In June 2017, some of the first circulating vaccine-derived poliovirus type 2 (VDPV2) cases were reported in Deir Ez-Zor governorate, in eastern Syria, confirming an outbreak of polio. Since then, 74 cases were reported, with the most recent case reported on 21 September 2017.
Despite being a high-risk country with large scale population movements, inadequate health infrastructure, and accessibility issues, the outbreak response was successfully carried out. Health workers reached out to children to raise immunity levels, vaccinate children, and stop the outbreak, regardless of the location or socio-political climate.
An official outbreak response assessment was carried out by experts on global health, virology, and epidemiology, which concluded that the outbreak could now be closed.
“(Disease) Surveillance is stronger today than it was 18 months ago, when the initial cases were detected…so, as we celebrate what is a remarkable achievement in stopping this outbreak, amid very challenging circumstances, we must not lose sight of the risks posed by continued circulation of virus in other parts of our Region,” said Chris Maher, Manager for Polio Eradication in the WHO Eastern Mediterranean Region.
Read the full statement here.
From the front passenger seat of a small utility truck, Mahmoud Al-Sabr hangs out the window, looking for families and any child under five years old to be vaccinated against polio. As the car he travels in dodges rubble and remnants of buildings that once stood tall in Raqqa city, he flicks the ‘on’ switch for his megaphone.
“From today up to January 20, free and safe vaccine, all children must be vaccinated to be protected from the poliovirus that hit Syria for the second time,” he calls, beckoning families with young children who have recently returned to Raqqa city to come outside of their makeshift homes amongst destroyed buildings, to have their children vaccinated.
In 2017, amidst the protracted conflict and humanitarian crisis in Syria, an outbreak of circulating vaccine-derived poliovirus type 2 (cVDPV2) was detected, threatening an already vulnerable population.
Due to ongoing conflict, Raqqa city, which was once host to half of the governorates population, had been unreached by any vaccination activity or health service since April 2016. During the first phase of the outbreak response, more than 350,000 resident, refugee and displaced children were vaccinated against polio in Syria, but “Raqqa city remained inaccessible,” says Mahmoud.
In January 2018, polio vaccinators conducted the first vaccination activity in the city since it became accessible again, following the end of armed opposition group control.
There were no longer accurate maps or microplans that vaccinators could use to guide them in their work. Unrecognizable, the city was a picture of devastation with few dwellings untouched by the violence that once caused families to flee. The house-to-house vaccination campaign that usually helps the programme to reach every child under five wouldn’t work here. Teams knew they would have to innovate to seek out families wherever they were residing to vaccinate their children.
“All children must be vaccinated to protect against poliovirus,” Mahmoud echoes around shelled out buildings, and slowly mothers and fathers carrying their children start to appear in the street.
Mahmoud and Ahmed Al-Ibraim are one of 12 mobile teams that are going street by street, building by building, by car in search of children to vaccinate. Carrying megaphones to alert families of their presence and to tell them of the precious vaccines they carry that will protect their children from the paralysing but preventable poliovirus, they slowly cover areas of the city now unrecognizable.
“No one could enter Raqqa City now for two years,” says Abdul-Latif Al-Mousa, a lawyer from the city who joined the outbreak response as a Raqqa City supervisor for polio campaigns. “So children have not been vaccinated here since that time. Now that people have returned, we are learning where they have returned from and we vaccinate them regardless.”
“We must reach each child with the vaccine to protect them – polio is preventable, why should they suffer more?” Ahmed appeals.
Campaign brings vaccines and familiar faces
Vaccines were not the only thing to return to Raqqa City in January. It was the first time that WHO polio focal point Dr Almothanna could return to Raqqa City after being force to flee under the rule of the armed opposition group. Imprisoned for refusing the demands of the group, friends and neighbours of Dr Almothanna facilitated his escape from the city in 2016.
Dissatisfied but not deterred, Dr Almothanna continued to work with the polio programme, serving the whole governorate except his own city. Over the course of the January 2018 campaign, he worked tirelessly with vaccination teams to ensure more than 20 000 children under the age of five in Raqqa City received a dose of mOPV2 to protect them against polio. For many, it was the first vaccination they had received. In the additional campaigns that followed in March 2018, even more children were reached.
