The Heads of State of the G7 countries, at the annual meeting held in the UK on 11-13 June 2021, highlighted the need for increased global efforts to detect global public health threats, by building international surveillance on existing networks such as polio surveillance. In the context of COVID-19, and in their official communiqué, the G7 stated: “we support the establishment… of a global pandemic radar… that builds on existing detection systems such as the influenza and polio programmes.”
The unique value of the polio infrastructure in supporting COVID-19 response efforts was recently underscored by other global fora, including the World Health Assembly in May, and the G7 health ministers meeting in June.
An integral part of the new GPEI Strategy 2022-2026 is to ensure close coordination with broader public health efforts, to not only achieve a lasting world free of all polioviruses, but also one where the polio infrastructure will continue to benefit other public health emergencies long after the disease has been eradicated.
Key to success, however, will be the continued support and engagement of the international development community, including by ensuring that previous pledges are fully and rapidly operationalized.
In 1996, wild poliovirus was paralysing more than 75 000 children in the African Region every year, and Nelson Mandela and Rotary International issued a call to “Kick Polio Out of Africa!” The task was daunting. Polio staff had to deal with highly mobile populations, restricted access to children because of conflict and insecurity, fragile health systems and a fast-moving virus. Nigeria, as recently as 2012, accounted for more than half of all wild polio cases worldwide.
Ridding Africa of the wild poliovirus in the face of such daunting obstacles was, in the words of WHO Director-General Dr Tedros Adhanom Ghebreyesus, “one of the greatest public health achievements of our time”. It is an achievement built on the dedication of health workers – mainly women – who traveled by every available means – foot, car, boat, bike and more – to reach children with the polio vaccine.
One of the greatest public health achievements of our time.
One of those workers, Lami Isah Kyadawa, supported polio “immunization plus days” for almost 12 years before joining the network of volunteer community mobilizers in Sokoto State, Nigeria, in 2015. In her time fighting polio, she has overcome vaccine hesitancy, countered misinformation and even lost the sight in one eye in an accident returning from a polio mobilization campaign. But, for Lami, the sacrifices have all been worth it:
“It makes me proud to know that I was part of those that ensured the eradication of polio came to pass in Nigeria and now we can focus on improving routine immunization and other diseases.”
Eradicating wild polio in the African Region is a monumental feat, not just because of the scale of the task but because of the coordination and leadership required at all levels of the Global Polio Eradication Initiative (GPEI) to get the job done. It involved strategists with imagination, who found solutions to reaching children in regions rife with conflict and insecurity. It required constant surveillance to test cases of paralysis and check sewage for the virus, and it relied upon the commitment of all 47 countries in the African Region.
Since 1996, nine billion doses of oral polio vaccine have been provided, averting an estimated 1.8 million cases of wild poliovirus on the continent. Building on this success, countries in the African Region are now using the polio eradication infrastructure’s robust immunization and surveillance capacities to strengthen their health systems. The infrastructure, with thousands of health workers and volunteers, community and religious leaders, parents and families mobilized to “Kick Polio Out of Africa”, provides a strong foundation for countering other public health threats.
Responding to the pandemic and laying a foundation for the future
Long before the coronavirus pandemic, stopping wild polio brought far-reaching benefits beyond saving children from paralysis, including protecting them from other vaccine-preventable diseases and detecting and responding to outbreaks.
Thus, when COVID-19 struck, the GPEI’s staff and infrastructure were in place and equipped to be the first to respond. Thousands of polio workers in the WHO’s African, Eastern Mediterranean and South-East Asian Regions shifted their focus to COVID-19. Polio emergency operation centres quickly adapted to respond to the pandemic through surveillance, contact tracing and specimen transport, provision of soap and hand sanitizer, distribution of training materials for medical personnel and front-line workers and coordinated engagement with community and religious leaders and media on mitigation measures.
Polio staff have long been the eyes and ears of national health systems. In one example, polio laboratories in Pakistan provided COVID-19 testing and sequencing, while the polio eradication call centre became (and remains) the national COVID-19 hotline, dealing with up to 70 000 calls a day
Polio staff trained more than 18 600 health professionals, and polio community mobilizers engaged 7000 religious leaders and 26 000 influencers to provide information on COVID-19 to their communities. Through messaging applications, mosque announcements and public address systems on motorbikes and rickshaws, polio community outreach networks have reached millions of households.
How polio staff in Pakistan shifted their focus to COVID-19:
The pandemic has shown that the polio network can continue to serve other public health programmes, especially in health emergencies. For instance, in Pakistan, active polio surveillance at high-priority sites helped to confirm more than 1000 COVID-19 cases, more than 4400 suspected cases and nearly 500 probable cases. Staff have also used their expertise in data management to improve the quality and timeliness of data during the pandemic. This adaptable skill set makes polio personnel invaluable to health systems and communities.
Looking ahead, transition of polio personnel and infrastructure into public health systems is being planned in countries with large polio eradication programmes, led by national authorities. In places where there is insufficient national capacity, critical immunization, disease detection, emergency preparedness and response capacities will be supported by WHO’s immunization and emergencies programmes until national authorities can fully take over. Sustaining these capacities will require sustainable funding, but, as Africa’s remarkable achievement confirms, the wisdom of investing in polio eradication and sustaining its legacy is clear, as the networks set up for polio eradication will prove vital to advancing global public health security and achieving healthier populations.
PN: President Knaack, thank you for taking the time to speak to us. A little more than a year into the global COVID-19 pandemic, what is your take on the current situation, also with a view of the global effort to eradicate polio?
HK: There are many interesting lessons we learned over the past 12 months. The first is the value of strong health systems, which perhaps in countries like mine – Germany – we have over the past decades taken for granted. But we have seen how important strong health systems are to a functional society, and how fragile that society is if those systems are at risk of collapse. In terms of PolioPlus, of course, the reality is that it is precisely children who live in areas with poor health systems who are most at risk of contracting diseases such as polio. So everything must be done to strengthen health systems systematically, everywhere, to help prevent any disease.
The second lesson is the value of scientific knowledge. COVID-19 is of course a new pathogen affecting the world, and there remain many unanswered questions. How does it really transmit? Who and where are the primary transmittors? How significant and widespread are asymptomatic (meaning undetected) infections and what role do they play in the pandemic? And most importantly, how best to protect our populations, with a minimum impact on everyday life? These are precisely the same questions that were posed about polio in the 1950s. People felt the same fear back then about polio, as we do now about COVID. Polio would indiscriminately hit communities, seemingly without rhyme or reason. Parents would send their children to school in the morning, and they would be stricken by polio later that same day. Lack of knowledge is what is so terrifying about the COVID-19 pandemic. It also means we are to a large degree unable to really target strategies in the most effective way. What polio has shown us is the true value of scientific knowledge. We know how polio transmits, where it is circulating, who is most at risk, and most importantly, we have the tools and the knowledge to protect our populations. This knowledge enables us to target our eradication strategies in the most effective manner, and the result is that the disease has been beaten back over the past few decades to just two endemic countries worldwide. Most recently, Africa was certified as free of all wild polioviruses, a tremendous achievement which could not have been possible without scientific knowledge guiding us. So while we grapple for answers with COVID, for polio eradication, we must now focus entirely on operational implementation. If we optimize implementation, success will follow.
And the third lesson is perhaps the most important: we cannot indefinitely sustain the effort to eradicate polio. We have been on the ‘final stretch’ for several years now. Tantalizingly close to global eradication, but still falling one percent short. In 2020, we saw tremendous disruptions to our operations due to COVID-19. We never know when the next COVID-19 will come along, to again disrupt everything. Last year, the polio program came away with a very serious black eye, so to speak. But we have the opportunity to come back stronger. We must now capitalize on it. We know what we need to do to finish polio. We must now finish the job. We must all recommit and redouble our efforts. If we do that, we will give the world one less infectious disease to worry about once and for all.
PN: You recently called on the Rotary network worldwide to use its experiences from PolioPlus in supporting the COVID-19 response. Could you elaborate on that?
HK: We have a global network of more than 1.2 million volunteers worldwide. This network has been consistently and systematically utilized to help engage everyone from heads of state to mothers in the most remote areas of rural India for polio eradication. We have helped secure vaccine supply and distribution, and increased trust in vaccines among communities. In the process, we have learned many lessons on what it takes to address a public health threat and these same lessons now should be applied to the COVID-19 response, especially as vaccines are now starting to be rolled out. That is why I thought it was important to call on our membership network to use their experiences and apply it to the COVID-19 response.
PN: What has been the reaction so far?
HK: Overwhelmingly supportive, I would say. As an example, in Germany, Switzerland, Liechtenstein, Austria and other countries in Europe, Rotarians are encouraging active participation of the provided vaccination service. And because COVID vaccination is provided free of charge, vaccinated individuals are encouraged to instead donate the cost of what this vaccine would have cost them – approximately US$25 – to PolioPlus. This has a dual benefit: they are protected from COVID and contributing to the global response, and they are ensuring children are also protected against polio, critically important now as the COVID-pandemic has significantly disrupted health services and an estimated more than 80 million children worldwide are at increased risk of diseases such as polio.
PN: And from what we understand, the Rotary PolioPlus network of National PolioPlus Committees has in any event been supporting global pandemic response over the past 12 months already, is that correct?
