The discovery in the summer of 2022 that poliovirus had been found in sewers in London as well as in an unvaccinated community in New York startled many who had long forgotten about polio. The outbreak was a perfect demonstration that vaccines are often so successful at stopping deadly diseases, that we can be lulled into a false complacency.

Although the disease is now endemic only in Afghanistan and Pakistan, it was a dangerous childhood disease across the world for much of the late 19th and early 20th centuries. Although polio vaccines were introduced as routine immunisations in the 1970s, which reduced cases substantially, by the late 1980s, polio still was paralysing over 1,000 children a day.

In 1988, the launch of Global Polio Eradication Initiative (GPEI, of which Gavi is a member) had a galvanising effect on efforts to eliminate the disease, bringing together governments, donors, local communities and health workers in a joint effort to raise awareness of the disease and widen access to polio vaccines.

Cases began to drop dramatically and are down 99%, with most countries having zero cases. An estimated 20 million children have been prevented from getting polio since the GPEI was launched. When Nigeria was declared free of wild poliovirus in 2020, it was a major achievement: it had been one of the last few countries where the disease had clung on.

As remarkable as these successes have been, polio experts warn that there is no room for easing off on eradication efforts until the world is polio-free. Infectious diseases that are nearly wiped out can bounce back with alarming ease when the global circumstances change – measles rates have started climbing in the past few years as vaccination rates have fallen in Europe and the US.

Uneven polio vaccine coverage across the world, compounded by the COVID-19 pandemic’s toll on routine immunisation worldwide, has meant the disease has popped up in unexpected places. In October 2021, Ukraine saw an outbreak, followed by a case of wild poliovirus in February 2022 in Malawi. In March, vaccine-derived polio was spotted in Israel, and in Pakistan, where the disease is still entrenched, more polio cases were recorded in the first quarter of 2022 than in the whole of 2021.

Although polio only affects a handful of countries currently, the potential threat from its continued circulation means that the World Health Organization still classifies it as a Public Health Emergency of International Concern (PHEIC) despite this classification being given back in 2014.

An ancient disease

Polio is one the world’s oldest diseases – 14th century Egyptian engravings have been found depicting a priest with a withered leg, the trademark of a disease that can paralyse the leg, leading to muscle weakness and shrinking. The British physician Michael Underwood produced the first clinical description of the disease in 1789. In 1840, the German orthopaedic doctor Dr Jacob Von Heine understood that poliomyelitis was a distinct disease from other forms of paralysis and theorised it had an infectious cause. The poliovirus that causes the disease was identified in 1909 by Austrian immunologist Karl Landsteiner.

The disease is caused by a highly infectious virus that spreads when people ingest food or water contaminated by human faeces, or through poor hygiene. Because of this it is common in areas where there is poor access to clean water and sanitation.

The virus mostly affects children. Around 70% of infections are asymptomatic or cause mild symptoms such as headache, fever, and neck stiffness, but it can also invade the nervous system and cause paralysis and, in extreme cases when the person’s breathing muscles are paralysed, it can kill. In some survivors, the nerve damage can cause post-polio syndrome, a disorder in which they may have muscle weakness that deteriorates over time, causing pain and fatigue and leaving them disabled.

There are three wild types of poliovirus (WPV) – type 1, type 2, and type 3. Type 2 was declared eradicated in September 2015, with the last case detected in India in 1999. Type 3 was declared eradicated in October 2019, having last been detected in November 2012. Type 1 remains in Afghanistan and Pakistan.

Vaccine development

There are two types of polio vaccines – an inactivated (killed) polio vaccine (IPV) developed by Dr Jonas Salk and first used in 1955, and a live attenuated (weakened) oral polio vaccine (OPV) developed by Dr Albert Sabin and first used in 1961.

IPV is made from inactivated wild-type poliovirus strains of each type; it is an injectable vaccine and in many countries is given with other routine childhood immunisations such as against diphtheria, tetanus and pertussis.

OPV consists of a mixture of live attenuated poliovirus strains of each of the three serotypes. It is safe and effective, however, the use of OPV in areas with poor water and sanitation can occasionally have an unwanted side effect – the live vaccine-virus shed by vaccinated individuals can in very rare cases mutate and spread in communities that are not fully vaccinated against polio.

The lower the population immunity, the longer the vaccine-derived virus can spread. This version of the virus can sometimes regain its ability to damage the nervous system and lead to paralysis – this is called a circulating vaccine-derived poliovirus (cVDPV).

Although IPV is an effective vaccine and valuable in countries with zero incidence of polio, it is better used as a precaution, since it does not trigger the same immune response as OPV and therefore is not as effective in stopping active poliovirus transmission. OPV induces mucosal immunity in the intestine, the primary site where poliovirus replicates – in this way, the vaccine prevents shedding of the virus into the environment and can limit or stop person-to-person transmission. This is critical in communities with poor water and sanitation, where people are more likely to be exposed to water-borne pathogens.

Thus, although IPV has has recently been introduced into routine immunisation programmes in Gavi supported countries, OPV is still needed in countries where transmission needs to be stopped.

The last mile to eradication

The polio eradication effort was badly hit by the pandemic, but is now regaining ground. One new weapon in the arsenal is a new vaccine – the novel oral polio vaccine (nOPV2) – which has been modified to be more genetically stable than the Sabin strain and less likely to cause cases from vaccine-derived virus.

In November 2020, nOPV2 received a recommendation for use under WHO’s Emergency Use Listing (EUL) procedure to be able to roll it out rapidly. As of June 2022, approximately 370 million doses of nOPV2 have been administered in 20 countries – including Benin, Cameroon, Congo, Djibouti, Egypt, Ethiopia, The Gambia, Guinea-Bissau, Liberia, Mauritania, Mozambique, Niger, Nigeria, Senegal, Sierra Leone, Tajikistan and Uganda.