The microplans developed by vaccinator teams in the first vaccination round have become a critical road map for reaching children and families with health services, accounting for the locations of returned families and information about neighbouring families that teams had not yet located. In the second round, the microplans were updated to include new families who had returned.
Syria reported 74 circulating vaccine-derived poliovirus cases between March and September 2017. It has been more than six months since the last case was reported (21 September 2017). Efforts are continuing to boost immunity in vulnerable populations, maintain sensitive surveillance for polioviruses and strengthen routine immunization to enhance the population immunity.
The poliovirus remains in just a few small pockets around the world. However, these final hiding places are some of the most challenging settings on earth in which to eradicate a disease. Finding and stopping a virus whose special power is staying hidden is no mean feat, especially in remote or inaccessible places.
Disease detectives around the world are working tirelessly to find every last virus in these hard to reach places. Some areas are vast and sparsely populated, such as the broad plains and river beds making up areas of the Lake Chad region. Others are densely packed residential areas of Afghanistan, where security issues can sometimes make immunization difficult. In areas of Syria, civil war continues to rage through towns, communities, and families. Yet these challenges are not enough to stop the surveillance system.
In such difficult environments, the polio surveillance system must overcome numerous challenges to ensure that the poliovirus is tracked. Experts look for the virus in children with symptoms of acute flaccid paralysis and also in water samples from sewage systems in high risk areas.
For Dr Arshad Quddus, Coordinator for the detection and interruption of poliovirus at WHO headquarters, the key to overcoming the challenges facing polio surveillance is tapping into communities. Illustrating his point, he draws a circle on a piece of paper, placing a dot in the middle. In Afghanistan, he explains, that dot represents a surveillance focal point, based at a District Health Centre or hospital. The circle extending from them is their information network – a collection of mullahs, healers, health-care providers, teachers, parents and other surveillance recruits – who have been trained to spot cases of acute flaccid paralysis in their community that could turn out to be polio.
Each volunteer is given a book in which to write down the information they find, and a phone number to call. If they come across a case in their local community, they must ring their focal point, setting in action a series of events that will allow the child to be examined, stool samples to be taken from them to be tested in the laboratory for polio and their close contacts tested.
The system may seem simple, but insecurity, weather and challenging landscapes can be obstacles. In Afghanistan, the programme has developed creative ways to ensure that nothing stands in the way of the surveillance system being able to work as it needs to. In most cases, following the reporting of a case of acute flaccid paralysis, health workers will visit the child’s home to inspect them, and collect stool samples from the child to send for lab testing for the poliovirus. However, if the area is inaccessible, the child and their caregivers are transported to the nearest hospital in a safe area for inspection.
For Dr Quddus, the success of this system in Afghanistan is clear: “We have regular reports of where the poliovirus is circulating in difficult and hard-to-reach communities and this shows us we are being successful, despite tremendous challenges.”
Surveillance in conflict zones
These diverse methods also strengthen surveillance in countries where the security situation is rapidly changing. In Syria, the health-care system has been weakened due to conflict, with many of those at the heart of the polio surveillance system displaced. By building new networks in camps for internally displaced families where communities are created by proximity, and recruiting surveillance volunteers at the key points of entry and exit into the worst of the conflict zones, the polio surveillance system ensured that an outbreak of circulating vaccine-derived poliovirus in 2017 was rapidly identified and an outbreak response launched. The programme also thought outside of the box in Borno, Nigeria, by training medical corps being deployed to reach conflict-affected populations to spot signs of the virus.
The polio surveillance system is strengthened by a mixture of community, adaptability, and fierce commitment to finding every last trace of virus. These are the lessons learned that help find the virus everywhere, from urban districts of Afghanistan, to hard-to-reach areas of Nigeria. For Dr Quddus, “It is the individuals on the ground willing to give their all that will enable us to achieve eradication. The surveillance system is the eyes and ears of polio eradication, showing us where to focus our best efforts to vaccinate every last child.”
