Circulating vaccine-derived poliovirus

Stopping any polio outbreak starts with vaccine procurement, transport by airplanes and trucks, distribution involving complex logistics, and eventually the oral administration of the vaccine by drops in the mouths of every eligible child.

However, there is another, lesser known but equally important process that must also take place to halt transmission of the poliovirus. It begins with a humble stool sample – a thumb-sized smudge of poop – taken from a child with acute flaccid paralysis (AFP), then delivered to the nearest laboratory that can test the sample specifically for poliovirus.

But nowhere in Yemen is there any such lab. So the long and arduous journey of any stool sample from a Yemeni child to a receiving lab can take up to several days – following an easterly route, to the neighboring country of Oman.

An explanation of how stool samples are transported over such a distance starts with why: monitoring children under 15 years of age for signs of AFP, which is the most common sign of poliovirus infection. The Global Polio Eradication Initiative has set a benchmark of at least three AFP cases per 100,000 children under 15 years of age, a standard that Yemen has consistently met, thanks to the effectiveness of its surveillance system. This achievement is all the more remarkable considering that Yemen is entering its ninth year of internal conflict, with resulting population displacements, widespread food and fuel shortages, and a devastated health system (in which only 46% of hospitals and health facilities are only partially functioning or completely out of service).

Read the rest of the story here.

Since 1988, the number of children affected by polio has reduced by 99 per cent. While the end of polio is within reach, immunization efforts can easily be derailed by the rapid spread of vaccine misinformation, putting vulnerable children at risk.

Take for example Pakistan, one of the two countries where polio remains endemic, where fake videos of children falling sick after receiving polio vaccination spread like wildfire on social media a few years ago. The misinformation caused mass panic and derailed long-fought efforts to immunize millions of children across the country.

While it is near impossible to eliminate misinformation after it has spread, national health systems can actively monitor for and address misinformation as it arises. This is where the Digital Community Engagement (DCE) initiative is proving effective. Based on the Vaccine Misinformation Management Guide, the DCE was launched as a first-of-its kind misinformation management model in 2021 by UNICEF and The Public Good Projects.

The DCE is made up of a central hub that tracks polio misinformation online, develops accurate messaging, and supports digital volunteers and UNICEF country offices. The hub is driven by a global team of experts spread across public health, social behaviour change, online social listening, advertising, content design and influencer marketing.

“In many countries, UNICEF and partners are already working to combat online misinformation in various ways. DCE’s aim is not to replace these systems but strengthen their existing efforts,” said Adnan Shahzad, the Digital Communication Manager of the UNICEF Polio Eradication Team.

The polio ‘listening post’

“Social listening is like a disease surveillance system, but instead of the virus, we track and analyze misinformation. Using cutting-edge digital media and tools we collect and analyze publicly available data on polio and vaccines across social media, digital media, broadcast news and print media platforms,” said Shahzad.

In 2022, over 5 million online social listening results were analysed from 41 countries in more than 100 languages. The most common misinformation pieces claimed that vaccines were unsafe and that they could cause other diseases. Other fear-inducing misinformation involved how vaccines are being used by rich countries or individuals to control the world and depopulate certain continents.

Misinformation pieces are analysed and categorised as low, medium or high risks based on its potential impact to vaccination efforts and how quickly it is spreading. When a high-risk misinformation is going viral (within a 24-hour period), the DCE central hub sends an urgent alert to UNICEF country and regional offices and also sends a weekly compilation of news and alerts in the form of a newsletter

Examples of high-risk misinformation alerted to country teams:

Clear and accurate messages are crucial

“What we say must be accurate and easy to understand for everyone,” says Soterine Tsanga, Polio Outbreak Response SBC specialist with UNICEF, who is also involved in the roll out of DCE to countries. “When there’s a polio outbreak, our goal is to respond swiftly to reach children with vaccination and stop further spread of the virus. We cannot afford to have our own messaging causing confusion among mothers and fathers,” she adds.

Backed by scientific evidence and facts, messages on polio are carefully prepared at the DCE hub in English, French, Urdu and Pashto. The team organizes content into a bank for quick retrieval based on reoccurring themes, such as vaccine effectiveness, safety and side effects.

