GPEI-Polio leaders in Pakistan on extraordinary operations visit

Dr Nadeem Jan, newly-appointed interim Federal Health Minister Pakistan, and Aidan O’Leary, Chair of the GPEI Strategy Committee. © NEOC Pakistan

4 September 2023 – Recognising the importance of Pakistan in the global polio eradication effort, as one of the last two WPV1-endemic countries, the operational polio leadership of WHO and the US Centers for Disease Control and Prevention (CDC) travelled this week to Pakistan to observe first-hand operations, latest developments and innovations, and meet with newly-appointed political leadership. The delegation, which was in-country from 29 August to 1 September, consisted of Director of Polio Eradication at WHO Headquarters and Chair of the Global Polio Eradication Initiative (GPEI) Strategy Committee Aidan O’Leary from WHO and Richard Franka, Team Lead of the Pakistan Team at Polio Eradication Branch, CDC.

The GPEI leaders noted the unprecedented historic opportunity to achieve success in the country this year, with WPV1 transmission at record-low levels. At the same time, the group noted the high level of engagement and political will for the effort, at all levels. Meeting with Dr Nadeem Jan, newly-appointed interim Federal Health Minister who visited the polio National Emergency Operations Centre (NEOC) on his very first day in office last month, the delegation received assurance that polio eradication is a key operational priority for Dr Jan’s tenure.

Provincial caretaker Health Minister Dr Saad Niaz and Aidan O’Leary discuss steps the programme is taking to keep track of polio cases in Karachi. © NEOC Pakistan

Dr Jan stated: “It is important for us that our country and global partners and donors stand together in this final leg of the eradication journey. I am a polio worker at heart. I will ensure that not only does polio remain a priority at all tiers of governance, but efforts are more targeted and intensified.”

This level of commitment was further mirrored at meetings with other national and provincial political and health leaders, including the Engineer-in-Chief at the General Headquarters in Islamabad, provincial health ministers of Khyber Pakhtunkhwa and Sindh, and the Chief Secretary of Sindh, to ensure the new interim administration in the country carries the positive momentum forward. Together, concrete ways to capitalize on the current epidemiological opportunity were discussed, including in fully implementing recommendations by the recent Technical Advisory Group (TAG) for Polio Eradication in Pakistan and Afghanistan, in particular in implementing area-specific and tailored tactics to overcome area-specific challenges to reaching remaining un- or under-vaccinated children. The delegation also visited field activities and witnessed first-hand the tremendous efforts, innovations and commitments undertaken by polio workers and local communities, including in the remaining WPV1-endemic districts of the southern area of Khyber Pakhtunkhwa.

Speaking on behalf of the delegation, Aidan O’Leary commented: “Rarely have I seen this level of commitment to achieve success. On behalf of the GPEI, and on behalf of children and parents everywhere, I would like to thank and commend authorities at all levels in Pakistan for their tremendous engagement, leadership and commitment to reaching every last child. Literally no stone is being left unturned to find and vaccinate all remaining unvaccinated children, in particular in the remaining endemic areas of the southern area of Khyber Pakhtunkhwa province. With this level of commitment, I am confident a polio-free Pakistan will soon be achieved, and GPEI partners of course remain committed in supporting Pakistan’s authorities in this quest.”

The delegation was also attended by members of the international development community, including local representatives of Rotary International.

ISLAMABAD, JULY 21, 2023 – A high-level delegation of the Global Polio Eradication Initiative (GPEI), including the Polio Oversight Board, visited Pakistan to discuss the impact of political transition on eradication efforts and the strategies in place to vaccinate children that remain unreached in the polio-endemic districts of southern Khyber Pakhtunkhwa.

Led by Dr Chris Elias, Chair of the Polio Oversight Board and President Global Development, Bill & Melinda Gates Foundation, the delegation included WHO Regional Director for the Eastern Mediterranean Region Dr Ahmad Al-Mandhari, UNICEF South Asia’s Deputy Regional Director Noala Skinner, CDC’s Polio Eradication Branch Chief Dr Omotayo Bolu, Chief Programme Strategy Officer from Gavi-the Vaccine Alliance, Aurelia Nguyen, Trustee of Rotary International Foundation Aziz Memon, and High Commissioner of Canada in Pakistan Leslie Scanlon, who represented all donors to the GPEI.

This was the first visit by the POB and representatives from all GPEI partners to Pakistan in 2023. The POB is the highest decision-making and oversight body of the GPEI.

During the four-day visit from 16 – 20 July that included Lahore, Peshawar and Islamabad, the delegates visited the National and Provincial Emergency Operations Centers, attended a meeting of the National Task Force on Polio Eradication, and held separate meetings with the leadership of the Pakistan Army, Health Minister Abdul Qadir Patel and Foreign Minister Bilawal Bhutto Zardari.

“Pakistan continues to make important progress in the fight to eradicate polio. I’m impressed by the commitment I’ve seen again this week from the federal and provincial governments in getting the job done,” said POB Chair Dr Chris Elias. “The experience globally is that strong government leadership is key in the final push to defeat polio.”

The delegation also met the Governor of Punjab, Chief Minister of Khyber Pakhtunkhwa and provincial chief secretaries, health secretaries, commissioners and deputy commissioners of priority districts of Punjab and Khyber Pakhtunkhwa in Lahore and Peshawar, respectively, and met with the Chief Secretary of Balochistan.

“While the challenges before us are formidable and complex, I remain cautiously optimistic about the goal of interrupting transmission of poliovirus in Pakistan by the end of this year. This will require solidarity and collective action at all levels to enable rigorous implementation of the strategy, that must be fully supported by communities and the political, administrative and security leadership,” said WHO Regional Director Dr Ahmed Al-Mandhari.

Endemic transmission of wild poliovirus remains restricted to seven districts in the south of Khyber Pakhtunkhwa province, namely Tank, Bannu, North Waziristan, South Waziristan Upper, South Waziristan Lower, DI Khan and Lakki Marwat.

A vaccination campaign is ongoing in the seven endemic districts named “Reaching the Unreached.” The campaign specifically targets over 270,000 children under five in 69 low-performing union councils where vaccine coverage for polio and other essential immunization has been inadequate.

“Under our regional vision of health for all by all, WHO will continue supporting Pakistan’s polio programme to give our future generations a world free from polio,” Dr Al-Mandhari added.

UNICEF’s Deputy Regional Director Noala Skinner appreciated the leadership. “We applaud the leadership of Pakistan and the dedication of frontline workers, including thousands of women, who tirelessly vaccinate and protect millions of children from the deadly poliovirus,” she said, adding, “The next six months are critical for Pakistan’s efforts to eradicate polio. We are so close to our goal of reaching all children with polio vaccines. Together, we must ensure that the programme is able to reach every child in Pakistan, regardless of where they live.”

Dr Humayun Asghar. © WHO/EMRO

The vast machinery of the global polio eradication programme is much like the inner workings of a clock – a network of interconnected people, organizations and programmes that together are more powerful than the sum of their parts. Collaboration is foundational to eradication, and every eradicator plays a part in edging the programme closer to its goals.

But in some cases, individual eradicators develop capacities or practices that enable programmatic leaps. Dr Humayun Asghar is one of those outsize drivers of progress. His initiatives around early laboratory testing of stool samples of children with acute flaccid paralysis (AFP), his efforts to create a cross-regional network of labs, and his efforts to set up a large pioneering network of environmental surveillance sites in Egypt are innovations that today power the programme’s surveillance capacity. We know where the virus is, even in the absence of paralytic polio cases, largely thanks to his work.

In 1988, when Dr Humayun joined the National Institute of Health (NIH) in Pakistan’s capital city of Islamabad, polio was paralysing more than 1000 children worldwide every day and the Global Polio Eradication Initiative (GPEI) was just being set up. Dr Humayun spotted an opportunity to stop the spread of poliovirus by tracking it – which meant identifying which children with AFP were infected with poliovirus and which children were experiencing paralysis for other reasons. In 1991, Dr Humayun began to contact pediatricians and, later, vaccinators, to collect stool samples from children who presented with AFP to test them for poliovirus infection. In a nod to the doctors’ and vaccinators’ contribution, Dr Humayun shared the results immediately with the reporting individual, regardless of their location.

The information filled a gap for physicians who wanted to know why their patients were unwell, and it provided a new level of detail on the virus’ whereabouts. Word got around and soon, more and more doctors started sending in their AFP patients’ stool samples. As the practice grew, processes needed to be formalized: Dr Humayun and his colleagues had to ensure stool samples were reaching them in the right conditions for testing, which led to the establishment of a set of criteria and standard operating procedures around the transportation of stool samples – something known today as the reverse cold chain.

The dawn of AFP surveillance in Pakistan

This new system unveiled the dawn of an era of detailed, systematic surveillance for AFP, the most common, tell-tale symptom of poliovirus infection. That it grew out of mutual trust and collaboration with focal points in the community reaffirmed Dr Humayun’s belief, “If you offer service to the community, the community serves you.”

Site selection during establishment of polio environmental surveillance in Pakistan. © WHO/EMRO

In their quest to fill in gaps in disease surveillance and formalize a practice of testing samples from AFP patients, Dr Humayun and his colleagues succeeded in establishing the first poliovirus laboratory in Pakistan.

Dr Hamid Jafari, WHO Polio Director for the Eastern Mediterranean Region, says this contribution to eradication cannot be overstated.

