Following wide engagement of stakeholders – from lab workers to engineers to certification bodies responsible for signing off on the lockdown of poliovirus strains after certification of eradication – WHO’s chief guidance document for poliovirus containment has been given an overhaul. The update to the WHO Global Action Plan for Poliovirus Containment (GAP-IV, previously GAP-III) comes at the request of the WHO Containment Advisory Group (CAG) and streamlines the tool with other relevant WHO guidance and technical recommendations made by CAG. Its availability is expected to help accelerate containment implementation worldwide.
Containment involves biosafety and biosecurity requirements for laboratories and vaccine production sites, or any other place handling and storing eradicated polioviruses, to minimize the risk of these pathogens being released into communities. It also concerns risk mitigation measures associated with field use of some live oral polio vaccines. WHO urges facilities holding virus to move through its Containment Certification Scheme, and follow guidance contained in GAP-IV.
“Retention of poliovirus materials for what their governments deem to be critical functions is a risk and responsibility for all countries that choose to do so,” said Prof David Heymann, Chair of the CAG and professor of infectious disease epidemiology at the London School of Hygiene and Tropical Medicine. “GAP provides guidance that aims to minimize the risk of escape of the poliovirus from a retention facility, and we hope that the revised publication ̶ which stakeholders in polio eradication helped shape ̶ will ensure faster action by countries that decide to retain poliovirus materials,” he said.
“The revision of the guidance has been a long time in the making and comes with a lot of anticipation,” stated Dr Harpal Singh, WHO polio technical officer and CAG secretariat. “WHO and CAG have taken on board the numerous concerns and feedback from Member States with regards to carrying out the guidance, and a certain degree of flexibility based on local risk mitigation measures has been applied in some areas, whilst maintaining the rigor of evidence-based best practice,” he added. “We anticipate that this will result in a better implementation of the requirements for Member States opting to retain [poliovirus] materials, and having their facilities certified,” he added.
To date, two of three strains of wild poliovirus have been declared globally eradicated – type 2 and type 3. Countries around the world, however, continue to handle and store these viruses for functions including polio vaccine manufacture, diagnostics and research, among others. It is essential that any facility holding poliovirus types 2 and/or wild or VDPV type 3 stocks, regardless of purpose, either put in place the necessary biorisk management measures outlined in GAP or destroy their virus stocks.
“The world is on the precipice of eradication of wild poliovirus type 1 with the lowest ever case count recorded in 2021, and we got rid of WPV2 and WPV3 in 2015 and 2019, respectively. While some progress has been made, we’re actually quite behind schedule in ensuring those two eradicated serotypes are properly contained, and more needs to be done in this regard,” said Aidan O’Leary, head of WHO’s polio eradication programme.
There are currently 25 countries hosting 65 facilities officially designated by their respective governments to retain poliovirus materials. The majority of countries have established a National Authority for Containment for domestic oversight over containment action, in line with commitments from the 2018 resolution, and work is underway to progress their facilities through the Containment Certification Scheme.
For now, containment measures apply to all type 2 and wild and vaccine-derived type 3 materials.
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.
As a result of ongoing disease surveillance, the Global Polio Laboratory Network (GPLN) has confirmed that a child in Changara district, Tête province, Mozambique, was paralyzed by type 1 wild poliovirus (WPV1).
The child experienced onset of paralysis on 25 March 2022, and sequencing of the virus confirms that it is linked to the imported WPV1 case confirmed in Malawi in February.
While this detection of another WPV1 in the southeast Africa region is a concern, it is not unexpected following the Malawi detection in February and further underscores the importance for all countries to prioritize immunization of children against polio.
Mozambique has participated in the multi-country coordinated vaccination campaigns in response to Malawi’s imported WPV1, with two vaccination rounds already conducted. The most recent took place at end of April, with 4.2 million children vaccinated across the country, and the Global Polio Eradication Initiative (GPEI) is supporting countries to strengthen disease surveillance and prepare for the remaining two campaign rounds. These will cover Malawi, Tanzania, Mozambique and Zambia, with Zimbabwe joining the later rounds to ultimately help reach over 23 million children under five years with polio vaccine by end of August 2022.
Mozambique last recorded a case of wild polio in 1992 though the country has more recently been affected by an outbreak of circulating vaccine-derived poliovirus type 2 (cVDPV2). Three cases have been detected since April 2021 and vaccination campaigns in response to the outbreak are continuing, which include use of the novel oral polio vaccine type 2 (nOPV2).
Wild polio remains endemic in just two countries – Pakistan and Afghanistan. The WPV1 detection in Mozambique does not affect the WHO African Region’s wild poliovirus-free certification status officially marked in August 2020, as the virus strain originated in Pakistan. However, any child paralysed by polio is one too many. The polio eradication programme has seen importations from endemic countries to regions that have been certified wild poliovirus-free in the past and has moved quickly to successfully stop transmission of the virus in these areas.
Polio anywhere is a threat to children everywhere. It is vital that all parties ensure that the GPEI has the support it needs to implement its five-year eradication Strategy in full and ensure no child is paralysed by polio ever again.
17 February 2022 As a result of ongoing disease surveillance, the Global Polio Laboratory Network (GPLN) has confirmed the presence of type 1 wild poliovirus (WPV1) in a child suffering from paralysis in Tsabango, Lilongwe, Malawi. Analysis shows that the virus is genetically linked to WPV1 that was detected in Pakistan’s Sindh province in October 2019.
The three-year-old girl in Malawi experienced onset of paralysis on 19 November 2021, and stool specimens were collected for testing on 26 and 27 November. Sequencing of the virus conducted in February by the National Institute for Communicable Diseases in South Africa and the U.S. Centers for Disease Control and Prevention confirmed this case as WPV1.
Detection of WPV1 outside the world’s two remaining endemic countries, Pakistan and Afghanistan, is a serious concern and underscores the importance of prioritizing polio immunization activities. Until polio is fully eradicated, all countries remain at risk of importation and must maintain high vaccination coverage to protect all children from polio.
The GPEI is supporting health authorities in Malawi to conduct a thorough assessment of the situation and begin urgent immunization activities in the subregion to mitigate any risk of spread. Surveillance measures are also being expanded in Malawi and neighboring countries to detect any other potential undetected transmission.
As an imported case from Pakistan, this detection does not affect the WHO African Region’s wild poliovirus-free certification status officially marked in August 2020. Malawi last recorded a case of wild poliovirus in 1992. The polio eradication programme has seen importations from endemic countries to regions that have been certified wild poliovirus-free in the past, and has moved quickly to successfully stop transmission of the virus in these areas.
Polio anywhere is a threat to children everywhere. Now is the time for all parties to recommit to ending all forms of polio for good.
Sudan borders a number of countries facing outbreaks of circulating vaccine-derived poliovirus, including Chad and the Central African Republic (CAR) to the west, and Ethiopia and Somalia to the east. Population movements between these countries increase the risk of importation of polio to Sudan. The World Health Organization and national health authorities in Sudan are scaling up efforts to reduce the risk of poliovirus transmission to the country.
To prevent a possible outbreak, health authorities have been working amidst immense operational challenges to carry out vaccination campaigns and strengthen disease surveillance. Public health teams in Sudan and CAR are collaborating to share details of vaccinated refugee children with their country of origin, and exchange information on upcoming supplementary immunization activities and reported cases of Acute Flaccid Paralysis.
Sudan was declared free of wild poliovirus in 2015, but remains at considerable risk for poliovirus importation or a VDPV outbreak. Much of the risk is shaped by Sudan’s unique population dynamics, and by the devastating effect of population movement, conflict and instability affecting routine immunization. Additionally, nomads, who account for around 10% of Sudan’s population, regularly move across borders to graze animals in Chad and CAR.