Read more in the Reaching the Hard-to-Reach series
The year’s end offers the chance to reflect on the polio programme’s milestones and challenges in 2017, and look ahead to what we can achieve in the coming year. 2017 saw the fewest wild polio cases in history — a total of 17 cases, or a 50% reduction from the year before—with these cases occurring in just two countries: Afghanistan and Pakistan. Yet the need to reach every last child is more important than ever, as demonstrated by surveillance gaps in Nigeria and outbreaks of vaccine-derived polio in Syria and the Democratic Republic of the Congo.
From programme strategies that helped protect progress and overcome obstacles, to commitments from donors and partners, 2017 demonstrated the resolve required to achieve a polio-free future. Accelerating progress in the new year and ending polio for good will require maintaining these political and financial commitments as well as building upon the programme’s efforts to find the virus wherever it exists.
Rooting out the virus
Throughout 2017, developments in disease surveillance – both in humans and in the environment – allowed the programme to better hone in on the virus and identify its remaining hiding places.
For example, in Afghanistan, blood tests helped pinpoint which children have been reached and where gaps in immunity persist, allowing health workers to launch targeted vaccination responses. In Sudan, a pilot study used a new method of quality control to help ensure that stool samples arrive at the lab in the right condition for testing. And throughout the Eastern Mediterranean Region, environmental surveillance networks were expanded and strengthened.
These innovations are building robust, sensitive surveillance networks around the world that pick up every trace of the virus and enable the programme to develop targeted immunisation responses before polio has the chance to paralyse children.
The year also came with new challenges, including outbreaks of circulating vaccine-derived polio in Syria and the Democratic Republic of the Congo, where conflict has ravaged the health infrastructure. In these communities, and others where polio still exists, difficult terrain, conflict and highly mobile populations can all stand as hurdles to vaccinating children. Yet the polio programme continues to find new and effective ways of delivering vaccines.
For example, in Afghanistan, a collaboration with a mobile circus is sharing important messages about polio vaccination with hard-to-reach populations, including those living in camps for internally displaced persons. In Pakistan, campaigns based at border crossings and train stations vaccinated children on the move who might otherwise have been missed by traditional methods. And in Syria, dedicated workers are delivering vaccines at transit points and registration centres for internally displaced persons. Thanks to these strategies, more than 255,000 children have been vaccinated in Deir Ez-Zor, 140,000 were reached in Raqqa and the programme continues to work to reach every child.
Renewed commitment to end the disease
Complementing these programmatic innovations were political and financial commitments that highlighted polio eradication as a priority for global health leaders. These included:
- In May, the World Health Assembly reiterated the importance of eradicating polio and strategically transitioning the programme’s assets, and the G20 Health Ministers recognized the contribution of the polio infrastructure in helping countries face health emergencies during their first-ever meeting in Berlin.
- At the Rotary International Convention in June, health leaders gathered and pledged US$1.2 billion to end polio. Just months later, the UK demonstrated its own longstanding commitment to eradication with a $130 million pledge.
- At the G7 Health Ministers meeting in November, leaders once again affirmed their dedication to polio eradication as part of their broader commitment to strengthen health systems.
Looking ahead to 2018
Next year, country programmes will need to continue working to ramp up surveillance, particularly in Nigeria, and reach children everywhere with vaccines. Cross-border coordination between Pakistan and Afghanistan, which has already had a huge impact in reducing cases, will continue to be critically important to stopping transmission.
At the same time, the global community is beginning to solidify plans for keeping the world polio-free once eradication is achieved. Countries are developing strategies for transitioning the infrastructure and tools that they currently use to fight polio. And the GPEI is working with global stakeholders and partners to develop the Polio Post-Certification Strategy, which will define the activities needed to keep polio from returning after the virus is eradicated.
If the remaining endemic countries continue to do all that they can to stop the virus, and if the global community continues to meet the level of political and financial commitment needed to make and keep children everywhere polio-free, 2018 will bring the world’s best opportunity yet to end the disease.
Amidst conflict and humanitarian crisis in Syria, health workers are battling to end the current polio outbreak. Since the World Health Organization announced the outbreak on 8 June 2017, 70 cases have been confirmed, with 67 in Deir Ez-Zor governorate, two in Raqqa and one in Homs.
WHO and UNICEF are supporting the Government of Syria and local authorities to end the outbreak. Two mass vaccination campaigns have taken place, thanks to dedicated health care workers on the ground, striving to reach resident, refugee and internally displaced children. Despite the challenges of holding vaccination campaigns in a conflict zone and effectively reaching displaced populations from infected areas, more than 255,000 have been vaccinated in Deir Ez-Zor, and more than 140,000 in Raqqa.