“Dr Humayun has sowed the seeds of AFP surveillance in Pakistan all through his own initiative and drive and nurtured and supported the lab network in the Eastern Mediterranean Region; as one of the architects of the regional and global laboratory network, he has contributed to building a great legacy.”

Advancing the Region’s work

Over the intervening decades, Dr Humayun has helped the Region’s laboratory network grow in size and skill, bringing in new practices such as testing for poliovirus in sewage water (environmental surveillance) and then harnessing this new practice to test for the presence of other diseases – most recently, COVID-19. He also took the practice out of the Eastern Mediterranean Region and into the African Region, supporting the polio laboratory in Nigeria to introduce environmental surveillance.

Collecting the first sample for polio environmental surveillance while training health workers, Nigeria. © WHO

Testing for and tracking the virus in stool samples and sewage water enabled the programme to identify different types of poliovirus, and by building on this, a practice was developed to conduct nucleotide sequencing, which provides a fuller picture of viruses’ lineage and allows scientists to identify which family any given poliovirus belongs to. Dr Humayun attributes these accomplishments to laboratory staff, who strengthened their own capacity to diagnose polio without waiting for results from other global specialized laboratories.

Supporting others to grow

Since he joined WHO’s Eastern Mediterranean Region in February 2002, Dr Humayun has served in several capacities – as Scientist Virologist, Regional Advisor for Public Health Laboratories, and finally as the Coordinator for the Region’s Poliovirus surveillance, Laboratory support and Data management. He credits two mentors in particular for inspiring his career – the late Dr Helmy Wahdan, former Polio Director for WHO’s Eastern Mediterranean Region, and Dr Olen Kew, a poliovirus scientist – and, over the course of his career, has tried to pay that inspiration forwards.

“Dr Humayun has mentored and supported young scientists and laboratory specialists across the Region to advance their skills and careers,” said Dr Nima Saeed Abid, WHO Representative for Sudan. “He has been a true leader in his field.”

Perhaps unsurprisingly, Dr Humayun believes one of the keys to eradicating polio lies not in the lab, but in people: in empowering and engaging the workforce by incentivizing them with education, training and promotion.

On the occasion of his retirement in May 2023, Dr Humayun expressed gratitude that he was able to witness and contribute to two important milestones: the eradication of wild poliovirus types 2 and 3.

And when the eradication of WPV1 does happen, he says, “I will be cheering from the sidelines, alongside so many other vital contributors to the programme’s legacy.”

Global leaders and stakeholders have been unanimously declaring their solidarity to achieving a lasting world free of all forms of polioviruses.

Convening this week at the World Health Assembly in Geneva, Switzerland, Ministers of Health from around the globe evaluated the unique epidemiological opportunity which currently exists, in particular in eradicating all remaining chains of endemic wild poliovirus in a handful of districts of just two countries – Pakistan and Afghanistan. As a record number of Member States and civil society partners took to the floor, key to success, all experts agreed, must be on adapting operations and reaching remaining un- or under-immunized children in just seven subnational most consequential geographies, with collectively account for 90% of all new polio cases, including in a gender-equitable and integrated manner. To ensure lasting success, delegates urged country-specific solutions for polio transition. In response to both a wild poliovirus outbreak in south-eastern Africa and multi-country circulating vaccine-derived poliovirus outbreaks, extraordinary special sessions were led by WHO and its Regional Office for Africa between affected Member States and partners, to discuss concrete steps to stopping all outbreaks affecting the Region by end of year.

The World Health Assembly comes on the heels of last week’s G7 Leaders and G7 Health Ministers meetings in Japan, where both meetings highlighted the urgent need to ensure a world free of polio can be rapidly achieved. Next week, Rotarians from around the world are convening at the Rotary International Convention in Melbourne, Australia, to ensure civil society support for the effort will go hand-in-hand with public sector engagement.

Speaking on behalf of both Pakistan and the entire Eastern Mediterranean, Mr A.Q. Patel, Pakistan Federal Minister for National Health Services, Regulations and Coordination, said: “We are in the final leg of eradication and we are doing everything we have to do to achieve success. The virus is restricted to its smallest-ever geographical footprint, and the (polio) programmes in both Pakistan and Afghanistan continue to vastly expand their hunt for the virus and mount robust campaigns to reach all children, not just with polio vaccine, but indeed other antigens as well. We could not have come this far without the strong support and goodwill of all Member States, however there is still more to be done at the heart of all our work, and for the future of all generations of children. We need continued and sustained financial and political support from all Member States and partners, in order to give every child, no matter where they live, the promise of a polio-free world.”

H.E. Dr Hanan Mohammad Al-Kuwari, Minister of Public Health of Qatar, and Co-Chair of the Eastern Mediterranean Regional Subcommittee for Polio Eradication and Outbreaks, commented: “In our Region, we have made significant progress in both containing the spread of wild poliovirus and closing outbreaks of vaccine variant polio. Afghanistan and Pakistan have restricted the virus to the smallest geographical footprint in history and are now doubling up efforts to fully interrupt the remaining transmission. The engines fueling this progress are manifold, but the two most powerful, and the two I truly believe will get us across the line, are improved immunity and better surveillance. We are reaching and vaccinating more children, more often, and we are using the most sensitive and robust surveillance measures in history to ensure that if the virus is there, we are not missing it. Excellencies, partners and colleagues, I ask this as clearly as I can: Stay the course. Dig deep to do what needs to be done. Stand with us and be part of history.”

Noting the global commitments being made, Jean-Luc Perrin, Rotary International’s Representative to the United Nations in Geneva, told the global health community at the Assembly: “Polio eradication is a rare example of enduring, truly global collaboration toward a goal whose achievement will benefit all nations in perpetuity, while contributing toward broader global health priorities. We cannot take progress or possible victory for granted. Let us make collective history and End Polio Now!”

In conclusion: global leaders continue to note the very real window of opportunity for success this year, but that this window will not remain open for long. The virus will again gain in strength. Only collective and global collaboration will result in ultimate success, and delegates and leaders urge all stakeholders to keep the focus firmly on one overriding objective: reaching remaining un- or under-vaccinated children in the most consequential geographies. A collective responsibility, but if achieved, will result in success in 2023.

Additional quotes from the World Health Assembly:

“WHO and our partners remain steadfastly committed to finishing the job of consigning polio to history. Last year, three million children previously inaccessible in Afghanistan received polio vaccines for the first time. And in October, donors pledged US$2.6 billion to support the push for eradication. At the same time, as part of the polio transition, more than 50 countries have integrated polio assets to support immunization, disease detection and emergency response. We must make sure that the significant investments in polio eradication do not die with polio, but are used to build the health systems to deliver the services that these communities so badly need.”- Dr Tedros Adhanom Ghebreyesus, Director-General, World Health Organization

“Wild poliovirus transmission has been cornered to the smallest ever geographic locations in the Eastern Region of Afghanistan and seven districts in southern part of Khyber Pakhtunkhwa in Pakistan. However, the last 100-metre dash presents its own challenges and we must do all we can to achieve success.” Dr Hamid Jafari, Director for Polio Eradication for the Eastern Mediterranean, on behalf of Dr Ahmed Al-Mandhari, Regional Director, World Health Organization Eastern Mediterranean Region

“The African Region, which was certified free of wild poliovirus in 2020, has set itself the objective of stopping the transmission of all types of 2 polioviruses by the end of 2023 and integrating polio assets into activities that strengthen broader disease surveillance. It is also deploying integrated public health teams to respond to other emergencies, building on experiences from past poliovirus outbreaks and leveraging the polio network and infrastructure for response activities.” – Delegation of Burkina Faso, speaking on behalf of the entire African Region.

Islamabad – An announcement over a loudspeaker from the mosque captures the attention of parents and their children. The voice announces that a polio campaign is taking place in the settlement and vaccinators will be coming to give two drops to children under five. Eight teams of two vaccinators each are already on their way, each starting their day from the farthest house in the community and making their way to the center.

In January, when Pakistan detected a positive wild poliovirus from a sewage sample with genetic links to the virus circulating in Afghanistan, the polio teams jointly conducted a detailed epidemiological investigation to trace the routes of virus movement and identify infected populations. In a matter of weeks, a response was planned and implemented, vaccinating around 6.37 million children from 13 – 17 February. In this article we take you to an Afghan refugee settlement in Islamabad, one of the 30 districts that were covered partially and where the outbreak response focused on mobile and cross-border populations.

The story looks at three important components of a campaign: vaccinators, vaccines and tally sheets.

Vaccinators: the backbone of programme

“Who is there”, asks a man from inside the house, in Pushto.

“Polio team,” responds Salma who speaks Pushto. “We are here to give polio drops. Do you have children under five at home?”

A tall man with a three-year-old boy in his arms, opens the door and welcomes the two vaccinators. Salma introduces herself and her team member Amina and asks the father if either of their children had received polio drops that day. The father confirms that in this round, his children did not receive any polio drops.

“Can I give them the polio drops?”, asks Salma.

The father responded back energetically, “Of course, you can! I want my child to grow up healthy!”

This is when Salma opens the blue box. Inside it are ice packs and vials of oral polio vaccine. She talks to the little daughter and asks her to open her mouth and gives her two drops from the vial.

After giving the drops, she marks the girl’s little finger. “You can show this incase anyone asks if you got the polio drops.”

Amina, on the other hand, fills out the tally sheet that she will later submit to her supervisor. If this information is incorrect, it can impact the overall operational coverage data for the campaign.

