Horn of Africa

Compared to the busy streets of Hargeisa, Somaliland, just 20 kilometres outside of the city are broad stretches of barren land—home to the nomads. Nomadism is part of Somalia’s culture, and there are thousands of families throughout the country who lead pastoral lifestyles, raising livestock and moving their animals and families as the seasons change. Their frequent movement means that children are not always nearby a health clinic to receive their scheduled vaccinations on time. Such disruption or delay in receiving vaccines can result in low or no protection against common childhood infections.

If children are not immunized against polio, they risk contracting the virus and developing paralysis. They also risk passing polioviruses to other under-immunized children. But the polio eradication teams are committed to reach every last child with polio vaccine notwithstanding challenging terrains.

Look through the lives of polio vaccinators in Somaliland on the third day of the vaccination campaign activities as part of the larger efforts to reach over 1.1 million children with the oral polio vaccine.

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In the last week of October, Djibouti’s Ministry of Health, working with WHO, UNICEF and other partners, successfully carried out the country’s first polio National Immunization Days (NIDs) since 2015.

A child being vaccinated at the NID launch in Djibouti. WHO/Djibouti — A child being vaccinated at the NID launch in Djibouti. © WHO/Djibouti

While Djibouti has not had a case of polio since 1999, the recent outbreaks of polio in neighbouring countries in the Horn of Africa, and the low levels of routine immunization coverage in some areas in the country, are indications that Djibouti is still at risk if poliovirus spreads through population movements. Other countries in the Horn of Africa are already cooperating to stop the ongoing outbreak and to reduce the risk of spread, and especially considering that Djibouti is on a major migration route in the Horn of Africa, it makes a lot of sense for Djibouti to join in this coordinated response.

For Dr Ahmed Zouiten, the acting WHO Representative (WR) in Djibouti, this context demanded action.

“I prefer to deal with a campaign for prevention than to have to deal with an outbreak of polio,” he said.

With that in mind, an NID planned for 2019 was brought forward and carried out over 23-26 October. The target was 120 000 children under five years of age, a number suggested by Djibouti’s last census, in 2009. Two strategies were proposed: one approach, where children would be vaccinated at fixed points (health facilities) and a complementary door-to-door approach using two-person teams (a vaccinator and a registration person).

In the days and weeks before the NID, all partners, including the government, WHO and UNICEF, used a variety of communication channels – from outdoor signage to radio spots – to ensure that communities were informed not just of the risks of polio, but also of the importance of protecting children from vaccine preventable diseases.

A mother and her child at the launch of the Djibouti NID. WHO/Djibouti — A mother and her child at the launch of the Djibouti NID. © WHO/Djibouti

The campaign’s official launch ceremony was held at the Youssouf Abdillahi Iftini Polyclinic in Balbala neighborhood, Djibouti City, in the presence of Djibouti’s Minister of Health, WHO and UNICEF representatives, and other partners. Over the course of the following days, vaccinators surpassed targets, vaccinating all children under five they encountered living on Djibouti territory, regardless of their origin, including nomadic populations, refugees and migrant children.

Although final numbers are still being tabulated through independent monitoring mechanisms, initial results suggest high coverage of the target population. This means vaccinators reached the estimated target number of children, and more, such as newer cohorts of children not accounted for in earlier estimates. Catching these children helps to further inform immunization estimates for any further campaigns.

For Dr Zouiten, a result like this is something to celebrate.

“Today, our children are on their way to being better protected, and we are launching a second campaign in the near future to follow up on that,” he said.

“Before, we had some worries; we thought that the circulation of poliovirus in the region posed a risk. Now with this first vaccination campaign, we know we are on the right path to ensure the children of Djibouti are protected. These results weren’t easy to achieve, but were made possible through collaboration between the Ministry of Health, the partnership between WHO, UNICEF and others.”

Given the high risk of importation of poliovirus, the Government of Djibouti, WHO and UNICEF are not taking any chances: plans are in the works for a second and third NID to roll out in 2019. With an outbreak in the region, it is critical for nearby countries to strengthen their own immunity levels and ensure routine immunization and disease surveillance systems are strong enough to detect any virus circulation. Despite the cost and effort of staging national immunization activities, in this case, all partners agree: an ounce of prevention really is worth a pound of outbreak response.

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Jean-Marc Olivé, Chairman of the Technical Advisory Group (TAG), addressing the participants. WHO/L.Dore

From the 27 – 29 November, the Technical Advisory Group (TAG) met in Nairobi to review the outbreak response in Somalia, Ethiopia and Kenya, and preparedness measures in Yemen, Uganda, Tanzania, Sudan, South Sudan and Djibouti in case of international spread.

Jean-Marc Olivé, Chairman of the TAG, spoke to WHO about the recommendations made to address the challenges faced by countries, his hopes for eradication and his life in the programme.

