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

 

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Vaccination campaigns rapidly boost immunity of refugees vulnerable to outbreaks of communicable diseases.

Newly arrived refugees at the Dadaab refugee camp, northern Kenya. Riccardo Gangale/UNICEF
Newly arrived refugees at the Dadaab refugee camp, northern Kenya.
Riccardo Gangale/UNICEF

8 August 2011 – The Horn of Africa is facing its worst drought in over 50 years; child malnutrition rates are more than double or triple the 15% emergency threshold and are expected to rise.

Malnourished children are more prone to sicknesses and diseases, such as measles. An outbreak in the Kobe refugee camp in Ethiopia, for example, has already resulted in 47 confirmed cases of measles, including three deaths.

From 25–29 July, the Kenyan Ministry of Health, WHO Kenya and Somalia and UNICEF Kenya and Somalia launched a cross-border vaccination campaign for children living around Dadaab, a large settlement for Somali refugees in north-eastern Kenya. After registration, newly arrived Somali refugees in the Dadaab camps are medically screened and vaccinated. To protect the host population in the area, a vaccination campaign, lead by WHO, targeted about 215 000 children under five, with measles and polio vaccines, together with vitamin A and deworming tablets.

This photo story  and video illustrate in more detail the nature of the vaccination campaign.

A Somalian child is vaccinated against polio during a nationwide immunization campaign Christine McNab/WHO

NAIROBI, Kenya, 20 March 2011 – On the eve of celebrating four years without polio in Somalia, the country kicks off National Immunization Days on Sunday 20 March, with a focus on ensuring that no eligible child is left unvaccinated during the three days of the campaign. During 2011, two rounds of polio vaccinations are planned.

WHO Representative for Somalia, Dr Marthe Everard, noted the success of the polio immunization efforts in Somalia. “Somalia marks on 25 March 2011 the 4th anniversary of being polio-free. This shows that polio can be eradicated everywhere, even in the most challenging and difficult settings,” she said. “With Somalia still being at risk from polio virus importation and spread from countries where the virus is still circulating, we must remain ever-vigilant to do all efforts to maintain high immmunity of children under the age of five.”

This week’s National Immunization Days will play a critical role in protecting the Somali children from the crippling disease. During these days, over 1.8 million children under the age of five will be targeted across the country. The campaign is being spearheaded by health authorities at national and local levels, in collaboration with WHO, UNICEF, other polio eradication partners and the Somali communities.

UNICEF Representative for Somalia, Rozanne Chorlton, underlined the need to reach every child, saying “If we are to ensure that no new cases of polio emerge in Somalia, vaccination teams must be able to access every community, every household, and every child aged under-five.”

Insecurity and inaccessibility in some parts of the country, especially in South Central regions, remains a major concern to reach out to all targetted children . South Central Somalia is home to an estimated 70% of all children aged under-five. In 2010, over 800,000 children missed out on the opportunity to receive the two polio drops. The WHO and UNICEF Representatives have called on all parties to the ongoing conflict to respect the humanitarian mandate of the vaccination teams, and guarantee their safe passage across the country.

The Somali National Immunization Days are supported through financial contributions from a number of donors including the governments of Italy, Germany, and Norway, the US Centers for Disease Control and Prevention (CDC), Swedish International Development Cooperation Agency (SIDA), UK Department for International Development (DFID) and Rotary International. Each round of polio vaccination is estimated to cost around US$ 1 million.

Attack a stark reminder of the dangers faced by public health workers.

Osman Hussein Ibrahim (left), District Polio Officer in Mogadishu, Somalia,was tragically killed while on polio duties on 22 August. WHO

On the morning of 22 August 2010, Mr Osman Hussein Ibrahim, District Polio Officer in Mogadishu, Somalia, was shot and killed by a stray bullet while on his way to supervise polio National Immunization Days (NIDs) and Child Health Days.

Born in 1961 in Lower Shabelle, Somalia, Mr Ibrahim began work with the World Health Organization (WHO) in 2001. He was instrumental in helping eradicate polio from the country, including following re-infection in 2005. A committed, highly-motivated, hard-working team player, Mr Ibrahim was known for his ability to work effectively under very difficult conditions – his nearly ten years of service for polio eradication in Mogadishu (the most dangerous place in Somalia) being a clear testament to this. In a separate incident on 24 August, District Polio Officer Mr Muse Ahmed Janago sustained injuries resulting from flying mortar fragments, in Mogadishu. Following treatment at a hospital, he was thankfully released and has already returned to duty, preparing for NIDs in September.

These tragic incidents are stark reminders of the risks faced by those working to eradicate polio in many parts of the world.

Throughout the 20 years of the Global Polio Eradication Initiative, vaccinators and other polio staff have faced the risk of murder, assault, kidnapping and natural disasters on all continents, despite UN security measures. The vast majority of these workers are volunteers; nearly all – staff and volunteers – live and work in remote or disadvantaged areas, to ensure that every child has access to vaccination.

The Polio Eradication Heroes Fund recognizes health workers and volunteers who have incurred serious injury or lost their lives as a direct consequence of their participation in polio eradication activities. The families of the workers receive a certificate recognizing the victim’s heroic commitment to polio eradication and a cash tribute.

Those wishing to give may do so online or by contacting the Polio Eradication Heroes Fund at the CDC Foundation, 50 Hurt Plaza – Suite 765, Atlanta, GA 30303, USA.

10000 health workers stop polio in one of most dangerous places on earth

Polio immunization of a nomadic child. Frequent population movements across Somalia meant that children of nomadic populations were at particular risk of polio.

Polio immunization of a nomadic child. Frequent population movements across Somalia meant that children of nomadic populations were at particular risk of polio.

25 March 2008, Geneva, Switzerland – Somalia is again polio-free, the Global Polio Eradication Initiative (GPEI) announced today, calling it a ‘historic achievement’ in public health. Somalia has not reported a case since 25 March 2007, a landmark moment in the intensified eradication effort launched last year to wipe out the disease in the remaining few strongholds.

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