On leaving the house, Amina takes out her chalk and marks the door of the house with key information that will mention what day they visited, the number of children under five in the house and if there was any child with symptoms of acute flaccid paralysis.

One house done, now on to the next one.

Vaccines: two drops for every child

“It is not always this straightforward,” says Amina. “Sometimes parents are skeptical about the vaccine and don’t want us to vaccinate their children. I often take the drops myself to show them how safe the vaccines are. When they see me taking these drops, it helps us build confidence with them.”

The polio programme has a long history of systematically listening to community concerns and addressing them, often engaging influencers such as religious leaders, to underscore the safety and efficacy of polio vaccines. This has helped address vaccine hesitancy and reached more children, building their immunity against this debilitating disease. At this settlement, occasional announcements were made through the mosque, informing people that a polio campaign was taking place and encouraging them to vaccinate their children. The result of these efforts has helped the programme significantly reduce the number of refusals across the country.

The blue box Amina carries with her has a large red “End Polio” sticker and it can carry up to 20 vaccine vials, nestled between the ice packs. Each vial contains 20 doses. She pays special attention to the box making sure the temperature is always maintained and the vaccines are kept out of direct sunlight. Vials that have been used, those that are unused and the ones in use are all kept in separate bags in the cold box.

Tally Sheets: supporting real-time corrective actions

The third important piece of a polio campaign is the tally sheet. In rudimentary terms, it is a piece of paper with many tiny boxes that deliver a telling story of number and ages of children, those who were vaccinated, those who were missed, location where the campaign is taking place and number of doses delivered. In case of any refusals, the vaccinator mentions the reason for refusal at the back of the tally sheet. It tells how well an area has been covered and the remaining gaps.

Markings on a house entrance after visitation by polio vaccinators. © WHO/EMRO

The authenticity of this data is a crucial component of operational coverage. It allows supervisors to identify gaps, present progress and advise corrective actions for vaccination teams. Each evening, this data is used to measure the campaign’s operational coverage.

In one of the houses where the vaccinators entered, the mother mentioned that the child had already been vaccinated. However, no finger of the child was marked , while the others each had a blue mark on their pinky finger. Taking no chances, the vaccinator took out the vial and gave the child drops and then marked the finger. The tally sheet cannot be marked unless a child has been vaccinated and finger-marked.

Getting past the finish line

Up until April, Pakistan has conducted four polio vaccination campaigns. With the support of 390,000 polio workers, almost 43 million children under-five were vaccinated during a five-day nationwide vaccination campaign. There are multiple campaigns planned for the year ahead, requiring hours of strategic and evidence-based planning led by the national and provincial emergency operations centres.

Leaving nothing to chance during this last 100 meter dash towards eradication, the programme has also started implementing innovative interventions, such as the nomad population mapping and vaccination of high-risk mobile populations, engaging public health students for monitoring campaigns through the Lot Quality Assurance Sampling survey and the co-design initiative that engages women polio workers to develop solutions for improving campaigns and identifying potential livelihood opportunities for them in the future.

For Amina and Salma, the conclusion of the February round meant that children under five had received the vaccine to build strong immunity against the poliovirus. However, the journey to eradication continues. After a short break, the programme will begin working on validating the next set of microplans. All of this work is essential to ensure that the virus really finds no place left to hide and no child left to paralyze.

Islamabad – As he rode his motorbike out of the relative safety of Bannu city on a September morning, Danyal Sikandri was nervous. It was his first day on a new assignment, and he was riding out into the district outskirts with colleague Yasir Shah in search of a reclusive group of people – nomads.

Their task was to find nomadic settlements and vaccinate the children there against polio and other vaccine-preventable diseases. Sikandri has been involved with the Pakistan Polio Eradication Programme since 2019, first as vaccinator and then area in-charge. Therefore, he was no stranger to interacting with people. But with this assignment, he didn’t know what to expect, since he would be travelling long distances to find people who might not speak the same language, might be unwelcoming or worse, he could end up in an area which may not be secure.

After travelling for about 36 kilometers, the team found a nomadic settlement in Domel. A group of families clustered together in makeshift tents made of plastic sheets and cloth. Sikandri approached the elders and explained why they were there. The nomads, who had come from Afghanistan and were temporarily camped in Domel, warmly welcomed the vaccinators in their midst.

As Sikandri vaccinated 14 children in the camp that day, his nervousness dissipated, and a resolve set in – to bring life-saving vaccines to as many nomadic children as he could.

“When I met them, I saw how different their lifestyle is, since they are constantly on the move and far from health facilities,” says Sikandri. “They want to protect their children from diseases too, so they are happy to see us. They tell us that it is the first time that vaccinators have come to their tents to vaccinate their children.”

Sikandri is one half of a two-member special mobile team which works under Pakistan Polio Programme’s latest initiative to reach segments of the population with polio and essential vaccines, which they would otherwise not have access to. The nomad vaccination initiative was launched in September 2022 in the seven endemic districts of southern Khyber-Pakhtunkhwa (KP) and expanded to four districts of Punjab neighboring these districts in October. The initiative was further expanded to include more districts from Punjab in January and Balochistan in early March. A total of 80 mobile teams in 22 districts have been deployed so far to reach nomadic children.

“With this initiative, we are filling a crucial gap. In the past, we were vaccinating children on the move, in buses, on train stations and other transit points, but the children that were being left out were from nomadic populations. This initiative is a product of extensive research, where we mapped out population movements and based on that information, made mobile vaccination teams to reach nomadic children with polio as well as all essential immunization necessary for their health and safety,” said Dr Zainul Abedin Khan, the National Team Lead for WHO’s Polio Operations in Pakistan.

“This is an excellent initiative of the Government of Pakistan, with support of polio partners, to protect children who had never been vaccinated before. This initiative will keep expanding based on the movement patterns. With this, we hope that population immunity is increased, and poliovirus is interrupted permanently,” he added.

“They want to protect their children from diseases too, so they are happy to see us. They tell us that it is the first time that vaccinators have come to their tents to vaccinate their children.”

Since nomads are highly mobile, the children in these communities are missed during routine vaccination campaigns or even at transit vaccination sites because they may not be passing through formal routes. This means their immunity remains weak, they are vulnerable to disease and can potentially transmit poliovirus as they travel across country and district borders.

In 2022, the program conducted a comprehensive survey of nomadic movement patterns in February and March in 14 districts of KP, Punjab and Balochistan. The survey found that nomadic movement begins in southern KP in September and ends in March, with the nomads setting up temporary camps as they pass through various districts.

“It is difficult for our door-to-door vaccination teams to reach them since a majority of nomads live on district borders or peripheries and it is not even known when they are coming,” said Muhammad Asif Javaid, who leads the program’s High-Risk and Mobile Population Unit (HRMU) and is spearheading this initiative. “They are frequently on the move, staying in places temporarily, never settling, so they miss the opportunity to receive polio and routine immunization.”

In the first phase of implementation, two special mobile teams – consisting of a trained vaccinator and a team assistant – were deployed in each of the seven districts of southern KP and four districts of Punjab. Subsequently, the project was expanded to cover 22 districts of the country.

Union council staff collect data on nomads visiting their areas. This information along with weekly micro-plans and targets are provided to vaccinators, who travel across their assigned UCs to visit these settlements. They provide polio and other essential vaccinations to children in the camps and issue vaccination cards to the families to ensure the data remains on record.

Javaid said that these teams are also helping with surveillance for cases of acute flaccid paralysis (AFP) by asking families and looking for any children who might have AFP, and then ensuring that it is reported to relevant authorities for further testing.

As of March 31, more than 114,600 children under the age of five had received the oral polio vaccine, 71,206 had received the inactivated polio vaccine, while nearly 20,000 routine immunization antigens have been administered to eligible children, under this initiative.

“Currently the program is actively working to vaccinate chronically missed children and is focusing on reaching missed populations rather than prioritizing geography alone,” Dr Zainul Abedin Khan added.

The task is challenging for vaccinators, who travel many kilometers out of urban centers to find nomadic settlements. They might run out of fuel, the settlement might have packed up and left by the time they arrive, or they may encounter hostility, but the vaccinators take it in their stride, happy to be safeguarding children’s futures.

For Sikandri, the experience has been rewarding. He has seen areas of his native district now that he had never seen before, and he feels his communication skills have improved since he began working on this project.

“We have received a lot of love from these people. When we vaccinate their children, they are thankful and pray for us. It feels good that people like them and their children are also being taken care of,” said Sikandri.

FATEHPUR – In Fatehpur, any mention of the month of August is followed by the word ‘qayamat’.

In Urdu, qayamat is used to express what the end of the world would look like. It could be a physical or metaphorical experience and is often used to describe a feeling, a feeling of utter devastation and destruction, when all is reduced to nothingness.

The world really did seem to end for the people here in Fatehpur, Rajanpur district, when the monsoons, once a celebrated time of the year in Pakistan, brought with them the climate’s wrath. Fatehpur was among the 90 calamity-hit districts in the country after the super floods and rains left a third of Pakistan under water and affected one in seven people in the country of over 220 million.

“We only had 25 minutes to leave the house. All I did was lock the door and run with my family after we heard the announcements to evacuate,” says Sughra Javed, a Lady Health Vaccinator, part of the polio immunization campaign.