The high demand for this vaccination, however, is causing a supply constraint that the GPEI is working to ease. The GPEI advises that in situations where there is co-circulation of poliovirus strains, trivalent oral polio vaccine (tOPV) may be the best choice of vaccine.

Considerable challenges remain in eradicating polio in the two endemic countries. In Pakistan, difficulties in accessing high-risk mobile communities remain, and this is exacerbated by people refusing to get their children vaccinated because of misinformation or community fatigue, as well as low routine immunisation coverage in some parts of the country.

Afghanistan shares many of these challenges, including vaccine hesitancy, with the added challenge of decades of conflict and insecurity leading to fragile health systems that are unable to sustain routine immunisations. This has meant that many communities are missed or under-vaccinated, leaving children at risk of polio.

Now that polio vaccination programmes have resumed, eradication efforts have stepped up, ramping up vaccine coverage by boosting vaccine supply and engaging the trust of communities to overcome misinformation and raise awareness of the need for the vaccine, which can mean bringing in community and religious leaders.

The last mile to ending polio has been in sight for years, but the pandemic has thrown progress off course. While the road to eradication remains challenging, the ability of polio to re-emerge unexpectedly proves the need to continue to strive towards ensuring a polio-free world. For now, the disease is endemic in two low-income countries; there is no guarantee it will stay that way.

Reposted with permission from: www.gavi.org/vaccineswork

Dashboard showing real-time data on active case finding and routine immunization from integrated supportive supervisory visits to priority sites in Senegal. © WHO
Dashboard showing real-time data on active case finding and routine immunization from integrated supportive supervisory visits to priority sites in Senegal. © WHO

While the WHO Africa Region (AFRO) has been facing its last hurdle in eradicating polio of all types since being certified indigenous wild polio free in 2020, a circulating variant of polio virus type two has been present in 26 countries with more than 1,000 cases between them, coupled with the recent importation of two wild polio type 1 cases. To help reverse this trend, the WHO/AFRO Geographic Information Systems (GIS) Center is equipping over 200 key country office focal points and Ministry of Health personnel across 47 countries with essential innovative technologies to better address outbreaks with necessary speed and quality.

Concluding a series of one-week capacity-building workshops over the past six months and targeting of the WHO  regions of Central, East & Southern, and West Africa –  – the AFRO GIS Center, with the support of the Bill & Melinda Gates Foundation (BMGF), WHO HQ Polio Unit and GIS Centre for Health, the United States Centers for Disease Control and Prevention (CDC), and Novel-t on-boarded digital GIS and Mobile Health (mHealth) technologies to support regional and national agendas particularly on planning and analysis for improvement of surveillance, campaigns and outbreak response for polio and all other routine immunization and outbreaks. While the initial investment was made by polio these tools are being leveraged for all health interventions.

A group of participants from the AFRO Geographic Information System (GIS) and Information Visualization Capacity Building Training session, in Dakar, Senegal. © WHO
A group of participants from the AFRO Geographic Information System (GIS) and Information Visualization Capacity Building Training session, in Dakar, Senegal. © WHO

“These are solutions to advance national and regional agendas even beyond polio” stated Kebba Touray, Technical Manager – AFRO GIS Centre, “the COVID-19 pandemic response was able to advance using the AFRO polio GIS Centre’s technical support with the development of real-time data collection, analysis and monitoring tools and generated several products including dashboards (providing easy availability and visualization of information), which facilitated rapid decision making for response activities across the region.”

The GIS Capacity Building training transferred knowledge to key country office focal points and Ministry of Health personnel across Africa on innovations to better enable countries to:

  • Design country-level specific static and dynamic maps – using platforms such as Microsoft Power BI, and ArcGIS – for the outbreak response and provide real time analysis through the dashboards.
  • Provide country specific information visualization (using Dashboards) to publish in the existing AFR-mHealth workspace at AFRO and in their respective public health systems.
  • Develop data collection, data validation and monitoring mechanisms that provides increased accuracy on immunization information and populations through the Open Data Kit (ODK) platform to enhance mobile data collection.
  • Use AFRO GIS and information visualization innovative solutions at country level to receive real-time information on active surveillance visits conducted at health facility level, environmental surveillance site performance, rapid population estimates data, vaccination team movement during polio campaigns, among others.

“I am particularly eager to take back the new capacity I have on ODK and PowerBI when monitoring our entire Expanded Programme on Immunization (‎EPI)‎ interventions” stated participant Dexter Merchant, Assistant Director for Monitoring and Evaluation at the Ministry of Health in Liberia, “using ODK as the process to collect data on where we have essential services and where we don’t is going to make things move a lot faster and more efficiently in identifying gap, I am confident these tools will now be integrated in Liberia”.

John Kipterer and Frank Salet moderating a PowerBI training session at the GIS capacity building workshop in the Dakar. © WHO
John Kipterer and Frank Salet moderating a PowerBI training session at the GIS capacity building workshop in the Dakar. © WHO

To ensure sustainability, country accountability and ownership, in-country GIS working groups which will constitute personnel from WHO and Ministries of Health will be established to continue efforts of knowledge transfer and capacity building principally amongst data managers, GIS analysts, and surveillance officers.

In closing, the WHO Representative in Senegal, Dr. Lucile Imboua and host of the last training series emphasized the “need to ensure harmonization of all the GIS tools and to be flexible to accommodate the use of other tools across different programs.”

The underlining consensus from all WHO, government and partner participants is that in order to end polio and strengthen health systems, the region heavily relies on the innovative technologies of GIS in executing health responses. The use of GIS innovations with precision in accuracy, transparency, accountability and ease of application and sustainability provides a huge opportunity to reach every last child across the 47 countries, eradicate polio from the region, and serve public health for all.

Dr Mutahar Ahmed, R, reviewing the location of AFP cases with Dr Khaled Al-Moayad, Director of Disease Control and Surveillance in Sanaa, Yemen © Omar Nasr / WHO Yemen
Dr Mutahar Ahmed, R, reviewing the location of AFP cases with Dr Khaled Al-Moayad, Director of Disease Control and Surveillance in Sanaa, Yemen © Omar Nasr / WHO Yemen

At his office in Sana’a, Yemen, Dr Mutahar Ahmed stands before a wall-sized map of his country and feels the weight of the world on his shoulders.