What are the main challenges faced by the countries of the Horn of Africa in the drive to stop the outbreaks?

The major challenges have been the same for a long time – like, the issue of inaccessibility due to conflict and humanitarian crises. If we cannot access populations then it is very difficult to cover them properly during vaccination campaigns and so it is hard to stop poliovirus transmission. This is not a programme-related issue, it is a political one. Until we have access, it will be very difficult to make it.

I have said it before and I will say it again: access is success.

I think the second challenge is – and this is one of the reasons why we still have the transmission of circulating vaccine-derived poliovirus in the Horn of Africa – is persistently low vaccination coverage. There are still remote areas, rural areas, heavily populated urban areas where routine immunization has really never been able to offer the same services and coverage as in more accessible areas with fewer challenges.

Since last TAG meeting in the Horn of Africa, what progress have you seen?

I have seen the capacity really building up in the Horn of Africa. The biggest shift is that we now have collected a lot of data about surveillance, about immunization coverage, vaccination campaigns, communications, and also data by the type of population we are reaching and not reaching. What is missing now, and what was the focus of this TAG, is to use this data to monitor progress and orient the programme toward those difficult areas. We have to use the data to tell us a story about what is happening and what to do next.

Jean-Marc Olivé vaccinating a child in Kandahar, Afghanistan. © WHO/Afghanistan

What were the most important recommendations made by the TAG this time around?

I think the most important is to follow the plan that has been set up for the three outbreak countries to interrupt transmission. Secondly, the countries that have not been yet infected by the virus should have a preparedness plan to ensure that if there are any problems they can move swiftly into action.

The Horn of Africa has seen several outbreaks in the past. What must be done to break the pattern and keep the region polio-free once and for all?

They have identified the problems. They just have to implement the solutions! We need to be sharing and analysing knowledge, information, and building capacity at the local level to ensure that we are on the right track to success.

I say to all the countries, go to the areas where you know you have problems and engage local communities and health authorities. Most of the issues can only be addressed at local levels by local people who understand the situation. Help them to do that, and monitor progress.

This is your thirteenth TAG; what have you learned about the process of international review?

First, you have to work as one team in support of National Teams, all agencies together. There cannot be any agency that claims, “This is us, we are doing that, this is WHO, this is UNICEF…”; this is the Global Polio Eradication Initiative, working together with all committed partners, using the competencies that each of them has. If you don’t address issues comprehensively as one, effective interventions are much more difficult to implement.

How long have you worked on polio eradication? What lessons have you learnt from this experience?

I was involved in the eradication of polio in the Americas. We started in 1985. We did it from A to Z in 9 years. We had very good leadership, commitment from the Government and partners, clear guidelines, very strong monitoring, and solid and reactive support to the field. Then we moved on into measles elimination with the same engagement – and the same results.

Because I have seen it happen, I know it is feasible. I think this is what keeps me so motivated. Polio eradication is a fantastic initiative. If we focus on weak and problematic areas within countries, if Governments and Partners continue to be engaged, we will make it. It’s going to be tough, mainly because of inaccessibility.

Is there anything else you want to add?

The people working in this programme, particularly local people working in the countries are amazing. They are the basis of any future public health intervention. In Pakistan and Afghanistan, woman are more and more playing an important role. This is an incredible advancement and an incredible contribution that was previously thought to be impossible.

But nothing is impossible – you just push, go slowly and constructively you will manage to gain ground over the virus.

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What is polio surveillance?

One of the most challenging aspects of polio eradication is timely disease surveillance: knowing where the poliovirus is lurking, so we can roll out targeted immunization activities quickly and effectively. With new tools, eradicators are getting the information they need in real time.

For the past three decades, there have been two approaches to find polio: passive and active surveillance. Passive surveillance involves health workers routinely reporting cases of acute flaccid paralysis (AFP) as they find them in health facilities. Active surveillance takes place where there is a higher level of concern that polio might be present. Experts go to hospitals, clinics and even community healers to search out cases of AFP. This approach, often called active case searching, reduces the risk that cases are missed due to human error – people forgetting to report AFP or health care workers or community healers not knowing that they need to report the case.

However, in active case search the key steps of detecting, reporting and investigating the case might not always be happening consistently in all health facilities. There can be a delay of two months or more between a child being paralyzed, experts finding out and alerting the polio surveillance system. In an outbreak setting, this can be long enough for the virus to infect and paralyze more children, moving from one area to another. There was an obvious need to make the surveillance system even more reliable and time-sensitive to ensure the polio surveillance framework is as robust as ever.

Never missing a beat again

©WHO EMRO/Sara Williams
With the Integrated Surveillance and Routine Immunization Supervision system, surveillance officers use an app on their mobile phones to document active case searching as it happens, by tagging the location of every healthcare facility they visit and check.