But locks could provide little protection from the scale of the disaster that was to come. Shahida left for her mother’s house and came back two weeks later, only to find three-feet-deep water all around and the belongings she had gathered for years, old cotton blankets, a TV set, clothes folded in trunks, all gone.

There was little time here to process this loss. Around a week later, the health workers were back on the field serving at health camps that began in late August, nearly 10 days after Rajanpur experienced its worst floods in history.

“I would be working, vaccinating, but it was so difficult to focus. Seeing the broken structure of my house made me want to run away when I was home, and when in the field at work, it was unbearable to see so many people suffering. One after the other, house after house was destroyed,” says Nasreen Faiz, who was among polio team members part of the September campaign.

“My entire village was finished. The crops were gone, the homes were gone, the animals were dead. But at least we had work, I would keep thinking of the people who didn’t even have work,” she adds.

Rajanpur was among districts where the nationwide immunization campaign was suspended as the calamity unfolded. But polio work continued a month after, in between the destroyed cotton crops and cracked land, still too soft to step on.

For Dr. Shahzad Baig, the Coordinator of the National Emergency Operations Centre (NEOC), it was painful to witness his country experience a humanitarian crisis of this scale. “In the Polio Program, we are all part of one large family. When the floods came, it felt like I was sitting at a distance in Islamabad and witnessing my family members suffer. The very first thing I wanted us to do as a program was to find a way to support our people. On every forum, I would request for help to rebuild the homes of our frontline workers.”

The process of assessing the damage was an arduous one. There are over 350,000 health workers part of the program and to identify the people impacted as well as the extent of their loss, was challenging.

Dr Altaf Bosan, the National Technical Focal Person, explains the challenges of determining the impact of the floods with a workforce as large as that of the polio program.

“It was really a very difficult exercise. We went through multiple layers of verification to determine the number of people affected by the floods. This was done at three levels: through the Emergency Operation Centres at the district and province, and the NEOC,” says Dr Bosan.

Through a comprehensive assessment, the Polio Program determined that more than 12,500 polio workers across the country were affected, and funds were secured for the frontline workers who suffered full or partial damage to their homes. In total, cheques worth Rs216 million have been distributed among 10,500 polio workers so far.

On the first working day of the new year, January 2, Mr. Abdul Qadir Patel, the Federal Health Minister handed over cheques to the Provincial Coordinators of the Emergency Operations Centres (EOC). In Sindh, the process was completed at the end of last year following an inauguration by the Health Minister in Thatta district.

“I really commend the team working on it. It really was not an easy task to manage cheques for each individual and deliver them across the country,” Dr Bosan adds.

Nasreen has also received the cheque for financial support as have some of her other colleagues. It is a good time to receive it, she says, because “the winter is too harsh and the need for rebuilding so much greater.”

“I don’t know what can really compensate for their loss, if anything,” says Dr Baig. “Our purpose was to help support as much as we possibly could.”

Addressing social norms

Giza, Egypt, is home to the ancient world-renowned pyramids and a medical marvel of the modern age — the accredited Polio Regional Reference Laboratory (RRL) at the Egyptian Holding Company for Biological Products and Vaccines (VACSERA). Director of the polio regional reference laboratory,

Amira Zaghloul oversees five different departments, working closely with her 25-member team. They regularly conduct poliovirus diagnostic tests on stool samples obtained from children as well as sewage samples from Egypt. Additionally, they carry out sequencing of samples that have been identified as positive for polio in Egypt, Iran, Iraq, Jordan, Sudan, and Syria, which determines if the polioviruses confirmed are related to any other ones. Their goal is to meet tight deadlines, to swiftly respond to any detection of the poliovirus.

Like her counterparts across the Region, Ms Zaghloul and her colleagues rely on the latest laboratory and digital technology. With support from partners, they regularly upgrade their technology and skills to ensure the shortest possible time between sample collection and churning out results. Soon, for example, Ms Zaghloul and her team will acquire the next generation of sequencing technology – that will help test the entire genome of a virus, or genetic materials that make up a virus, and identify any mutations. This will also help to determine the origin of detected polioviruses, and track epidemiological patterns of spread.

Her work doesn’t come without challenges though. When she first took on this role, Ms Zaghloul faced negative social perceptions of being a female leader of a mixed team of men and women. To address this, Ms Zaghloul introduced rules and regulations that apply to all, regardless of age and gender.

People working in health should exemplify a spirit of perseverance, devotion, hope and ambition – regardless of their gender – she emphasizes.

Negotiating to receive samples for polio tests

When Dr Hanan Al Kindi finally settled on what to study − over virology, medicine or business — she had no idea she would need negotiation skills in her job. As the head of nine polio and measles laboratory departments that test samples from Bahrain, Qatar, United Arab Emirates and Yemen for polioviruses, Dr Al Kindi ensures everything runs like clockwork.

At times, this involves thinking out of the box. After noting huge time lags in the delivery of stool samples – used to test for polioviruses – from Yemen to Oman, Dr Al Kindi rolled up her sleeves and got to action. She learnt that after driving through mountains and deserts to reach Oman’s borders, the refrigerated trucks that transport stool samples were kept at the border for hours of inspection. Dr Al Kindi and her team got the contacts of officials at the border and invited them over for a chat.

Her determined negotiation skills and ability to read the room – to understand when peripheral stakeholders such as officials at the border and couriers needed more context about the laboratory’s role in saving children from polio — eventually helped reduce the red tape at the border. This means Dr Al Kindi and her team can test for polioviruses and turn over their results to the polio programme in Yemen in less time than before. This steers timely and appropriate outbreak response activities, including polio immunization campaigns to protect children from polio.

Working in an equitable environment

Dr Nayab Mahmood plays a vital role in ensuring samples are tested for poliovirus as swiftly as possible for timely interventions in Afghanistan and Pakistan – the only two countries left with naturally occurring poliovirus.

Dr Mahmood is a virologist serving the polio programme of the Regional Reference Polio Laboratory at Pakistan’s National Institutes of Health in Islamabad. Her role involves intricate technical procedures, including molecular diagnostics, and genetic sequencing of the poliovirus genome. This work helps to determine how wild polioviruses are spreading across both endemic countries.

Being part of an emergency programme means that Dr Mahmood and her colleagues need to be available 24 hours a day – a pace that is impossible to maintain without feeling an impact in one’s personal life. She feels that the best way to maintain a work-life balance is for each member of a team to communicate their needs with each other, which further helps the programme’s leaders like her to shape policies and programmes that enable a good work-life balance.

Grateful that she hasn’t had to challenge any stereotypes related to gender dynamics in her role,
Dr Mahmood credits this to directives in her workplace that support gender equality, and to the culture of her individual team. These attributes have blended to create an equitable environment where everyone can use their abilities.

Sharing rare, much-needed skills

Chief of the Laboratory of Clinical Virology in the Pasteur Institute of Tunis, Professor Henda Triki makes a concerted effort to share her knowledge with others. Her altruistic spirit goes beyond her laboratory, especially as her specialty of work is still rare in North Africa: She teaches virology at the Faculty of Medicine of Tunis, and constantly keeps an eye on how best to upgrade her team’s skills and technology at work.

Professor Henda Professor Triki has a collaborative leadership style at work, which results in her sharing her team-building skills with her colleagues – which has helped them address challenges many times before, including during the COVID-19 pandemic. Amidst the chaos and anxiety during the pandemic, Professor Triki and her team had strong moments of solidarity and collaborative work.

Professor Triki wants her fellow female colleagues to be proud of working for the polio eradication programme, as it offers great opportunities. It has allowed women to distinguish themselves from others by acquiring skills that other laboratories do not have. She is pleased to note now that there are many women who are the face of specialized laboratory work in the Eastern Mediterranean Region.

This year, the UN’s theme for International Women’s Day is ‘DigitALL: Innovation and technology for gender equality’.

Originally published here.

A moderator speaks in a workshop for the female frontline workers initiative. © BMGF/Sang-hee Min

ISLAMABAD – Poultry farming, EPI technicians, creative writing, midwifery, embroidery, online businesses: it’s a room filled with possibilities and dreams when women health workers come together to imagine their lives in a polio-free Pakistan.

These ambitions surface during the workshops the Pakistan Polio Programme initiated last year, as part of a unique project to actively listen to female frontline workers in the areas at highest risk for poliovirus transmission across the country.

The initiative used a bottom-up, data-informed approach to better understand the experiences of women on the frontlines and hear their ideas for how the programme can better support them to do their jobs safely and effectively. And came with a prior promise: leadership from all partners at the Emergency Operations Centres were to review – and implement – workable solutions.

This systematic listening process, which began in July 2022 and concluded last week, was done in two parts: First, an independent research company was brought on to conduct more than 2,600 randomized, anonymous surveys with polio frontline workers across Pakistan to understand their unique challenges and experiences in the field. After this, based on the results of these surveys, 14 workshops were designed to hear from women frontline workers themselves on what they think are the solutions to the challenges they face.

Female health workers from the polio endemic districts of Bannu, DI Khan, Lakki Marwat and Tank in southern Khyber Pakhtunkhwa to the geographically challenging terrains of Chaman, Quetta and Killa Abdullah in Balochistan to Punjab in central Pakistan to Sindh in the south of the country to the capital city of Islamabad were brought together in this series of workshops.

Participants during the workshops. © BMGF/Sang-hee Min

The workshops were also moderated by a third party to allow for open and honest discussions, and carefully curated to create spaces where, for the first time, the women were the chief guests, they were the people who mattered most, while everyone else had one job: to listen.