Quashing rumours

“A big part of UNICEF’s social behaviour change work for polio eradication involves engaging local community mobilisers who continuously listen to concerns about vaccines, clarify doubts and encourage parents and caregivers to vaccinate their children. DCE is the online version of this approach aimed at engaging online communities to quash false information before it becomes viral,” said Sheeba Afghani, the Chief of Social Behaviour Change with the UNICEF Polio Eradication Programme.

The DCE hub recruits digital volunteers through an interactive online platform called uInfluence to promote accurate polio and vaccine information. Digital volunteers or ‘uInfluencers’ are everyday social media users, many of them young people who are already active in online communities.

“I grew up seeing many people suffering from polio and other diseases. We struggled to find solutions for the problems in our community. I want to help by being a source of accurate information about polio,” said Liam, a 26-year-old digital volunteer.

20-year-old Mariam is a first-year student in Management living in Dakar, Senegal. In her spare time, she supported UNICEF as a digital volunteer for a media campaign to share information about polio, tracking misinformation and responding to questions about polio. © UNICEF/Joire

Liam is one of 75,000 digital volunteers working with uInfluence. They repurpose content shared by uInfluence on Facebook and Instagram, dispel vaccine and polio misinformation, and increase engagement on social posts. In 2022, content posted through uInfluence channels and amplified by digital volunteers reached 74 million people.

DCE’s general population advertisement (ad) campaign has also yielded positive results. An ad campaign in January 20203 on Facebook and Instagram encouraged parents and caregivers between ages 18–45 years in Egypt, Mozambique, Nigeria, Pakistan, Somalia, Togo and Zambia to visit the “Polio Facts” page on the uInfluence website. By March 2023, the campaign had reached 7.6 million parents. A post-campaign survey with the target populations helped identify knowledge, attitudes, and perceptions about vaccine safety, efficacy (See Figure 1.) , and polio risk, likelihood of vaccinating children, recommending the vaccine to others, and sharing information on the vaccine.

Local outreach and digital engagement

“The concept behind establishing the DCE central hub was to offer enduring tools for country offices, enabling them to craft localized digital health communications and establish a system that mirrors the central hub,” said Andrea Valencia, the Global Program Manager at PGP.

“DCE presents a significant opportunity for countries to prioritize their communication efforts by employing best practices in messaging. This enables them to bridge the gap between their on-the-groundwork and digital communities, while fostering trust in childhood immunization,” she added.

Pakistan’s polio eradication programme has managed several misinformation crises in the past, many of them about the polio vaccine. In October 2022, a Facebook post falsely claimed that a child had died after receiving the polio vaccine in Balochistan, when in fact she had succumbed to severe pneumonia. The polio social media team responded quickly with a video message from the doctor who had examined the child, stating the real cause of death. Meta and the Pakistan Telecom Authority were alerted as it posed a high risk to the polio vaccination campaign. Meta’s independent Fact Check Team called Soch launched an independent investigation and published an articlediscrediting the misinformation.

Proportion of parents and caregivers in Egypt, Mozambique, Nigeria, Pakistan, Somalia, Togo and Zambia who believe vaccines are effective in protecting children from polio (DCE’s general population ad campaign Jan-March 2023)

In the Democratic Republic of Congo, UNICEF is tapping into its network of young fact checkers (Veilleurs du Web) and U-Reporters to tackle misinformation online and offline using DCE tools. During a polio vaccination campaign in July 2023, U-Reporters spoke with mothers and fathers about polio vaccines in markets, churches and mosques while the fact checkers tracked and responded to fake news and rumours related to polio vaccines.

In Afghanistan, religious leaders are building trust in polio vaccines through their sermons in madrassas, or Islamic schools, and mosques. In Kandahar, an Islamic radio programme helps assuage fears and misinformation about vaccines. The national authorities have also offered their support in managing polio vaccine misinformation. Moving forward, the country is planning to establish a misinformation management taskforce at regional and national level to effectively manage polio vaccine misinformation.