Contingency plans for an additional vaccination campaign are being put in place to reach children under the age of five with monovalent oral polio vaccine type 2 in the infected zones and areas hosting high risk populations, particularly recently displaced families from Deir Ez-Zor.
Two different vaccines are being used to ensure that population immunity against polio is rapidly increased. The monovalent oral polio vaccine type 2 is being used to rapidly increase immunity against type 2 polio. To boost immunity against type 2 and also provide protection against types 1 and 3, the inactivated poliovirus vaccine is also being provided to children aged between 2 and 23 months in high risk areas.
Preventing spread of polio
While all hands are on deck to stop polio, outbreak response teams are also working hard and adapting complementary strategies such as vaccination at transit points and registration centres for internally displaced persons from infected zones, to prevent spread of the virus to other parts of the country. The inactivated poliovirus vaccine is being used strategically in high risk areas, especially where there are high numbers of internally displaced families.
In order to reduce the threat of polio spreading to the countries surrounding Syria, vaccination activities have been carried out in Iraq, Lebanon and Turkey. These activities are aiming to reach both Syrian children and those from local communities to limit the possibility for the virus to spread across international borders.
Searching for the virus
Knowing where the virus is at all times is crucial to stop the outbreak. Surveillance is ongoing across the country, with doctors, community members and vaccinators on the alert for any child with potential symptoms of polio. The surveillance system is operating well, despite the challenges of transporting stool samples from children with symptoms to laboratories for testing.
Plans are also in place to begin environmental surveillance in Syria by the end of the year. This will enable laboratories to identify the presence of polio in sewerage to provide early warning.
The information from disease surveillance being used to inform where and when vaccination campaigns need to take place.
Vaccine derived polio
The current outbreak in Syria is caused by circulating vaccine derived poliovirus type 2, a very rare virus that can occur when population immunity against polio is very low. In Syria, conflict and insecurity have compromised community access to immunization services, which has allowed the weakened virus in the oral polio vaccine to spread between under-immunized individuals and, over a long period of time, mutate into a virulent form that can cause paralysis. The only way to stop transmission of vaccine-derived poliovirus is with an immunization response, the same as with any outbreak of wild polio. With high levels of population immunity, the virus will no longer be able to survive and the outbreak will come to a close.
Three mass immunization rounds have been carried out in Deir Ez-Zor and Raqqa governorates, Syria, in response to an outbreak of circulating vaccine-derived poliovirus type-2 (cVDPV2). The latest round, targeting resident, refugee and internally displaced children less than five years in Deir Ez-Zor concluded 28 August.
“The detection of circulating vaccine-derived poliovirus indicates that there has been low population immunity in affected areas for a considerable period of time,” said Chris Maher, manager of WHO’s regional polio eradication programme based in Amman, Jordan. “WHO is working with all parties on the ground to ensure access to and vaccination of all children under five in these areas, to put an end to this outbreak as quickly as possible,” he said.
As of the end of August, 39 cases of cVDPV2 have been confirmed in Syria ‒ 37 cases from Deir Ez-Zor governorate, and 1 case each from Raqqa and Homs governorates. All three governorates are affected by active conflict.
“Conflict and inaccessibility continue to hamper efforts to raise population immunity levels in areas across the country. These same factors that paved the way for the outbreak of wild poliovirus in Syria in 2013,” said Maher. “We are using the same approaches to achieving access that were successfully used in responding to the 2013 outbreak, and working together with all partners to make sure that children can be reached with vaccine,” he added.
In addition to ensuring access for vaccination teams, innovative methods have been used to increase response reach and effectiveness. The advertising of campaigns through bakeries, and engagement of a local ice cream factory to assist with the daily freezing and refreezing of ice packs for vaccinator cold boxes, are examples.
“Vaccinators on the ground in Deir Ez-Zor and Raqqa continue to face difficult circumstances, but their efforts show clear dedication to protect children against this preventable disease,” said Maher. “We must maintain this high level of commitment and drive,” he said.