HK: The ‘Plus’ in PolioPlus has always stood for the fact that we are eradicating polio, but doing it in such a way that we are in fact doing much more, by supporting broader public health efforts. I’m extremely proud that Rotary and Rotarians around the world have helped bring the world to the threshold of being wild polio-free. But I’m perhaps even more proud of the ‘plus’ – or ‘added’ value – that this network has provided in the process. Things that are largely unseen, but which are very evident and concrete. So indeed, Rotarians have been actively engaged in the pandemic response, particularly in high-risk areas such as Pakistan, and Nigeria. We have supported contact tracing, educated communities on hygiene and distancing measures, supporting testing and other tactics. We have a unique set of experiences, and more importantly a unique infrastructure and network, to help during such crises. It’s morally the only way to operate. And actually, it is operationally beneficial also to polio eradication, as we are engaging with communities on broader terms, and not just on polio.
PN: Thank you again for taking the time to speak with us. Do you have any final thoughts or reflections for our readers?
HK: If we did not know it before, we certainly know now how quickly and dangerously infectious diseases spread around the globe. Polio is no different, and we know that it will not stay confined to Pakistan and Afghanistan if we don’t stop transmission there as soon as possible. We know that given the chance, this disease will come roaring back, and within ten years, we would again see 200,000 children paralysed every single year, all over the world. Perhaps even in my country, Germany. That would be a humanitarian catastrophe that must be averted at all costs.
The good news is that it can be averted. We know what it takes. Pakistan and Afghanistan are re-launching their national eradication efforts in an intensified, emergency manner, following a disrupted 2020. This is encouraging to see. Mirroring this engagement must be the strengthened commitments by the international development community. We must ensure that the financial resources are urgently mobilised to finish polio once and for all. I am particularly proud that my own government, Germany, for example, has just recently committed an additional 35 million EURO to the effort, along with an additional 10 million EURO for efforts in Nigeria and Pakistan. Such support is particularly critical now, given that more than 80 million children are at heightened risk of diseases such a polio due to COVID-19 disruptions, and late last year, UNICEF and WHO issued an emergency call for action to urgently address this. And as we have seen, by supporting polio eradication, donors effectively get twice as much for their contribution: they help contribute to polio eradication, but also by doing so help contribute to the polio network’s support to public health emergencies such as COVID-19.
In short, we have it in our own hands to achieve success. There are no technical or biological reasons why polio should persist anywhere in the world. It is now a question of political and societal will. If we all redouble our efforts, success will follow.
Please consider making a contribution to Rotary’s PolioPlus fund, and have your donation matched 2-to-1 by the Bill & Melinda Gates Foundation.
As COVID-19 reached Somalia, Mohamed readied himself to respond. For years, he had been building strong relationships with local health officers and communities to deliver polio vaccines to every child. Now, he would use those relationships to try to track the spread of the pandemic.
In Nigeria, Dr Rosemary Onyibe, a Polio Eradication Zonal Coordinator for WHO, felt her duty was calling. “My expertise is needed to serve my community,” she remembers thinking. Within days, she was working on Nigeria’s COVID-19 response.
These two individuals are part of a team of 5923 polio eradication personnel, who pivoted in a matter of weeks to fight COVID-19 in some of the most vulnerable settings in the world. A recent report published by WHO comprehensively documents the significant role played by polio eradication personnel during the pandemic, and urges strong action to sustain this network to deliver essential public health services after polio is eradicated. By doing so, we can ensure we are ready to respond to established and emergent diseases in future.
The polio programme has a long history of stepping up during health emergencies to fill the gaps that no one else can. As COVID-19 changed lives around the globe, polio staff led outbreak response teams and trained laboratory staff to detect the virus. Polio disease surveillance officers searched for COVID-19 cases and thousands of frontline polio workers shared information on the disease with their communities. In some countries, polio emergency operations centres were converted for the pandemic response. As the situation has evolved, so have polio programme contributions – in coming months, the programme plans to use its expertise in immunization to help to deliver COVID-19 vaccines, as well as urgently reach at least 80 million childrenwho have missed out on vital vaccines during the pandemic.
As one of WHO’s largest operational workforces, comprising nearly 18% of the organization’s programme budget in 2020-21, the widespread utilisation of polio-funded infrastructure and human resources for COVID-19 has brought into focus why we must retain this network for the future. When polio is eradicated, funding for the programme’s vast infrastructure will end. Through the “polio transition” process, WHO is working to transfer the polio network to serve other public health goals, including the broader immunization, health emergencies and health systems strengthening agenda. This is no easy task – detailed planning and dedicated funding is needed to permanently integrate assets and functions into national health systems.
The report finds that COVID-19, whilst presenting challenges, provides an opportunity to accelerate this “transition” process. In the coming months, WHO regional offices will begin to launch ‘integrated public health teams’, which will bring together individuals with expertise in polio eradication, emergency response and immunization to work collaboratively on the next stages of COVID-19 response and recovery. Showing “transition in action”, these teams will exemplify one way via which health systems could be supported in future. Simultaneously, WHO is continuing work to support countries to develop detailed plans modelling how polio capabilities can be sustained.
The critical role that polio assets have played in tackling multiple health emergencies, in supporting immunization activities and in COVID-19 response, demonstrate that these assets have a clear role to advance future national and global health security. This will also help to sustain a polio-free world. In the South East Asia Region, which was certified free of wild polio in 2014, almost 2600 polio and immunization staff used their experience of managing immunization programmes in emergency settings to respond to COVID-19. Their work included undertaking training of health staff and village governors in Indonesia, acting as a focal point for the COVID-19 response in Cox’s Bazar, Bangladesh, and drafting vaccination plans for Rohingya refugees. In Nepal, the network supported COVID-19 field investigations and case clusters, whilst in Myanmar, personnel formed part of the pandemic incident management team, and supported disease surveillance. These contributions underline that sustaining polio and immunization capacity puts us in a better position to respond when health crises arise.
The report also details how polio assets were able to reach nomadic communities in Kenya to warn them about virus spread, deliver an integrated digital platform for tracking case investigations across the African region, and answer 70 000 calls a day through a polio call centre adapted for COVID-19 in Pakistan. In Uttar Pradesh, India, polio micro-plans were adapted to survey 208 million people twice in three months for COVID-19, resulting in the identification of over 200 000 individuals with symptoms of the virus. Such diversity of operations plays a key role in protecting our collective health.
In a time when sturdy public health systems are particularly vital, we must ensure that polio infrastructure is transitioned to tackle pressing health issues long into the future.
For a detailed costing of polio contributions to COVID-19 response and a country-level breakdown of how the polio network stepped up, please see the report annexes.
Meeting virtually at this week’s WHO Executive Board (EB), global health leaders and ministers of health urged for concerted and emergency efforts to finally rid the world of polio, noting a global and collective responsibility to finish the disease once and for all. Delegates also reiterated their support for the sustainable transitioning of polio assets, recognizing that successful polio transition and polio eradication are twin goals.
Noting that endemic wild poliovirus is now restricted to just two countries – the lowest number in history – with the African region being certified as wild polio-free in August 2020, delegates urged intensified efforts to wipe out the remaining chains of transmission of this strain and prevent global resurgence. The representatives of both Pakistan and Afghanistan demonstrated strong commitments to this goal and urged collective responsibility to achieve success. Delegates also expressed strong appreciation for the establishment of the Eastern Mediterranean Ministerial Regional Subcommittee on Polio Eradication and Outbreaks, by WHO Regional Director Dr Ahmed Al-Mandhari, which focuses on critical barriers to overcome to achieve zero poliovirus.
The EB urged all stakeholders to follow WHO and UNICEF’s joint emergency call to action, launched 6 November 2020, including by prioritising polio in national budgets as they rebuild their immunization programmes in the wake of COVID-19, and urgently mobilising additional resources for polio emergency outbreak response. To address the increasing global health emergency associated with circulating vaccine-derived poliovirus (cVDPV) outbreaks, delegates expressed appreciation of new strategic approaches, including the roll-out of novel oral polio vaccine type 2 (nOPV2), a next-generation OPV aimed at more effectively and sustainably addressing these outbreaks. This vaccine, which was recently granted a WHO Emergency Use Listing recommendation, is anticipated to be initially rolled-out in the first quarter of 2021. The GPEI is working with countries affected and at high risk of cVDPV2 to prepare for possible use of the vaccine.
Amid the new COVID-19 reality, the EB also expressed deep appreciation for the GPEI’s ongoing support to COVID-19 response. In December 2020, the heads of the GPEI core partners at their final Polio Oversight Board (POB) meeting of the year, confirmed that the polio infrastructure will continue to provide such support, including to the COVID-19 vaccine roll-out.
Member States additionally reiterated their support of polio transition, emphasising the need to ensure sustained, robust public health programming. Several EB members urged for strengthening the links built between the polio, immunization and emergencies programmes during COVID-19 response in the next phase of the pandemic, including for the effective rollout of the COVID-19 vaccine.
Director-General of WHO, Dr Tedros Adhanom Ghebreyesus, commented, “We share the understanding that polio eradication and transition are equally important targets: as we work towards eradication we must think about the future. This is how we will ensure that health systems retain capacity and are strengthened long after polio is ended.”
WHO’s Deputy Director-General, Dr Zsuzsanna Jakab, noted the increasing cross-programmatic integration between polio and other public health programmes, including the introduction of integrated public health teams in countries prioritized for polio transition, bringing together polio, emergencies and immunization expertise. The Regional Director for the African Region, Dr Matshidiso Moeti, emphasised that the work of polio personnel to support the pandemic response, “highlight[s]… the importance of working in interconnected ways going forward.” Dr Al-Mandhari, addressing the delegates, said: “Polio continues to be a public health emergency of international concern. Now is the time to be shoring up the polio programme and mobilizing funding, including domestic funds, so that this remarkable public health and pandemic response mechanism can remain robust and can be integrated into broader public health services across the region. Now is the time for full regional solidarity and mobilization.”