In Yemen, DCE trainings helped the Ministry of Public Health, Social Services Centre, Community Radio stations and a Helpline for Internally Displaced Persons collaborate in establishing basic tools to track rumours and misinformation. They have also expanded the existing COVID-19 helpline managed by medical doctors to track misinformation, respond with accurate information on other health issues, and shar monthly reports with all health partners. Based on the DCE polio message bank model, Yemen is now developing similar resources on measles and oral cholera vaccines.

More opportunities ahead

“DCE can be used for other programmes too. It is an invaluable asset for countering misinformation in health, immunization, and other programmes for the well-being of children,” said Shahzad.

While there has been tremendous progress in getting the social listening and misinformation alert systems up and running, there is always more to do. DCE is now focused on strengthening local misinformation response teams while continuing to engage online communities through digital volunteers.

For Gulzar Ahmed Khan, a 28-year-old polio social mobilizer in Pakistan, tracking and addressing polio misinformation is more important than ever.

“Where I work, people have poor understanding of health matters, especially around vaccines. They fear vaccines, they fear us, the polio workers. I explain to them: I’m here for you, for the health and safety of your children. I’m here despite the intense heat and the biting cold. When you refuse to vaccinate, it is the children who will suffer the most. My only motivation is that children and families are spared the suffering of polio,” says Khan.

A child from the Roma community receives oral polio vaccine at a community health care centre in Mukachevo district, Ukraine, on 27 February 2023. © WHO/EURO

WHO/Europe has declared an outbreak of poliovirus in Ukraine, detected in October 2021, officially closed. The European Regional Commission for the Certification of Poliomyelitis Eradication endorsed the closure of the outbreak during its annual meeting on 8 September 2023. The country has achieved this milestone – stopping transmission of the virus that threatened the lives and futures of its children and preventing spread to other countries – in the face of the ongoing war.

The comprehensive outbreak response, initiated by the Ministry of Health of Ukraine in December 2021, faced multiple challenges since the end of February 2022, including massive population displacement, destruction of health-care infrastructure and disruption of logistical routes for medical product deliveries.

“Stopping the spread of poliovirus in the midst of a devastating war is a major achievement and a clear demonstration of the highest level of political commitment of the Government of Ukraine to the welfare of its population,” said Dr Hans Henri P. Kluge, WHO Regional Director for Europe.

“In the face of unprecedented challenges, the necessary steps taken by the Ministry of Health of Ukraine to prevent the spread of poliovirus within and beyond the borders of Ukraine are immensely commendable.”

The decision to close the outbreak was based on:

the recommendations of a poliovirus outbreak response assessment (OBRA) conducted by Global Polio Eradication Initiative (GPEI) partners, including WHO, in May 2023;
additional documentation provided by Ukraine in support of the ongoing surveillance, immunization and communication efforts since May; and
a comprehensive review of poliovirus surveillance and vaccination performance in the countries hosting the majority of the Ukrainian refugee population.

The outbreak was first detected in a young child in Ukraine in October 2021, following the importation of a poliovirus that had emerged in Pakistan and was previously detected in Tajikistan in 2021. A second child became paralysed in December 2021, and an additional 19 close contacts tested positive without developing symptoms.

“The Ministry of Health of Ukraine declared importation of this poliovirus a local public health emergency, and acted swiftly since its detection in close coordination with the global public health community,” said Dr Viktor Liashko, Minister of Health of Ukraine.

Dr Liashko continued, “The outbreak is now closed, but our work to prevent polio and other vaccine-preventable diseases in Ukraine continues despite all obstacles. As long as polio remains a threat globally, Ukraine will remain vulnerable. The Ministry of Health is committed to strengthening vaccine-preventable disease surveillance and working to achieve and sustain high routine immunization coverage nationwide to protect every child.”

What does it take to stop a polio outbreak?

In October 2021 the detection of poliovirus in Ukraine triggered the declaration of a public health emergency in affected oblasts, the creation of a response working group with technical support from GPEI and WHO specialists, and an immediate epidemiological investigation including contact tracing and environmental sampling at a summer camp, school and residences where the virus had been initially detected.