Deir Ez-Zor has carried out two mass immunization rounds in July and August while Raqqa has carried out one. The second round for Raqqa is planned for after the Eid holiday.
Inactivated polio vaccine (IPV) is being given to targeted children in each of the second rounds along with the oral vaccine to maximize individual and community protection.
“These local polio vaccination campaigns represent a significant step that has culminated in the close cooperation between WHO, UNICEF and local health partners to reach all targeted children under five in Ar-Raqqa and Deir Ez-Zor governorates,” said Elizabeth Hoff, WHO Representative in Syria.
“Despite security challenges, WHO is committed to ensure the distribution of polio vaccines and the implementation of the local campaigns as planned with a view to achieving sound wellbeing and growth for children with a special attention given to the affected governorates,” Hoff added.
In addition to supporting the response, WHO and partners are also working with neighboring countries to enhance immunization and disease surveillance activities in high-risk areas.
Circulating vaccine-derived poliovirus can occur in rare instances when population immunity against polio is very low. In these settings, the weakened virus found in the oral polio vaccine can spread between under-immunized individuals and over time, mutate into a virulent form that can cause paralysis. The only way to stop transmission of vaccine-derived poliovirus is with an immunization response, the same as with any outbreak of wild polio. With high levels of population immunity, the virus will no longer be able to survive and the outbreak will come to a close.
More on Syria
A circulating vaccine-derived poliovirus type 2 (cVDPV2) outbreak has been confirmed in the Deir-Ez-Zor Governorate of the Syrian Arab Republic. The virus strain was isolated from two cases of acute flaccid paralysis (AFP), with onset of paralysis on 5 March and 6 May, as well as from a healthy child in the same community.
Outbreak response plans are being finalized, in line with internationally-agreed outbreak response protocols, including plans for targeted vaccination campaigns to rapidly raise population immunity. An initial risk analysis has been conducted, finding low overall population immunity levels in the area but solid levels of disease surveillance. Active searches are being conducted for additional cases of acute flaccid paralysis. Surveillance and immunization activities are also being strengthened in neighbouring countries.
Although access to Deir-Ez-Zor is compromised due to insecurity, the Governorate has been partially reached by several vaccination campaigns against polio and other vaccine-preventable diseases since the beginning of 2016. Most recently, two campaigns have been conducted in March and April 2017 using bivalent oral polio vaccine (OPV). However, only limited coverage was possible through these campaigns. Syria also introduced two doses of inactivated polio vaccine in the infant routine immunization schedule in 2018.
The detection of the cases demonstrates that disease surveillance systems are functional in Syria. The polio programme is working with local authorities and organisations on the ground to respond immediately, using proven strategies. In 2013-2014, Deir-Ez-Zor was the epicentre of a wild poliovirus type 1 (WPV1) outbreak, resulting in 36 cases at the time. This outbreak was successfully stopped; the now-detected cVDPV2 strain is unrelated to the WPV1 outbreak.
Circulating VDPVs are extremely rare forms of poliovirus, mutated from strains in the oral polio vaccine (OPV) that can emerge in under-immunised populations. OPV has been a critical tool in eliminating 99.9% of polio cases worldwide, and while cVDPV is rare, the GPEI is actively working with countries to eradicate both vaccine-derived and wild polio. The same strategies that are eliminating wild poliovirus also stop cVDPV – it remains critical that all countries maintain strong disease surveillance and ensure all children are vaccinated.
More information on Syria
23 January 2016 – Syria is approaching 2 years without a reported case of polio today despite enormous challenges adversely affecting the delivery of health services, including childhood vaccinations.
Polio resurged in Syria in October 2013 after 14 years of absence, following a sharp drop in immunization coverage and importation of wild poliovirus. 35 cases were reported in 2013 (25 in Deir ez-Zor, 5 in Aleppo, 3 in Idleb, 2 in Al-Hassakeh) and 1 in Hama in January 2014. Transmission was halted after a series of mass vaccination campaigns held across the country reaching more than 2.9 million children under 5 years of age with repeat doses of oral polio vaccine (OPV).