Speaking on behalf of children worldwide, Rotary International – the civil society arm of the GPEI partnership – thanked global health leaders for their continued dedication to polio eradication and public health, sentiments echoed by several other partners, including the United Nations Foundation (UNF). UNF expressed concern about the drop in population immunity, especially for polio and measles, declared support for the joint emergency call to action to prioritize investments for preventing and responding to polio and measles outbreaks, and urged continued focus on strengthening immunization programmes.
The EB discussion will also help inform the finalization of the new strategic plan. This strengthened strategic plan – being developed in broad consultation with partners, stakeholders and countries – is based on best practices and lessons learned, and focuses on fully implementing approaches proven to work. It is expected to be presented to the World Health Assembly in May.
“If we did not know it before, we certainly know now how quickly infectious diseases can spread across the world and wild polio is one such infectious disease. Unlike with COVID-19, where many medical and scientific questions remain unanswered, we know precisely what it takes to stop polio,” said Aidan O’Leary, newly-appointed Director of the Global Polio Eradication Initiative at WHO. “We know how polio transmits, who is primarily at risk and we have all the tools and approaches needed to stop it. That is what this strengthened strategic plan is all about – to bring all the solutions together into a single roadmap to achieve success and through focusing on more effective implementation. What discussions at the EB this week clearly displayed is a strong global sense of commitment and solidarity to do just that: better implementation of what we know works. Together, if we do that, success will follow and we will be able to give the world one less infectious disease to worry about, once and for all.”
Speaking more broadly on global public health issues, the EB welcomed confirmation by the United States of its intention to remain a member of WHO. In a statement by the United States, the country underscored WHO’s critical role in the world’s fight against COVID-19 and countless other threats to global health and health security, confirming it would continue to be a full participant and global leader in confronting such threats and advancing global health and health security.
With masks on their faces and sanitizers in their pockets, an immunization team makes their way through the narrow lanes of Lahore’s historic old city.
“Our children are like flowers and these anti-polio drives help them grow up healthy and strong,” says Zubair, who along with his colleague Afzal is part of Pakistan’s 260,000-strong frontline vaccinator workforce.
It is the second day of the National Immunization Days (NID) campaign, which launched on 21 September, and the third immunization drive after a four-month suspension of door-to door campaigns due to the risks associated with COVID-19.
After polio campaigns were stopped in March 2020, the number of polio cases in Pakistan continued to increase. An initial small-scale round of vaccinations resumed in July, when over 700,000 children were reached. A second round went ahead in August, where 32 million children were vaccinated across the country. In both campaigns, vaccinators took precautions to prevent the spread of COVID-19, including wearing masks and regularly washing hands.
Making their way from the crowded streets of Taxila Gate, the polio team reaches a historic cultural hub of Lahore city called Heera Mandi.
In this neighbourhood, the team knocks on one door after another. “Sister, do you have children under five at home?”,they say.
When the answer is yes, one of the vaccinators stands to the side while Zubair hands them a hand sanitizer. They all stand at a safe distance from each other, to remain compliant with COVID-19 safety measures, and to make sure the dual message of the necessary fight against both polio and COVID-19 reaches home.
Zubair says that since the resumption of immunization campaigns in Pakistan, parents have been more enthusiastic to ensure their children are vaccinated.
Next door, a Maulana (a religious cleric) answers. When he sees the polio team, he immediately goes back inside. Team members worry that he may reject the vaccine, but soon enough, he returns with his two children.
“Did you ever believe that the polio vaccination was a conspiracy?,” the Maulana is asked. In some parts of Pakistan, false rumours about the vaccine have damaged confidence in immunization, with sometimes devastating results for children subsequently infected with polio.
“No Sir, only a fool can think like that,” he replies.
Afzal, another member of the immunization team, says that he finds his work fulfilling because it allows him to directly speak to parents about polio and explain that they can give their children a healthy future by vaccinating them.
With a physical disability, Afzal often faces discrimination based on his health condition. He explains that this hasn’t prevent him from pursuing his ambitions.
“I never allowed my disability to become an obstacle. I completed my master’s degree while attending regular classes at college, and now I have been working with the polio programme for nine years.”
“If a family is hesitant during a polio campaign, I approach the parents,” he says. “I show the parents my polio-affected leg and ask them if they really want their child to have one too. This changes hesitation to acceptance.”
Health workers like Zubair and Azfal are working every day to achieve the dream of ending polio in Pakistan. With their effort and the efforts of thousands like them, the September campaign successfully reached over 39 million children across the country. These promising results, achieved during a pandemic, are a testament to an ongoing commitment to overcome challenges and move Pakistan closer to a polio-free future.
O’Leary took over as Director for Polio Eradication at WHO on 1 January 2021, from Michel Zaffran, who will enter a well-deserved retirement end-February. O’Leary brings with him a vast array of experience in both polio eradication and emergencies, including through the United Nations Office for the Coordination of Humanitarian Affairs (OCHA).
PN: Aidan, Michel, thank you both for taking the time to speak with us today. Aidan – you are taking over from Michel as Director for Polio Eradication at WHO. Polio is 99% eradicated globally, but it has been at 99% for many years. Ultimately, your job will be to achieve that elusive 100%. Do you find the task ahead daunting?
A-O’L: I’m not sure ‘daunting’ is the adjective I would use. But ‘challenging’ for sure. As you say, we have been at 99% for many years now. We have reduced the incidence of polio from 350,000 children paralysed every year in 1988, to less than 1,000 in 2020. But that is not enough, not if we are trying to eradicate a disease. Polio is a highly-infectious disease, and if we did not know it before COVID-19, we certainly know now how quickly infectious diseases can spread globally. If we do not eradicate polio, this virus will resurge globally.
PN: As new Director, what will be your priorities?
A-O’L: My priority, and all of our priorities, must be simply this: find and vaccinate every last child. If we do that, poliovirus will have nowhere to hide. That means in the first instance finding out where those last remaining unreached children are, and what obstacles stand in the way to vaccinating them. Is it because of lack of infrastructure? Insecurity or inaccessibility? Lack of proper operational planning? Population movements? Resistance? Gender-related barriers? If we can identify the underlying reasons, we can adapt our operations and really zero in on those last remaining virus strains.
PN: Michel, you have led this effort for the past five years, and during that time have guided the effort to restrict wild poliovirus transmission to just Pakistan and Afghanistan. You have overseen the achievement of a wild polio-free Africa, an incredible achievement. However, this time has also seen an increase in emergence of circulating vaccine-derived poliovirus, or cVDPV, outbreaks. How do you see the priorities going forward?
MZ: The goal of this effort is of course to ensure that no child will ever again be paralysed by any poliovirus, be it wild or vaccine-derived. This we have to achieve in phases. First, we have to interrupt all remaining wild poliovirus strains, before we can then ultimately stop use of oral polio vaccine, or OPV for short, in order to eliminate the long-term risks of cVDPVs. Aidan has tremendous experience, in both remaining wild poliovirus endemic countries, having led the OCHA office in Afghanistan and having been Chief of Polio Eradication in Pakistan for UNICEF. So he knows the challenges and realities involved. Eradicating the last remaining strains of wild poliovirus must be the overriding priority – success ultimately hinges on that.
At the same time, we have new strategies, tools and approaches to address the increasing cVDPV emergency, notably the novel OPV type 2, or nOPV2 for short, to more effectively and sustainably stop such strains. Ultimately, though, we need to reach children. Only vaccinations save lives, not vaccines.
A-O’L: Michel just mentioned an important word: emergency. And that is precisely what we are facing with polio, whether it’s wild or vaccine-derived. I believe my experience working in emergency settings can help us achieve our goal, including by linking polio operations more closely to other emergency efforts. That is also one of the reasons why WHO and UNICEF recently jointly issued an emergency call for action on polio and measles, and we hope all stakeholders will respond accordingly.
MZ: I would echo that. Particularly in a post-COVID world, the programme must also continue to adapt its approaches and operations, and no longer work so much in isolation. We have to integrate with other efforts including emergency response and broader routine immunization efforts.
A-O’L: I would just add that Michel is really leaving me with a solid base to operate from. He and his teams across the GPEI partnership have built up such a strong infrastructure. I’m thinking here for example of the gender equality work of the programme – it has really been trail-blazing and I know other health and development efforts are looking to our experience on this. It’s a great opportunity to further leverage and expand collaboration with others. So we’ve really become a global leader in many new ways of working, and ultimately, that can only mean more support for this effort.
PN: Thank you so much for speaking with us today. Could we ask for final thoughts from both of you?
A-O’L: We have many challenges, but if any network can achieve success, it is the GPEI network. Our greatest strength that we have is partnerships. Starting with Rotary International and Rotarians worldwide who are tirelessly working towards success, to our other partners including at my old organization UNICEF and our newest partner Gavi who is helping to integrate the programme, and of course ultimately to donor and country governments and communities: this is where our strength and power lies. If we harness this partnership effectively, if we all work together, then we will reach that last remaining child, and we will ensure that this disease is eradicated once and for all.