“When you get respect, you get everything. It’s the first time that we have talked, and other people have listened,” says Fauzia Naseem, an Area-In-Charge from Chaman.

As each of the two-day workshops finished, there was excitement, energy and almost a sense of disbelief that hours had been dedicated to listening to them. “I’ve been here since 2017 and no one has ever really asked us what we think. Otherwise we are only told where to go and what to do. Today I feel like what we say matters,” says Samreen, a polio worker, from Tank.

“This is a very special project – and a very insightful one too. It offers us the opportunity to gain from the wealth of knowledge of the polio programme’s frontline staff. For the very first time, the people who actually do the work of delivering the vaccine to a child have been systematically asked how they think it should be done. We are currently looking into their suggested solutions and seeing which are implementable and can be taken forward,” said Dr Shahzad Baig, the Coordinator of the National Emergency Operations Centre in Islamabad.

“For many women, this is the first time they are together to just talk to each other, hear from each other, take a selfie and be in a space where they have the right to simple joys that they otherwise may not have access to. The workshops for women from southern Khyber Pakhtunkhwa were particularly special. These were held in Islamabad and for many women, this was the first time they had visited the country’s capital city. Their excitement and sheer joy was infectious. It lit up the room,” said Dr Atiya Abro, Deputy Director Ministry of National Health Services.

Moderators guide the participants during a workshop for the female frontline workers initiative. © BMGF/Sang-hee Min

The last session in all workshops was dedicated to listening and understanding the women’s diverse interests in other career pathways after polio, and what skills or support the workers felt would be needed for them to transition into these jobs in the future.

This initiative was coordinated by the Pakistan Polio Programme’s National Gender Group, comprised of representatives from the government and partner agencies including WHO, UNICEF, BMGF and N-STOP.

“Having the opportunity to listen and give center stage to these women has been a true privilege. It’s encouraging to see such strong commitment from Pakistan programme leadership to support these female health workers – not only in their work toward our collective goal of eradicating polio, but also to facilitate transitions into other potential livelihood opportunities in the future. We look forward to the next phases of this exciting initiative as well,” said Sang-Hee Min, Senior Programme Officer, Bill & Melinda Gates Foundation and member of the National Gender Group.

“Polio teams are a valuable asset to our country,” said Dr Baig. “It is very important to me that when we finish polio from Pakistan, we don’t just pack up and leave but utilize this incredible workforce. We build systems and create opportunities to serve the workforce, a majority of them women, and find some way, however small, in giving back to the people who have worked tirelessly to protect the children of our country.”

Acknowledging that our common goal is to attain ‘Health for All by All’, which is a call for solidarity and action among all stakeholders;

Noting the progress achieved globally in eradicating wild poliovirus transmission since 1988, with endemic wild poliovirus transmission restricted to just two countries – Afghanistan and Pakistan;

Recalling that 2023 is the target year for interrupting all remaining poliovirus transmission globally, as per the Global Polio Eradication Initiative Strategy 2022–2026: Delivering on a Promise;

Appreciating the recent, intensified efforts made by both Afghanistan and Pakistan, resulting in a unique epidemiological window of opportunity to achieve success in 2023, as characterized by:

the geographic restriction of wild poliovirus transmission in 2022 to eastern Afghanistan and a few districts of north-western Pakistan;

the absence of any wild poliovirus case since September 2022;

the significant decline in genetic biodiversity of wild poliovirus to just a single lineage in each country; and

the successful interruption of circulating vaccine-derived polioviruses;

Emphasizing that the opportunity to interrupt wild poliovirus transmission must be seized now, given the unprecedented epidemiological progress and the inherent risks of delays in stopping polio, which would likely result in resurgence of polio;

Underscoring the ongoing risk of transmission of wild poliovirus, with detection of wild poliovirus from environmental samples in both countries since January 2023, confirming cross-border transmission ;

Highlighting that the key to success lies in reaching remaining zero-dose children (children who are un- or under-immunized) with oral polio vaccine in the most consequential geographies,¹ operating within a broader humanitarian emergency response, including increasing access to all populations in some areas;

Underscoring the importance and heroic work of health workers at the forefront in insecure settings, especially women, whose support and participation is critical to the eradication effort;

Recognizing the sustained commitment by leaders at all levels, notably by political leaders and law enforcement agencies, community and religious leaders, civil society, Global Polio Eradication Initiative partners, especially Rotary International, parents, caregivers and all health workers;

Recalling that the international spread of poliovirus constitutes a Public Health Emergency of International Concern under the International Health Regulations (2005);

Appreciating the support provided by the GPEI in responding to the devastating floods affecting Pakistan and the tragic earthquake affecting Afghanistan in 2022;

Appreciating the commitment of the United Arab Emirates through the initiative of His Highness Sheikh Mohamed bin Zayed Al Nahyan, President of UAE, to promote and support polio eradication in Pakistan through the UAE Pakistan Assistance Programme;

Recognizing the longstanding support of donors like Rotary International and acknowledging the historical financial support of other Member States to the eradication effort, including the Kingdom of Saudi Arabia, Kuwait, Oman and Qatar;

Appreciating and supporting the decision of the WHO Regional Director for the Eastern Mediterranean to formally grade all polio emergencies and to apply relevant emergency standard operating procedures to WHO operations to address polio emergencies;

We, Member States of the Regional Subcommittee for Polio Eradication and Outbreaks for the Eastern Mediterranean,

DECLARE THAT:

1. We will focus all efforts on reaching remaining missed children with oral polio vaccine, within a broader humanitarian response context in the remaining most consequential geography of eastern Afghanistan and in north-western Pakistan;

COMMIT TO:

2. Mobilizing all necessary engagement and support by all political, community and civil society leaders and sectors across the Region, to fully achieve interruption of wild poliovirus transmission in the Region;

3. Facilitating the necessary support to fully implement all aspects of the Global Polio Eradication Initiative Strategy 2022–2026, including by ensuring rapid detection of and response to any poliovirus from any source, and implementing high-quality outbreak response;

4. Fostering coordination with other public health efforts, to ensure closer integration in particular with routine immunization efforts;

REQUEST THAT:

5. The international development and humanitarian communities and donors strengthen their support for full implementation of the National Emergency Action Plans to Eradicate Polio in Afghanistan and Pakistan; and

6. The Regional Director continue his strong leadership and efforts to achieve a Region free of all polioviruses for good, including by advocating for all necessary financial and technical support, reviewing progress, planning corrective actions as necessary and regularly informing Member States of the aforementioned and of any further action required through the World Health Organization Executive Board, World Health Assembly and Regional Committee for the Eastern Mediterranean.

PAKISTAN marked a historic moment for polio eradication a year ago. On Jan 27, 2022, for the first time, we clocked in a year without polio paralysing a child. There was a euphoric feeling that the country had finally turned a corner. The long battle to end this disease was thought to be close to an end. But the virus had other ideas.

Despite aggressive vaccination efforts, polio was surviving and continuing to spread in a small area in southern KP. First detected only in sewage water, the virus then paralysed a 15-month boy in North Waziristan. It was the first case of polio in nearly 15 months. I was in Karachi with several members of our team when the news came. Although not surprising given the circulation detected in the environment, it was heartbreaking to hear that another child in Pakistan would never walk again because of an easily preventable disease.

Emergency responses were immediately finalised. While preparing for the work ahead, memories took me back to Borno in Nigeria, a country where I spent a decade fighting polio. After the ‘last case’ of polio in Nigeria was reported in 2014, I started to check my phone every morning, relieved that another day had passed without the virus resurfacing. Typically, it takes three years without any poliovirus for a country to be declared polio-free. But in August 2016, 30 months after the last detection of the virus, a child from a security-compromised area of Borno was found paralysed by polio. As there was poor surveillance and no ability to vaccinate, the virus had found its hiding place. One paralysed child became three. And the outbreak brought Nigeria back to square one.

I knew that the case in North Waziristan was following a familiar pattern, but it was greatly challenging, nonetheless. The year 2022 was excruciatingly demanding. It was a year of feeling the weight of huge challenges, but moving on and choosing courage, commitment and hope every time.

We have aggressively responded to any outbreak in the country, restricting the virus to just seven districts in southern KP. Our virus surveillance network has nearly doubled. We have charted the movement patterns of nomads to reach children otherwise deprived of essential immunisation. We have launched a novel project that allows us to listen to hundreds of front-line women health workers and hear their recommendations for reaching the end goal. And we are consistently working towards improving overall healthcare in areas most at risk from polio.

Polio eradication has had remarkable support and remained a priority in one of the hardest years for the country. The prime minister holds quarterly meetings on polio eradication, bringing provincial and federal leadership together. The federal health minister has visited different provinces to encourage and support provincial health ministries. There is uniform consensus and commitment across all political parties that Pakistan must win this battle against polio, and now is the time.

This commitment is there at every level, from federal health secretaries, chief secretaries and chief ministers, to the deputy commissioners directly overseeing implementation. The military and law enforcement have given the programme their absolute support, making immunisation possible in some of the hardest areas to reach, while global advocates for polio eradication, including Bill Gates and the regional directors of WHO and Unicef, have made polio eradication a top priority in their visits to the country.

We have begun 2023 with great hope and greater commitment. The first nationwide campaign was recently concluded. Despite rain, cold, snow and ice, polio workers carried on with inspirational dedication. They are the face of Pakistan’s sincerity, perseverance and hard work.