“I am pleased and impressed that Syria has maintained a zero polio status for the past 2 years, given its current crisis context,” said Ms Elizabeth Hoff, WHO Representative to Syria. “This is a testament to the dedication and grit of Syrian health workers. Remember, the country is still at high risk of polio, and to keep Syria polio-free we must continue to carry out vaccination campaigns to increase immunity, focusing particularly on children in hard-to-reach areas,” she said. “We must also continue to strengthen disease surveillance systems to monitor for polio. We need to be prepared if the virus resurfaces,” she added.
“This is a major milestone for Syria,” said Hanaa Singer, UNICEF Representative in Syria. “We pay tribute to all health workers and volunteers who made this possible. We must grant them further protection and champion their efforts to reach every child, everywhere across Syria, particularly in hard-to-reach areas. Maintaining these gains remains of paramount importance.”
Read full statement
January 21 will mark a year since the last case of polio was reported in Syria. This significant milestone is thanks to a tremendous effort by all those involved in outbreak response since the first case was confirmed in October 2013 and was followed by a series of intense vaccination activities starting that same month.
Before this outbreak, Syria had not seen an endemic case of wild poliovirus since 1999. The civil war was devastating to public health in the country, and levels of immunization fell from 99% coverage to 52%. Spreading along with the conflict into Iraq, the polio virus had paralysed 36 children in Syria and two in Iraq by the end of April 2014.
A year with no reported cases in Syria, and 9 months since a case in Iraq, is a remarkable achievement that has drawn on the commitment of the governments of the region, health actors, and the commitment of parents to get the vaccines for their children. Chris Maher, Manager for Polio Eradication and Emergencies in the Middle East for the World Health Organization (WHO), commends the support that the outbreak response received, despite the challenges of operating within a severely disrupted public health system. Local authorities were very supportive, and the strong culture of the population seeking out immunization services increased the uptake of the vaccine.
Following an outbreak, mass immunization campaigns are the first tool used by health services to stop it in its tracks. With several years since the last mass campaigns, international support was needed in order to enable governments and health actors to rapidly coordinate large scale campaigns, not only in infected countries but in the surrounding countries. The mass displacement of people from and within Syria and Iraq meant that a coordinated regional response was crucial to efforts. Lebanon saw an influx of refugees that was equivalent to around a quarter of its national population, requiring a huge scale-up in immunization capacity. Alongside campaigns and the training of health workers, community engagement increasingly became a challenge due to population movements, as population figures from before the civil war were no longer accurate. This made developing a population-appropriate vaccine delivery service very difficult.
Despite these major challenges, the outbreak seems to have been brought under control. In the face of the destruction of infrastructure, both physical and human, a year with no cases in Syria is an opportunity to reflect on the incredible joint efforts that have been made to end the outbreak.
Maintaining the gains in Syria and Iraq remain of paramount importance. While polio continues to circulate in Pakistan and Afghanistan, children everywhere – especially in countries with social and political ties to this reservoir of the virus – remain at risk of paralysis caused by polio.
Syria is fast approaching a year without a case of polio, following major outbreak response activities in the country, even in the midst of a severe humanitarian crisis, and across the region. Health administrators and workers in all parts of Syria, across conflict lines, are fully focused on making sure that every case of polio is detected. As long as polio is endemic in Pakistan, which has major migration and trade relations with the Middle East, countries in the region remain vigilant about polio transmission and plan to continue mass vaccination activities to protect their children.
Find out more about the current situation in Syria by following a live interview with Chris Maher, Manager for Polio Eradication and Emergency Support , at 1400 Eastern Standard Time (1900 GMT). The video will also be available afterwards at the same link.
Ask a question to the reporter ahead of or during the interview by tweeting @devindthorpe.
More than 2 million children were immunized against polio last week
14 January 2014 – According to preliminary results more than 2 million children were immunized against polio across Syria last week during a third round of vaccination in response to a polio outbreak in the country.
The activities were carried out by local health and community authorities supported by UNICEF, WHO, the Syrian Arab Red Crescent and other partners, navigating the complex conflict landscape. Collaboration with humanitarian agencies and the local communities helped reach children in a number of contested areas that were not reached in the previous campaigns in October and December. With each campaign, more families are taking part in the vaccination activities, and more actors are cooperating and supporting the immunization effort across Syria.