Over 8 million children under the age of five are estimated to live in Sudan – an age group considered to be most vulnerable to contracting and being paralyzed by poliovirus. Sudan also has large numbers of internally displaced people and refugees, many in the areas of the country with the lowest levels of routine immunization, such as the Darfur region.
In September and October 2019, states on the border between Sudan and CAR implemented accelerated routine immunization to provide children with coverage against a variety of vaccine-preventable diseases. Teams conducted reviews of vaccination facilities and posts in border areas, and orientation sessions were held in healthcare settings to reinforce reporting cases of Acute Flaccid Paralysis. Children received oral polio vaccine, pentavalent vaccine, and inactivated polio vaccine. Initial data from the campaigns suggests a spike in coverage, with teams reaching many children previously unprotected.
The nomads of the Lake Chad Basin account for 3%–5% of the population and are one of the most underserved communities when it comes to health.
When Chad had to respond to the detection of wild poliovirus in Nigeria in 2016, it was crucial to vaccinate nomadic children. The World Health Organization, the United States Centers for Disease Control and Prevention and partners created a database of population numbers, movements, and immunization records. ‘Lake Chad response teams’, each with four specialists – an epidemiologist, a social mobilizer, a vaccinator and a data recorder – fanned out, data in hand, to reach every nomadic child with polio vaccines.
Often teams began by speaking to nomads in a market or on a road and then asking to follow them to their temporary camp. The Lake Chad Basin covers almost 8% of the African continent and trying to find groups amongst the vast expanse of semi-arid savannah was almost impossible without this kind of time-consuming work.
Upon arriving in a camp, the social mobilizer in each response team explained to family elders and parents the purpose of the vaccination and the benefits for their children. The response teams asked for permission to begin vaccination.
“They see themselves as neglected in society,” explains Ajiri Okpure Atagbaza, a GIS consultant in the WHO Regional Office for Africa Geographic Information System Centre, who spent three years as part of the Chad response team working with nomads. “When you came with aid, they welcomed you. As long as you spoke their language, they were open to it.”
Children received all immunizations for their age alongside polio vaccine, as part of an integrated approach to health delivery. The parents were given an immunization card recording which vaccines had been administered.
Each team carried a smartphone application used to capture the locations of the nomadic camps, the results of acute flaccid paralysis case surveillance, and information gained through conversations with the community, such as how long they had been in their current location, previous and future camp locations, the population size and vaccination rates. This information was uploaded to bolster the database to help plan future health services.
From April to August 2019, the Lake Chad response teams reached 1067 nomad groups in 17 districts in Chad alone and vaccinated more than 27,000 children. Across all five countries making up the Basin, more than 40,000 children in 3451 nomadic camps in 62 high-risk districts received their routine immunizations, including protection against polio. The information recorded during these activities will be used in routine immunization planning to ensure that children continue to receive all their vaccinations according to the schedule.
Q: Outbreaks of circulating Vaccine-Derived Poliovirus type 2 (cVDPV2) are popping up in a lot of countries. How do you explain this? Did the programme know this would happen after the oral polio vaccine ‘switch’?
There have been 47 cVDPV2 outbreaks in 20 countries since the switch in April 2016. Some of these outbreaks are spreading over more than one country. Taking the three years before the switch as a frame of reference, there were 8 cVDPV2 outbreaks in five countries altogether in 2013, 2014 and 2015.
Based on epidemiological modelling studies, we anticipated cVDPV2 outbreaks following the removal of the type 2 component from oral polio vaccine in 2016, via the trivalent to bivalent OPV “switch”. And we anticipated that VDPV cases would outnumber wild poliovirus cases in the endgame. However, what the modelling did not predict was the number and scale of these outbreaks, some of which have proven very difficult to stop.
The reason we are seeing a growing number of cVDPV2 outbreaks, particularly in Africa, is the result of a growing cohort of children without mucosal immunity to type 2 poliovirus, while at the same time the [polio] programme uses monovalent oral polio vaccine type 2 (mOPV2) to respond to existing cVDPV2 outbreaks.
The monovalent vaccine [mOPV2] is currently our only tool to interrupt transmission of cVDPV2 and it is very effective when there is sufficient vaccination coverage in the communities we are targeting to avoid an outbreak. However, when campaign quality is poor and not enough children are reached with the vaccine, we run a risk of seeding new viruses among under-immunized populations. There has been evidence of this happening in and outside of outbreak response zones. We are currently developing a new strategy for stopping cVDPV2 outbreaks, and at the same time preventing new outbreaks.
Q: With a limited global stockpile of mOPV2, is there sufficient vaccine to respond to these and future outbreaks?
No. Current mOPV2 stock is insufficient to cater for the number of outbreaks and the sizes of populations requiring it. The GPEI is working with vaccine manufacturers to boost production of mOPV2 and we expect to meet targeted quantities in 2020.
The vaccine will continue to be used for cVDPV2 outbreak response until a new and more genetically stable oral polio vaccine, known as novel oral polio vaccine type 2 (nOPV2), currently under clinical development, is available.
Q. What does increased production of mOPV2 mean for vaccine manufacturers in terms of containment? On one hand, the polio programme is asking for more live type 2-containing OPV. And on the other, it’s pushing for strict containment of all type 2 wild and Sabin polioviruses.
It’s a balance. The world needs enough mOPV2 stocks to help with the elimination of cVDPV2, and type 2 live attenuated poliovirus is needed to produce this vaccine. Yes, we are asking vaccine manufacturers to make more vaccine, but [vaccine] production and containment of type 2 virus are not mutually exclusive pursuits. Polio vaccine manufacture is costly, particularly when demand calls for rapid scale-up of outputs. Containment is also costly. But this is not a reason to put it on hold and stop efforts to ensure safe and secure handling and storage of virus. Quite the opposite: the impetus for putting in place adequate biorisk management systems should be greater, given the higher level of risk of human exposure to poliovirus in and around these facilities.
Q. What about manufacturers of inactivated polio vaccine (IPV)? Can they afford to relax?
IPV is made with killed, or inactivated strains of wild poliovirus types 1, 2 and 3, or their Sabin counterparts. Any facility manufacturing polio vaccines using the type 2 serotype – be it wild or Sabin ̶ and type 3 wild poliovirus since the declaration of its global eradication in October, is required to implement containment measures set out by WHO. This of course also applies to any other type of facilities holding the viruses, for example, research or diagnostic labs.
Holding on to these viruses is a risk and responsibility, and appropriate measures must be taken to protect communities from reintroduction and resurgence.
The world needs IPV and will continue to need it for the foreseeable future. We need vaccine production to continue in well-managed facilities that incorporate GAPIII approaches to biorisk management.
Q. of Sabin 2 remains a priority, while simultaneously, mOPV2 made up of Sabin 2 is being used in countries around the world. What gives?
First, we must be clear that use of mOPV2 is not a decision that is taken lightly. A thorough risk-benefit analysis is conducted before an advisory committee makes a recommendation and it is submitted to the Director-General of WHO for his approval.
It is never ideal to use mOPV2 and reintroduce Sabin 2, which should be under containment. However, as I mentioned earlier, mOPV2 is currently the only tool available to stop outbreaks of cVDPV2 and we must use it.
The reason we continue to push for containment of Sabin 2 viruses in countries not experiencing cVDPV2 outbreaks is precisely to prevent further emergences of VDPV2, which can cause outbreaks of cVDPV2 more easily now because of the very low population mucosal immunity to type 2 poliovirus.
Q. sounds like we are fighting fire with fire with mOPV2. Are we?
Many outbreaks have been stopped using mOPV2. However, in areas with low routine vaccination coverage, and thus low immunity, we are indeed reintroducing Sabin 2 in naïve populations and seeding new outbreaks. We are currently reviewing all aspects of our cVDPV2 approach and developing a new strategy that examines all options and tools ensuring we are using each for full impact. This includes improving our outbreak response so that it is appropriate in scope and effective, and accelerating the development and roll-out of a new vaccine that is less likely to seed outbreaks.