In order to ensure that active search is conducted timely with real time evidence the polio surveillance systems in Kenya, Ethiopia, Uganda, Eritrea, South Sudan, and Tanzania have adopted an easy-to-use, portable disease surveillance monitoring tool. It delivers unprecedented accuracy across huge areas. The best bit? Most people already have the basic component in their pockets: their mobile phones.

The tool is known as Integrated Surveillance and Routine Immunization Supervision. The idea is simple: surveillance officers use an app on their mobile phones to document active case searching as it happens, by tagging the location of every healthcare facility they visit and check.

“This provides real-time monitoring in the field. Previously, officers would report having done active case searching after the fact – like, ‘I was here and I did x, y, z’. But this is vulnerable to human error in remembering accurately. Sometimes, before we introduced it, someone would go to a distant, rural area and not be able to pinpoint their location on a map for others to follow up. Now, we are sure we are not missing things.” said Christopher Kamugisha, WHO’s Horn of Africa Outbreak Coordinator.

©WHO EMRO/Sara Williams
The map that is generated at the national level allows public health experts responding to the polio outbreak the opportunity to see where the gaps in surveillance for polio are in real time.

The app guides surveillance officers through a checklist (questions cover resources available at the facility, polio, measles and routine immunization) that they fill out and send then and there, using their mobile phones, even without an internet connection. It can also provide on-the-spot data analysis so that the surveillance officer can take immediate, evidence-based action.

With a swipe of the screen, users marry surveillance findings to the facility’s location and send the information to a centrally generated map. This gives staff at the national level a clearer picture of where surveillance is working and where it is not, including data on where possible polio cases are, so they know where to direct extra resources.

It also means health workers actively searching for AFP do not have to spend extra time ensuring the information gathered in the field is being shared with the right people for them to take action. For the ongoing outbreak of circulating vaccine-derived poliovirus in the Horn of Africa, this means better disease surveillance – and a better chance to protect children against polio.

A girl receives two drops of the oral polio vaccine during an immunization campaign in Somalia. © UNICEF

21 June 2018 – The Ministry of Foreign Affairs of the Republic of Korea announced today an additional US$ 2 million to fund polio outbreak response and surveillance activities in the Horn of Africa. This commitment makes Korea the first country to support outbreak response efforts in the region, critical to protecting global progress toward ending polio.

The Global Polio Eradication Initiative (GPEI) welcomed the contribution, with $1.5 million for UNICEF and $0.5 million for WHO.

This funding was raised through an innovative financing mechanism called the Global Disease Eradication Fund, through which KRW₩1,000 was collected from each international passenger flying out of Korean airports by the Government of Korea. Thanks to this Fund, every passenger flying from Korea directly supports global efforts to stop polio, an infectious disease that can lead to paralysis or even death, and can travel long distances undetected.

When the GPEI first began in 1988, polio paralysed more than 350,000 children each year in over 125 countries in the world. Today, there have only been eight cases to date in 2018, and polio is closer than ever to becoming the second human disease to ever be eradicated.

This progress is made possible through the ongoing support of donors, partners, and countless health workers around the world. Contributions from donors like Korea allow the GPEI to vaccinate and protect more than 450 million children against polio each year.

This additional funding follows a US$ 4 million commitment from the Republic of Korea announced at the Global Polio Pledging Event around the Rotary International Convention in June 2017. This contribution was matched by the Bill & Melinda Gates Foundation, doubling its impact to US$ 8 million.

“The Global Disease Eradication Fund is an incredibly innovative financing mechanism, and the funds raised will support UNICEF’s efforts to protect every last child from polio,” said Akhil Iyer, UNICEF Director of Polio Eradication. “We remain grateful to the Republic of Korea for their continued commitment to halting polio outbreaks and driving progress to eradicating polio once and for all.”

“The unique support of the Republic of Korea has been crucial for the remarkable progress we have made in polio eradication, especially in responding to outbreaks,” said Dr Michel Zaffran, Director of the Polio Eradication Programme at the World Health Organization. “These additional funds come at a critical time as we support the outbreak response in the Horn of Africa region by scaling up surveillance to ensure no virus goes undetected.”

The Republic of Korea has been a longtime supporter of the GPEI, contributing to outbreak response efforts in Syria, the Democratic Republic of Congo and the Lake Chad region, with a broad range of activities including delivering polio vaccines, intensifying surveillance, and convincing caregivers to vaccinate their children through community engagement.

Generous support from donors like the Republic of Korea remains essential to stopping outbreaks, ending this paralysing disease and ultimately achieving a polio-free world.