“The situation here in Yemen is very complex, and the problems we face are quite immense,” said Dr Ahmed.

As Yemen’s national surveillance coordinator, Dr Ahmed leads the country’s acute flaccid paralysis (AFP) surveillance efforts, the primary means of tracking poliovirus transmission. With an explosive outbreak of circulating vaccine-derived poliovirus type 2 having paralysed 115 children and counting, and with swathes of the country’s infrastructure – from roads to hospitals – decimated by conflict, you’d be forgiven for thinking that his and his team’s efforts to surveil for poliovirus were falling short or otherwise compromised. But you’d be wrong.

In Yemen, despite a long-running conflict and complex humanitarian disaster that has significantly impacted health care, AFP surveillance indicators tell a promising story of a functioning system where case detection, sample collection and laboratory analysis – the steps that enable us to detect poliovirus so we can respond to it – are, in fact, on track.

Surveillance data allows the polio programme to identify new AFP cases and to test those cases to determine whether polio infection is the cause. In this way, a robust and wide-reaching AFP surveillance system enables health workers to detect the presence and circulation of poliovirus.

Dr Mutahar Ahmed, national surveillance coordinator, at a health facility in Sanaa, Yemen. © Omar Nasr / WHO Yemen
Dr Mutahar Ahmed, national surveillance coordinator, at a health facility in Sanaa, Yemen. © Omar Nasr / WHO Yemen

“In addition to our work building the engagement and knowledge of pediatricians and clinicians, we are reaching the community and community-based health care providers including traditional healers. We also appeal to families for their support in reporting cases. The more aware they are of the symptoms of paralysis in a child, the quicker our surveillance coordinators can collect the stool sample for analysis,” said Dr Ahmed.

Early detection of symptoms such as AFP is a crucial step in the chain of polio surveillance. If a case of paralysis is not reported within the first 14 days of the onset of symptoms, the reliability of testing the sample in the lab reduces significantly. In Yemen, the AFP surveillance system in high-risk districts is supported by volunteers trained in community-based surveillance. In 2021, 82% of AFP cases were detected early, within the first seven days of the onset of paralysis, which is above the global target of 80%.

Once a case is detected and stool samples are collected, it’s vital to make sure the samples reach the laboratory in good condition.

“Two stool samples are required from each child showing symptoms of paralysis. Both samples need to be collected within the first 14 days, 24 hours apart. They need to be correctly labelled, and their temperature needs to be maintained at between 2 and 8 degrees. Otherwise, they are not adequate samples,” said Dr Ahmed.

In 2021, 921 AFP cases were detected. Of these cases, 87.84% had adequate specimens collected, which is above the global target of 80%.

Along with stool adequacy, another key performance indicator for surveillance is the non-polio AFP rate. This refers to the detection of diseases, other than polio, that can cause AFP. Yemen’s non-polio AFP rate is 5.96 per 100,000 children aged below 15 years in 2021, significantly higher than the global standard of three per 100,000 for polio outbreak countries like Yemen. This accomplishment points to the sensitivity of Yemen’s surveillance system due to the relentless efforts and commitment of the surveillance personnel working with Dr Ahmed.

Dr Mutahar Ahmed, L, inspecting samples with Dr Abdullah Yahya, assistant national coordinator for AFP surveillance © Omar Nasr / WHO Yemen
Dr Mutahar Ahmed, L, inspecting samples with Dr Abdullah Yahya, assistant national coordinator for AFP surveillance © Omar Nasr / WHO Yemen

Due to electricity shortages, maintaining the cold chain (keeping vaccines cold) and reverse cold chain (keeping stool samples cold) poses a significant challenge for the programme. To overcome this and further increase the efficiency and sensitivity of the surveillance system to detect polioviruses as quickly as possible, solar power panels have been installed in health facilities at the central and governorate levels to support the storage and transfer of stool samples. One indicator of the impact of this change is Yemen’s non-polio enterovirus rate, which tells us what percent of stool samples tested negative for poliovirus, but were in such condition that they could still test positive for enteroviruses. In 2021, that rate was 20 percent above the global target of 10 percent.

Because Yemen does not have a poliovirus laboratory in-country for testing, samples are first collected at the central level in Sana’a and then sent by road to Muscat, Oman. The journey can take up to seven days, barring any obstacles or emergencies.

“Working in this role is a challenge, but what I particularly enjoy is how we are able to turn these challenges into opportunities for the AFP surveillance programme. The AFP indicators for the last year show us how far we have come in our journey,” said Dr Ahmed.

He explained why these indicators are so critical to the polio programme.

“The fact that our indicators are above the minimum global standards shows that the surveillance system is functioning, sensitive and responsive, despite the critical humanitarian situation. The data from our surveillance work has helped us identify the outbreak of circulating vaccine-derived polioviruses type-1 and type-2. The situation is quite fragile, but we are committed to addressing these challenges, and we will continue to do so.”

WHO has supported Yemen to establish an environmental surveillance system to supplement its AFP surveillance system and support early detection of polioviruses and more timely responses.

The Global Polio Laboratory Network (GPLN) has confirmed the isolation of type 2 vaccine-derived poliovirus (VDPV2) from environmental samples in London, United Kingdom (UK), which were detected as part of ongoing disease surveillance.  It is important to note that the virus has been isolated from environmental samples only – no associated cases of paralysis have been detected.  Recent coverage for the primary course of DTaP/IPV/Hib/HepB vaccination, which protects against several diseases including polio, in London suggests immunization coverage of 86.6%.