Q: When will nOPV2 be available?
Clinical trials are underway. There are numerous influencing factors but if all goes according to plan, our estimate is that approximately 100 million doses of the vaccine could be ready by mid-2020, with another 100 million by the end of the year. We are also working with the WHO prequalification team, which independently reviews all vaccine data to ensure a consistent quality in accordance with international standards to enable the vaccine to be used as quickly as possible by affected countries under an Emergency Use Listing (EUL), a risk-based procedure for assessing vaccines for use during public health emergencies—such as polio.
The vaccine is also being developed for types 1 and 3 polioviruses; however, this is further away in terms of production.
On the long road to global polio eradication, the programme has achieved four important milestones, representing four out of six WHO regions that have been certified as having interrupted transmission of wild poliovirus (WPVs): Region of the Americas (1994), the Western Pacific Region (2000), the European Region (2002), and the South-East Asia Region (2014).
At present, only the Eastern Mediterranean and African regions— no WPV reported in Africa since 2016, the African region may be eligible for regional certification as early as late 2019—remain to be certified in the path towards global eradication and hence constitute a key priority.
But who decides that a region is free of WPV?
The Eastern Mediterranean Regional Commission for Certification of Poliomyelitis Eradication (ERCC) is an independent body appointed in 1995 by the WHO Regional Director for Eastern Mediterranean to oversee the certification and containment processes in the region. It is the only body with the power to certify the Region free from wild polio, which convenes annually. Here are the outcomes of the recent ERCC meeting:
Urgent need to address regional priorities
The Commission noted with concern the need to stop the ongoing wild poliovirus type 1 transmission in the only two remaining polio-endemic countries in the Region: Afghanistan and Pakistan. The RCC acknowledged the on-going eradication efforts but strongly recommended the full implementation of the respective national emergency polio programmes through complete political and programmatic support to tackle the WPV1 transmission in the common Pak-Afghan epidemiological corridor, which remains unabated. The Commission also expressed concern about the current circulating vaccine-derived poliovirus type 2 and 3 transmissions in Somalia.
Wild poliovirus type 3certification prospects
The Commission, however, marked the good progress made towards curbing wild poliovirus type 3 (WPV3). Extensive analyses of the stool and environmental surveillance samples provided evidence that no WPV3 is in transmission in the Region. Based on the epidemiology, EMRO – along with the rest of the world – may be up for global WPV3-free certification by the GCC, potentially certifying two of three poliovirus strains eradicated—WPV2 strain was certified as globally eradicated in 2015.
Stepping-up is the need of the hour
So far, sixty cases of WPV1 are reported from two countries (Pakistan and Afghanistan) in 2019. Given the existing WPV1 transmission in the two remaining endemic countries of the Region, the RCC asked that the Member States undertake a firm commitment necessary for reaching zero.
Eastern Mediterranean Regional Commission for Certification of Polio Eradication (ERCC)
The Thirty-third meeting of the EMRO RCC was held in Muscat, Oman, to discuss the Regional progress towards a polio-free certification. The meeting brought together members of the RCC, chairpersons of the National Certification Committees, polio programme representatives of 21 countries, and WHO staff from the headquarters, regional, and the endemic countries. Representatives from Rotary International and the Centers for Disease Control and Prevention were also in attendance.
Comprised of public health and scientific experts, the regional certification commissions are independent of the WHO and national polio programmes. Global certification will follow the successful certification of all six WHO regions and will be conducted by the Global Certification Committee (GCC).
Final reports of the annual Eastern Mediterranean Regional Certification Commission intercountry meetings.
After concerted efforts spanning decades, polio eradication efforts are in the homestretch and experts are advising how to fast-track the last mile.
The SAGE convened in Geneva from 2-4 April 2019 to discuss all things related to vaccines and immunizations, including poliovirus and the global eradication efforts around it. SAGE reviewed the latest global polio epidemiology, the new Global Polio Eradication Endgame Strategy 2019-2023, and what the post-eradication world could look like.
Double down and escalate the fight to end wild poliovirus
While SAGE noted the achievements and the progress of the Global Polio Eradication Initiative—reducing the incidence of polio by 99%, absence of wild polio virus type 3 cases, and evidence of Nigeria being wild poliovirus free for over two years—the group displayed cautious optimism about meeting the timeline set out for global eradication of wild poliovirus.
The remaining challenges to fill vaccination coverage gaps—including restricted access, socio-political challenges, and large mobile populations—complicate the efforts to rid the world of poliovirus. However, the GPEI has developed a clear-cut five- year plan to secure a decisive win, the GPEI Polio Endgame Strategy 2019-2023, developed in broad consultation with stakeholders, including SAGE members.
Inactivated Polio Vaccine (IPV)—progress in roll-out continues
From the public health standpoint, Inactivated Polio Vaccine (IPV) can be used indefinitely even after polio eradication. As of April 2019, all 33 countries which had not yet introduced IPV into their routine immunization activities have now done so.
The projected IPV supply is thought to be sufficient enough for the introduction of a two-dose IPV schedule in all countries by 2022, and to catch-up all children missed due to earlier supply shortages, by 2020/2021.
Guidelines Endorsed
As per SAGE recommendations made in October 2016, GPEI developed guidelines for poliovirus surveillance among persons with primary immunodeficiency. After reviewing the guidelines, the SAGE endorsed the guidelines for implementation in high priority countries.
The meeting report will be published in the WHO Weekly Epidemiological Record by May 2019.
The Strategic Advisory Group of Experts (SAGE) on Immunization was established by the Director-General of the World Health Organization in 1999 to provide guidance on the work of WHO. SAGE is the principal advisory group to WHO for vaccines and immunization. It is charged with advising WHO on overall global policies and strategies, ranging from vaccines and technology, research and development, to delivery of immunization and its linkages with other health interventions. SAGE is concerned not just with childhood vaccines and immunization, but all vaccine-preventable diseases.
From the gold standard of detecting and investigating cases of acute flaccid paralysis (AFP) to testing environmental samples from sewage collection sites, timelyand sensitive surveillance is key to locating and eradicating polio. And in the endgame to finish the job, closing all remaining gaps in detection and investigation capacity is critical.
Global Polio Eradication Initiative has developed Global Polio Surveillance Action Plan, 2018 – 2020 to help endemic, outbreak and high-risk countries measure and enhance the sensitivity of their surveillance systems. It provides new strategies that may be useful in improving detection of polioviruses, and is designed to increase coordination across field team, laboratory and information management staff.
The Action Plan outlines activities and indicators at the global, regional and country levels for all priority countries, centred around six core objectives to strengthen surveillance systems, and is anchored within the broader strategic framework of the GPEI.
The Endgame Plan through 2018 brought the world another year closer to being polio-free. While we had hoped to be finished by now, 2018 set the tone for the new strategic plan, building on the lessons learned and mapping out a certification strategy by 2023. 2018 was also marked by expanded efforts to reach children with vaccines, the launch of innovative tools and strategies, critical policy decisions and renewed donor commitment to the fight.
Circulation of wild poliovirus (WPV) continues in the common epidemiological block in Afghanistan and Pakistan. However, both countries steadily worked to improve the quality of their vaccination campaigns in 2018 through National Emergency Action Plans, with a particular focus on closing any immunity gaps to put the countries on track to successfully stop WPV in the near future. Given the priority on polio eradication, WHO Director General, WHO Regional Director for the Eastern Mediterranean and President, Global Development at Bill & Melinda Gates Foundation started off the new year with a four-day visit to meet the heads of state and have a first-hand experience of the on-the-ground eradication efforts in both the countries.