Health workers take a wastewater sample at a sewage site near Uzhgorod, Ukraine on 28 February 2023. © WHO/EURO

On 30 December 2021 the Ministry of Health approved an action plan in response to the outbreak that included, among other initiatives, an accelerated immunization catch-up campaign for children aged 6 months to 6 years who had not received the required doses through routine immunization.

The campaign began in mid-February 2022, but its scale and pace were significantly affected by the war in Ukraine. GPEI partners including WHO provided technical and operational support tailored to the context to build capacity and strengthen routine immunization services, disease surveillance, communication and transportation of samples to reference laboratories abroad.

Dr Jarno Habicht, WHO Representative in Ukraine, coordinated the WHO response within the country. “WHO and GPEI partners have been on the ground from day one, supporting Ukraine’s health authorities, medical and public-health professionals, laboratory staff, and communities to keep this virus from spreading,” he explained. “The excellent collaboration and perseverance of the local and international teams to protect children in the most difficult of circumstances has been truly inspiring.”

Despite the many challenges in implementing the national action plan for the outbreak response, no new detections of poliovirus were identified after December 2021. The OBRA conducted in May 2023 assessed the critical components of the outbreak response, such as the quality of surveillance (and thereby the risk of undetected poliovirus transmission), planning and coordination, the vaccination campaign, routine immunization performance, communication, and vaccine management. Based on the field assessment and review of the documentation, the OBRA concluded that poliovirus was no longer circulating in Ukraine.

The OBRA in Ukraine was followed by a comprehensive review of actions taken by Bulgaria, Czechia, Hungary, Poland, the Republic of Moldova, Romania and Slovakia. This was coordinated by WHO/Europe with financial support from the United States Agency for International Development (USAID).

The review assessed the actions to expand capacities to detect the virus, identify gaps in vaccination coverage and increase coverage of the local populations hosting Ukrainian refugees, and offer vaccination to refugees entering from Ukraine. This review, along with the additional information provided by Ukraine on actions implemented during the months following the OBRA, enabled WHO/Europe to declare the outbreak officially closed.

Mr Robb Butler, Director of the Division of Communicable Diseases, Environment and Health at WHO/Europe, stated, “Ukraine has been steadfast in recent years in its efforts to achieve and sustain high routine vaccination coverage, and within the realm of the European Immunization Agenda 2030, WHO/Europe will continue to support health authorities to prevent further outbreaks of vaccine-preventable diseases including polio, measles, diphtheria and many more.”

Mr Butler concluded, “Tremendous credit goes to the health professionals and parents who continue to make every effort to vaccinate children on schedule to protect them from the threat of polio and other diseases, even while navigating the daily realities and dangers of war.”

Geospatial Tracking Systems have a critical role to play in the monitoring of vaccination teams during polio outbreak response campaigns. With support from the World Health Organization (WHO) and the rest of the Global Polio Eradication Initiative (GPEI), the mobile application was most recently utilized in Brazzaville during a national vaccination campaign from June 9 to 11, 2023, led by Congo’s Ministry of Health. Read more on the WHO Afro website.

Once children are vaccinated against polio, they are marked on their fingers to confirm their vaccination status. © WHO/AFRO

With 117 confirmed cases of circulating variant polioviruses and 107 detections in sampled wastewater so far in the African Region in 2023, the Africa Regional Certification Commission (ARCC) has urged countries and health partners to urgently address gaps in polio immunity to avert outbreaks.

The ARCC, which held it 31st meeting in the Democratic Republic of the Congo from 3 to 7 July, also called for an accelerate implementation of supplementary immunization activities, while considering challenges in accessibility to services including gender-related issues. The commission stressed the importance of gender equality in the polio fight, noting the crucial role women play in management, supervision, decision-making, message development and monitoring for polio control. The ARCC also urged countries to conduct robust preparations and ensure the vaccination campaigns are of the highest quality.

“The guidance will allow health authorities and partners to provide focused support to strengthen microplanning and social mobilization in areas with poor campaign performance, among other key areas of action“ said Professor Rose Leke, head of the Africa Regional Certification Commission.