The six months ahead are crucial to eradication. This is the closest Pakistan has ever been to interrupting transmission. But the risk of the virus continuing to circulate in the seven districts of KP’s south, and the risk of it exploding beyond and bringing the virus back to polio-free areas, is real.

Polio eradication now needs a renewed countrywide sense of urgency. It needs to be important to all of us to see this virus vanquished. After three decades of the polio programme in Pakistan, there is understandable fatigue. But this is not the time to tire. This is the time to believe. A world free of polio was the birth of a dream. In countless countries at countless times, it has felt like an impossible dream — until it was possible and actually happened.

Over 99 per cent of the world has made this dream come true. And it will come true for our children too if we take this as a collective fight and finish the job. Now is the time to strengthen that resolve, to come together and make the end of polio possible.

Written by Shahzad Baig, Lead, Pakistan Polio Eradication Initiative.

This article was originally published in Dawn on January 27, 2023.

In October 2022, the Technical Advisory Group (TAG) for Afghanistan and Pakistan met in Muscat, Oman, to conduct a thorough review of ongoing polio eradication efforts in the remaining polio endemic countries. During the 6-day meeting they also provided strategic technical guidance on steering efforts towards successful interruption of the poliovirus in both countries in 2023.

Polio programmes make significant progress, despite challenges

The TAG recognized the accomplishments of the polio programmes despite longstanding humanitarian crisis in Afghanistan and unprecedented levels of flooding across Pakistan that affected almost 33 million people. The progress comes due to concerted efforts by all stakeholders across all levels, intense vaccination schedule, timely programmatic pivots to changing epidemiology and the full support of law enforcement and security agencies in implementation of polio vaccination campaigns.

Members noted the high level of sustained political commitment to polio in both countries. In Afghanistan, since the political transition, nationwide campaigns have allowed the polio programme access to almost 10 million children, 3.5 million of whom were previously inaccessible. In Pakistan, intensified vaccination activities and strategic approaches were used to reach missed children.

The TAG also acknowledged the strategic role played by the Emergency Operations Centres (EOCs) in strengthening coordination and providing programmatic oversight at the national and regional levels.

Promising epidemiological trends provide a window of opportunity

Remarkable improvements in epidemiology in Afghanistan and Pakistan provide a window of opportunity for interrupting transmission of wild poliovirus. In Pakistan, the virus is endemic only in the southern districts of Khyber Pakhtunkhwa province, and in Afghanistan both cases have been reported from the eastern region. However, no cross-border transmission was recorded in 2022.

In addition to the limited geographical spread, the biodiversity of the genetic clusters is also at an all-time low: down from 8 in 2020 to 2 in 2022 in Afghanistan and from 11 in 2020 to one in 2022 in Pakistan.

Moreover, there has been no detection of circulating vaccine-derived poliovirus type 2 (cVDPV2) in either country in the last year. The last cVDPV2 case in Afghanistan had onset of paralysis on 9 July 2021, and the last cVDPV2 case in Pakistan had onset of paralysis on 23 April 2021.

Given the promising epidemiological trends seen in 2022, the TAG noted the possibility of full interruption of polioviruses this year. However, for the 2 programmes to succeed, the TAG proposed major strategic shifts in categorization of risks based on the epidemiological trends. The group of experts’ recommendations include context-specific tactics and technical guidance on activities to prioritize until mid-2023, when the TAGs for Afghanistan and Pakistan will meet again.

This new categorization redefines and re-demarcates the endemic zones in Afghanistan and Pakistan from the outbreak districts and the rest of the country where it is important to maintain children’s immunity. Additionally, it identifies highly vulnerable and consequential areas that are an additional risk category for Pakistan, where historically core reservoirs may play a role in establishing circulation in an event of reinfection.

The TAG also endorsed the 2023 polio supplementary immunization activities’ calendars for Afghanistan and Pakistan and emphasized continued cross-border coordination between the 2 countries, particularly in the key corridors. Finally, the TAG encouraged the continued use of strategies to integrate gender and social behavioural change communication into the programme’s activities, to reach every last child.

To read the reports from the Technical Advisory Group meeting on Afghanistan and Pakistan, click here.

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The site at Pezand Pana Dafter in Nangarhar province has produced three positive environmental samples since coming online in September. © WHO/Afghanistan

The review team, comprising of experts including virologists and epidemiologists, visited Afghanistan in June, conducting a comprehensive nationwide assessment of the country’s polio surveillance system. Among their recommendations was the need to address gaps in environmental surveillance and expand the number of environmental surveillance sites in areas deemed high risk for polio, including the country’s east, southeast, south and west regions, to ensure any presence of the virus is quickly detected.

Afghanistan’s AFP surveillance system – monitoring for signs of Acute Flaccid Paralysis in children under 15 years of age – is complemented by environmental surveillance – the collection of sewage samples at designated sites to check for the presence of the virus in the community. Together, they enable the programme to detect where the virus may be circulating and, importantly, mount a timely response.

Following the review’s recommendations, three new environmental surveillance sites have now come online, bringing the total number of sites in Afghanistan to 32. One of those sites, at Pezand Pana Dafter in Nangarhar province has produced three positive environmental samples since coming online in September. The programme quickly mounted a response targeting 1.4 million children under 5 years of age in all four eastern provinces – Nangarhar, Kunar, Laghman and Nuristan.

“Surveillance is the eyes and ears of the polio programme, and environmental surveillance plays an important part in eradicating polio because it enables the programme to detect the presence of the virus,” says Dr. Khushhal Khan Zaman, who oversees polio surveillance for WHO Afghanistan. “Environmental surveillance tells us very plainly where transmission is likely happening.”

WHO guidelines stipulate that an environmental site be located in areas with substantial populations, and with flowing sewage water. In Afghanistan, sites are established in major cities and larger population centres with existing wastewater and drainage systems. Communities with mobile populations are also a focus. Samples are regularly taken and sent to a WHO-accredited polio laboratory for testing.

Afghanistan has made significant progress in interrupting transmission of the virus. From 56 children paralysed by WPV1 in 2020, so far this year there have been two cases, in Paktika and Kunar provinces. Seventeen positive environmental samples have been detected in 2022, all in the country’s east region.

Further environmental surveillance sites are planned as WHO Afghanistan continues to implement recommendations from the surveillance review.

A child in Karachi receiving the polio vaccine. @WHO

There is unprecedented support and commitment to ending polio in Pakistan by 2023, and with the current momentum maintained, the country will be able to interrupt transmission in the coming year, a high-level global delegation on polio concluded at the end of its visit to the country on Thursday.

The delegation was led by Chair of the Polio Oversight Board (POB) Dr Chris Elias, WHO Regional Director Dr Ahmed Al-Mandhari and UNICEF Regional Director George Laryea-Adjei.

“The last steps to ending polio are the toughest but eradication is within reach thanks to the hard work happening in Pakistan,” Dr Elias said.

“During my three-day visit, I was again impressed by the resolve of the government and community, especially frontline workers, to ensure polio is gone forever,” he added. “Reaching every child during the upcoming polio campaigns and strengthening the routine immunization system are now critical to success.”

The Polio Oversight Board is the highest decision-making body of the Global Polio Eradication Initiative. This is the delegation’s second visit together to Pakistan this year. The earlier visit was in May following the detection of a polio case in Pakistan after nearly 15 months. The recent visit comes following the destruction of several health facilities and mass displacement due to catastrophic floods, which increased the risk of polio transmission.

WHO Regional Director Dr Ahmed Al-Mandhari reaffirmed that Pakistan is in the “final stretch” of the road to eradication.

“The progress this year has well-positioned the country to end all poliovirus transmission in 2023. However, ensuring that we reach our goal will require sustained political and administrative commitment during 2023, a year of elections and political transition,” he said. “Under our regional vision of health for all by all, we all have a role to play in ending polio through our collective solidarity and action.”

UNICEF Regional Director for South Asia George Laryea-Adjei said that Pakistan’s success in containing the spread of polio through joint efforts by the government, donors, frontline health workers and partners is truly commendable.

“The recent flooding has exacerbated health risks for millions of children, especially those living in districts historically at the highest risk for polio, so we must redouble efforts to engage parents and caregivers to protect these children,” he said. “The end of polio is near, and we must now go the last mile to ensure every child is protected against this debilitating disease.”

During the visit, the delegation met the prime minister, federal health minister, Pakistan Army’s engineer-in-chief and the heads of provincial governments of Balochistan, Khyber Pakhtunkhwa and Sindh, and reiterated support to help Pakistan end poliovirus transmission by 2023.

Pledging table

2022 pledges from various donors

As Pakistan continues to struggle from the effects of the devastating floods affecting parts of the country, polio staff on the ground continue to assist emergency relief efforts.

In flood-affected districts, the polio effort is supporting establishment of critical health camps, to provide basic clinical services, particularly ensuring treatment of water-borne and vector-borne diseases, and distributing water purification tablets. All routine immunization antigens are also provided to target children and pregnant women. Staff are actively conducting surveillance for communicable diseases, identifying nutrition needs of displaced populations, and collecting and analysing life-saving data to help target response strategies. Polio programmes around the world have a long history of supporting broader public health and humanitarian emergencies, as was the situation earlier this year in Afghanistan, following the devasting earthquake there.