In August, Nigeria marked two years since detecting any WPV. With continuing improvements in access to the country’s northeast, as well as efforts to strengthen surveillance and routine immunization, the entire African region may be eligible for being certified WPV-free as early as late this year or early 2020. What’s more, the world has not detected type 3 WPV since 2012 and the strain could be certified eradicated sometime this year.
Program innovation
The programme is constantly developing new ways to more effectively track the virus, vaccinate more children and harness new tools to help end the disease for good.
In Nigeria and the surrounding region, health workers launched new tools to enable faster, more comprehensive disease surveillance. e-Surve, a smartphone app, guides officers through conversations with local health officials, offering prompts on how to identify and report suspected cases of disease. Then, with the touch of a button, responses are submitted to a central database where health officials can analyze and track outbreaks across multiple districts in real-time.
Beyond surveillance, health workers worked tirelessly to bring the polio vaccine to the remote communities of Lake Chad. Dotted with hundreds of small islands, the lake is one of the most challenging places on earth to deliver health services. Vaccinators must travel by boat on multi-day trips to deliver polio vaccines to isolated island villages, using solar-powered refrigerators to keep their precious cargo cool. In 2018, vaccination campaigns on the lake reached thousands of children for the first time – children who would otherwise have gone unprotected.
The programme also took important steps in developing new tools including, novel oral polio vaccine (nOPV), if studies show to be successful, could provide a safer form of OPV that provides the same level of protection without the small risk of vaccine-derived polio in under-immunized populations.
Battling circulating vaccine-derived poliovirus
In 2018, the Democratic Republic of the Congo, Niger, Nigeria, Papua New Guinea, Kenya, Somalia and Mozambique experienced outbreaks of circulating vaccine-derived polio (cVDPV). Although these cases are still rare – and only happen in places where immunity is low. The polio eradication initiative has two urgent tasks: eradicate WPV quickly as possible and stop the use of OPV globally, which in tandem will prevent new cVDPV strains from cropping up.
The program uses the same proven strategies for stopping wild polio in responding to cVDPV cases. These strategies, coupled with the rapid mobilization of resources on the ground, can bring outbreaks under control.
In December, an international group of public health experts determined that the 2017 cVDPV2 outbreak in Syria has been successfully stopped. This news follows 18 months of intensive vaccination and surveillance efforts led by the GPEI and local partners in conflict-affected, previously inaccessible areas. In Papua New Guinea, the programme carried out 100 days of emergency response this past summer and is continuing to vaccinate and expand surveillance across the country.
Bringing an end to ongoing cVDPV outbreaks remains an urgent priority for the program in 2019.
New policy decisions
At the World Health Assembly in May, Member States adopted a landmark resolution on poliovirus containment to help accelerate progress in this field and ensure that poliovirus materials are appropriately contained under strict biosafety and biosecurity handling and storage conditions. The programme also finalized a comprehensive Post-Certification Strategy that specifies the global, technical standards for containment, vaccination and surveillance activities that will be essential to maintaining a polio-free world in the decade following certification.
Recognizing the ongoing challenge posed by cVDPVs, the Global Commission for the Certification of Poliomyelitis Eradication (GCC) met in November and recommended an updated process for declaring the world polio-free. This plan will start with the certification of WPV3 eradication, followed by WPV1, and include a separate independent process to validate the absence of vaccine-derived polio.
Comprised of members, advisers, and invited Member States, the 19th IHR Emergency Committee met in November. The Committee unanimously agreed that poliovirus continues to be a global emergency and complacency at this stage could become the biggest hindrance. “We have the tools, we need to focus on what works, we need to get to every child,” commented Prof. Helen Rees, Chairperson of the Committee. “The reality is that there is no reason why we should not be able to finish this job, but we have to keep at it.” “We have achieved eradication of a disease once before, with smallpox,” Rees concluded. “The world is a much better place without smallpox. It’s now more urgent than ever that we redouble our efforts and finish this job once and for all as well.”
In 2018, the GPEI took major steps in adopting a more gender-responsive approach and strengthening gender mainstreaming across its interventions. The GPEI Gender Technical Brief highlighted the programme’s commitment to gender equality and included a thorough analysis of various gender-related barriers to immunization, surveillance and communication.
The programme introduced new gender-sensitive indicators to ensure that girls and boys are equally reached with polio vaccines, to track the timeliness of disease surveillance for girls and boys, and to monitor the rate of women’s participation as frontline workers in the endemic countries. The GPEI continues to regularly collect and analyze sex-disaggregated data and conduct gender analysis to further strengthen the reach and effectiveness of vaccination campaigns.
Donor countries made new financial contributions to the programme in 2018. Polio-affected countries also demonstrated continued political commitment to eradication efforts. The Democratic Republic of the Congo signed the Kinshasa Declaration committing to improve vaccination coverage rates in sixteen provinces throughout the country, and Nigeria approved a $150 million loan from the World Bank to scale up immunization services and end polio.
Looking ahead: 2019 and beyond
Over the last five years, the programme has been guided by the 2013-2018 Polio Eradication & Endgame Strategic Plan, helping to bring the world to the brink of polio eradication. This spring, the programme will finalize a new strategy –GPEI Strategic Plan 2019-2023– which will aim to sharpen the tools and tactics that led to this incredible progress. In 2019, the GPEI will also launch its first-ever Gender Strategy to further guide its gender-responsive programming and to increase women’s meaningful and equal participation at all levels of the programme.
Success in the coming years will hinge on harnessing renewed financial and political support to fully implement the plan at all levels, with our one clear goal in sight: reach every last child with the polio vaccine to end this disease once and for all. Echoing similar sentiments, Chairs of the effort’s main advisory bodies issued an extraordinary joint statement, urging all to step up their performance to end polio. 2019 may very well be the watershed year that the world will finally eradicate polio, thanks to the global expertise and experience over 3 decades.
In an extraordinary joint statement by the Chairs of the main independent, advisory and oversight committees of the GPEI, the Chairs urge everyone involved in polio eradication to ensure polio will finally be assigned to the history books by 2023. The authors are the chairs of the Strategic Advisory Group of Experts on immunization (SAGE), the Independent Monitoring Board, the Emergency Committee of the International Health Regulations (IHR) Regarding International Spread of Poliovirus and the Global Commission for the Certification of the Eradication of Poliomyelitis (GCC).
The Endgame Plan through 2018 has brought the world to the brink of being polio-free. A new Strategic Plan 2019-2023 aims to build on the lessons learned since 2013.
The joint statement urges everyone involved in the effort to find ways to excel in their roles. If this happens, the statement continues, success will follow. But otherwise, come 2023, the world will find itself exactly where it is today: tantalizingly close. But in an eradication effort, tantalizingly close is not good enough.
The statement therefore issues an impassioned plea to everyone to dedicate themselves to one clear objective: to reach that very last child with polio vaccine. By excelling in our roles. It means stepping up the level of performance even further. It means using the proven tools of eradication and building blocks that have been established in parts of the world that have been free of polio for years.
The Chairs remind us that as a global community, we have stood where we stand today once before, with smallpox. And we achieved the eradication of smallpox. And the world is a much better place without smallpox.
So, let us make the world again a better place. Together. Let us eradicate polio.
Since polio was confirmed in Somalia in late 2017, health authorities have led a complex response to twin outbreaks of circulating vaccine-derived poliovirus type 2 and type 3 (cVDPV2 and cVDPV3), paying special attention to high-risk populations: nomads, internally displaced people (IDPs), and people living in peri-urban slums and rural areas.
So far, five of Somalia’s 12 infected children are from nomadic communities, and another four are from internally displaced families living in urban areas. To boost immunization among eligible children in these populations, vaccination activities have placed a special focus on reaching these communities.