The meeting gathered representatives of national and provincial health authorities from Chad, the Democratic Republic of the Congo, Ethiopia, Madagascar, Mali and Mozambique who committed to strengthen disease surveillance and consolidate the Expanded Programme on Immunization in hard-to-reach areas, with the support of the World Health Organization (WHO) and health partners.

Attendees took note of the increasing risk of poliovirus type 1 beyond Madagascar and the DRC, especially with the deterioration of routine immunization during the COVID-19 pandemic. Concerns were also raised regarding the persistently security-compromised areas, especially in Nigeria, that are impeding the elimination of circulating variant poliovirus type 2 (cVDPV2).

The commission, therefore, encouraged health authorities to also expand the use of Geospatial Information Systems to improve quality of surveillance and outbreak response.

“We are looking forward to implementing the additional ARCC recommendations to guide how we can deliver on the promise of polio-free Democratic Republic of the Congo and Africa,” said Dr Serge Emmanuel Holenn, Deputy Minister of Health of the Democratic Republic of the Congo, who applauded the commission, WHO and the Global Polio Eradication Initiative partners for the continued financial and technical support in the fight against polio in the country.

In addition to the DRC, Chad, Ethiopia, Madagascar, Mali and Mozambique also presented progress in polio control and lessons learned. Although certification of polio eradication occurs at the regional level, all countries with polio-free status are required to provide the certification commission with annual updates. These containment reports and outbreak preparedness plans allow for continuous monitoring.

The ARCC commended health authorities for their leadership in responding to ongoing polio outbreaks, as “this reflects the deep commitment and continued collective efforts by African countries and partner organizations to the fight against polio,” said Professor Leke.

The ARCC is an independent body established in 1998 to oversee the certification status of the African region as free from indigenous wild poliovirus. It continues to evaluate reliability of data in documentation submitted by National Certification Committees to ensure that countries are adhering to the criteria set for the global certification of wild polio virus. The ARCC meets twice a year to review progress made in the annual certification updates of selected countries on polio eradication activities of all the 47 member’s state of the WHO African region.

Originally published on the WHO AFRO website.

Through ongoing surveillance, the Global Polio Eradication Initiative (GPEI) has received notification of the detection of circulating vaccine-derived poliovirus type 2 (cVDPV2) in Burundi and the Democratic Republic of the Congo (DRC) linked with the novel oral polio vaccine type 2 (nOPV2). The viruses were isolated from the stool samples of seven children with acute flaccid paralysis (AFP) – six in DRC (eastern Tanganyika and South Kivu provinces), one in Burundi (Bujumbura Rural province) – and from five environmental samples collected in Burundi (Bujumbura Mairie province). All reported isolates stem from two separate and new emergences of cVDPV2 linked with nOPV2 that originated in Tanganyika and South Kivu provinces in DRC.

GPEI is supporting local authorities in both and neighbouring countries to conduct a thorough risk assessment and plan vaccination responses to reduce the risk of further transmission, as per outbreak response protocols. Burundi and DRC have scheduled initial vaccination campaigns to be conducted in April and based on the ongoing risk assessment, subsequent campaigns may be expanded to include areas in neighbouring countries.

Additionally, both AFP and environmental surveillance are being stepped up in the areas of detection, and the operationalization of further environmental surveillance sites is being evaluated. Samples from Burundi, DRC, and neighboring countries are also being prioritized for testing by the Global Polio Laboratory Network.

These are the first instances of cVDPV2 linked with nOPV2 since roll-out of the vaccine began in March 2021*. While detection of these outbreaks is a tragedy for the families and communities affected, it is not unexpected with wider use of the vaccine. All available clinical and field evidence continues to demonstrate that nOPV2 is safe and effective and has a significantly lower risk of reverting to a form that cause paralysis in low immunity settings when compared to monovalent oral polio vaccine type 2 (mOPV2).

To date, close to 600 million doses of nOPV2 have been administered across 28 countries globally, and the majority of countries have seen no further transmission of cVDPV2 after two immunization rounds. Throughout the vaccine’s extensive field use, the strains in DRC and Burundi are the only two cVDPV2 emergences detected that have been linked with nOPV2. A preliminary assessment suggests an estimated 30-40 new cVDPV2 emergences, conditional on surveillance inputs, would have been detected by 1 March 2023 if mOPV2 was used instead of nOPV2 at the same scale.