At the same time, the polio programme is adapting its operations, to ensure polio eradication efforts can continue unabated, even amid the tragedy. The programme is at a critical juncture – intensive response is ongoing to stop this year’s outbreak in southern Khyber Pakhtunkhwa. Virus linked to this outbreak was this month detected in an environmental sample from Karachi, in the south of the country. At the same time, the high transmission season for polio transmission is now starting and this transmission risks being particularly intense given the floods.

But despite these challenges, polio staff are working double-time: adapting polio approaches, while supporting life-saving flood relief efforts.

“I have been fortunate enough to be present when a number of countries successfully eradicated polio,” commented Dr Hamid Jafari, Director for Polio Eradication at the World Health Organization’s Regional Office for the Eastern Mediterranean. “Rarely have I seen such commitment and dedication than I have seen in Pakistan – from national political leaders, to health workers, right to the mother and father on the ground. To all who are involved, all I can say is: Thank you! You are making a huge difference to people’s lives, which goes far beyond the effort to eradicate polio.”

While detection of virus in Karachi is not unexpected, given the large-scale and frequent population movements between Karachi and the rest of the country, in particular Khyber Pakhtunkhwa. urgent efforts are underway, coordinated by the national and provincial Emergency Operations Centres (NEOC and PEOC), to continue surveillance efforts in greater Karachi and further boost immunity levels through health camps, to prevent polio from establishing a foothold in Pakistan’s largest city which has historically been a major polio reservoir.

Despite the extraordinary climatic conditions and consequent operational challenges aggravated by the collapse of infrastructure, the programme continued with the August polio campaign – including across Karachi – and re-adjusted the schedule in all accessible areas. While the immunization campaign could not be conducted in Balochistan and parts of Sindh, the effort managed to reach nearly 32 million children in the country, with health workers wading through deep water to reach children with the life-saving vaccine.

At the same time, the programme has undertaken contingency planning to resume intensified vaccination activities in southern Khyber Pakhtunkhwa to stop the outbreak, as soon as the situation allows. The programme continues to innovate, adapt, and find opportunities to build children’s immunity through vaccination at health camps, at transit points, in settlements for displaced persons.

And, of course, national and subnational authorities are coordinating activities with neighbouring Afghanistan, particularly in border regions, given that both countries represent a single epidemiological block. Confirmation this month of Afghanistan’s second case this year, from Kunar province, confirms the risk any residual transmission on either side of the border continues to pose to children across this block.

Kunar, along with the rest of the country’s Eastern Region, is part of one of three, critical cross-border epidemiological corridors with Pakistan, the northern corridor specifically comprising of Eastern Region and central Khyber Pakhtunkhwa in Pakistan. Case response is currently being planned in the immediate area and the broader corridor. The other two cross-border epidemiological corridors are the southern corridor, comprising Quetta Block of Pakistan and Southern Region, Afghanistan; and, the central corridor, comprising southern Khyber Pakhtunkhwa and South-East Region in Afghanistan.

Districts along the border of Pakistan and Afghanistan in the three epidemiological corridors are at high-risk for poliovirus transmission, given the high proportion of zero-dose children and inconsistent quality of polio vaccination campaigns in some areas.

The Pakistan and Afghanistan polio programmes continue to coordinate on surveillance and vaccination activities through the Global Polio Eradication Initiative Support Hub, based in Amman, Jordan.

A polio worker administers the oral polio vaccine to a child in Karachi. Credit: @SalmanMahar

Polio is one of the world’s most devastating diseases. It mainly affects children under five and in one in 200 cases it results in lifelong paralysis. Amazing progress has been made in fighting polio globally: according to UNICEF, there were a reported 20,000 children paralysed by polio in Pakistan in 1994. By 2021, new paralysis cases had dropped to just one child. However, as long as just one child remains infected, all children are at risk.

Identifying and reaching unvaccinated children has been a challenge, but big data startups like Zenysis, in partnership with Pakistan government partners, are making inroads.

Vaccination data is only useful if it’s accurate

Abid Hasan is the project manager for Zenysis – a Gavi INFUSE pacesetter since 2017 – in Pakistan, and he explains the barriers to a more effective vaccination programme in the country:

“Data is like people, in that if data sets don’t talk to each other then they won’t work well. Zenysis gets data and data sets talking.”

Community health workers employed through Pakistan’s Polio Eradication Programme and the Expanded Programme of Immunisation go door to door to collect vaccination data, sometimes using datasheets, sometimes paper, sometimes recording data through WhatsApp. It can be difficult to track families with no formal address, or mobile communities with no fixed address. With 14 million children requiring a polio vaccination every two months, recording accurate data is a mammoth task.

The resulting data can be imperfect, with duplication a particular challenge. This is where Zenysis’s platform comes in. Zenysis software integrates, de-deplicates and harmonises more than 20 siloed datasets, including polio data, immunisation registries and population data.

Combined, the data can be used far more effectively for analysis and, importantly, action on the ground. The result? A new and improved vaccination plan, personalised for each vaccinator’s district – known as a microplan.

A Community Health Worker goes door to door during the August polio campaign to give children the oral polio vaccine. She finds a newborn zero-dose child and records that data into her register. Credit: @SalmanMahar — A Community Health Worker goes door to door during the August polio campaign to give children the oral polio vaccine. She finds a newborn zero-dose child and records that data into her register.
Credit: @SalmanMahar

Microplans help health workers target zero-dose children

The enhanced microplans provide health workers with granular information on each child in a region, including their vaccination status, age and address. This information can be used to identify individual children and highlight neighbourhoods where there are clusters of unvaccinated (zero-dose) children. This in turn means better use of time and energy, and better outcomes for communities.

The effect, explains Hasan, is seen in three key areas. “Firstly, the newmicroplans give community health workers the real picture. Second, frontline workers now have a plan to follow and are no longer using broad or inflated data that is hard to actionize. Third, this approach is measurable – when you reach a target, that goes into the system. With accurate data, you can really see the impact.”

Health workers on the ground have seen the difference. Sadaf, a community health worker for Polio, in Karachi, says: “Before the microplans the vaccinators were given a long list of children with duplicate entries in them, and they were extremely difficult to track. After receiving these microplans we can easily decide where to set up our outreach sites and mobilise children to bring them there for vaccination in a systematic manner.”

The impact has been impressive. Since January 2022, the Expanded Programme on Immunisation in the Sindh region has used the Zenysis platform to identify over 28,500 true zero-dose children in the region and vaccinate 12,724 of them with the aid of microplans. In March to June of this year, 3,854 zero-dose children were vaccinated with the help of the new microplans in the regions where they have been implemented.

Community Health Workers using Zenysis provided microplans to identify houses with zero-dose children in high risk areas of Karachi. Credit: @SalmanMahar — Community Health Workers using Zenysis provided microplans to identify houses with zero-dose children in high risk areas of Karachi.
Credit: @SalmanMahar

Gavi support has been vital in creating goals and driving change

Zenysis was part of Gavi’s INFUSE programme, which connects high-impact innovations with the countries that need them most. Hasan explains that for countries like Pakistan, the investment from Gavi is vital to enhance healthcare budgets, but also to help provide momentum and set goals for vaccination programmes.

Looking ahead, Zenysis is collaborating closely with government partners to expand the platform and vaccination approach throughout Sindh province, tackle other vaccine-preventable diseases, and improve the government’s technical platform management capacity.

As Hasan says, “Not everyone is a data expert – but if you can go on a platform, go into a dashboard, and see all your data into one workspace then you can reach a zero-dose child and their family, and get them vaccinated.”

And with each child vaccinated, we get a step closer to a world where infection by wild poliovirus is a thing of the past.

Reposted with permission from gavi.org

In 2021, when the news of cancer hit, Nomina Akhtar felt her world collapsing. It was discovered too late. By the time she knew, it was already stage-3 breast cancer.

Since 2015, Akhtar has been part of Pakistan’s polio programme as a community health worker. During these six years, she has found friends and well-wishers among her team members who have given her the support to carry on.

Akhtar, 43 and a mother of three continues to work for polio eradication as she undergoes treatment for cancer. “I gathered my courage and promised that I will fight till the end and live for my children. All my family, colleagues and seniors were with me whenever I needed support. That gave me courage and made me believe that I could, in fact, beat cancer.”

Based in Peshawar, Nomina’s husband and her three children, aged six, seven and 18, rely solely on her income. The lockdowns due to the pandemic caused her husband, a motorcycle mechanic, to close down his shop that has yet to reopen.

A life with cancer has been both physically and emotionally exhausting. She is undergoing both radiation and chemotherapy in Peshawar. This means a commute of almost 20 kilometers after a whole day of work.

“When I have to go for chemotherapy after work, it becomes very draining. I have to take public transport and wait at the hospital for hours. There are times when I have to return without treatment because either the machine is faulty or something else comes up. This treatment regime along with the medicine will continue for at least five years. It’s excruciatingly painful,” she says.

Polio programme: a great source of strength for Akhtar

“My colleagues are like my extended family, and I am like a sister to them. When I found out about my cancer, they wept with me. They have stood by my children and myself every step of the way.”

The supervisor of her area, Uzma Mansoor, says that when they first heard the news, they were devastated. “But it’s great to see that she has not lost hope and is fighting the disease like a champion,” she said.

The community she works in has also been incredibly supportive. “Some of the people in my work area came to know about my illness and they appreciated the fact that despite fighting cancer, I come to their doorstep during every polio campaign. Irrespective of extreme temperatures and illness, I am there to vaccinate their children and protect them from this life-threatening disease. Their support has increased manifold after this.”