Somalia has a rich culture of people leading pastoral lifestyles, raising livestock and moving with them as the seasons and the weather change. Nomadism has a long history in Somalia and nomads have a special place in Somali society: almost a third of Somalia’s people are nomads. However, they do not observe formal international borders – just like the poliovirus. For health workers, this context poses a significant challenge: How can you be sure you have vaccinated every last child when so many children are on the move?
For health workers, this means searching for polio symptoms in more than 900 health facilities across the country, as well as nutritional centres, camps for IDPs, and key sites along Somalia’s borders. At transit points, along borders and at water collection points, polio teams work to vaccinate children moving in and out of areas experiencing conflict or with limited access to health services. In high-risk areas, the Somali Government, WHO and UNICEF hire local vaccinators – people known and trusted by their communities – and when additional security is necessary, polio partners provide it.
Gaining high-level political goodwill
Even in an emergency, cross-border collaboration is not always easy to come by. In the Horn of Africa outbreak, regional collaboration moved into high gear in September, when health ministers from across the region and representatives from the Intergovernmental Authority on Development (IGAD) countries came together in the Kenyan town of Garissa to reiterate their commitment to ending polio.
One of the event’s key messages was around the risks posed by the easy and frequent mobility of communities across borders. Kenya’s national polio immunization ambassador, former UN Person of the Year and polio survivor, Harold Kipchumba, spoke directly to the pastoral communities in the region.
Kipchumba highlighted their focus on vaccinating animals, and urged parents in these communities to use the same vigour to vaccinate their children against polio, so they are able to serve as future herders for their families.
A regional response to support high-risk populations
The Technical Advisory Group, an independent body of experts that monitors outbreaks and offers guidance, recommended that countries in the region strengthen their coordination. In response, the Horn of Africa Coordination Unit coordinates joint responses among HoA countries – work that includes monitoring current outbreaks, and collaboratively planning, mapping, conducting immunization campaigns and communicating with various audiences. This ensures that countries work together in partnership rather than in silos, viewing the outbreak as one epidemiological block.
At regional and district levels, teams have spent the last few months building records of every settlement in their area, by lifestyle (nomad, IDP, peri-urban slums, rural). The highest priority: locating special populations – internally displaced persons, refugees, nomadic families, people living in informal settlements in urban areas and communities living in access-compromised areas – in order to reach them with vital polio vaccine.
A vital step in reaching more children, particularly those on the move, has been to move away from paper records and use electronic tools to collect data on children reached and missed during campaigns. This gives data specialists and decision-makers timely, accurate information, allowing them to analyze data in real time and flag areas with where high numbers of children are missed, so teams can revisit these households the following day.
Getting vaccines to the doorstep is not the only challenge for polio eradication teams in Somalia. Parents and caregivers also need information to ensure their children are vaccinated – something Kipchumba spoke to. On rare occasions, vaccinators meet families unconvinced of the need for vaccinations, particularly when the family has a newborn child or a sick child. In the lead up to every campaign, teams of social mobilizers, sometimes joined by influential Islamic leaders or scholars, visit communities to alert them of dates of polio immunization campaigns and the benefits of vaccination. Here, too, special attention is paid to nomadic communities, as polio teams liaise with elders from these communities in order to learn more about these communities and their needs, and to inform community members in appropriate ways about immunization dates and benefits of vaccination.
In the last week of October, Djibouti’s Ministry of Health, working with WHO, UNICEF and other partners, successfully carried out the country’s first polio National Immunization Days (NIDs) since 2015.
While Djibouti has not had a case of polio since 1999, the recent outbreaks of polio in neighbouring countries in the Horn of Africa, and the low levels of routine immunization coverage in some areas in the country, are indications that Djibouti is still at risk if poliovirus spreads through population movements. Other countries in the Horn of Africa are already cooperating to stop the ongoing outbreak and to reduce the risk of spread, and especially considering that Djibouti is on a major migration route in the Horn of Africa, it makes a lot of sense for Djibouti to join in this coordinated response.
For Dr Ahmed Zouiten, the acting WHO Representative (WR) in Djibouti, this context demanded action.
“I prefer to deal with a campaign for prevention than to have to deal with an outbreak of polio,” he said.
With that in mind, an NID planned for 2019 was brought forward and carried out over 23-26 October. The target was 120 000 children under five years of age, a number suggested by Djibouti’s last census, in 2009. Two strategies were proposed: one approach, where children would be vaccinated at fixed points (health facilities) and a complementary door-to-door approach using two-person teams (a vaccinator and a registration person).
In the days and weeks before the NID, all partners, including the government, WHO and UNICEF, used a variety of communication channels – from outdoor signage to radio spots – to ensure that communities were informed not just of the risks of polio, but also of the importance of protecting children from vaccine preventable diseases.
The campaign’s official launch ceremony was held at the Youssouf Abdillahi Iftini Polyclinic in Balbala neighborhood, Djibouti City, in the presence of Djibouti’s Minister of Health, WHO and UNICEF representatives, and other partners. Over the course of the following days, vaccinators surpassed targets, vaccinating all children under five they encountered living on Djibouti territory, regardless of their origin, including nomadic populations, refugees and migrant children.
Although final numbers are still being tabulated through independent monitoring mechanisms, initial results suggest high coverage of the target population. This means vaccinators reached the estimated target number of children, and more, such as newer cohorts of children not accounted for in earlier estimates. Catching these children helps to further inform immunization estimates for any further campaigns.
For Dr Zouiten, a result like this is something to celebrate.
“Today, our children are on their way to being better protected, and we are launching a second campaign in the near future to follow up on that,” he said.
“Before, we had some worries; we thought that the circulation of poliovirus in the region posed a risk. Now with this first vaccination campaign, we know we are on the right path to ensure the children of Djibouti are protected. These results weren’t easy to achieve, but were made possible through collaboration between the Ministry of Health, the partnership between WHO, UNICEF and others.”
Given the high risk of importation of poliovirus, the Government of Djibouti, WHO and UNICEF are not taking any chances: plans are in the works for a second and third NID to roll out in 2019. With an outbreak in the region, it is critical for nearby countries to strengthen their own immunity levels and ensure routine immunization and disease surveillance systems are strong enough to detect any virus circulation. Despite the cost and effort of staging national immunization activities, in this case, all partners agree: an ounce of prevention really is worth a pound of outbreak response.
Left: Shire gives child two drops of the oral polio vaccine to protect them against lifelong paralysis Right: Shire works with vaccination teams to prepare cold boxes to carry polio vaccines
I have spent nearly my whole career working on eradication programmes – first smallpox, then polio. Eradication has been a rewarding career for me because I am so curious to know what is happening in the world. Every time I see a disease that we have worked so long to stop returning, I become so unhappy and know I need to work to stop it.
I worked for the smallpox eradication programme back in the 1970s. I was an epidemiologist – this means that my job was to track the disease and plan how we could stop it.
We used to hold vaccination campaigns at night because then we knew everyone would be at home, and we wouldn’t risk missing a single person. As our cars pulled up out of the dark, people would peer out of their houses to see what was happening. Somalis are very curious! As we brought them the vaccine, occasionally someone would make trouble, but mostly people were pleased to see us.
Somalia was the last country where smallpox was found in the whole world. When I knew we had really ended it in 1977, I was so happy. My name was printed there on the certification document – it was something to be proud of. We had freed the world from smallpox!
I remember one of my friends calling me in 1997 to tell me we were going to eradicate another disease, and that we had to look out for something called ‘AFP’. I thought to myself, what is this ‘AFP’? I hadn’t heard of it. They explained to me that it means acute flaccid paralysis – and that it was the symptom of a disease called polio.
Then one day in 1999, I received a call asking if I would come and work for the second eradication programme in my single lifetime. They said, “If you are ready, we will make you a coordinator. We don’t know if there is polio in Somalia or not, but we want you to come and see.” I jumped at the chance.