Dr Ranieri Guerra, Assistant Director-General for Strategic Initiatives at WHO, thanks Mr Lee Jang-Keun, Deputy Permanent Representative of the Republic of Korea, for his country’s generous contribution at a grant signing ceremony in Geneva. © WHO/S. Ramo

The Puntland Health Ministry/UN agency convoy on the road to Jeriban District to investigate the polio outbreak. @UNICEF Somalia/2014

24 July 2014 – PUNTLAND, Somalia: UN agencies in Somalia combined forces once again to help a joint UNICEF and WHO team visit a remote district of Puntland in north east Somalia where four people have contracted polio this year.

The victims – a young father who died and three children who were paralysed – all came from Jariban district, a long drive on a dusty track from the nearest main town Galkayo in an area known for pirates and armed gangs. As these were the only four polio cases in Somalia so far this year, it was essential to visit the area to discover how the virus got there and how to stop it spreading further. However the terrain, distance, logistics and above all security concerns made it an extremely challenging proposition.

After coordination and cooperation involving at least four UN agencies, the convoy set off on at dawn on 22 July and drove seven hours from Galkayo to Jariban town, where the team met a group of elders to discuss the outbreak and raise awareness. The town has only one Mother and Child Health clinic run by the Red Crescent Society but no hospital or other facilities. The following day they drove another three hours to Towfiq village where they visited the family of the 29 year old man who had died after contracting polio.

‘This was a very sad visit – the man’s wife said she and their five children had been vaccinated but he had not. He was the only breadwinner in the family,’ said Dr. Abraham Mulugeta, WHO Somalia’s Polio Team Leader.

The three children who were paralysed by polio this year live in villages close to Towfiq that are only accessible on foot, so the team could not visit them. However experts had already met one of the children, two year old Asha, who had earlier been brought by her mother who was desperate for help to Galkayo.

While in Towfiq, the team watched the door to door vaccination campaign for children – the third round of vaccinations since the outbreak was discovered in the area in May this year. There will be another campaign in August in the whole of Mudug region and surrounding areas, for adults as well. There is no health facility in Towfiq so these campaigns are crucial to stop the virus spreading.

Vaccinators have been selected from the local community, and clan leaders and elders are being informed about the need for vaccination. More volunteers have been recruited to search actively for any cases of paralysis so that any polio can be swiftly found and the community adequately protected.

Polio vaccinators in Somalia WHO/H. Shukla — Polio vaccinators in Somalia
WHO/H. Shukla

Q: You work closely with vaccinators: who are they and what does their day look like?

Vaccinators are carefully selected by the Community District Field Assistants (DFA). Many of these vaccinators are females from local communities who have been trained on polio vaccination. They play a key role as they walk from door to door, talking to families, giving vaccine – all to protect children against polio.

Vaccinators work long hours, starting at dusk and continuing through the evening only to break briefly for lunch. They vaccinate around 100 children each day and often walk many kilometers to reach pastoralist, nomadic and migrant populations. Vaccinators’ days can be unpredictable: if a security analysis identifies a window of accessibility in a previously inaccessible area, locally recruited volunteers will quickly go in to deliver additional doses of oral vaccines.

Q: What are the biggest challenges to vaccination?

In Somalia, there are a number of challenges, starting with insecurity. In the South and Central zones, more than 35 districts are still partially or completely inaccessible due to insecurity.

Even in secure regions, implementing successful campaigns is difficult because more than half of the population lives in remote areas, and many communities are nomadic, traveling across Somalia and into Kenya and Ethiopia. We have set up 300 transit vaccination points across the country to vaccinate these people, but it remains difficult.

Another challenge is maintaining a cold chain system: with a lack of infrastructure in many parts of the country, vaccinators must use frozen ice packs to keep vaccines cold, which can be difficult when traveling across vast rural areas.

Q: How do the local populations react to vaccinators?

In general, people want vaccine. The Ministry of Health uses radio broadcasting to educate the community on vaccines and to announce polio campaigns, which is very effective because Somalia relies on the radio to obtain information. What’s more, vaccinators tend to come from the community they are working in, which helps build trust and vaccine acceptance.

Q: You work closely with vaccinators: who are they and what does their day look like?

Q: What are the biggest challenges to vaccination?

In Somalia, there are a number of challenges, starting with insecurity. In the South and Central zones, more than 35 districts are still partially or completely inaccessible due to insecurity.

Q: How do the local populations react to vaccinators?

“We’re all immunized against polio!” UNICEF Africa

Six months after polio found its way back to the Horn of Africa, the pace of transmission appears to be slowing.

After several rounds of immunization campaigns, the number of cases being reported at the outbreak’s epicentre in Mogadishu, Somalia, has dropped off. At the same time, Kenya has not seen a case in more than four months and Ethiopia has contained the outbreak to the Somali region alone.

That may be little consolation, however, for the more than 200 children across the Horn of Africa whose lives have been changed forever by this devastating disease – and the outbreak is not completely finished yet. There’s no room for complacency with the high risk that polio will continue to spread.