Initially, vaccine-like type 2 poliovirus (SL2) had been isolated from samples taken from the same site between February and May 2022. Genetic analysis suggests that the new VDPV2 and previous SL2 isolates have a common origin, still to be identified, but the technical definition and criteria for ‘circulation’ of VDPV2 are not met at this time.  Additional sewage samples collected upstream from the main waste-water treatment plant’s inlet are being analysed.

Investigations and response by the UK Health Security Agency are ongoing  to:

  • assess both origin and risk of circulation associated with these isolates;
  • strengthen poliovirus surveillance including enterovirus and environmental;
  • explore routine immunization catch-up of children who are under-immunized, including of families that have recently arrived in the UK from countries with recent use of type 2-containing oral polio vaccine; and,
  • enhance communications about this incident to health professionals and caregivers.

It is important that all countries, in particular those with a high volume of travel and contact with polio-affected countries and areas, strengthen surveillance in order to rapidly detect any new virus importation and to facilitate a rapid response. Countries, territories, and areas should also maintain uniformly high routine immunization coverage at the district level and at the lowest administrative level to protect children from polio and to minimize the consequences of any new virus being introduced.

Any form of poliovirus anywhere is a threat to children everywhere. It is critical that the GPEI Polio Eradication Strategy 2022-2026 is fully resourced and fully implemented everywhere, to ensure a world free of all forms of poliovirus can be attained.

Dr. Nabil vaccinating administering polio drops to one of his grandsons in front of the community to convince people about the safety of the polio vaccine. © UNICEF Yemen
Dr. Nabil vaccinating administering polio drops to one of his grandsons in front of the community to convince people about the safety of the polio vaccine. ©UNICEF/Firdous

It’s been a long day for Dr. Nabeel Abdu Omar Ali. Since early morning, he has been going from  one house to the next in a community in Aden, Yemen – listening to the concerns of parents and speaking to them about the importance of vaccination to save their children from polio. And he plans to continue till the sun goes down.

“The weather is pleasant now and I want to meet as many parents as possible, especially those who have concerns about vaccines. In a month’s time, the heat and humidity will be unbearable, making it difficult to walk from house to house,” says Dr. Nabeel.

Nicknamed “the mobile imam” by his peers, Dr. Nabeel is a pediatrician by profession, and a certified imam (Islamic teacher) from the Ministry of Endowment in Southern Yemen. He uses his religious knowledge and medical facts to educate the public about the importance of vaccination in protecting children from polio and other deadly diseases.

A few weeks back, he visited several families who were refusing vaccines in a nearby neighborhood. In addition to speaking to them about the safety and benefits of the polio vaccine, the ‘mobile Imam’ administered polio drops to his grandchildren in front of everyone at the community meeting.

“When the people saw a doctor and Imam like me vaccinating my own grandchildren, I think it was easier for them to believe that the vaccine was safe for their children too,” says Dr. Nabeel with a smile.

Reaching out to other Imams for support 

Dr. Nabeel frequently reaches out to other Imams, training them about the benefits of vaccination and encourages them to share with the public during their Friday sermons.

Dr. Nabeel accompanying a polio vaccination team from one house to the next to speak with parents and caregivers. © UNICEF Yemen
Dr. Nabeel accompanying a polio vaccination team from one house to the next to speak with parents and caregivers. ©UNICEF/Firdous

“Imams are very influential in our communities – to raise awareness, shape social values, and promote positive attitudes, behaviours and practices. For example, a single sermon is powerful enough to change misconceptions about vaccines in some communities. If Imams are fully equipped with accurate information, it goes a long way in build trust and creating vaccine acceptance among the people – helping children in the community to stay health and free from polio and other vaccine-preventable diseases,” he adds.

The ongoing conflict in Yemen has severely damaged the health and basic infrastructure. There are frequent interruptions in power supply, and this often creates suspicion among community members as well as Imams whether vaccines are being stored safely.

“I was training a group of imams and they shared their doubts about the safety of the vaccine. They were skeptical about how refrigerators could store polio vaccines safely when there are so many power cuts in the area.”

In response, Dr. Nabeel organized a tour for the group to a vaccine storage facility where they were able to see and learn about special refrigerators that are powered by solar energy when there are power cuts.

Promoting the benefits of vaccination for over a decade

Dr. Nabeel has been working for the immunization programme in Yemen for over 12 years, partnering with UNICEF for numerous polio vaccination campaigns and routine immunization services.

When he first started out as pediatrician, he met many children who were paralyzed by polio. He felt frustrated that so many children would have to suffer for the rest of their lives by a disease that could have been easily prevented by a vaccine. That is when he decided to dedicate his time to educate caregivers and parents on the benefits of vaccination.

Dr. Nabeel (third from left) speaking with male members of a local community on the benefits of vaccination for children’s health and well-being. Photo: ©UNICEF Yemen
Dr. Nabeel (third from left) speaking with male members of a local community on the benefits of vaccination for children’s health and well-being. Photo: ©UNICEF/Firdous

“There are many misconceptions about vaccines. Throughout my career I have been confronted by people who were resistant to the idea of vaccination. Some people think that the vaccine will make them infertile, while others believe it’s some kind of a conspiracy.  However, my many years of work in immunization and knowledge of religious scriptures has proven to be valuable so far in building trust in vaccine in communities,” says Dr. Nabeel.

The ‘mobile Imam’ is also quite adept in working with the media to promote vaccination. He is often seen and heard on TV and radio talk shows speaking about the benefits of vaccination and answering to questions from concerned parents and caregivers.

“I use a mixed approach to address vaccine hesitancy and dispel misinformation about vaccines. Sometimes it is helpful to talk about vaccines during Friday sermon, while other times, it is more effective to explain to a caller on a radio programme why vaccines are important,” he explains with a smile.

World Cup winners, Olympic champions and celebrities aren’t the first people who come to mind when thinking of those involved in the effort to end polio. But on 12 June, they’ll unite for the world’s biggest celebrity football match and raise support toward ensuring no child is paralysed by this disease again.