We started to search, looking for AFP cases, to collect stool samples and then to send them to the laboratory for testing. And soon, we had confirmation that polio was in Somalia. As soon as we found cases, lots of people came from inside and outside Somalia to help.
By 2002, we found the last case of indigenous polio, and thought the game was won. I even joked to my friends saying, what will we do now that polio is eradicated? They said to me, no – we still have polio in Nigeria, Egypt, Pakistan, many other countries – another case will come. We have to be prepared to stop it if it comes.
And true enough, we had an outbreak in 2005, and again in 2013. Each time we stopped it. Last year, we found circulating vaccine-derived poliovirus type 2. Vaccine-derived polio causes paralysis just like wild polio, and we must eradicate it too.
We started to organize ourselves and held two vaccination campaigns. But then we found another virus – circulating vaccine-derived poliovirus type 3. So now, we are responding to two outbreaks that need different vaccines at the same time. If we miss cases and miss getting vaccines to all children, we can’t stop polio. It is hard, but we will end these outbreaks just as we ended wild polio before.
Eradicating polio has been very difficult – more difficult than it was to end smallpox. I suffered – me and my wife were even kidnapped once. But I am always motivated to keep going. My motivation was never my salary – to stay alive, I need to work. I must know what is going on in my country, if my people are safe. From morning until night, my job is to make sure activities can go on peacefully. My family are my true reason for committing my life to eradication. I have seven children, and 30 grandchildren; I never once missed getting any of them vaccinated. Never.
I am sure that we will finish this job. When we eradicate polio, I will be so happy – I will have been involved in the certification of the second human disease ever to be eradicated. I feel so lucky to have spent my life working for these two eradication programmes; I am proud to tell stories to my grandchildren of my life’s work.
Eradicating polio won’t take a miracle. It is a job. It needs a lot of hard work to end an outbreak. There is no other way – the only way is to work hard, to find cases, and to respond. We hope that in the coming months we will make it. I do believe we will make it. Inshallah.
Gafo is the first case of polio in Papua New Guinea in almost two decades. WHO PNG/J.Rivaca
For six-year old Gafo that fateful April 2018 morning was supposed to be the start of just another day full of running around and playing with friends. Ignoring the pain in his legs, Gafo tried to get out of bed, but he fell and struggled to get back up. Over the course of the next two days, Gafo’s condition continued to deteriorate. On the third day, Gafo and his family visited the Angau Memorial General Hospital in Lae, Morobe, in the central northern coast of Papua New Guinea, only to find out that he had polio.
As soon as Gafo’s story broke, a National Emergency was declared by the Government and a mass polio vaccination campaign was initiated. Gafo became the foremost champion of polio awareness, and served as a cautionary tale for families and young children to get vaccinated.
Since his diagnosis, Gafo has made progress. Though he can now walk with his signature gait, Gafo and his parents understand that polio is irreversible, but is preventable and eradicable. Gafo hopes to become a doctor one day. Read about his entire journey from being an ordinary child to breaking news, and how his story has helped contain polio in Papua New Guinea.
This story is originally from the Papua New Guinea Polio Outbreak Response First 100 Days report.
Nine hours away from the nearest large town, Dr Adele Daleke Lisi Aluma speaks to Robert, who manages a small health clinic on an island in the Lake Chad Basin. With paperwork spread around them, she listens carefully he responds to each question: Can you tell me how to recognise the symptoms of a potential polio case? Can you show me the records of any measles cases since I last visited?
In the past, she would be writing down details of the disease surveillance system in this village in a notebook, spending time later typing up her notes, and emailing them to a central database. Today, thanks to the introduction of an electronic surveillance approach for active surveillance and monitoring of disease outbreaks, she inputs Robert’s answers directly into an app, allowing for quick, accurate, and up-to-date data collection.
Hundreds of kilometres away in Nigeria, on the other side of the basin, surveillance officer Dr Namadi Lawal also feels the difference that innovative application-based technology has made to operations. For years, his employer, the National Primary Health Care Development Agency, depended on paper-based recording methods.
When the World Health Organization introduced the electronic surveillance (e-Surve) approach, Dr Namadi discovered he was receiving far more accurate information in real time, making his work to defeat the poliovirus more efficient.
“e-Surve is such a wonderful innovation. I can only imagine how much more accurate data I would have collected in a fast and effective manner if I had adopted this approach long time ago,” he says.
The e-Surve approach involves the use of a smartphone application to ensure that health workers know what symptoms they should be looking for and how to report suspected cases of vaccine-preventable disease.
After using the application to guide their conversations with health workers, disease surveillance and notification officers send the results of the questionnaire to a central database, where the data can be analysed and sorted by health district.
This is one way to keep track of an outbreak response that covers areas of five different countries, all with their own unique health challenges.
“This is remarkable progress as it shows where we can actually reach for surveillance”, said Dr Isaac Adewole, Nigeria’s Minister of Health, as he was presented with a dashboard of e-Surve during the recent opening ceremony of the African Regional Certification Commission in Nigeria.
New technology helps to reduce outbreak risk
This innovation is particularly important as when cases of disease are not properly reported, an outbreak can be in full swing before a country even realises that there is a problem.
Active disease surveillance, where officers physically go out to communities to speak to health staff and parents, is proven to increase case detection rates. There are hundreds of these frontline workers spread out across the Lake Chad Basin, each conducting multiple visits every month. Before mobile technology, the outcomes of these visits were cumbersome to track, time consuming to catalogue, and difficult to analyse for a prompt response.
Real-time reporting stems the spread of diseases
With e-Surve, governments and partners in the polio programme and other health programmes can easily see trends, track data, and take action. This encourages a preventive approach to disease outbreaks rather than a reactive one.
In Nigeria, as of May 2018, about 18 840 active surveillance visits to health facilities had been made using e-Surve technology: as a result, over 3000 suspected cases of vaccine-preventable diseases – previously unreported from health facilities – were identified and investigated.
Strong support from government
Behind the new technology stands commitment from governments, communities, and partners to close the polio outbreak response. Dr. Sume Gerald at the WHO Nigeria office, states that “e-Surveillance in Nigeria is government-led and driven, supported by WHO.”
Through innovation, determination, and commitment at all levels, those working to end polio are getting ever closer to their goal.
Dar es Salam refugee camp, in Bagassola district, Chad, is home to thousands of refugees. 95% of the population is Nigerian, displaced by years of violent insurgency, drought and insecurity in the Lake Chad basin. Some have lived in the camp since 2014.
Here, temperatures soar to 45 degree Celsius nearly every day. Dust is inescapable, colouring everything a shade of yellow. Houses are constructed from tents, tarpaulins and reeds, pitched onto sand. There is no employment, few shops, and no green areas.
Kilometers from the lake, residents have no access to the water around which their livelihoods revolved, as fishing people, as traders at the markets located around the island network, or as cattle farmers. This renders them almost entirely reliant on aid. The edge of the camp is an enormous parking lot, filled with trucks loaded with donations. Signs interrupt the landscape, attributing the camp’s schools, football pitches, and water stations to different funding sources.
Polio immunization is a core health intervention offered by the health centre here, with monthly house to house vaccination protecting every child from the virus.
“We vaccinate to keep them healthy”
In return for their work, vaccinators receive a small payment, one of the few ways of earning money in the camp. In Dar es Salam, there are thirty positions, currently filled by 24 men and six women, and applications are very competitive. Those chosen for the role are talented vaccinators, who really know their community.
Laurence speaks multiple languages, adeptly communicating with virtually everyone in the camp. He is a fatherly figure, engaging parents in conversations about the importance of vaccination whilst his colleague gives vaccine drops to siblings. Their mother is a seamstress, constructing garments on a table under one of the few leafy trees. Laurence engages her in conversation, explaining why the polio vaccine is so important.