Focused safety, effectiveness and genetic stability monitoring will continue for the duration of the vaccine’s use under WHO Emergency Use Listing (EUL) and work continues to advance towards nOPV2’s WHO prequalification, expected by the end of this year.

Importantly, eastern DRC is classified as one of GPEI’s seven most consequential geographies for poliovirus outbreak risk. Complex humanitarian challenges in the country, including insecurity, have created longstanding barriers to reaching every child with the polio vaccine. This has contributed to the continued spread of variant poliovirus within DRC and its exportation to nearby countries. GPEI continues to adapt its strategy and work with local authorities to protect all children from this devastating disease through targeted, flexible campaign efforts.

Ultimately, no vaccine sitting in a vial can protect a child. The success of nOPV2 and any polio vaccine depends on the ability to rapidly implement high-quality immunization campaigns to ensure that every child is vaccinated and poliovirus’ spread is stopped.

*cVDPV2 isolates collected in 2021 in Kebbi, Nigeria (from two cases and one contact), have since been confirmed to be linked to nOPV2. The Kebbi cases are therefore the first instances of cVDPV2 connected to nOPV2. No further circulation linked to the Kebbi isolates has been detected.

On 19 January 2023, representatives from the World Health Organization (WHO), United Nations Children’s Fund (UNICEF), and the Ministry of Health of Syria concluded a three day joint mission on polio transition planning.

The team conducted various meetings with national counterparts, United Nations agencies and other stakeholders to assess the current situation, and identify the needs and resources required to maintain polio-essential functions and strengthen routine immunization to maintain Syria’s polio-free status. As part of the mission, the team agreed on the way forward to design a roadmap to support and sustain the ongoing integration of polio assets to ensure long-term benefits for immunization and emergency response.

While Syria is a polio-free country, it is at very high risk of imported polio outbreaks. In the last decade, the country experienced two polio outbreaks, including an outbreak of wild poliovirus following an importation from Pakistan in 2013, that paralyzed 36 children. In addition, a 2017 outbreak of circulating vaccine-derived poliovirus type 2 (cVDPV2) left 74 children paralyzed. In both cases, the country managed to contain the poliovirus and stopped the outbreak in less than a year using intensive polio vaccination campaigns and surveillance.

WHO is working closely with the Government and other stakeholders to maintain highly sensitive surveillance for polio and capacities to detect and respond to polio outbreaks swiftly. Furthermore, WHO and UNICEF are supporting the country to leverage the capacity and rich legacy built from years of polio operations to strengthen the essential immunization programme and capacities to detect and respond to other disease outbreaks.

“The main goal of this mission is to ensure that the polio essential functions are well preserved,” said Dr Rana Hajjeh, Director of Programme Management at WHO’s Regional Office for the Eastern Mediterranean. “We at WHO emphasize the importance of strengthening essential programmes like the national routine immunization and also strengthening the emergency response to take advantage of all the polio assets and building health systems. Overall, Syria has integrated polio functions very well in their national immunization programme and we will do our best to continue supporting them as needed,” she added.

Polio essential functions are managed by the Ministry of Health, with the technical and logistical support of WHO. Given the importance of ensuring the sustainability of functions, with support from Gavi, the Vaccine Alliance, both partners have been able to cover critical programme needs pertaining to routine immunization, including polio.

“While protecting the success achieved in containing the poliovirus outbreaks in record time, we should combine our efforts at all levels to maintain the high levels of immunity of the Syrian people against this life-threatening disease,” said Dr Iman Shankiti, WHO Representative a.i. for Syria. “WHO is working closely with the Ministry of Health and all other partners to resume the robust immunization programme in Syria,” she added.

Children show their inked fingers - a sign they have been vaccinated against polio. © WHO/Afghanistan — Children show their inked fingers – a sign they have been vaccinated against polio. © WHO/Afghanistan

2022 may well go down in history as the year of contrasts in the global effort to eradicate polio. At first glance, with polio detections in places such as New York and London and an increase in cases in Pakistan, it may seem that the effort is backsliding. And while any detection of any poliovirus is a setback—particularly in areas where the disease had been long gone, like southeast Africa—a deeper analysis reveals a more encouraging story: 2022 saw perhaps some of the most significant progress in the programme’s history, and has set up the global polio effort for a unique opportunity to achieve success in 2023.