MZ: For me it has been an absolute honour and privilege to lead this effort for the past years, and I leave with a sense of real optimism. I believe Aidan is the right person for this job right now. In November, at the World Health Assembly, we saw tremendous support for polio eradication from Member States. We have new tools, such as nOPV2, and tremendous new commitments. We are working on a new strategy, to lead us to success. But ultimately, all comes down now to implementation. 2020, the COVID year, taught us many lessons. Many of the questions that are still being asked about COVID – how does it transmit, where is it primarily circulating, what are the best tools and strategies to stop it – have been answered for polio. We know what the virus is doing, how it is behaving, and who it is affecting. Most importantly, we know what we have to do to stop it, and we have all the tools to stop it. But what 2020 also taught us is that this cannot last forever. We never know when a next COVID emergency comes along, which will disrupt everything. In polio eradication, we are being given another chance in 2021, after a bruising 2020. We have to capitalize on it. We have to focus everything on implementation. If we do that, success will follow.
In a newly-released statement following the final meeting of the Polio Oversight Board (POB) that was held virtually on 18 December 2020, the POB looks back at the support that the programme provided to respond to the COVID-19 pandemic, while remaining strongly devoted to the goal of a polio-free world. The POB reaffirms its commitment that polio-funded assets are available to countries to respond to the COVID-19 pandemic, especially in the next phase of COVID-19 vaccine introduction and delivery.
The POB also believes that for countries introducing COVID-19 vaccine, there are lessons and experiences to be learnt from the rollout of nOPV2 under the EUL recommendation, if emergency regulatory pathways such as WHO EUL are used, including in the areas of monitoring readiness-verification, safety surveillance, and regulatory considerations.
On a wintery November day, vaccinators across Afghanistan wrapped up warm, checked that they had facemasks and hand sanitizer, and headed out into the cold morning. Their mission? To reach 9.9 million children with polio vaccines, before snowfall blocked their way.
From valleys to muddy lanes, we look at some of the environments where vaccinators work, as well as some of the key challenges that have made 2020 one of the toughest years for polio eradicators.
For some vaccinators, the first snows had already arrived. At the top of the Panjshir valley, Ziaullah and Nawid Ahmad started their day at 7am.
“We walked six hours to Sar-e Tangi and back to take polio drops to the last houses in the valley”, said Ziaullah. The mountainous roads in this area are impassable by car, so vaccinators walk many kilometers to the most remote villages. Sar-e Tangi means ‘top narrow edge’, and the view during the long winter is of snowy peaks.
A few kilometers from Sar-e Tangi, father Arsalan Khan was proud to have protected his own and other children in the extended family with polio drops. He said, “I ensure all the children in the family are vaccinated during each round the drops were offered and of course I will keep vaccinating them each time the vaccinators visit our village”.
Khan continued, “The vaccinators walk long distances across the mountain slopes to our villages, sometimes during harsh weather conditions, to bring polio drops to our doors.”
“Thanks to the people and countries that support the vaccination campaigns and make it possible for the drops to reach our doorsteps.”
In Badakhstan, Mr. Azizullah had COVID-19 safety measures on his mind. Like all vaccinators working for the polio programme, he had been trained on how to safely deliver polio drops during the pandemic. The temperature was below zero, with the first snow on the ground, as Mr. Azizullah walked through the rugged terrain from home to home, ensuring to wear his mask and regularly sanitize his hands.
Mr. Abdul Basit and Misbahuddin, volunteers in nearby Aab Barik village said, “It is cold and walking through muddy lanes is not easy, but we have to do our job. There was one case of polio in Badakhshan so that means there is probably virus circulation and we have to stop that”.
Mr. Abdullah, a university lecturer observing vaccination activities in Herat, said, “I believe a vaccinator’s job is more important than mine. I really appreciate their work and appreciate the international community for making the polio immunization operations possible in Afghanistan with their financial support.”
“I believe that all these efforts will be fruitful, hopefully soon, and we will get rid of the virus in our country”.
The November campaign was particularly aimed at boosting the immunity of unvaccinated children, and children who have not received their full vaccine doses. Many children have missed out on polio vaccines and other routine immunizations due to a pause in vaccination activities in the first few months of the COVID-19 pandemic. Health workers are now racing against time to protect the youngest children from the poliovirus.
Ms. Sitara, mother of Yasameen, who was wrapped up warm against the elements, said, “I am very happy to be able to immunize my daughter and protect her against polio”.
In the east region of Afghanistan, 8,530 volunteers, 160 district coordinators and 786 cluster supervisors were hard at work, aiming to reach as many children as possible during the campaign.
Dr. Akram Hussain, Polio Eradication Initiative Team Lead for WHO in the region explained, “We were not able to do house to house campaigns in some parts of the region. As a result many children were missed during the October vaccination campaigns”.
Despite the best efforts of vaccinators, in October, 3.4 million children nationwide missed vaccines due to factors including insecurity, the COVID-19 pandemic and vaccine mistrust. The year 2020 has seen a significant rise in polio cases and detection of the virus in the environment, and the disease is present in almost all provinces.
The programme is aiming to reach more children and tackle virus spread next year. Activities include targeted campaigns in high risk districts, collaborating with the religious scholars from the Islamic Advisory Group to encourage vaccine uptake and communicating more effectively with communities.
The incredible contributions of the polio programme to COVID-19 response are testimony to the agility and adaptability of Afghanistan’s programme in the most difficult circumstances. Many hope that lessons learnt from this experience can be applied to achieving the eradication goal.
Ending polio requires everyone – including polio personnel, communities, parents, governments and stakeholders – to commit to overcoming challenges. As the weather turns colder and snow continues to fall, many are looking ahead to what 2021 holds for polio eradication in Afghanistan.
The COVID-19 pandemic has brought the need for strong health systems and global health security into sharp focus. Last week, the United Kingdom’s Foreign, Commonwealth and Development Office (FCDO) agreed a £30 million increase in the first payment to the World Health Organization of their 2019 – 2023 pledge, meaning that the total amount released for polio eradication activities is £70 million. Coming amidst challenges posed by the COVID-19 pandemic, including a growing immunity gap, this gesture is a testament to the UK government’s strong commitment to investing in high impact programmes that strengthen global health security – including the polio programme.
Throughout the COVID-19 pandemic, the Global Polio Eradication Initiative (GPEI) has played an integral role in the global response, contributing physical assets, outbreak response expertise and a trained workforce to slow the spread of the novel coronavirus. This support was largely made possible thank to donors like the United Kingdom.
The United Kingdom is a historic donor to efforts to end polio, committing an exceptional £400 million to eradication activities in the period from 2019 – 2023. Since 1985, the UK has contributed over US $1.6 billion, and has played an integral role in preventing the paralysis of more than 18 million children.
Widespread polio vaccination efforts over the past 30 years have led to a 99.9% decrease in global polio cases. Health workers, local governments, global partners and generous donors have made this progress possible. The increased payment by the UK will ensure that this progress against polio is not lost due to disruptions by the COVID-19 pandemic, and that the polio programme can continue to play an essential role in supporting pandemic response efforts around the world.
As the U.K. prepares to host the upcoming G7 meeting, the GPEI is hopeful that issues around global health security and health systems strengthening, to which polio can contribute, will be prioritized.
N’Djamena – One of the largest polio immunization campaigns in the African Region this year has just concluded in Chad, where over 3.3 million children in 91 districts were vaccinated. This pushes the total number of children vaccinated against polio to over forty million across 16 countries in the Region, since campaigns resumed following a necessary pause in immunizations due to the COVID-19 pandemic.
While Africa was declared free of the wild poliovirus in August 2020, another form of polio continues to affect children: circulating vaccine-derived poliovirus, or cVDPV. This type of polio is rare and can only occur in areas where not enough children are immunized. The only way to stop spread of cVDPV is through immunization.
The current type 2 cVDPV outbreak in Chad was detected in February 2020—yet immunizations were halted due to COVID-19 and the virus spread to 36 districts across the country, paralyzing more than 80 children and even leading to cases in neighbouring Sudan and the Central African Republic.
“Viruses do not respect national borders,” said Dr Ndoutabé Modjirom, head of the polio Rapid Response Team at the World Health Organization (WHO) African Region. “Given Chad’s central geographic location and its mobile populations, it was important to carry out a large-scale campaign that targeted key populations and high-risk areas throughout the country.”
The vaccination campaign was carried out in two phases, the first taking place between 13-15 November and the second from 27-29 November.
While mass polio vaccination campaigns were stopped across Africa due to COVID-19 restrictions, they resumed in July 2020. The response in the region overall, and in Chad in particular, demonstrates the commitment by Global Polio Eradication Initiative partners and countries across Africa to stop polio, even amidst the difficult operating context of COVID-19.
“The number of children reached since polio campaigns have resumed is extremely encouraging,” said Dr Matshidiso Moeti, WHO Regional Director for Africa. “This large-scale campaign in Chad during COVID-19 is a reflection of the Region’s commitment and ability to face multiple difficult health challenges and protect the health of all children.”
Although campaigns were on hold for several months, work did not stop. Chad’s team of national and international polio experts together with the AFRO Rapid Response Team tracked the virus, conducted a comprehensive risk assessment, and planned an outbreak response to take place as soon as it was safe to do so, taking into account timelines in outbreak response standards of practice. Consultations were also held with the national COVID-19 task force to ensure that best practices in infection prevention and control would be followed. The commitment and efforts of the Ministry of Health and other key national and regional health leaders and partners, including UNICEF, were instrumental in conducting the campaign.
“With increased immunizations and the continued commitment of health leaders and partners, we are confident that we will soon see the end of this outbreak and the end of all forms of polio in Africa,” said Dr Jean Bosco Ndihokubwayo, WHO representative for Chad.
About polio eradication
The Global Polio Eradication Initiative is spearheaded by WHO, Rotary International, the US Centers for Disease Control and Prevention (CDC), UNICEF, the Bill & Melinda Gates Foundation and Gavi, the Vaccine Alliance.