“We are seeing high demand for immunization among the population. This reflects the increasing public awareness of the risks of polio, which until this past autumn had not been seen in Syria since 1999,” says Chris Maher, a WHO epidemiologist and senior adviser on polio eradication, “When families know that immunization is offered, they make a great effort to get their children vaccinated.”
The increasing momentum of the response is a result of improving information flow, on-going training of health workers and volunteers, better planning and the engagement of more stakeholders. However, heavy fighting in some areas disrupted operations; it is estimated that at least 100,000 children were deprived of vaccination as a result.
Although the overall response to this polio outbreak has been robust, with health authorities using every opportunity to reach children and monitor impact, collating information from all areas is difficult and coverage figures are still being compiled for the two recent campaigns.
In December, the region carried out the largest-ever immunization response in the Middle East, aiming to vaccinate more than 22 million children. Campaigns were held in Egypt, Iraq, Jordan, Lebanon, the West Bank and Gaza, Syria and Turkey.
Such campaigns are planned to continue over the next six months, to protect children in the region from poliovirus. As donors mobilize for the broader humanitarian response to the Syrian crisis in the ‘Kuwait II’ conference, among the first to respond to the polio outbreak were Rotary International, the Governments of Austria, Estonia and Germany, and the European Community Humanitarian Office (ECHO).
The push to immunize all children against polio has been hampered by the ongoing crisis in the Syrian Arab Republic. WHO and UNICEF have appealed to all parties to cooperate, including through temporary pauses in hostilities where needed, to allow vaccination campaigns to take place and for all children to be protected.
When Dr Salah Salem Haithami, a medical officer with WHO, heard that polio had reappeared in the Syrian Arab Republic, his first thought was: can I go there to help? He had been working for a dozen years on polio eradication in Sudan, but just days later he was deployed to Damascus.
Haithami’s second thought was for children in Yemen, his own country. “Polio does not have a passport – it can affect any child anywhere in the world,” he says. “My motivation is to help stop the polio outbreak in Syria and, in this way, to prevent children outside of Syria from being paralyzed for life.”
Since he arrived in Damascus in October, Haithami has focussed day and night on the polio vaccination campaign. “I have helped order vaccines and other supplies. I have shared our experience from the Sudan and other countries and got agreement for new tactics like house-to-house visits and finger-marking, so that vaccinators really reach every single child. I have met with people in all sectors of Syrian society to try and gain crucial support for the campaigns,” he explains.
“All children have the right to be protected from the crippling poliovirus, and the provision of healthcare must remain neutral, regardless of the context.”
Dr Ala Alwan, Regional Director
The first suspected polio cases in Syria were flagged on 17 October 2013. On 29 October the Government of Syria announced that wild poliovirus had been isolated from 10 paralyzed children in Deir Ez Zour, one of the most fiercely contested areas of the country. Even before this laboratory confirmation, health authorities across the region had begun the planning and implementation of a comprehensive outbreak response. That campaign started on 24 October.
As of late November, 17 children had been paralyzed by polio in three separate Governorates of the Syrian Arab Republic, which had previously not recorded polio for over a decade.
The push to immunize all children against polio has been hampered by the ongoing internal conflict in the Syrian Arab Republic. “We are appealing to all parties to cooperate with temporary pauses in hostilities over the coming 6 months to allow vaccination campaigns to take place and for all children to be reached,” says Dr Ala Alwan, Regional Director, WHO Eastern Mediterranean Regional Office. “All children have the right to be protected from the crippling poliovirus, and the provision of healthcare must remain neutral, regardless of the context.”
Recognizing the high risk of spread to countries in the region and beyond, in October/November 7 countries and territories held mass polio vaccination campaigns targeting 22 million children under the age of 5 years. In a joint resolution in early November, all countries of the WHO Eastern Mediterranean Region declared the escalating polio situation to be an emergency for the entire Region, calling for support in negotiating and establishing access to those children who are currently unreached with polio vaccination, in both the Middle East and in Pakistan, from where the outbreak virus had originated. It is estimated that campaigns will need to continue for the next 6 to 8 months to ensure all children in Syria and surrounding countries are vaccinated.