Sahibullah, the Union Council Polio Officer of her area, says not only does Nomina continue to vaccinate children, but she is a role model for all other polio workers.

“It was God’s will, and we will face it with courage,” says her husband Aurangzeb Akhtar. “Despite being ill, Nomina is the one who keeps us going. She is working and earning for our family as well as motivating us to not lose hope. My children and I are so proud of her. Inshallah she will get well very soon.”

Nomina has strong conviction. She is fighting cancer and polio simultaneously, and is determined that she will defeat both very soon. “At least cancer has treatment,” she says. “Polio is incurable and the sooner we end this disease forever, the better.”

Development and Health Ministers of the G7 countries met in Berlin, Germany, last week to hold urgent joint consultations on “supporting vaccine equity and pandemic preparedness in developing countries”. The joint group highlighted the need to accelerate equitable and sustainable access to vaccines everywhere, and to strengthen pandemic preparedness and response in low- and middle-income countries. At the same time, however, the meeting cautioned against letting global crises interfere with other development and public health priorities and urged continued support for existing efforts, including global polio eradication.

The global effort to eradicate polio is a clear and concrete example of the value of working in close integration with other development and public health efforts, and contribute to global pandemic preparedness and response. Polio staff continue to contribute to the COVID-19 pandemic response and immunization recovery efforts, together with the introduction and roll-out of COVID-19 vaccines.

In April 2022, GPEI partners, led by WHO Director-General, launched the ‘Investment Case for Polio Eradication’, the sister document to the Polio Eradication Strategy 2022-2026, which lays out the economic and humanitarian rationale for investing in a polio-free world, as well as the broader benefits of polio eradication.

In October 2022, Germany will generously co-host a global pledging moment, giving the international development community the opportunity to publicly re-commit to this effort, including to support a stronger and sustainably-funded WHO, so that the organization can maintain its capacity to support countries in achieving and sustaining polio eradication, and continue to benefit broader public health efforts, including support for pandemic preparedness and response.

In this two-part video series, we chat with Dr Ananda Bandyopadhyay, Deputy Director of Polio Technology, Research & Analytics, BMGF, about the new tool in GPEI’s kit to combat cVDPV2: novel oral polio vaccine type 2 (nOPV2).

GENEVA, 26 April 2022

Today, the Global Polio Eradication Initiative (GPEI) announced that it is seeking new commitments to fund its 2022-2026 Strategy at a virtual event to launch its investment case. The strategy, if fully funded, will see the vaccination of 370 million children annually for the next five years and the continuation of global surveillance activities for polio and other diseases in 50 countries.

During the virtual launch, the Government of Germany, which holds the G7 presidency in 2022, announced that the country will co-host the pledging moment for the GPEI Strategy during the 2022 World Health Summit in October.

“A strong and fully funded polio programme will benefit health systems around the world. That is why it is so crucial that all stakeholders now commit to ensuring that the new eradication strategy can be implemented in full,” said Niels Annen, Parliamentary State Secretary to the Federal Minister for Economic Cooperation and Development, Germany. “The polio pledging moment at the World Health Summit this October is a critical opportunity for donors and partners to reiterate their support for a polio-free world. We can only succeed if we make polio eradication our shared priority.”

Wild poliovirus cases are at a historic low and the disease is endemic in just Pakistan and Afghanistan, presenting a unique opportunity to interrupt transmission. However, recent developments, due in part to impacts of the COVID-19 pandemic, underscore the fragility of this progress. In February 2022, Malawi confirmed its first case of wild polio in three decades and the first on the African continent since 2016, linked to virus originating in Pakistan, and in April 2022 Pakistan recorded its first wild polio case since January 2021. Meanwhile, outbreaks of cVDPV, variants of the poliovirus that can emerge in under-immunized communities, were recently detected in Israel and Ukraine and circulate in several countries in Africa and Asia.

The investment case outlines new modelling that shows achieving eradication could save an estimated US $33.1 billion this century, compared to the price of controlling polio outbreaks. At the launch event, GPEI leaders and polio-affected countries urged renewed political and financial support to end polio and protect children and future generations from the paralysis it causes.

“Despite enormous progress, polio still paralyses far too many children around the world – and even one child is too many,” said UNICEF Executive Director Catherine Russell. “We simply cannot allow another child to suffer from this devastating disease – not when we know how to prevent it. Not when we are so close. We must do whatever it takes to finish the fight – and achieve a polio-free world for every child.”

“The re-emergence of polio in Malawi after three decades was a tragic reminder that until polio is wiped off the face of the earth, it can spread globally and harm children anywhere. I urge all countries to unite behind the Global Polio Eradication Initiative and ensure it has the support and resources it needs to end polio for everyone everywhere,” said Hon. Khumbize Kandodo Chiponda MP, Minister of Health, Malawi.

The new eradication strategy centres on integrating polio activities with other essential health programs in affected countries, better reaching children in the highest risk communities who have never been vaccinated, andstrengthening engagement with local leaders and influencers to build trust and vaccine acceptance.

“The children of Pakistan and Afghanistan deserve to live a life free of an incurable, paralyzing disease. With continued global support, we can make polio a disease of the past,” said Dr Shahzad Baig, National Coordinator, Pakistan Polio Eradication Programme. “The polio programme is also working to increase overall health equity in the highest-risk communities by addressing area needs holistically, including by strengthening routine immunization, improving health facilities, and organizing health camps.”

The investment case outlines how support for eradication efforts will enable essential health services in under-served communities and strengthen the world’s defences against future health threats.

Since 2020, GPEI infrastructure and staff have provided critical support to governments as they respond to the COVID-19 pandemic, including by promoting COVID-safe practices, leveraging polio surveillance and lab networks to detect the virus, and assisting COVID-19 vaccination efforts through health worker trainings, community mobilization, data management and other activities.

“The global effort to consign polio to the history books will not only help to spare future generations from this devastating disease, but serve to strengthen health systems and health security,” said Dr. Tedros Adhanom Ghebreyesus, WHO Director-General.

Additional quotes from the GPEI Investment Case:

“We have the knowledge and tools to wipe polio off the face of the earth. GPEI needs the resources to take us the last mile to eradicating this awful disease. Investing in GPEI will also help us detect and respond to other health emergencies. We can’t waver now. Let’s all take this opportunity to fully support GPEI, and create a world in which no child is paralyzed by polio ever again,” said Bill Gates, Co-chair, Bill & Melinda Gates Foundation.

“An investment in polio eradication goes further than fighting one disease. It is the ultimate investment in both equity and sustainability – it is for everyone and forever. An important component of GPEI’s Strategy focuses on integrating the planning and coordination of polio activities and essential health services to reach zero-dose children who have never been immunized with routine vaccines, therefore contributing to the goals of the Immunization Agenda 2030.” said Seth Berkley, Chief Executive Officer, Gavi, the Vaccine Alliance.

“Twenty million people are walking today because of polio vaccination, and we have learned, improved and innovated along the way. We are stronger and more resilient as we enter the last lap of this marathon to protect all future generations of the world’s children from polio. Please join us; with our will and our collective resources, we can seize the unprecedented opportunity to cross the finish line that lies before us,” said Mike McGovern, Chair, International PolioPlus Committee, Rotary International.

Downloads

Investment Case 2022-2026

Media contacts:

Oliver Rosenbauer
Communications Officer, World Health Organization
Email: rosenbauero@who.int
Tel: +41 79 500 6536

Ben Winkel
Communications Director, Global Health Strategies
Email: bwinkel@globalhealthstrategies.com
Tel: +1 323 382 2290

Sabrina Sidhu
UNICEF New York
Email: ssidhu@unicef.org
Tel: +19174761537

April 2022 – Convening this month in Geneva, Switzerland, the Strategic Advisory Group of Experts on immunization (SAGE), the global advisory body to the World Health Organization (WHO) on all things immunization, urged concerted action to finish wild polioviruses once and for all.

The group, reviewing the global wild poliovirus epidemiology, highlighted the unique opportunity, given current record low levels of this strain. At the same time, it noted the continuing risks, highlighted in particular by detection of wild poliovirus in Malawi in February, linked to wild poliovirus originating in Pakistan.

On circulating vaccine-derived poliovirus (cVDPV) outbreaks, SAGE expressed concern at continuing transmission, in particular in Nigeria which now accounts for close to 90% of all global cVDPV type 2 cases, as well as the situation in Ukraine, and its disruption to health services, urging for strengthening of immunization and surveillance across Europe. It also noted the recent detection of cVDPV type 3 in Israel in children, and in environmental samples in occupied Palestinian territories, and urged high-quality vaccination activities and strengthened surveillance.

Preparing for the post-certification era, the group underscored the importance of global cessation of all live, attenuated oral polio vaccine (OPV) use from routine immunization, planned one year after global certification of wild poliovirus eradication. To ensure appropriate planning, coordination and implementation, the group endorsed the establishment of an ‘OPV Cessation Team’, to consist of wider-than-GPEI stakeholder participation and ensure leadership on all aspects of OPV cessation.

SAGE will continue to review available evidence and best practices on a broad range of GPEI-related programmatic interventions, including as relevant the increasing role of inactivated polio vaccine (IPV), including in outbreak response and effects of novel oral polio vaccine type 2 (nOPV2), as part of global efforts to secure a lasting world free of all forms of poliovirus.

This International Women’s Day, we get to meet some of the women leading the polio eradication efforts in Pakistan.