Usain Bolt, Damian Lewis, Carli Lloyd and Andriy Shevchenko are among those who will play in Soccer Aid for UNICEF this year, as an England XI take on the Soccer Aid World XI in London. Through public donations, they’ll be raising funds to help UNICEF provide vaccines, fight malnutrition, and provide safe spaces to protect children in times of crisis.

For polio specifically, these funds will help support the incredible work of polio workers like the brave women in Nigeria who are the backbone of eradication efforts. This volunteer community mobilizer network of 20,000 people is crucial to reaching every child with polio vaccines, and was a key reason behind Nigeria’s success in stamping out wild polio and contributing to the African region being certified free of the virus.

This year is a critical moment in the fight to achieve a polio-free world. Thanks to the 2022-2026 GPEI Strategy and low rates of wild polio transmission globally—the virus is endemic in just two countries—we have an historic opportunity to end this disease.

But achieving that goal needs a team effort to overcome the final challenges, such as reaching children in insecure areas and vaccine hesitancy. As we’ve seen recently with two wild polio cases in southeast Africa imported from Pakistan where it is endemic, while polio persists anywhere in the world no child is safe.

The polio program is co-hosting its pledging moment for the 2022-2026 Strategy with Germany this October at the World Health Summit, where it will be vital for donors and governments to commit the $4.8 billion necessary to fully fund the programme and finish the job.

You can play your part in the eradication effort, too, by heading to the Soccer Aid page to find out how you can ensure children receive the polio vaccine and are protected from lifelong polio paralysis.

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.

Three-year-old Yumna, niece of Samar al-Sheikh, receives her dose of OPV at Biddo UNRWA health facility on 18 May 2022. © WHO/occupied Palestinian territory
Three-year-old Yumna, niece of Samar al-Sheikh, receives her dose of OPV at Biddo UNRWA health facility on 18 May 2022. © WHO/occupied Palestinian territory

Over four days in the middle of May, parents in the governorates of Bethlehem and Jerusalem were urged to take their children under age five to health facilities for a supplementary dose of oral polio vaccine. The aim: boost immunity to poliovirus in the face of increased regional risk.

Unlike most polio campaigns in the Eastern Mediterranean Region, the mechanism for the campaign in occupied Palestinian territory (oPt) was via health facilities, rather than house to house. This can be a major ask for parents, who must organize time and transport to get children to health facilities during a relatively brief window.

Round 1, from Monday 16 May through Thursday 19 May, tested the resolve of a community that is famously pro-vaccine (routine immunization coverage across oPt is typically between 98% and 100%), but like parents everywhere, juggling work, childcare and other commitments.

While most often, mothers took their children for vaccination, in many of the health facilities where vaccination took place, grandmothers were seen supporting mothers or even stepping into their shoes.

“I brought my granddaughters today to take the polio vaccine because their mother is studying in university and their father is working,” said Abeer Nasrallah, who brought Zeina (two) and Mariam (three) to El-Azariyeh, a Palestinian Ministry of Health clinic in Jerusalem governorate.

Tamam Taha, a nurse at the Biddo UNRWA health facility, greets a mother at the campaign registration desk. © WHO/occupied Palestinian territory
Tamam Taha, a nurse at the Biddo UNRWA health facility, greets a mother at the campaign registration desk. © WHO/occupied Palestinian territory

In Biddo, an area of Jerusalem governorate where the main UNRWA clinic serves both local families and those from more remote regions, a steady stream of clinic visitors climbed out of mini-buses and taxis after lengthy journeys.

“Many Bedouins come to us from remote areas like Bani Samuel and Beit Iksa, although the transportation from their areas is very hard for two reasons. First, the roads are very difficult, and second, there are a lot of checkpoints that could keep you waiting for hours,” said Tamam Taha, a nurse at the Biddo UNRWA health facility.

“We have good numbers of people coming to the clinic, both refugee and non-refugees, and we give the vaccine to all of them,” she said.

One of the groups she served was headed by Samar Al-Sheikh, a mother of one who arrived with three girls in tow.

“I brought my brother’s daughters because he can’t come. Usually, I would walk from my home, but I took public transportation today because I have three kids with me. It was hard to manage them, but it’s important to give them the vaccine,” she said.

In some cases, the hurdles parents faced to bring their children to health facilities were starkly visible.

Nidal Kandeel, father of Janette (three) and Jolan (21 months), arrived at Biddo UNRWA health facility on crutches.

“I got an injury in my work a year ago, and I’m now disabled for the rest of my life. It was hard for me to come to the clinic using public transportation, but I know how important it is for my children to take the polio vaccine, and this is why I am here,” he said.

Nidal Kandeel, father of Janette (three) and Jolan (21 months), arrived at Biddo UNRWA health facility on crutches after being injured at the workplace a year ago. © WHO/occupied Palestinian territory
Nidal Kandeel, father of Janette (three) and Jolan (21 months), arrived at Biddo UNRWA health facility on crutches after being injured at the workplace a year ago. © WHO/occupied Palestinian territory

While the results of this preventative campaign are still pending, clinics promoted the campaign heavily through their own social media groups, and health workers explained that logistics aside, it wasn’t difficult to convince Palestinian parents of the need to vaccinate under-fives.

 “There is a lot of demand for this vaccine. Many people have been coming since this morning to get their children to take the vaccine. In the last hour, we have vaccinated more than 100 children,” said Khawla Abu Khdeir a nurse running the registration desk at El-Azariyeh.

Following the four-day vaccination blitz at health facilities, nursing teams will review registers of children vaccinated and cross-reference these with patient lists. Parents of children who weren’t vaccinated will be telephoned and efforts made to reach those children through in-clinic follow-up or outreach.

Round two of the bivalent oral polio vaccine (bOPV) campaign is expected in mid to late June, with the aim of raising immunity levels in these two governorates.

Palestine has been polio-free for more than 25 years, thanks to a robust routine immunization programme and a strong culture of vaccine acceptance.