Endemic wild poliovirus transmission in both Pakistan and Afghanistan is becoming increasingly geographically restricted, with fewer virus lineages remaining active. The bulk of variant type 2 polio (cVDPV2) cases are also becoming more restricted, with 90% of all global cases restricted to three ‘consequential geographies’ (eastern Democratic Republic of Congo, northern Yemen and northern Nigeria). And emergency outbreak response efforts to wild poliovirus type 1 in southeast Africa continue to gain momentum.

To evaluate this progress as 2022 draws to a close, independent technical expert and advisory groups are taking an in-depth look at the prevailing epidemiology, assessing impact of eradication efforts and putting forth key strategic approaches to enable an all-out effort against the virus in the first half of 2023.

The first of these groups met in early October, when the Technical Advisory Group (TAG) for Pakistan reviewed vaccination coverage and disease surveillance across the country. Despite the increase in new cases, the TAG found the outbreak to be extremely geographically confined, thanks to concerted emergency efforts led by the government and supported by partners. Today, polio transmission is restricted to the six districts of southern Khyber Pakhtunkhwa province—a fraction of the country’s 180 districts. Encouragingly, the virus has not re-established a foothold outside the core outbreak zone, meaning the traditional reservoirs of Karachi, Peshawar and Quetta are no longer endemic to the virus, a historical first.

More good news came out of the TAG’s analysis of the genetic biodiversity of virus transmission. In 2020, Pakistan had 11 separate chains of virus transmission. This was reduced to four in 2021, and today, just one family of the virus remains in the country. The approaches being implemented in Pakistan are working—despite some serious challenges.

Pakistan’s polio team supporting flood relief efforts © NEOC

In September, Pakistan experienced catastrophic flooding that impacted more than 33 million people and submerged one third of the country under water. In the face of this tragedy, and despite being affected themselves, polio staff supported the broader relief efforts while adapting polio operations to ensure that the eradication effort could continue unabated. Long-time polio eradicator and Director for Polio Eradication in WHO’s Eastern Mediterranean Region, Dr Hamid Jafari, said: “Rarely have I seen such commitment and dedication than I have seen in Pakistan – from national leaders, to health workers, right to the mother and father on the ground.

They are making a huge difference to people’s lives, which goes far beyond the effort to eradicate polio.”

In December, a high-level delegation led by GPEI Polio Oversight Board (POB) Chair Dr Chris Elias, WHO Regional Director Dr Ahmed Al-Mandhari and UNICEF Regional Director George Laryea-Adjei visited Pakistan during a nationwide vaccination campaign. After meeting with women health workers, provincial and national polio coordinators and even the Prime Minister, the group concluded that there is unprecedented support and commitment to ending polio in the country in 2023.

In Afghanistan too, an epidemiological deep dive reveals a promising picture: just over twelve months on from the political developments in the country in 2021, access to all children in the country continues to improve, albeit against a tragic backdrop of a severe and acute humanitarian crisis. More than 3.5 million children in Afghanistan who had been out-of-reach for almost five years can now be reached with polio vaccines, and thanks to strong vaccination and disease surveillance efforts, polio transmission has been restricted to just two chains in two provinces. And following the country’s devastating earthquake in June, polio teams sprang into immediate action to both support the broader emergency relief effort and adapt polio operations.

This progress in Pakistan and Afghanistan is identical to what epidemiologists observed during the ‘end game’ efforts in global polio reservoirs in the past, notably Nigeria, India and Egypt, giving rise to optimism that these remaining two endemic countries are on the right track.

Expert groups focus on outbreaks…

2022 saw a number of high-profile polio events, like the detections in New York City and London, but it is important to recognize the distinction between these and the outbreaks that have the capacity to endanger, or at least significantly delay, the global eradication goal.