On 6 November, WHO and UNICEF jointly issued an urgent call to action to avert major measles and polio epidemics as COVID-19 continues to disrupt immunization services worldwide, leaving millions of vulnerable children at heightened risk of preventable childhood diseases. Learn more about the call to action.
Fahima Ahmed Hassan is a 25-year-old community mobilizer who goes the extra mile to ensure parents of children under the age of five are informed of Somalia’s polio vaccination campaigns and are ready for their children to be vaccinated.
Fahima and the other mobilisers are from the local community and they lay the groundwork for vaccinators ahead of campaigns. They work tirelessly to reach every house, speaking to families to help them understand, trust, and accept the vaccine.
On a mid-October morning, children and their families are waiting anxiously. They have been informed, by Fahima and through loudspeaker announcements, that a team of vaccinators will be visiting their community.
Amid the COVID-19 pandemic, some people are concerned and worried about taking their children for vaccinations. They fear they might contract the virus or expose their children to it. Together with her team, Fahima takes every precaution to keep herself and the community she serves protected.
She explains that it is critical to show the community that vaccination can go ahead while maintaining physical distancing, wearing protective masks and using hand sanitizer.
Somalia’s vaccine advocates
Some people do not need to be convinced about the benefits of immunization. Asha Osman Yarow is one of them. She is patiently waiting for her son to be vaccinated.
“I decided to vaccinate my children because their health is important to me,” Asha says, holding her young son. “Vaccines protect children against diseases, like polio, measles and others.”
“Praise be to Allah that these services come to us,” chimes in Sahro Mohamed Haile. “I encourage all mothers to take care of their children, vaccinate them and keep records of their vaccination status. Me, I’m here today with my grandson,” she adds with a smile.
Others in the community are more reluctant to accept vaccines. “At first, I refused to vaccinate my children. I heard people say that the vaccines were no good and that they were made by non-Muslims. I was scared,” explains 30-year-old Wardo. “After speaking to the community mobilizers, I realized that the vaccines are good for my children’s health – and I changed my mind.”
“I understand where they are coming from, and I do my best to give them information and convince them that vaccinations are beneficial,” says Fahima. “Illiteracy, lack of education and myths make people reject the vaccines.”
Together with the other community mobilizers, Fahima engages elders, religious leaders and community influencers as well as urging parents until the very last minute to come forward.
“I’ve vaccinated all of my children and I was one of the first people in my community to support vaccines,” says Isha Hassan Saney, a fellow community mobilizer. She believes showing a good example helps to convince others in the community to vaccinate their children.
“I am motivated to serve the community, especially the mothers and children, because they need to be taken care of,” Fahima says. “There is no better reward than seeing them healthy.”
COVID-19 shows why vaccines are so important
Despite COVID-19, and the enhanced risk of infecting her husband and her extended family members when she comes home, Fahima continues to show up for work and doesn’t let fear take over.
The COVID-19 pandemic has revealed what is at stake when communities do not have the protective shield of immunization against an infectious disease. When vaccines are available, they are the most effective tool to prevent dangerous disease outbreaks.
Staying informed about their benefits and understanding the risks of not getting vaccinated has never been so important. Fahima and the other community mobilizers play an instrumental role in this.
During the recent polio immunization campaign, 8 951 vaccinators went door to door and 3 390 community mobilizers, including Fahima and her team, sensitized communities. The two-part campaign, organized by the Federal Ministry of Health, UNICEF and WHO, reached more than a million children under the age of five in south and central regions of Somalia.
Member States, including from polio-affected and high-risk countries, underscored the damage COVID-19 has caused to immunization systems around the world, leaving children at much more risk of preventable diseases such as polio. Delegates urged all stakeholders to follow WHO and UNICEF’s joint call for emergency action launched on 6 November to prioritise polio in national budgets as they rebuild their immunization systems in the wake of COVID-19, and the need to urgently mobilise an additional US$ 400 million for polio for emergency outbreak response over the next 14 months. In particular, Turkey and Vietnam have already responded to the call, mobilising additional resources and commitments to the effort.
The Assembly expressed appreciation at the GPEI’s ongoing and strategic efforts to maintain the programme amidst the ‘new reality’, in particular the support the polio infrastructure provides to COVID-19-response efforts. Many interventions underscored the critical role that polio staff and assets play in public health globally and underline the urgency of integrating these assets into the wider public health infrastructure.
Delegates expressed concern at the increase in circulating vaccine-derived poliovirus (cVDPV) outbreaks, and urged rapid roll-out of novel oral polio vaccine type 2 (nOPV2), a next-generation oral polio vaccine aimed at more effectively and sustainably addressing these outbreaks. This vaccine is anticipated to be initially rolled-out by January 2021.
Speaking on behalf of children worldwide, Rotary International – the civil society arm of the GPEI partnership – thanked the global health leaders for their continued dedication to polio eradication and public health, and appealed for intensified global action to address immunization coverage gaps, by prioritizing investment in robust immunization systems to prevent deadly and debilitating diseases such as polio and measles.
GENEVA/ NEW YORK, 6 November 2020 – UNICEF and the World Health Organization (WHO) today issued an urgent call to action to avert major measles and polio epidemics as COVID-19 continues to disrupt immunization services worldwide, leaving millions of vulnerable children at heightened risk of preventable childhood diseases.
The two organizations estimate that US$655 million (US$400 million for polio and US$255 million for measles) are needed to address dangerous immunity gaps in non-Gavi eligible countries and target age groups.
“COVID-19 has had a devastating effect on health services and in particular immunization services, worldwide,” commented Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “But unlike with COVID, we have the tools and knowledge to stop diseases such as polio and measles. What we need are the resources and commitments to put these tools and knowledge into action. If we do that, children’s lives will be saved.”
“We cannot allow the fight against one deadly disease to cause us to lose ground in the fight against other diseases,” said Henrietta Fore, UNICEF Executive Director. “Addressing the global COVID-19 pandemic is critical. However, other deadly diseases also threaten the lives of millions of children in some of the poorest areas of the world. That is why today we are urgently calling for global action from country leaders, donors and partners. We need additional financial resources to safely resume vaccination campaigns and prioritize immunization systems that are critical to protect children and avert other epidemics besides COVID-19.”
In recent years, there has been a global resurgence of measles with ongoing outbreaks in all parts of the world. Vaccination coverage gaps have been further exacerbated in 2020 by COVID-19. In 2019, measles climbed to the highest number of new infections in more than two decades. Annual measles mortality data for 2019 to be released next week will show the continued negative toll that sustained outbreaks are having in many countries around the world.
At the same time, poliovirus transmission is expected to increase in Pakistan and Afghanistan and in many under-immunized areas of Africa. Failure to eradicate polio now would lead to global resurgence of the disease, resulting in as many as 200,000 new cases annually, within 10 years.
New tools, including a next-generation novel oral polio vaccine and the forthcoming Measles Outbreak Strategic Response Plan are expected to be deployed over the coming months to help tackle these growing threats in a more effective and sustainable manner, and ultimately save lives. The Plan is a worldwide strategy to quickly and effectively prevent, detect and respond to measles outbreaks.
Notes to editors:
Download photos and broll on vaccinations, including polio and measles vaccinations here
Generous support from Gavi, the Vaccine Alliance, has enabled previous access to funding for outbreak response, preventive campaigns and routine immunization strengthening, including additional support for catch-up vaccination for children who were missed due to COVID-19 disruptions in Gavi-eligible countries. However, significant financing gaps remain in middle-income countries which are not Gavi-eligible. This call for emergency action will go to support those middle-income countries that are not eligible for support from Gavi.
UNICEF works in some of the world’s toughest places, to reach the world’s most disadvantaged children. Across 190 countries and territories, we work for every child, everywhere, to build a better world for everyone. For more information about UNICEF and its work for children, visit www.unicef.org. For more information about COVID-19, visit www.unicef.org/coronavirus. To know more about UNICEF’s work on immunization, visit https://www.unicef.org/immunization
The Global Polio Eradication Initiative is spearheaded by WHO, Rotary International, the US Centers for Disease Control and Prevention (CDC), UNICEF, the Bill & Melinda Gates Foundation and Gavi, the Vaccine Alliance.
About the Measles & Rubella Initiative
The Measles & Rubella Initiative (M&RI) is a partnership between the American Red Cross, the U.S. Centers for Disease Control and Prevention (CDC), UNICEF, the United Nations Foundation and the World Health Organization. Working with Gavi, the Vaccine Alliance, and other stakeholders, the Initiative is committed to achieving and maintaining a world without measles, rubella and congenital rubella syndrome. Since 2000, M&RI has helped deliver over 5.5 billion doses of measles vaccine to children worldwide and saved over 23 million lives by increasing vaccination coverage, responding to outbreaks, monitoring and evaluation, and supporting demand for vaccine.
From 30 August to 3 September, Somalia conducted an integrated measles and polio campaign in the Banadir region – the first immunization campaign held since the COVID-19 pandemic reached Somalia. Over the last seven months, health workers have been fully engaged in fighting the pandemic. This campaign, conducted whilst observing safety measures to prevent spread of COVID-19, was a chance to get back on track to protect children who have missed out on vital immunizations.
Ismail Taxta/Ildoog/WHO Somalia
The campaign was conducted by Somalia’s Federal Ministry of Health, with technical support from WHO and UNICEF, and financial support from the Global Polio Eradication Initiative and Gavi, the Vaccine Alliance. The campaign had initially been scheduled to take place in 2019 as part of a nationwide effort, but was postponed due to technical challenges.
