirus. Indeed, they continue to be used even now in order to ensure high vaccination coverage and keep their populations protected. It may be a matter of getting the right neighbourhood religious leader to announce vaccination campaigns during a sermon, or the right midwife to tell new mothers about vaccination, but one thing is for sure: success against polio is ensured one person at a time, even in a city of millions.

Read more in the Reaching the Hard to Reach series