Nurse Khawla Abu Khdeir (rear left) hands a mother a campaign information pamphlet at El-Azariyeh Ministry of Health clinic on 16 May 2022. © WHO/occupied Palestinian territory

But following the detection of circulating vaccine-derived poliovirus type 3 (cVDPV3) in sewage outflow in Wadi Alnar site, a junction between wastewater coming from inside the green line with wastewater coming from Bethlehem and Jerusalem, the Palestinian Ministry of Health launched efforts to boost immunity in the areas deemed most at risk.

The campaign was carried out with support from WHO, UNICEF and UNRWA’s Palestine country offices.

WHO’s Palestine office provided technical support to the Ministry in planning and executing this campaign, drawing on the extensive expertise of our regional polio eradication programme.

The vaccination campaign in Palestine is part of the global effort to eradicate poliovirus, spearheaded by the Global Polio Eradication Initiative.

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

 

On Monday 16 May, the Palestinian Ministry of Health will launch round one of a polio vaccination campaign targeting all children under age five in Bethlehem and Jerusalem.

The vaccination campaign is scheduled to run over three days: Monday 16 May through Wednesday 18 May 2022. Vaccination, using bivalent oral polio vaccine (bOPV), is free and will be offered at maternal and child centres and UNRWA centres throughout Bethlehem and Jerusalem.

Palestine has been polio-free for more than 25 years, thanks to a robust routine immunization programme and a strong culture of vaccine acceptance. But following the detection of circulating vaccine-derived poliovirus type 3 (cVDPV3) in sewage outflow in Wadi Alnar site, where there is a junction between wastewater coming from inside the green line with wastewater coming from Bethlehem and Jerusalem, the Ministry of Health has taken the decision to launch a preventative vaccination campaign to boost children’s immunity in the two areas deemed most at risk: Bethlehem and Jerusalem.

“It is all of our duty to keep Palestine polio-free by making sure that our children under the age of five receive the polio vaccine every time it is offered. I encourage every parent to make it a priority to vaccinate their children – for their sake, and for Palestine,” said Dr Mai al-Kaila, Minister of Health, Palestine.

The vaccination campaign is being carried out with support from WHO, UNICEF and UNRWA’s Palestine country offices.

“WHO’s Palestine office has provided technical support to the Ministry in planning and executing this campaign, drawing on the extensive expertise of our regional polio eradication programme. Palestine is in a strong position thanks to its routine immunization programme and to the value Palestinian parents put on childhood immunizations, but the regional risk of polio is increasing and it is absolutely crucial that we reach and vaccinate every child under age five in the target areas,” said WHO occupied Palestinian territory Representative Dr Rik Peeperkorn.

“It is critical that every child can access their right to a life free from polio and other vaccine-preventable diseases. UNICEF and its partners in this campaign are making every effort to ensure no child in Palestine will be affected by this debilitating disease. It is a duty upon all of us to keep Palestine polio free,” said UNICEF’s Special Representative to the State of Palestine Lucia Elmi.

Round two of the campaign will take place in June and will offer all children under age five a second two drops of polio vaccine, further boosting their immunity. Children living outside of Jerusalem and Bethlehem do not currently require an additional dose of oral polio vaccine. If their routine immunizations are up to date, they are well protected from poliovirus and other vaccine-preventable diseases.

Poliovirus primarily affects children under age five and can lead to lifelong paralysis. It can easily be prevented through vaccination. Parents are urged to accept polio vaccines every time they are offered.

The vaccination campaign in Palestine is part of the global effort to eradicate poliovirus, spearheaded by the Global Polio Eradication Initiative.

It is a hot afternoon in Chagai, a small community on the south bank of the River Gambia when the polio vaccination team arrives to a rapturous welcome. Children and women jump to their feet, some waving and swinging their hands as they pound their feet on the ground in near perfect sync with the beat of the drum.

This excitement is caused by one certain member of the vaccination team wearing a bush hat and playing the drums. Lamin Keita, 60, is a cultural musician supporting the vaccination team in raising awareness about polio and encouraging parents to vaccinate their children.  Lamin, popularly called Takatiti, because of one of his songs, is immediately surrounded by excited children, as he adjusts his beats to respond to the ecstasy and rigor of the dancers.

“When I arrive on the back of a pick-up truck with my megaphone and drums, children from the communities run after us in full excitement and jump up and down and ask me to play my drums,” Takatiti explains.

Whenever Takatiti enters a village with his drums, children and adults flock around him and jump and dance to his music, which gives him the opportunity to speak with community members about polio and the importance of vaccination in protecting children from the deadly disease. Photo: © UNICEF/UN0624019/ Lerneryd

This is what Takatiti is popular for – pulling crowds with his drums to communicate important messages like polio vaccination. For almost four decades, he has toured communities in the region, accompanying health workers as they seek to persuade parents and caregivers to vaccinate their children during mass vaccination campaigns like the polio campaign.

Local voices are the most powerful voices

Building trust in vaccines among parents and caregivers is the first critical step towards achieving high immunization coverage to stop the spread of polio. UNICEF, as a leading partner of the Global Polio Eradication Initiative (GPEI) for social and behaviour change, supports the government in strengthening engagements with communities, as the voices of local leaders and influencers like Takatiti play a powerful role in helping allay fears and concerns of parents and caregivers about vaccines.

“I have been making town announcements since the mid-1980s. I am aware of polio and its terrible consequences. Families hear myths and rumours and get concerned about vaccines. As they already know and trust me, I try my best to give them accurate information and clear their doubts, so that they can vaccinate their children against polio and other dangerous diseases,” Takatiti says.

“It’s important to deliver messages that are supported by facts in an effective way”

Days before the start of a polio vaccination campaign and during the campaign itself, Takatiti walks up and down the streets of villages, playing his drums and using his megaphone to talk to communities about the dangers of polio, how vaccination is the only way to protect children, and that polio vaccines are safe and free.