Ahead of the campaign, vaccines were procured and stored in optimum cool conditions. Microplans and maps were updated to help vaccinators reach all children at health facilities and fixed outreach sites. Building population immunity to polio and measles is extremely important in Somalia: Since the start of the year, 744 children in Banadir have contracted measles, accounting for half of the cases nationwide. Two forms of polioviruses, in circulation in Somalia since the end of 2017, have caused paralysis in 19 children across the country.
As part of the planning, 602 teams of health workers were given protective face masks and gloves, and were trained rigorously to keep themselves and their families safe from COVID-19. Every morning, they were checked to see if they had COVID-19 symptoms. Precautionary measures taken during the campaign included washing hands regularly, wearing face masks and ensuring physical distancing.
On the first day of the campaign, health teams set up fixed outreach vaccination sites and health facilities in different locations in Banadir. The aim was to reach as many children as possible: those living in urban and rural locations, those with nomadic lifestyles, and those living in camps for internally displaced persons.
All children under five who visited facilities during the campaign received deworming tablets and vitamin A, in addition to measles and polio vaccines. The inclusion of other health interventions in polio campaigns is a safe and effective way to help parents give their children the best possible protection against childhood diseases. This is particularly crucial in the Somali context, where children have limited access to health facilities, and population immunity is chronically low.
Two hundred and twenty-four district field assistants supervised more than 3000 vaccinators to ensure vaccinations were administered correctly and COVID-19 safety measures were observed. The campaign was also monitored by staff from the Ministry of Health, UNICEF and WHO.
Women and men played an important role in the campaign as social mobilizers, sharing messages on the benefits of vaccinations and COVID-19 prevention measures. Additionally, community volunteers helped to manage crowds of caregivers who visited health facilities and vaccination sites, ensuring that physical distancing was observed.
At the end of the day, all waste products from the campaign, including syringes, sharps and empty vials, were disposed of safely. By delivering multiple health interventions at once, cost savings can be achieved, and environmental impact is reduced when compared to delivering interventions separately.
Vaccination teams provided caregivers with vaccination cards for children, so that monitors could keep track of children who did not receive measles and polio vaccines.
Around 408 000 children aged between six months and five years (92% of those targeted by the campaign) received vaccinations against measles and 459 000 children aged under five (93% of the target) were vaccinated against polio. Ninety-two percent of children also received vitamin A and deworming tablets. This campaign proved that delivering health interventions amid COVID-19 in Somalia is achievable – and paved the way for subsequent campaigns to fill immunity gaps.
722,500 children were vaccinated during the SNID campaign.
Vaccinators in countries including Afghanistan, Angola, Burkina Faso and Pakistan took to the streets this month to fill urgent immunity gaps that have widened in the under-five population during a four month pause to polio campaigns due to COVID-19.
Campaigns resumed in alignment with strict COVID-19 prevention measures, including screening of vaccinators for symptoms of COVID-19, regular handwashing, provision of masks and a ‘no touch’ vaccination method to ensure that distance is maintained between the frontline worker and child. Only workers from local communities provided house-to-house vaccination to prevent introduction of SARS-CoV2 infection in non-infected areas.
Although necessary to protect both health workers and communities from COVID-19, the temporary pause in house-to-house campaigns, coupled with pandemic-related disruptions to routine immunization and other essential health services, has resulted in expanding transmission of poliovirus in communities worldwide. Modelling by the polio programme suggests a potentially devastating cost to eradication efforts if campaigns do not resume.
In Afghanistan, 7858 vaccinators aimed to vaccinate 1 101 740 children in three provinces. Vaccinators were trained on COVID-19 infection control and prevention measures and were equipped to answer parents’ questions about the pandemic. Through the campaign, teams distributed 500 000 posters and 380 000 flyers featuring COVID-19 prevention messages.
In Angola, 1 287 717 children under five years of age were reached by over 4000 vaccinators observing COVID-19 infection prevention and control measures. All health workers were trained on infection risk, and 90 000 masks and 23 000 hand sanitizers were distributed by the Ministry of Health.
In Burkina Faso, 174 304 children under five years of age were vaccinated in two high-risk districts by 2000 frontline workers. Vaccinators and health care workers were trained on maintaining physical distancing while conducting the vaccination. 41 250 masks and 200 litres of hand sanitizer were made available through the COVID-19 committee in the country to protect frontline workers and families during the campaign.
In Pakistan, almost 800 000 children under the age of five were reached by vaccinators in districts where there is an outbreak of circulating vaccine-derived poliovirus. Staff were trained on preventive measures to be followed during vaccination, including keeping physical distance inside homes and ensuring safe handling of a child while vaccinating and finger marking them.
“Our early stage analysis suggests that almost 80 million vaccination opportunities have been missed by children in our Region due to COVID-19, based on polio vaccination activities that had to be paused,” said Dr Hamid Jafari, Director for Polio Eradication in the Eastern Mediterranean Region. “That’s close to 60 million children who would have received important protection by vaccines against paralytic polio.”
Over the coming months, more countries plan to hold campaigns to close polio outbreaks and prevent further spread, when the local epidemiological situation permits.
“Our teams have been working across the Region to support the COVID-19 response since the beginning of the pandemic, as well as continuing with their work to eradicate polio,” said Dr Hamid Jafari. “We must now ensure that we work with communities to protect vulnerable children with vaccines, whilst ensuring strict safety and hygiene measures to prevent any further spread of COVID-19”.
Dr Matshidiso Moeti, WHO Regional Director for Africa, commented, “We cannot wait for the COVID-19 pandemic to be contained to resume immunization activities. If we stop immunization for too long, including for polio, vaccine-preventable diseases will have a detrimental effect on children’s health across the region.”
“The campaigns run by the Polio Eradication Programme demonstrate that mass immunization can be safely conducted under the strict implementation of COVID-19 infection prevention and control guidelines.”
For Somalis, COVID-19 is the most immediate crisis in a seemingly unending cycle of floods, food insecurity, conflict and outbreaks of vaccine-preventable diseases like measles, cholera and polio. Against this backdrop, the World Health Organization’s polio programme is working to steer the COVID response and, more broadly, maintain vaccine immunity levels and improve access to healthcare. It’s no easy feat.
Dr Mohamed Ali Kamil, the outgoing World Health Organization Polio Team Lead and COVID-19 incident manager for Somalia, is in awe of the commitment shown by health staff. He recently phoned a Polio Logistician diagnosed with COVID-19 who was experiencing symptoms, to insist he stop working remotely from his sickbed. Dr Kamil recalls, “He said, “No Sir, I will continue.”
Since the first COVID-19 case was diagnosed in Somalia on 16 March 2020, the polio programme has fought the pandemic from the ground up. Dr Kamil explains, “No other health programme has comparable expertise to serve the Somali population during COVID-19. During their time in the programme, members of the polio team have responded to many different disease outbreaks. This means they were well placed and well trained to respond to COVID-19.”
“The polio programme has spent years building staff capacity and systems to implement vaccination campaigns and detect the poliovirus in the community. In some ways, the team are the first and last line of defense.”
The response includes education, case identification, contact tracing, case management and data support. As of June, polio staff working as part of rapid response teams (RRTs) had reached 2.6 million people with messages about COVID-19 prevention. District Polio Officers within the RRTs have led the investigation of over 4500 people with suspected COVID-19 across the country. The country has set up three COVID-19 testing facilities and the polio structure established for the collection and shipment of stool samples from AFP cases has been used for the transportation of COVID-19 samples.
Throughout, polio personnel have continued their full-time work to end the circulating vaccine-derived poliovirus (cVDPV) outbreaks that have thus far paralyzed sixteen children since 2017.
The team are driven by a humanitarian commitment to the Somali population, who have suffered over 30 years of protracted conflict and insecurity. At least 5.2 million people are in need of humanitarian assistance, and secondary and tertiary healthcare is virtually non-existent outside of a few large cities. Health literacy is low, and populations are highly vulnerable to diseases like polio, measles, cholera and now COVID-19. In November 2019, widespread flooding brought further turmoil and danger to Somali families.
The team’s work is made more difficult by the emotional toll wrought by the pandemic. To date at least 143 health workers have been identified with COVID-19 infection. In April, Ibrahim Elmi Mohamed, a District Polio Officer who spent 19 years striving for a polio-free Somalia, died of a COVID-19-related illness. His death, one of many frontline staff around the world due to COVID-19, remind us of the risks they face every time they go to work.
Challenges lie ahead to defeat polio
Dr Kamil is clear that the polio programme will require ongoing funding and the support of authorities, partners and communities in order to maintain polio activities amidst the pandemic.
“To sustain the immunity gains we must implement a number of polio vaccination campaigns each year until the routine immunization programme can reach every Somali child with all polio vaccines. Somalia is extremely fragile and at high risk of becoming endemic for poliovirus if we do not maintain and support the polio infrastructure,” he says.
Since the cVDPV outbreaks were first detected in 2017, the programme has streamlined disease surveillance for cases of acute flaccid paralysis and other preventable diseases, including by introducing mobile technology to record details of suspected cases. For the first time, environmental disease surveillance was introduced. Over three years, frontline health workers have implemented more than 15 polio campaigns, including integrated campaigns with the measles programme.
Dr Kamil explains, “We still don’t know where the virus is coming from exactly. There are many inaccessible areas, where we cannot deliver vaccines or respond with immunization campaigns. We suspect that the virus is circulating among vulnerable children and communities living in these areas.”