Describing his work, he says, “I tell parents that the vaccine protects children from disease, especially in this sun, and that we vaccinate every month to keep them healthy.”
A precious document in a plastic bag
Chadian nationals living in nearby internally displaced persons camps don’t have the same entitlements as international refugees. Several hours’ drive from Dar es Salam, children lack access to even a basic health centre.
At a camp in Mélea, vaccinators perform routine immunization against measles and other diseases under a shelter made from branches. Cross-legged on the ground, they fill in paperwork, carefully administer injections, sooth babies, and dispose safely of needles. Other vaccinators give the oral polio vaccine to every child under the age of ten. These children are mostly from the islands, displaced by insurgency. Their vaccination history is patchy at best, and it is critical that they are protected.
One father arrives accompanied by his small, bouncy son. As the baby looks curiously at the scene in front of him, his dad draws out a tied plastic bag. Within is his son’s vaccination card, carefully protected from the temperatures and difficult physical environment of the camp.
A UNICEF health worker reads it, and realizes that the child is due another dose of polio vaccine. Squealing with confusion, the baby is laid back in his sibling’s arms, and two drops administered. The shock over, he is quickly back to smiling, rocked up and down as his dad folds up the card, and ties it up in the bag once more.
Back in Dar es Salam, DJórané Celestin, the responsible officer for the health centre explains the wider challenges of vaccination in this environment.
“We don’t just vaccinate within Dar es Salam in our campaigns. We are also responsible for 27 villages in the nearby surroundings. Reaching these places proves our biggest challenge.”
Away from the main route to Dar es Salam, there are no roads or signs, and many tracks are unpassable. To reach the 539 children known to live in the villages, vaccinators walk, or rent motorbikes, travelling for many hours.
This month, another round of vaccination in the Lake Chad island region concluded. Hundreds more refugee and internally displaced children are protected, in some of the most challenging and under-resourced places to grow up.
In the fight against the virus, two important tools are used to help prevent polio – two safe, effective vaccines. Only through full funding of these vaccines can worldwide immunity be achieved, and the virus eradicated.
Redoubling commitment towards this goal, last week, Gavi, The Vaccine Alliance, approve core funding for the inactivated poliovirus vaccine (IPV) for 2019 and 2020, to continue work to end polio, and protect every child.
Announcing this support, Gavi Board Chair Dr Ngozi Okonjo-Iweala said, “Polio will remain a threat until every child is protected against this crippling disease. That is why the vaccination of every child is the corner stone of the polio eradication effort. Introducing IPV to all countries to interrupt polio transmission and maintain zero cases represents an unprecedented push, and Gavi is proud to be part of it.”
Since 2013, the Gavi Board has supported IPV in all 70 Gavi-supported countries, through a dedicated funding stream financed by the Global Polio Eradication Initiative (GPEI) budget. Responding to continued wild poliovirus circulation in 2018, this most recent Gavi support represents an additional contribution, which will help ensure that the programme can continue its valuable work to protect every child worldwide.
The Gavi Board also approved an exceptional extension of support for Nigeria up to 2028, to help reach over 4.3 million under-immunized children in the country, who remain at risk of vaccine-preventable diseases including polio.
Michel Zaffran, Director of the Polio Eradication Programme at the World Health Organization, extended his thanks to the Gavi Board for their generous contribution, saying, “GPEI and Gavi are committing to work closer together than ever before, and take one more step towards the immunization of all children, to deliver and to sustain a polio-free world.”
For 15 years Daeng Xayaseng has been travelling through rugged, undulating countryside by motorbike and by foot to deliver vaccines to children in some of the most remote villages in Laos.
It’s hard work but she is determined: “We have a target of children to reach and we’ll achieve that no matter how long it takes,” she says. “We’ll keep working until we reach every child.”
Today her team visits Nampoung village, 4 hours north of the capital of Laos, to deliver polio vaccines.
“For 15 years I’ve been working on campaigns like this,” she says. “Today we’re here with our outreach team to vaccinate children against polio. We’ll also go house to house to make sure no child misses out on being vaccinated.”
“We don’t want there to be another outbreak of polio so we have to reach everyone,” says Daeng. “In order to do that, immunizing every child in remote communities like this is a priority to ensure everyone is protected.”
UNICEF and other partners of the Global Polio Eradication Initiative are supporting the Lao Government to reach nearly half a million children under five with potentially life-saving vaccines. More than 7,200 volunteers and 1,400 health workers like Daeng and her team have been mobilized to deliver the oral polio vaccine as well as other vaccinations such as measles-rubella.
“I’m very happy and proud to do this job,” says Daeng once the team has packed up. “I’m proud to do this job to serve the community and help in any way I can.”
Last month, Canada signed a generous pledge of Can$ 100 million to help eradicate polio in Afghanistan as well as in the two other endemic countries, Nigeria and Pakistan, and to continue to protect many polio-free countries. The pledge was announced by the Honourable Marie-Claude Bibeau, Minister of International Development and La Francophonie, at the 2017 Rotary International Convention in Atlanta.
In addition to previous donations of approximately Can$ 650 million, this most recent funding consists of Can$ 30 million to WHO and UNICEF to support programme activities in Afghanistan, and Can$ 70 million of flexible funding that can be used to support vaccination campaigns, rapid outbreak response, poliovirus surveillance and other critical eradication strategies and activities to reach every last child worldwide with a safe vaccine.
This latter funding is especially valuable to the programme, as it will help sustain the priority areas of work that make global polio eradication possible. In 2017, there were 22 cases of wild poliovirus reported worldwide, from only two countries, Afghanistan and Pakistan. In Nigeria, wild poliovirus was last detected in 2016. However, since 2001, there have been wild polio outbreaks in 41 countries that were previously polio-free.
Flexible funding, such as that provided by Canada, is critical to allow the programme to react quickly to the most urgent needs, successfully stopping each outbreak, and ensuring that every child is protected from polio worldwide.
Minister Marie-Claude Bibeau used the signing as an opportunity to underline Canada’s ongoing commitment. “Canada has been a supporter in the fight against polio from the very beginning and we are committed to seeing it through to the end,” she said. “Keeping the momentum is key, particularly in Afghanistan, Pakistan and Nigeria, where polio still exists. Canada remains committed to ensuring every child is immunized, particularly girls, who continue to face barriers.”
As a champion of feminist development, Canada has particularly emphasized the role played by women in the programme, from the front lines, to programme management and political leadership. Polio eradication moreover forms a crucial part of Canada’s “Right to Health” commitment, and has the potential to become one of the first tangible outcomes of the UN Sustainable Development Goals.
Akhil Iyer, Director of the Polio Eradication Programme at UNICEF said, “Whilst polio exists in the smallest geographic area in history, this includes some of the most dangerous and difficult-to-reach parts of the world. Canada’s long-standing political and financial commitment helps our dedicated health workers, mostly women, go the extra mile and vaccinate every child to build a polio-free world.”
With this funding and ongoing support, Canada is striving to protect every girl and boy child. In doing so, Canada is making history.
The funding is also a testament to the major role played by the Canadian people at every level of the polio eradication programme. To date, Canadian Rotarians have raised and contributed more than US$ 52 million to eradication efforts, whilst Canada’s citizens have played an important role in tracking progress and publically voicing their support to end polio through the Scientific Declaration on Polio Eradication, and the One Last Push Campaign.
Michel Zaffran, Director of the Polio Eradication Programme at the World Health Organization said, “The ongoing support of Canada is fundamental to the programme’s success. With their global advocacy in international forums such as the G20 and G7 and their strategic and high quality support in Afghanistan and across the world, we can ensure that polio is eradicated forever.”
Canada’s contribution comes at an important time for the programme, in the run up to the 2018 G7 Summit. Previous summits have recognized polio eradication efforts, noting that programme assets also help to strengthen other aspects of health and development. This year, the Presidency is held by Canada, the first country to place polio eradication on the G7 agenda.