“While we are pleased with the results achieved thus far, we must remain vigilant as there is still a risk that the virus could spread further, not only within the affected countries, but also cross borders into neighbouring countries,” said Steven Allen, UNICEF Regional Director for Eastern and Southern Africa. “Children in this region and elsewhere will not be safe from polio until we reach every unimmunized child.”

Across the Horn of Africa, close to one million children, most of them in Somalia, have never been immunized or have not received the required number of doses. Low immunization coverage was a key factor behind the outbreak, which was also fuelled by frequent population movement and areas of insecurity.

“WHO and UNICEF have supported countries in their response, working closely with health authorities as well as civil society groups to ensure children everywhere can be vaccinated,” said Hamid Jafari, Director, Polio Operations and Research, WHO.

With the outbreak slowing down, the affected countries are now moving into a new phase of polio outbreak response. The priority is to stop the residual transmission in South Central Somalia and in the Somali region of Ethiopia, reduce vulnerability by boosting immunity of populations and increasing immunization coverage, especially in hard-to-reach and inaccessible parts of the region.

In Somalia, in addition to immunization campaigns, strategies have been put in place to reach the most vulnerable children. Around areas affected by insecurity, 284 permanent vaccination posts have been set up at transit points, and vaccines are readily available in health facilities, so that children moving in or out will not miss out on the opportunity of immunization. In Ethiopia, 28 permanent vaccination points have also been set up in border-crossing and large transit points.

UNICEF and WHO require at least $88 million to support governments’ polio eradication efforts in 2014 and maintain the momentum built over the last six months.

Ali Maow Maalin, smallpox survivor and Somali polio eradication champion, passes away.

Ali Maow Maalin in 1977 – WHO /John F. Wickett

Ali Maow Maalin, recently described as being one of the “true heroes” of polio eradication, passed away on 22 July in his home district of Merka, Somalia, due to sudden illness.

The last person to be infected with naturally occurring smallpox anywhere in the world, Mr Maalin was struck with the virus in 1977 whilst working as a cook at a Merka hospital. Fearing the needle would be painful, he’d previously avoided vaccination by holding his arm when vaccinators came to visit, pretending he’d already received the shot. But after recovering from the potentially deadly illness, he vowed not to let others make the same mistake.

Mr Maalin used his story to illustrate the importance of vaccination and became an important advocate for polio eradication in Somalia, playing an instrumental role in its defeat of the disease in 2008: “Somalia was the last country with smallpox. I wanted to help ensure that we would not be the last place with polio too,” he told the BBC at the time.

A district polio officer, he died on the second day of the polio eradication vaccination campaign he was conducting in Merka district, part of the Supplementary Immunization Activities taking place 21-25 July in response to the current outbreak. A profile of Mr Maalin’s work described him as one of the eradication programme’s “most valuable local polio coordinators”.
Mr Maalin leaves behind a wife and three children. The thoughts of everyone at the Global Polio Eradication Initiative are with his family at this time.

In a polio outbreak in 2006, Namibia carried out several rapid vaccination campaigns for its entire population. UNICEF Namibia/Tony Figueira

Polio is a cunning virus. Just when a nation becomes a little too comfortable with their polio-free status, or when insecurity or some other disruption gets in the way of strong population immunity, that’s when polio pops up and attacks vulnerable communities.

As such, outbreaks will continue to occur until polio is completely eradicated. The Global Polio Eradication Initiative (GPEI) is hard at work making that happen; and the new Polio Eradication and Endgame Strategic Plan 2013-2018 has been designed to wipe out this virus within the next six years. But, in the meantime, the GPEI and the global community will have to be prepared to gain quick control over new outbreaks.

The World Health Assembly’s 2006 resolution on polio eradication – WHA59.1 – is considered the holy book of polio outbreak response. It contains a series of recommendations outlining the ideal response both from the affected country and the international organizations that support them.

Thanks to the resolution and the lessons learned since it was passed, the GPEI is getting better and better at putting an end to new outbreaks. Since 2011, only one outbreak has lasted longer than six months. In 2008, it took an average of 20 weeks to put a stop to a new outbreak; but by 2011, that was whittled down to 12 weeks.

So what exactly does the ideal outbreak response look like? Here is a breakdown:

On the ground

The response in the affected country begins immediately. Within 72 hours of the first polio case being confirmed, the country will conduct an initial investigation, activate the local response and make a request for an international risk assessment (if needed), so that they it can put together an emergency action plan. At least one mass polio immunization round will be conducted within the first 28 days, reaching at least two million children in the immediate area depending on the country’s population, with at least two vaccination campaigns to follow. Surveillance should also be sensitized enhanced, and routine immunization should be boosted to reach at least 80% of children across the country.