Dr Kamil feels strongly that the polio programme has a duty to support other health interventions. He says, “COVID-19 shows what the frontline polio staff can achieve and the strength of surveillance and response systems.’’
Despite the challenges, Dr Kamil retains his belief that with ongoing funding and support, the cVDPV outbreaks in Somalia can be brought to a close. He reflects, “COVID-19 is a huge emergency in Somalia. Our staff are working flat out, and we expect to see many more cases, but at the same time we must continue to fight polio. The Somali community and the world deserve to be free of this disease.”
“We must reschedule our March polio vaccination campaign which was delayed because of the COVID 19 outbreak. We must do everything possible to keep health workers safe from COVID-19. It’s a hard situation, but we must not stop until we overcome both viruses.”
Nida, a polio community worker in Lahore, is glued to her mobile phone. But this is not a leisurely conversation with a friend. She is messaging a mother in her neighbourhood who is worried about COVID-19.
Since the pandemic began, polio programme workers across the country have pivoted to use messaging applications, especially WhatsApp, to disseminate COVID-19 prevention and care messages to communities. This is one aspect of the extensive support being offered by the Pakistan polio programme to the COVID-19 response.
Over the last few months, the polio programme has produced a suite of videos, digital pamphlets and posters on COVID-19 prevention and care in formats that can be easily shared and viewed via messaging platforms.
“This is an example of resilience – how the polio team has adapted to the change and found an effective way to support the people across the country during the COVID-19 crisis,” said UNICEF’s Dennis Chimenya, the Communication Task Team lead of the Pakistan Polio Programme. “Standing with the community during these challenging times will certainly contribute to building further trust in polio frontline workers.”
Engaging religious and community influencers
Engaging religious leaders and local influencers is a critical part of effective community outreach. Now, many are receiving messages and calls from polio community workers seeking their support for the COVID-19 response.
Qari Zafar, a religious cleric at a mosque in Lahore, was a staunch opponent of restrictions to religious gatherings.
“Initially, I was totally against the idea of asking people to pray at home. I felt that people need to pray together at the mosque during this difficult time and support each other,” said Zafar.
“Then I started receiving messages and posters from [polio community workers] Nida and Uzma about how the coronavirus spreads. Our chats helped me understand the seriousness of the situation.”
“I have started making announcements through the mosque loudspeakers, asking people to offer their prayers at home, even during Ramadan. I also regularly message my followers, reminding them about healthy practices.”
The ‘new normal’ for community outreach work
“Messaging platforms have become the ‘new normal’ to carry out community outreach activities,” said Muhammad Asif, a polio frontline worker in Quetta, Balochistan province.
At the north west frontier region of Pakistan, in Khyber Pakhtunkhwa province, the polio communication teams have created 63 group chats, tailored for different audiences, to amplify COVID-19 preventive messages.
In Punjab, similar groups have helped the programme reach over 110,000 people with digital posters and leaflets. Messaging applications are also helping the programme communicate with religious pilgrims and other mobile populations, whose travel patterns put them at greater risk of becoming infected with COVID-19.
In Sindh, WhatsApp has helped the programme reach over 200,000 people at risk, 4,000 religious leaders, 3,000 influencers and more than 80 journalists with awareness materials and guidelines for ethical reporting.
“The potential of using such platforms under the present circumstances is huge. Yes, our movement is limited but we have to find a way to do our job and to ensure that the correct messages reach the right audience on time,” said Fatima Fraz, Communication for Development Specialist for the polio programme in Sindh.
“Just imagine, there are 14,000 polio frontline staff in Karachi. If each staff member sends out the messages and then follows up by phone with just 20 people, that’s 280,000 people reached right then and there.”
WHO has launched a dedicated messaging service in languages including Arabic, English, French, Hindi, Italian, Spanish, Portuguese, Urdu and Somali to keep people safe from coronavirus.
The polio eradication programme has stepped up to help the Sudanese Ministry of Health limit spread of the COVID-19 virus. The programme is working in 14 states in the country supporting COVID-19 surveillance, information dissemination and training of health workers.
Dr Niazy Abd Alhameed Abd Alwahab, a National Medical Officer for the polio programme since 2013, is one of the personnel playing a key role. He and colleagues recently led two WHO COVID-19 trainings in River Nile state, one for Rapid Response Teams (RRTs) and one for local hospital staff, in addition to supporting trainings run by the State Ministry of Health.
Thanks to the trainings, health workers in all seven localities in the state are ready to help individuals who are showing symptoms of COVID-19. In total, more than 3000 RRT members have been trained across Sudan with support from polio National Medical Officers.
By early May, River Nile state had suffered seven cases of COVID-19, with two fatalities. “The state is organized to respond”, Dr Niazy explains, “All patients are being treated in dedicated isolation facilities in hospitals, and medical staff are on high alert for more cases. We helped train teams so that they are able to serve the population.”
Training Rapid Response Teams
A five-day training of Rapid Response Teams, funded by WHO, was targeted at seven teams, one from each state locality. Of the 42 individuals trained, 30 were women and 12 were men. The Rapid Response Teams have been created for the COVID-19 response. Each team contains individuals with the collective public health experience to contribute to local efforts to fight the virus, spearheading work in contact tracing and engagement with the community.
The first day of training was attended by the Director General Health of the State Ministry of Health and the Head of the Emergency Humanitarian Assistance (EHA) department.
Dr Niazy explains that over the five days, participants gained a comprehensive understanding of Sudan’s COVID-19 surveillance and contact tracing systems, infection prevention and control practices, case management methods, and how to collect samples and arrange shipment to the national laboratory in Khartoum. Participants were also trained on how to use PPE safely and how best to wash their hands.
“Participants were encouraged to take part in interactive exercises to test and strengthen their knowledge, as well as take part in discussions,” he says.
“By the end of the training, all participants were fully trained and able to pass on their knowledge in their localities.”
Training local health staff
The polio programme also supported a two-day COVID-19 training for 34 women and 22 men who work in state hospitals as doctors, lab technicians, or other medical personnel. The programme continues to support the State Ministry of Health with further local trainings, including for medical registrars.
The situation in River Nile state is very challenging. There are chronic shortages of PPE, hand sanitizer and masks, and WHO is offering urgent support to help procure these. Severe shortages of fuel and currency are making response more difficult. Social norms in some communities dissuade individuals with COVID-19 symptoms from seeking medical assistance, and work must be carried out to build trust and ensure people with COVID-19 are found and offered care.
To serve the COVID-19 response and prevent virus spread, the polio eradication programme has had to scale back some of its usual work. Dr Niazy explains, “Vaccination campaigns are paused, and many private clinics are closed, some of the public health centres are turned into isolation centres as part of the response to this emergency. This makes detecting acute flaccid paralysis (AFP) more difficult, as health personnel are trained to report children with AFP who come to the health centres.”
Efforts are being made across the Eastern Mediterranean Region to minimize the impact of COVID-19 on the overall health of populations, during a time when many health activities cannot go ahead. In Sudan, a number of children do not have full immunity against polio, and it is critical that routine immunization continues where possible until vaccination campaigns resume.
Dr Hoda Youssef Atta, WHO Representative a,i, explains, “During the COVID-19 emergency the polio eradication programme is committed to providing expertise, training and medical skills to protect Sudan. However, as soon as it is safe to do so, we must scale up programme operations once more to protect vulnerable populations from polio.”
Expertise in polio eradication that has put Africa on the verge of being certified free of wild poliovirus has been brought to the frontlines of the COVID-19 fight. A network of responders from the World Health Organization (WHO) polio eradication programme and partner organizations is providing critical resources and skills to tackle the COVID-19 pandemic.
To boost testing in the WHO African Region, the WHO-coordinated polio laboratory network comprising 16 laboratories in 15 countries is now dedicating 50% of its capacity to COVID-19 testing. Hundreds of tests are carried out every day using polio testing machines in Algeria, Cameroon, Cote d’Ivoire, Ethiopia, Madagascar, Nigeria, Senegal and South Africa.
“In Africa, no one has the footprint of the polio programme nor the expertise for mounting effective response campaigns. So with COVID-19 threatening to overwhelm health systems, the extensive polio response network is once again lending crucial support as countries build up systems to contain COVID-19,” said Dr Matshidiso Moeti, the WHO Regional Director for Africa.
Contact tracing has also been a central pillar of the WHO polio programme’s support to the COVID-19 response. Mobile phone applications originally developed for health workers to use in polio outbreak response and disease surveillance have been adapted by WHO to be used against COVID-19. In Zimbabwe, for example, over 100 disease surveillance officers are using these tools for case investigations and contact tracing in many provinces where COVID-19 has been confirmed.
In addition, the WHO Geographic Information System (GIS) centre in Brazzaville, Congo – which was opened in 2017 to support the polio programme with adapted technologies and data management – is using its huge experience in outbreak response and disease surveillance to support countries with a range of GIS and software technology and manual solutions to respond to COVID-19. The GIS team is now working around the clock supporting countries to take up the technology for COVID-19 responses.
More than 2000 polio response experts from WHO, UNICEF, Rotary, as well as STOP consultants from the United States Centers for Disease Control and Prevention are supporting the COVID-19 response in the African Region. A quarter of WHO polio staff are dedicating more than 80% of their time towards COVID-19 efforts, with 65% anticipating a commitment of six months or more.
Alongside the support to the COVID-19 response, WHO polio staff are also maintaining critical functions including disease surveillance and planning to resume mass polio immunization campaigns once the situation permits to reduce the risk of new polio outbreaks.