Awa plays with her baby, Abdoulay, after he was vaccinated during the a polio vaccination campaign in Jenoi, The Gambia, on 21 March 2022. Photo: © UNICEF/UN0623991/Lerneryd
Awa plays with her baby, Abdoulay, after he was vaccinated during the a polio vaccination campaign in Jenoi, The Gambia, on 21 March 2022. Photo: © UNICEF/UN0623991/Lerneryd

“I always try to promote peace and healthy life for all. It’s important to deliver messages that are supported by facts in an effective way. The Government and UNICEF provided me correct information and facts about polio and vaccines, so I am happy to volunteer for the campaign.”

A country mobilizes to stop polio

“If people trust health workers to cure other diseases, then it makes sense to trust the same health workers to protect our children from polio. Health workers even give the polio vaccine to their own children – so we should not doubt their good intentions. It is my job to let people know this truth, without offending them, and encourage them to vaccinate their kids,” Takatiti said.

In August 2021, The Gambia declared a national public health emergency in response to outbreaks of non-wild variants of polio in the country.

Sainabou, a healthcare worker, administers the polio vaccine to school children at New Town School during a vaccination campaign in Bakau, The Gambia, on 19 March 2022. Photo: © UNICEF/UN0624057/Lerneryd
Sainabou, a healthcare worker, administers the polio vaccine to school children at New Town School during a vaccination campaign in Bakau, The Gambia, on 19 March 2022. Photo: © UNICEF/UN0624057/Lerneryd

The Gambian government, with support from WHO, UNICEF, US Centres for Disease Control and Prevention (CDC)and GPEI partners, quickly responded and started preparing for nationwide immunization campaigns – managing supply and safe storage of vaccines, strengthening surveillance and monitoring, training health workers and vaccinators, and engaging with local leaders and influencers to build trust in vaccines.

The country undertook its first national polio vaccination campaign in November 2021 and followed up with a second round in March 2022.

Thanks to thousands of health workers, vaccinators, and community influencers like Takatiti, the vaccination campaigns have reached over 380,000 children aged five years and below in The Gambia.

Children in Vakhsh region in Tajikistan receiving their first dose of oral polio vaccine. © WHO / Mukhsindzhon Abidzhanov
Children in Vakhsh region in Tajikistan receiving their first dose of oral polio vaccine. © WHO / Mukhsindzhon Abidzhanov

Infectious diseases like poliomyelitis (polio) know no borders. Importation and subsequent spread of the virus led to the paralysis of 34 children, and 26 others tested positive without developing symptoms of paralysis. Extensive immunization efforts began in February 2021, and no child, adult or environmental sample in Tajikistan has tested positive since August 2021.

The outbreak in Tajikistan marked the first detection of circulating vaccine-derived poliovirus type 2 (cVDPV2) in the WHO European Region. It is now the first cVDPV2 outbreak in the world to be declared officially closed following supplemental immunization using the novel oral polio vaccine type 2 (nOPV2).

The Region has been free of endemic poliovirus since 2002. Detection of just 1 case of polio – whether from a wild or vaccine-derived poliovirus – is considered an outbreak, and requires an immediate and comprehensive response.

“Tajikistan’s success in stopping this outbreak is a major achievement and a clear demonstration of the highest level of political commitment of the Government of Tajikistan,” says Dr Hans Henri P. Kluge, WHO Regional Director for Europe.

“This outbreak and the subsequent response came at a time when the health system was already overstretched by the COVID-19 pandemic and the country was mounting a massive COVID-19 vaccination drive. Both outbreak responses had to be done without disrupting the vitally important provision of other routine vaccines to children. We acknowledge the efforts of the Ministry of Health over the past several years, which resulted in a resilient immunization system able to successfully manage all these competing immunization priorities.”

Actions taken to stop the outbreak

Following confirmation of the outbreak, the Ministry of Health and Social Protection of the Population took immediate steps, with support and guidance from WHO and other Global Polio Eradication Initiative partners. Actions included enhanced poliovirus surveillance, intensive contact tracing and a thorough review of immunization coverage at subnational levels. A rigorous risk assessment was conducted to determine the outbreak response scale and choice of vaccine, and the country rapidly completed a comprehensive verification process for readiness to use the nOPV2 vaccine.

In February 2021, a high-quality nationwide inactivated polio vaccine campaign was conducted to close the immunity gap against poliovirus type 2 among the more than half a million children born from 2016 to 2018 who had been left vulnerable as a result of global inactivated polio vaccine (IPV) supply constraints following cessation of trivalent oral polio vaccine use.
From June to September 2021, 2 nationwide and 1 subnational nOPV2 immunization rounds were implemented for all children under 6 years of age, with coverage confirmed (through external assessment) to be greater than 95%. Extensive social mobilization and communication strategies were deployed to reach groups who were at risk of being missed, including internal migrants in urban areas and unregistered children.

Assessment of the outbreak response

Several criteria must be met to officially close an outbreak, including at least 6 consecutive months in which no poliovirus is detected. The independent experts of the Global Polio Eradication Initiative who conducted the assessment in Tajikistan also looked at the performance of routine polio vaccination, the coverage achieved during the supplemental immunization rounds, and the capacity and sensitivity of the polio surveillance system to detect any poliovirus circulation.

Following the thorough assessment, which included briefings at the national level and field visits to national referral hospitals, public hospitals, polyclinics, regional and district immunization programme offices, and public health centres, the team recommended closure of the outbreak.

nOPV2 – a new chapter in global efforts to eradicate polio

Ending this outbreak using nOPV2 is an important milestone for the global polio programme. The innovative vaccine is a key part of the new strategy to stop cVDPV2s. Clinical trials show that nOPV2 is safe and effective, and more genetically stable than the traditional type 2 oral polio vaccine.

Since the rollout of nOPV2 began in March 2021, over 265 million doses have been administered across 14 countries. The majority of countries using the vaccine have also managed to stop transmission of cVDPV2; however, this is the first official closure of an outbreak to take place following nOPV2 use.