Internationally

Internationally, it’s all about providing support to the affected country. Immediate priorities are to ensure they have enough funds, vaccines, finger markers and technical assistance to plan and execute their emergency plans. Outbreak managers are appointed at the regional and global level to coordinate with their counterparts on the ground, and within seven days the emergency action plan will be shared across the spearheading partner agencies.

Ongoing efforts

However, putting a stop to new outbreaks is about so much more than simply being reactive. First of all there is the continuing research into improving the tools and tactics used to tackle polio. So part of the reason why outbreaks are now being stopped more quickly than ever before is due to things like improved surveillance and lab methods (meaning it now takes less time to confirm the presence of polio; hence less time to conduct the first response campaign) and the fact that the GPEI now has more personnel at its disposal (including STOP teams), ready to be deployed to newly affected countries.

Better than outbreak control is outbreak prevention, and the ultimate prevention will be the eradication of polio and stronger immunization systems.

Learning lessons the hard way
Horn of Africa polio outbreak
Success against polio by end-2014 a realistic prospect: IMB

A health worker marks the finger of the President of Somalia to indicate that he has been vaccinated against polio. Courtesy Office of the President

Mogadishu, Somalia – President Hassan Sheikh Mohamoud was first in line to receive a polio vaccine as Somalia’s senior government officials gathered today at the Presidential Villa to launch Somalia’s first-ever polio campaign to vaccinate adults as well as children. This round of the campaign runs from 12 – 19 June, targeting different areas.

In Banadir Region – which includes the capital Mogadishu, where the first case was identified – adults as well as children are being given polio vaccination in an effort to stop the outbreak before it spreads into other regions and possibly into neighbouring countries. While polio mainly affects young children, adults can also catch the virus.
Somalia reported its first case of wild polio for more than six years on 9 May. Already 12 children have been paralyzed , including a 13-year old boy, all in southern Somalia. A further five cases have also been confirmed across the border in Kenya.

As part of the effort to stop one of the world’s only polio outbreaks in a previously polio-free country, the Prime Minister Abdi Farah Shirdon, Speaker of the House, Mohamed Osman Jawari, the Minister of Defence Abdikarin Hajji Mohamud Fiqi,and the Minister of Human Development and Public Services Dr Maryan Qasim all lined up to receive the drops of the oral polio vaccine.

“Polio has returned to Somalia after more than six years and now threatens not only our children but anyone who has not been vaccinated,” said President Hassan. “This is why we will be vaccinating everyone in Banadir, mothers, fathers, teenagers and elders as well as children. I call on the entire community to support this important health campaign. The vaccine is safe and effective and I will take it to ensure that I am protected.”

The launch was attended by the United Nations Humanitarian Coordinator, Philippe Lazzarini and the World Health Organization and UNICEF representatives Dr Ghulam Popal and Sikander Khan, who also took the vaccine.

“The leadership and oversight that both the President and Prime Minister have shown today in launching this polio campaign should be commended,” said Philippe Lazzarini.

“Since confirmation of the polio outbreak on 9 May, two campaigns have already been conducted in Somalia delivering lifesaving vaccines to children at risk of life long paralysis. This week more than four million Somalis will be vaccinated against polio in just eight days – an incredible achievement. The United Nations will continue to support the Somali people in every way possible in their efforts to rid the country of this preventable disease.”

Health experts are worried that the polio virus could spread into other parts of Somalia, including areas where many children and adults have not received adequate vaccinations, as well as internationally. To protect against any such spread, the response is taking several approaches. These include vaccination of different age groups and the set-up of permanent vaccination posts in places bordering areas with large numbers of unvaccinated people. Campaigns will continue to be conducted until polio is once more eliminated from Somalia.

The President expressed confidence that Somalia can again become polio free and thanked partners and supporters gathered at the launch.

“Somalia with the help of many partners and friends has eradicated polio before. On behalf of the Somali people I would like to thank the United Nations, WHO and UNICEF for their continued efforts to assist us develop as a nation with strong health systems and services. Together we can make a stronger, better, healthier Somalia where people can live and flourish free from the threat of preventable diseases like polio.”

The Horn of Africa is currently responding to an outbreak of wild poliovirus type 1 (WPV1). The first vaccination campaign in response to the outbreak, reaching 440 000 children, took place 14-16 May 2013 in Somalia and a second round of vaccination is planned for 26 May 2013 in synchronization with eastern parts of Kenya, targeting just over 1 million children.

A four-month-old girl near Dadaab, Kenya, developed symptoms of acute flaccid paralysis on 30 April 2013. Two healthy contacts of the child tested positive for WPV1. They are the first laboratory confirmed cases in Kenya since July 2011. In addition, a case of WPV1 in Banadir, Somalia was confirmed on 9 May 2013.

The risk to neighbouring countries is deemed as very high, due to large-scale population movements across the Horn of Africa and persistent immunity gaps in some areas. Dadaab hosts several refugee camps, housing nearly 500 000 persons from across the Horn of Africa.