WHO is working with UNICEF, other UN agencies, the Syrian Arab Red Crescent and its committed local volunteers, international and national NGOs, and other local and international groups providing humanitarian assistance to Syrians affected by the conflict to ensure that all children are vaccinated, no matter where they live. It is anticipated that outbreak response activities will need to continue for 6 to 8 months, depending on the area and based on the evolving epidemiology.
“This outbreak underscores the importance of ending polio everywhere, particularly in the 3 remaining endemic countries: Afghanistan, Nigeria and Pakistan,” Dr Alwan says. “As long as polio persists in these reservoirs, the world will always be at risk of outbreaks. We must do everything possible to reach all children in those areas.”
11 November 2013 – Genetic sequencing indicates that the isolated viruses are most closely linked to virus detected in environmental samples in Egypt in December 2012 (which in turn had been linked to wild poliovirus circulating in Pakistan). Closely related wild poliovirus strains have also been detected in environmental samples in Israel, West Bank and Gaza Strip since February 2013. Wild poliovirus had not been detected in the Syrian Arab Republic since 1999.
A comprehensive outbreak response continues to be implemented across the region. On 24 October 2013, an already-planned large-scale supplementary immunization activity was launched in the Syrian Arab Republic to vaccinate 1.6 million children against polio, measles, mumps and rubella, in both government-controlled and contested areas. Implementation of a supplementary immunization campaign in Deir Al Zour province commenced promptly when the first ‘hot’ acute flaccid paralysis (AFP) cases were reported. Larger-scale outbreak response across the Syrian Arab Republic and neighbouring countries will continue for at least 6-8 months depending on the area and based on the evolving situation.
Given the current situation in the Syrian Arab Republic, frequent population movements across the region and the immunization level in key areas, the risk of further international spread of wild poliovirus type 1 across the region is considered to be high. A surveillance alert has been issued for the region to actively search for additional potential cases.
WHO’s International Travel and Health recommends that all travellers to and from polio-infected areas be fully vaccinated against polio.
Following reports of a cluster of 22 acute flaccid paralysis (AFP) cases on 17 October 2013 in the Syrian Arab Republic, wild poliovirus type 1 (WPV1) has been isolated from ten of the cases under investigation. Final genetic sequencing results are pending to determine the origin of the isolated viruses. WPV had not been detected in Syria since 1999.
Most of the cases are very young (aged <2 years), and were un- or under-immunized. Estimated immunization rates in Syria declined from 91% in 2010 to 68% in 2012.
Even before this laboratory confirmation, health authorities in Syria and neighbouring countries had begun the planning and implementation of a comprehensive outbreak response. On 24 October, an already-planned large-scale supplementary immunization activity (SIA) was launched in Syria to vaccinate 1.6 million children against polio, measles, mumps and rubella, in both government-controlled and contested areas. Implementation of an SIA in Deir Al Zour province promptly commenced when the first ‘hot cases’ had been reported. Larger-scale outbreak response across Syria and neighbouring countries is anticipated to begin in early November, to last for at least six to eight months depending on the area and based on evolving epidemiology.
Given the current situation in Syria, frequent population movements across the region and subnational immunity gaps in key areas, the risk of further international spread of WPV1 across the region is considered to be high. A surveillance alert has been issued for the region to actively search for additional potential cases.
WHO’s International Travel and Health recommends that all travelers to and from polio-infected areas be fully vaccinated against polio.
On 17 October 2013, the World Health Organization (WHO) received reports of a cluster of acute flaccid paralysis (AFP) cases in the Syrian Arab Republic. This cluster of ‘hot’ AFP was detected in early October in Deir Al Zour province and is currently being investigated. Initial results from the national polio laboratory in Damascus indicate that two of the cases could be positive for polio – final results are awaited from the regional reference laboratory of the Eastern Mediterranean Region of WHO. Wild poliovirus was last reported in Syria in 1999.
The Ministry of Health of the Syrian Arab Republic confirms that it is treating this event as a cluster of ‘hot’ AFP cases, pending final laboratory confirmation, and an urgent response is currently being planned across the country. Syria is considered at high-risk for polio and other vaccine-preventable diseases due to the current situation.
A surveillance alert has been issued for the region to actively search for additional potential cases. Supplementary immunization activities in neighbouring countries are currently being planned.
WHO’s International Travel and Health recommends that all travelers to and from polio-infected areas be fully vaccinated against polio.