In addition to successfully halting transmission and lowering the risk of infection for millions of people, Tajikistan contributed to global research on nOPV2 with the support of WHO through an nOPV2 immunogenicity study. The country also participated in a global vaccine wastage study.

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

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

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

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

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

On 21 March, the Federal Government of Somalia, World Health Organization (WHO) and members of the Global Polio Eradication Initiative (GPEI) recommitted to stopping the ongoing outbreak of circulating poliovirus type 2 (cVDPV2) in Somalia at a three-day meeting convened in Nairobi, Kenya. High-level delegates at the meeting included HE Fawziya Abikar Nur, Federal Minister of Health and Human Services, Dr Mamunur Rahman Malik, WHO Representative to Somalia and Head of Mission, alongside senior representation from the Bill & Melinda Gates Foundation (BMGF), the Centers for Disease Control and Prevention (CDC), Rotary International, Save the Children, the United Nations Children’s Fund (UNICEF), and other UN agencies and partners.

Together, the Government, GPEI partners, which include WHO, UNICEF, the BMGF, CDC, Rotary International, GAVI, the Vaccine Alliance, and other key partners endorsed the Somalia Polio Eradication Action Plan 2022 to reaffirm their commitment.

The Somalia Polio Eradication Action Plan 2022 outlines a four-point call to action to stop the spread of the current outbreak, which is one of the longest lasting cVDPV2 outbreaks to be reported so far. The robust plan aims to direct partners’ efforts and resources towards boosting population immunity, making concerted efforts to reach high-risk populations — including inaccessible and nomadic communities and internally displaced persons — to strengthen their immunity, enhancing the search for poliovirus circulation, and strengthening coordination among all stakeholders. Some of the strategies that will be deployed include intensifying efforts to offer 5 opportunities for vaccination against polio in 2022, providing routine childhood immunization in high-risk locations, where children have missed out on vaccinations, and strengthening community engagement. Given how easy it is for the cVDPV2 virus to spill over international borders, the emergency plan also advocates for stronger cross-border coordination among the polio eradication programmes in Somalia, Kenya, Ethiopia and Djibouti.

“In the midst of the ongoing drought, and while recovering from the effects of the COVID-19 pandemic, our stakeholders must not forget how important it is to contain the ongoing poliovirus outbreak so that it does not spread any further and does not affect any more children’s lives,” said HE Fawziya Abikar Nur, Federal Minister of Health and Human Services. “On this occasion, I would like to extend my sincere gratitude to all our partners, and donors, for the immense efforts they have put into shielding millions of Somali children from polio over the years.”

“Since its inception 25 years ago, Somalia’s polio eradication programme has made progress, including by stopping outbreaks of wild poliovirus and, recently, one of circulating poliovirus type 3 in 2021. The programme has established a vast network of polio workforce and assets and we can do more not only to stop the current outbreak but to achieve broader health system goals through integration and effective use of our human and operational resources. Since 2018, Somalia has conducted several supplementary immunization campaigns. Despite these efforts, pockets of unvaccinated children remain, due to insecurity and limited access to health services,” said Dr Mamunur Rahman Malik, WHO Representative to Somalia.

The Somalia Polio Eradication Action Plan, which will be implemented in 2022, complements one of the goals outlined in the GPEI ‘Polio Eradication Strategy 2022–2026: Delivering on a Promise’, to stop cVDPV transmission and prevent outbreaks in non-endemic countries. It is also in line with Somalia’s national goals and UN Sustainable Development Goals (SDGs).

17 March 2022 — On Monday 7 March 2022, a case of circulating vaccine-derived poliovirus type 3 (cVDPV3) was confirmed in an unvaccinated girl aged three years and nine months in Israel. The girl had developed acute flaccid paralysis and upon testing of her stool, poliovirus was confirmed.

Further testing of the virus isolated from the girl revealed genetic links to VDPV3-strains detected in environmental samples collected between September 2021 and January 2022 from sites in Jerusalem and Bethlehem.

Circulating VDPV3 has also been confirmed in a sample taken from a contact in Jerusalem.  This child does not display any symptoms of paralysis.

A previous statement published on 10 March 2022 had indicated circulation of this VDPV3 also in occupied Palestinian territory; further field investigations concluded that at this time, circulation can only be confirmed in Israel.  This classification does not however change the risk this cVDPV3 presents to children in Israel and in the occupied Palestinian territory, nor the planned response activities.

 Although there is currently no evidence of circulation of this cVDPV3 in occupied Palestinian territory, the proximity and interconnectedness of communities on both sides of the border and the volume and frequency of cross-border population movement underscore the risk to unvaccinated children in both places.

Local health authorities in both Israel and occupied Palestinian territory are conducting field, epidemiological and virological investigations, to determine more clearly the source and origin of the isolated virus and potential risk of further spread associated with it. Discussions are ongoing to plan an immunization response as appropriate (extent and scale to be determined, potentially to include a series of immunization outreaches with both inactivated polio vaccine and bivalent oral polio vaccine, both in high-risk areas of Israel and occupied Palestinian territory).  At the same time, efforts are continuing to strengthen surveillance comprehensively in both Israel and occupied Palestinian territory.

Experts from headquarters, regional and country offices of the Global Polio Eradication Initiative (GPEI) partnership, which includes WHO, Rotary International (RI), the US Centers for Disease Control and Prevention (CDC), the United Nations Children’s Fund (UNICEF), Bill & Melinda Gates Foundation (BMGF) and Gavi, the Vaccine Alliance, are working together to help ensure an appropriate response and cessation of this outbreak.

Detection of this cVDPV3 underscores the importance of strong disease surveillance and high population immunity levels, in order to minimize the risk and consequences of any poliovirus introduction or emergence.

The GPEI partnership urges all health authorities to enhance surveillance for poliovirus and implement enhanced vaccination response to prevent further transmission, so that no child is at risk of lifelong paralysis from a disease that can so easily be prevented. GPEI is committed to assisting the health authorities in their efforts to stop the cVDPV3 outbreak.