Polio eradication efforts coordinated with broader health agenda

It is crucial that the polio currently circulating in Kenya does not reach the refugee camps in other parts of the country. Kate Holt/IRIN

With the detection of WPV in Kenya, it is crucial that transmission is rapidly interrupted to avoid further spread to neighbouring countries, especially those affected by drought and famine. Malnutrition lowers immunity, and the conditions in (and en route to) refugee camps allow communicable diseases, including polio, to easily spread. Furthermore, local health workers can be overburdened dealing with the health complications of the drought, affecting the provision of regular and routine healthcare. The hundreds of polio-funded staff on the ground in the Horn of Africa have expanded their mandate to help ensure that the most basic needs of the people of the Horn of Africa are met.

On 25 August, a Kenyan child was paralysed by wild poliovirus type 1 (WPV1). Genetic sequencing found the virus to be genetically related to WPV1 last seen in Uganda in November 2010, indicating that transmission had been ongoing, undetected, somewhere along the border between the two countries. The infected province is near to borders with both Uganda and Tanzania, increasing the risk of international spread. An outbreak response plan has been implemented, and vaccination campaigns have been conducted in Tanzania and Uganda, as well as in Kenya.

Meanwhile, funding remains an issue. The Global Polio Eradication Initiative as a whole faces a $US 535 million funding gap for 2011-2012, $US 77 million of which is earmarked for the Horn of Africa. The immediate gap for Kenya, Sudan and Uganda is US$ 4.58 million. Funding shortages in 2010 caused the curtailing of polio eradication activities, including in the district which has now reported a case. There is also a clear need for disease surveillance to be improved in the Horn of Africa, and greater funding is required to ensure the appropriate improvements can be made.

For more information, please see this briefing note giving a detailed overview of the current situation, key challenges, the Global Polio Eradication Initiative’s responses and current funding requirements, as of October 2011.

Brief on polio, response and funding needs in Horn of Africa

UNICEF releases a series of videos documenting vaccination campaigns in Kenya.

A community health worker goes door-to-door to vaccinate children during a measles and polio immunization campaign in the town of Dadaab. Siegfried Modola/UNICEF — A community health worker goes door-to-door to vaccinate children during a measles and polio immunization campaign in the town of Dadaab.
Siegfried Modola/UNICEF

In the wake of drought and famine across the Horn of Africa, thousands of refugees have made the journey to Kenya in search of food and water. The population of the world’s largest refugee camp in Dadaab is now around 400,000 and thousands more are displaced across the region. Crowding, inadequate sanitation and poor immunity due to malnutrition combine to create the perfect climate for diseases to spread – diseases like polio. Global Polio Eradication Initiative partner agencies continue to strive to prevent outbreaks of vaccine preventable diseases.

Two videos released by UNICEF show the work being done on the ground – the first in Dadaab and the second in Liboi on the Somali-Kenyan border. Across the Horn of Africa, polio-funded staff are involved in similar vaccination campaigns, working against the clock to improve the immunity of hundreds of thousands of malnourished children.

Thousands of people across the Horn of Africa are facing severe food and water shortages in what is being called “the worst drought in 60 years”. At the same time, high food prices are amplifying the drought’s impact.

Hawa Issak lives with her son in the Ifo refugee camp, in North Eastern Province, near the Kenya-Somalia border.
UNICEF/NYHQ2011

The Global Polio Eradication Initiative (GPEI) and its lead technical agency the World Health Organization (WHO) are working with several aid and humanitarian agencies, along with the governments of the affected countries, in a coordinated response to the escalating crisis.

Compounding the problem

With little access to food and water, and with ongoing conflict in some areas, many people are faced with little choice but to pack up and leave their homes and livelihoods. Refugee camps are facing an influx of thousands, and are subsequently having to look after many more than they were initially designed to care for. In June alone, over 30,000 Somali refugees were registered at the Dadaab Refugee Camp in northern Kenya, bringing the population of the camp up to more than 370,000.

The WHO in Kenya estimates that 20 to 34% of women and children in Kenya are suffering from global acute malnutrition. But beyond the clear dangers of malnutrition and dehydration, outbreaks of diseases are a constant threat. Reaching people with vaccines is complicated by the high levels of population movement, while the movement itself enables diseases to spread more quickly over a wider geographic area. People weakened by inadequate nutrition are also more vulnerable to infection. The lack of adequate sanitation has already led to deadly outbreaks of diarrhoea in Djibouti and Ethiopia. In the Dadaab camp, there have been 462 laboratory-confirmed measles cases, including 11 deaths. The threat of cholera and visceral leishmaniasis are spectres looming over the region.

A coordinated effort

The WHO is coordinating with many of the key players in international aid and working alongside the governments of the affected countries to help ensure their health, water, food and sanitation needs are met.