“It is important that the support to COVID-19 response does not jeopardize the progress made in stopping all forms of polio transmission in the region. The fight against the pandemic should not come at the detriment of other health emergencies,” emphasized Dr Moeti.
Focus: Using digital tools for contract tracing in Zimbabwe
“With Zimbabwe’s first COVID-19 case, we used paper tools to facilitate data management during case investigation and contact tracing, but our contact tracers faced many challenges with follow up and reporting,” says Manes Munyanyi, Deputy Director Health Information and Surveillance Systems for Zimbabwe’s Ministry of Health and Child Care.
“Using digital tools [provided by the polio programme] for outbreak responses cannot be overemphasized as the technology provides responders with data management, visualization and information dissemination platforms that support informed decision making at all levels.”
On 4 June 2020, the UK Government hosted Gavi’s third donor pledging conference, the Global Vaccine Summit, to mobilize at least US$ 7.4 billion to protect the next generation with vaccines, reduce disease inequality and create a healthier, safer and more prosperous world. Responding to this unique call for global solidarity, leaders from donor countries and the private sector made unprecedented commitments of US$ 8.8 billion in order to save up to 8 million lives.
Since 2019, the Global Polio Eradication Initiative (GPEI) has strengthened its collaboration with Gavi, inviting Gavi to become the sixth core partner of the GPEI. While the GPEI will continue its focus on interrupting virus transmission and eradicating polio through immunization campaigns using the oral polio vaccine (OPV), Gavi’s support for the inactivated polio vaccine (IPV) at an estimated cost of US$ 800 million during its 2021-25 strategic period represents the insurance policy for the success of the Polio Endgame Strategy.
Thanks to the remarkable mobilization and solidarity of leaders worldwide, Gavi will be able to maintain immunization in developing countries, mitigating the impact of the COVID-19 pandemic. Gavi will also be able to sustain health systems so that countries are ready to rapidly introduce COVID-19 vaccines. And by 2025 Gavi will have immunized more than 1.1 billion children, saving 22 million lives. Ngozi Okonjo-Iweala, Chair of the Gavi Board, highlighted why this is so important, saying, “Vaccinations should be recognized as a global public good. With your support and commitment, we can generate US$ 70 to US$ 80 billion additional economic benefits.”
Henrietta Fore, Executive Director of UNICEF, added, “We have effective vaccines against measles, polio and cholera. While circumstances may require us to temporarily pause some immunization efforts, these immunizations must restart as soon as possible, or we risk exchanging one deadly outbreak for another.” UN Secretary-General Antonio Guterres urged partners to “find safe ways to continue to deliver vaccinations during COVID-19.” GPEI, Gavi, WHO and UNICEF have issued guidance for countries to encourage resuming immunization activities once it is safe to do so, in recognition of the fact that numerous countries are facing COVID-19 and multiple other disease outbreaks.
During the Summit, top Gavi donors reaffirmed their leadership, including Norway, the UK and the USA, as well as the Bill & Melinda Gates Foundation. Prime Minister Boris Johnson pledged £1.65 billion, recommitting the UK as Gavi’s leading donor while the Gates Foundation committed US$ 1.6 billion. More than 60 leaders from all regions of the world in the Asia-Pacific, Middle East, Africa, Europe and the Americas pledged support to Gavi, the Vaccine Alliance both for its upcoming strategic period as well as for COVID-19 response.
The COVID-19 pandemic reminds us of the power of vaccines. WHO Director-General Tedros Adhanom noted, “COVID-19 is a devastating reminder that life is fragile, and that in our global village our individual health depends on our collective health. … Now is the moment for the world to come together in solidarity to realise the power of vaccines for everyone.” Responding to this challenge, Gavi has launched the Gavi Advance Market Commitment for COVID-19 (Gavi Covax AMC), which aims to raise additional funding in late June under the leadership of the European Union. Bill Gates, noted, “We would have to create Gavi if it did not exist today to solve the COVID-19 crisis.”
Michel Zaffran, director of the WHO polio eradication programme, said, “Congratulations to the Gavi family for this exemplary mobilization and demonstration of global solidarity. We are immensely grateful to Gavi and its donors for their precious partnership and generous support for the inactivated polio vaccine (IPV). The COVID-19 pandemic is a terrible tragedy, which brings us together more than ever and requires to think collectively how best to address the needs of the communities.”
Rotary, one of the six GPEI partners, echoed statements from other agencies. “Rotary and its members applaud the commitment of the donors and governments who have pledged their support to ensuring that vulnerable communities can receive lifesaving vaccinations,” said Michael K. McGovern, Polio Oversight Board and Chair of Rotary’s International PolioPlus Committee. “Continued investment from the global community in programmes such as the Global Polio Eradication Initiative is crucial to not only achieving the eradication of polio, but ensuring stronger health systems worldwide. This firm commitment truly embodies the “Plus” in PolioPlus.”
While the Global Vaccine Summit secured the IPV requirements for polio eradication efforts through 2025, further financial commitment is needed for the GPEI to restart the immunizations campaigns that have been paused during the COVID-19 pandemic. More intensive and integrated immunization activities are needed to finish the job and to strengthen the capacities of the governments, health workers and networks, so that the investment in polio eradication can serve as a foundation for future pandemic response. While celebrating the success of the Global Vaccine Summit, GPEI calls for reiterated donor support to eradicate polio once and for all.
“The road to the mountain village was rough. It’s only 50 kilometres, but it took more than 3 hours,” says Dr Fatima Ismail, a disease surveillance officer working in Somaliland. “We were bouncing in the car.”
In early 2020, Dr Fatima’s team headed to a remote village near Djibouti to check on a small boy. The boy’s right arm and leg showed a kind of paralysis that sometimes indicates polio. “The village polio volunteer in this mountainous area, geographically inaccessible, found an acute flaccid paralysis (AFP) case,” Dr Fatima remembers.
When children show signs of this paralysis, it is critical to get stool samples to a laboratory to determine whether they have polio. Polio teams ride camels in the desert or donkeys in the mountains when they have to. They brave conflict to get samples to laboratories. In brutally hot climates, they plug mini-freezers into car dashboards to keep samples cool.
All over the world, polio surveillance systems that have been built up over decades track infection sources, evaluate symptoms and transport samples to the laboratory — despite distance, natural disasters, and sometimes war. Now, disease surveillance network — reaching into the most far-flung corners of the globe — is being tapped to address the COVID-19 pandemic.
“In Somalia, the polio programme pivoted its workforce of thousands of frontline staff to support the effort as the cases of COVID-19 spread. Rapid response teams — made up of disease surveillance officers, community health care workers and volunteers — were trained to educate people about the virus and to test suspected cases. By April 2020, the teams were deployed in the field,” said Dr Mamunur Malik, WHO Representative in Somalia.
“In Somalia’s remote villages, they know us as their polio teams, and once they see us, what comes to their minds is that we’re giving them information about polio,” says Mohamed*, a surveillance officer. “So we also give them information about COVID-19. Social mobilisers tell them about COVID-19 symptoms, how to prevent getting infected, physical distancing, cleaning their hands very well with running water and soap.”
The careful procedures that the teams learned for polio surveillance have been adapted for COVID-19, where the required sample is a naso-pharyngeal swab. “We’ve trained our surveillance people on the case definition and how to collect the samples correctly, from people that meet the definition of a suspected case of COVID-19,” says Dr Fatima. “It’s the same infrastructure. After, when we collect the samples from the patient, we send it to the laboratory in Hargeisa.” WHO has given the laboratory equipment and supplies to test samples for COVID-19.
“As with polio samples, the samples of COVID-19 have to be refrigerated, the ice packs should be VERY cold,” says Mohamed. Teams are used to monitoring the packs’ temperature, even in Somalia’s hot weather.
“The logistical challenges we face with AFP/polio surveillance are still the same. This is the rainy season and the roads tend to be terrible,” says Mohamed. “You can’t get to certain places you normally get to, because of the situation on the road. Most of our vehicles can’t make it through the mud.” In those situations, teams work with other United Nations agencies to arrange special humanitarian flights to ship samples.
Frontline staff put their own lives on the line. In April 2020, the polio team lost a colleague due to COVID-19-related infection. Ibrahim Elmi Mohamed, who joined WHO in 2001, was working as a district polio officer in Lower Shabelle. His tragic death, one of many frontline staff around the world due to COVID-19, reminds us of the risks they face every day they go to work.
“Despite overwhelming challenges, teams are committed to continuing their polio work in tandem with the COVID-19 response. It is critical that polio surveillance continues during the pandemic, as Somalia is also fighting outbreaks of vaccine-derived polio type 2 and 3. With polio vaccination campaigns temporarily paused, the teams must be able to track any resulting spread of poliovirus and get ready to respond as soon as it is safe to do so,” says Dr Malik.
“All of us are still doing polio surveillance at the same time as we do surveillance for COVID-19,” says Dr Fatima. “I used to hear from my colleagues that the polio surveillance system is the strongest disease surveillance system. Any polio surveillance team can work in the detection of COVID-19 cases because of the system’s structure, the capacity and experience of the teams.”
Mohamed agrees. “My surveillance coordinator said don’t leave the AFP surveillance behind, follow that normal routine, don’t forget it and leave it aside.’”
As Somalia grapples with the COVID-19 pandemic, its trained teams are working quickly to prevent the spread of both COVID-19 and polioviruses. “What gives me hope in the COVID-19 response is when I look behind and I see what we have done with the polio teams, the impact we’ve had on so many lives,” says Mohamed. “We face everything and we overcome it.”