Aidan O’Leary, Director of the Global Polio Eradication Initiative (GPEI) at the World Health Organization (WHO), contextualized the situation: “90 percent of global media attention has been on the polio emergence in New York, London and Israel. However, 90 percent of actual cases are in eastern Democratic Republic of Congo, northern Yemen and northern Nigeria.” It is in those areas, commonly referred to as consequential geographies, that programmatic efforts must maintain their focus. Notably, these areas also overlap with some of the highest proportions of ‘zero-dose’ children—those who are either un- or under-vaccinated.

WHO medical officer Dr Audu Idowu conducts an acute flaccid paralysis examination in Jere Local Government Area, Borno State. ©WHO/Nigeria

While the outbreaks in northern Yemen and eastern DR Congo continue to expand at an alarming rate in 2022, the situation in northern Nigeria is far more encouraging. Nigeria accounted for two-thirds of all global cases in 2021, seeding outbreaks in 19 countries. In the second half of 2022, however, there has been a dramatic decrease in new detections, with just nine cases reported during that time.

In November, the Nigerian Government, with GPEI partners in attendance, hosted the Global Roundtable Discussion on variant type 2 polio outbreaks, reviewing progress in outbreak response following the upsurge in cases in 2021. The Roundtable recognized efforts to reach zero-dose children in consequential geographies throughout the country, in particular with the novel oral polio vaccine type 2 (nOPV2), as well as Nigeria’s focus on strengthening routine immunization with bivalent OPV and inactivated polio vaccine (IPV). Whichever strategy is used, however, the group cautioned: “coverage is king!” Any vaccine is only as good as the proportion of children it reaches.

The group’s conclusions and recommendations will be further evaluated by Nigeria’s Expert Review Committee on Polio Eradication and Routine Immunization (ERC).

Meanwhile, in southeast Africa, a comprehensive Outbreak Response Assessment reviewed the regional response to wild poliovirus type 1 (WPV1), linked to virus originating from Pakistan, with cases confirmed in Malawi and Mozambique. Experts noted the high-level, comprehensive support for the outbreak response across the region, and that vaccination campaigns have been consistently improving with time.

At the same time, the group concluded that the outbreaks are not over. With simultaneous outbreaks of WPV1, cVDPV1 and cVDPV2 affecting in particular Mozambique, the group put forward key recommendations and strategies, building on the momentum and knowledge gained over the past six months. These conclusions were further endorsed by the Africa Regional Certification Commission for Eradication (ARCC), which met in South Africa.

Challenges remain ahead. Zero-dose children must be reached, particularly in consequential geographies. Remaining financial resources to achieve success must be mobilized. Campaigns must be strengthened in southeast Africa. But despite initial appearances, 2022 put the world on an extremely strong footing to interrupt all remaining chains of poliovirus transmission by end 2023—the goal of the GPEI Strategy 2022-2026.

There is a clear momentum as the year draws to a close. We must carry it into 2023 for a final, concerted push. Success is in our hands.

Today, more than 2,800 leading scientists, physicians, and global health experts from 110 endemic, polio-affected, at-risk, and partner countries launched the 2022 Scientific Declaration on Polio Eradication. The GPEI welcomes this declaration, which sends a powerful message to the world that eradication is feasible and urgently needed now.

Although remarkable progress has been made, recent detections in countries that haven’t seen the virus for many years and persistent transmission in countries long plagued by the disease demonstrate that polio anywhere remains a threat to people everywhere. The GPEI is hopeful that this declaration can reenergize the global community around our shared vision of a polio-free world. It offers expert perspective on the promise of new tools and tactics, the benefits of polio investments to health systems, and the unacceptable consequences of failing to eradicate the disease.

The launch of the Scientific Declaration comes one week ahead of the polio pledging moment at the World Health Summit on 18 October 2022, where the GPEI seeks to raise funds in support of its 2022-2026 Strategy. The thousands of experts who have signed the Declaration endorse the GPEI’s strategic plan, while calling on partners, donors, polio-affected country leaders, and communities to recommit to the goal of eradication and ensure children everywhere are protected from this devastating preventable disease. With their support and the commitment of the world, we can and will end polio.

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

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

“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

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

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

“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

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

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

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.

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

“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

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

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.