The Global Polio Eradication Initiative partners extend their profound gratitude to the Government and to the citizens of Canada for their tremendous support and engagement to end polio globally.
Efforts to protect children from polio take place all over the world, in cities, in villages, at border checkpoints, and amongst some of the most difficult-to-access communities on earth. Vaccinators make it their job to immunize every child, everywhere.
In places where families are displaced and on the move due to conflict, it is especially important to ensure high population immunity, to protect all children and to prevent virus spread. In Iraq last month, vaccinators undertook a five-day campaign in five camps for internally displaced people around Erbil, in the north of the country, as part of the first spring Subnational Polio campaign targeting 1.6 million children in the high risk areas of Iraq (mainly in internally displaced person camps, and newly accessible areas).
Iraq has not had a case of indigenous wild poliovirus since 2000. However, due to the drastic drop in immunity in the country after years of conflict, two children were paralyzed when wild poliovirus was imported in 2014.
Poliovirus spreads from person to person, transmitted through populations. Last year, there were 74 cases of polio in Raqqa and Deir ez-Zor governorates in Syria. Over the border in Iraq, children in Mosul and Anbar are deemed to be at high risk of being infected because of the history of regular movement of armed groups between the two countries. Violence has caused many families to leave their homes – potentially carrying the virus with them as they travel to internally displaced persons camps and other destinations.
Baharka camp, one of the five internally displaced persons camps near Erbil, is where many families from Mosul, Anbar, and other areas currently reside. During the polio vaccination campaign, male and female vaccinators walked tent-to-tent to deliver vaccine to all children under the age of five. Their aim was to ensure whole-camp immunity by finding and protecting every child.
After visiting a household, the vaccinators marked on wood, stone and canvas how many children had received vaccine, along with information about any vaccine refusals. Over the course of the campaign, vaccinators aimed to reach 4203 children.
As well as twice-yearly vaccination campaigns, health workers in the Erbil camps look for signs of Acute Flaccid Paralysis (AFP) amongst children living there, which is one of the most common indicators of polio. Any suspected cases are recorded, and investigated through the poliovirus surveillance network. Since surveillance began in the camps, thirty AFP cases have been discovered and investigated for signs of the virus.
“We conduct continuous monitoring,” said WHO Polio Eradication Officer Dr Rebaz Lak. “If any child displays weakness of the limbs, the doctor must notify health authorities.”
Since 2014, more than five million civilians have fled their homes inside Iraq. At the same time, families are returning to places where instability has lessened. As many as two million displaced Iraqis are likely to return home this year, which means children will be on the move once more. This makes the vaccination of every child even more important – allowing them to travel safely, and be protected from virus when they reach their destination.
Some families choose to go home, but keep a safe place to flee to should violence return. Since Baharka camp opened, a number of families have travelled back to Mosul, but have maintained their displaced person status and a caravan in the camp. The World Health Organization carefully monitors the names and caravan numbers of the children in these groups, to ensure that vaccinators visit them whenever there is a campaign. Once vaccinated, each child has their little finger stained purple – an easy way to prevent children being missed.
Alongside the children protected in Baharka camp, the Global Polio Eradication Initiative partners vaccinate over 400 million children every year. Efforts to eradicate polio also help to fight other diseases at the same time, whilst the valuable polio eradication infrastructure, data and tools can help to strengthen the health systems of conflict-affected countries.
Thanks to the devotion of vaccinators and health workers, the displaced children of Mosul and Anbar are protected together from the virus. When they return home, they won’t have missed out on a valuable health intervention – allowing them to lead healthier, polio-free lives in the future.
On top of the US$ 120 million committed in 2013, last year, HH Sheikh Mohamed bin Zayed pledged an additional US$ 30 million towards polio eradication, and the UAE is active on the ground in Pakistan through the UAE-Pakistan Assistance Program
UAE support also funded more than 5000 committed full-time vaccinators in highest-risk districts of Pakistan
Last year saw the lowest number of wild poliovirus cases in history (22 worldwide); Pakistan reported a 97 percent decline in cases between 2014 and 2017
GENEVA (16 April 2018) – The Global Polio Eradication Initiative (GPEI) announced today that the UAE has completed the US$ 120 million commitment made by His Highness Sheikh Mohamed bin Zayed Al Nahyan at the 2013 Global Vaccine Summit in Abu Dhabi.
“We thank the UAE for their long-term generous support and unwavering dedication to polio eradication, and particularly the personal commitment of His Highness Sheikh Mohamed bin Zayed Al Nahyan, Crown Prince of Abu Dhabi,” WHO Director General Dr Tedros Adhanom Ghebreyesus said. “This is the kind of support that will ensure we reach every last child to complete the job and to show the way to delivering health to all.”
Polio is a highly infectious disease that can cause lifelong paralysis, but it is entirely preventable with vaccines. Only three countries remain which have never stopped polio: Afghanistan, Pakistan and Nigeria. When the polio eradication effort was launched in 1988, 350 000 children were paralyzed by polio every year across 125 countries.
Polio eradication efforts have since made remarkable progress and there were only 22 cases in 2017 – the lowest ever recorded number. However, a number of key challenges remain. Reaching the most vulnerable children with the polio vaccine is hampered by a range of hurdles including difficult terrain, insecurity, and large-scale population movements.
Following the Global Vaccine Summit, the UAE expanded its role through the UAE Pakistan Assistance Program (UAE-PAP) to ensure that further gains would be made where it was needed the most. Through the “Emirates Polio Campaign” initiative, the UAE has helped drive on-the-ground eradication efforts within the most vulnerable communities in Pakistan.
Speaking about the UAE’s work, His Excellency Mohamed Mazrouei, Undersecretary of the Crown Prince Court of Abu Dhabi said: “The UAE’s pivotal role in eradicating polio completely is not limited to being a donor only, but extends to include its capacity to convene key groups and provide on-ground support to deliver vaccines in the highest risk areas of Pakistan.
“The UAE’s support – both as a leading donor and passionate advocate – has been critical for getting as close as we’ve ever been to making history by eradicating polio,” UNICEF Director of Polio Eradication Akhil Iyer said. “This is a gift not only to the children of Pakistan but to all future generations of children, everywhere, who are so close to the goal of being able to be born and be raised in a polio-free world.”
Dr. Chris Elias, President of the Global Development Program, Bill & Melinda Gates Foundation, said: “The UAE and His Highness Sheikh Mohamed bin Zayed Al Nahyan have shown an unwavering commitment to end polio, and we are delighted to partner with them in this effort. Without their involvement, achieving a record low number of polio cases in 2017 would not have been possible.”
The UAE is a longtime supporter of the polio eradication program. In addition to the US$ 120 million that His Highness Sheikh Mohamed bin Zayed Al Nahyan pledged in 2013, he pledged a further US$ 30 million to polio eradication, announced by Bill Gates at the Rotary International Convention in Atlanta, USA in June 2017. With additional commitments in 2011 and 2014, in total, the UAE has contributed US$ 167.8 million since 2011 to help end polio, with direct support to Pakistan, Afghanistan, Somalia, Ethiopia, Kenya, and Sudan.
The Global Polio Eradication Initiative (GPEI) is led by national governments and spearheaded by the World Health Organization (WHO), Rotary International, the US Centers for Disease Control and Prevention (CDC), and the United Nations Children’s Fund (UNICEF), with the support of the Bill & Melinda Gates Foundation. Since its launch at the World Health Assembly in 1988, the GPEI has reduced the global incidence of polio by more than 99%.
The GPEI receives financial support from governments of countries affected by polio, private sector foundations, donor governments, multilateral organizations, private individuals, humanitarian and non-governmental organizations and corporate partners. A full list of all contributors is available on the GPEI website, http://polioeradication.org/financing/donors/