One example of multi-agency cooperation is the mass measles immunization campaign, launched under the leadership of WHO, taking place from 25-29 July. The campaign will target 215,000 children under five years of age in the Dadaab refugee camp, as well as the host districts of Fafi, Lagdera and Garissa in Kenya. Oral polio vaccine (OPV) will also be administered during the campaign. WHO will provide technical capability, funding and OPV, while UNICEF will provide measles vaccine and social mobilization expertise.

Polio eradication resources, staff playing an important role

The hundreds of skilled polio personnel in the Horn of Africa have been involved since the crisis began. Polio resources such as communications and transportation capability have also been made available. An existing Horn of Africa-wide body for collaboration on polio eradication has now expanded its mandate to deal with the drought. And while insecurity is an increasing problem, the polio network has been involved in initiating dialogue and developing plans to reach vulnerable populations in the coming weeks.

Child Health Days (CHDs), largely run by polio-funded staff, have already begun in Somaliland, Somalia, providing mothers and children with a package of health interventions including OPV, tetanus toxoid (for mothers), and measles vaccines, deworming treatment, nutritional screening and referral. Similar CHDs will take place in Puntland, Somalia from 17-21 July.

Polio staff are on guard for any new polio cases. They are also being used to ensure the overall health and wellbeing of those impacted by the drought. The existing polio surveillance network has been put on a heightened state of alert to monitor for any outbreaks in the Horn of Africa and its neighbours; and polio vaccines are being delivered as an additional health measure whenever possible. An important priority of the crisis response is to protect children in the region from polio and to prevent an outbreak. The last large outbreak in the Horn of Africa – originating in Nigeria – eventually spread all the way to Indonesia and was part of an outbreak which, throughout 2004 and 2005, paralysed 1400 children for life.

Financing to protect children in the Horn of Africa from polio

The polio funding requirements for all Horn of Africa countries are US$122 million for the next 18 months, with Sudan, South Sudan and Ethiopia accounting for the bulk of the need. A shortage of funding in the first quarter of 2011 forced the scaling back or delays in implementing supplementary immunization activities in Ethiopia, Djibouti, Uganda, Kenya and Eritrea, raising the possibility that large groups of children remain vulnerable to polio, especially as the drought forces more population movement and weakens immunity.

The Horn of Africa is officially polio-free, with Sudan, Kenya and Uganda having reported no wild poliovirus cases for more than a year.

Children line up for oral polio vaccine at a school in Sudan. Johann Hattingh/UNMIS — Children line up for oral polio vaccine at a school in Sudan.
Johann Hattingh/UNMIS

In the first half of 2009, an outbreak of wild poliovirus that originated in northern Nigeria spread from southern Sudan to Port Sudan, Kenya and Uganda. The cases in Port Sudan sparked particular international concern as it was from this area that, from 2004 to 2006, wild poliovirus type 1 spread to re-infect several countries, including Saudi Arabia, Somalia, Yemen and Indonesia.

However, the implementation of swiftly conducted mop-up campaigns followed by multiple immunization activities, all supported by high-level political commitment, stopped the outbreak within six months – and the region has now stayed polio-free for more than 12 months since the last case.

Recognizing that the epicentre of the outbreak was in southern Sudan, the President of the Government of Southern Sudan, His Excellency General Salva Kiir Mayardit, launched a ‘President Action Plan for Polio Eradication’, directing all state governments, county and district heads to personally oversee the quality of outbreak operations in their areas. Multiple immunization activities were held, and Sudan’s last case was reported on 27 June 2009.

Uganda drew praise for the speed with which it fully implemented the international polio outbreak response standards, conducting a mop-up immunization activity around the index case within days of it being confirmed, followed by multiple high-quality immunization activities, with no cases reported since 10 May 2009.

Kenya, which had been polio-free since 1984, implemented the Short Interval Additional Dose strategy, providing multiple doses of oral polio vaccine two weeks apart to the highest-risk populations in Turkana. The result was immediate, with the last case in Kenya reported on 30 July 2009. Ethiopia has been free of wild poliovirus since 2008 and Somalia since 2007.

The outbreak response was made possible by $500,000 in emergency grants by Rotary International.

Country: Horn of Africa

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Polio eradication efforts coordinated with broader health agenda

UNICEF releases a series of videos documenting vaccination campaigns in Kenya.

Thousands of people across the Horn of Africa are facing severe food and water shortages in what is being called “the worst drought in 60 years”. At the same time, high food prices are amplifying the drought’s impact.

Compounding the problem

A coordinated effort

Polio eradication resources, staff playing an important role

Financing to protect children in the Horn of Africa from polio

Related documents

The Horn of Africa is officially polio-free, with Sudan, Kenya and Uganda having reported no wild poliovirus cases for more than a year.