The Pakistan polio snapshot gives a monthly update on key information and activities of the polio eradication initiative in Pakistan.
In January:
As he climbs out of his car and walks across to the entrance of Bakassi camp for internally displaced persons in Borno, northern Nigeria, Dr Terna Nomwhange is met by a familiar sight. Standing at the gates, greeting a tired, dusty family laden with possessions, is a team of polio vaccinators. As families arrive at this sea of shelters following a long, hard journey, these people offering polio vaccines are the first sign that they have reached a place of protection.
Not only are families in northern Nigeria facing insecurity, a humanitarian crisis and the threat of polio, but since September they have also been at risk from an outbreak of yellow fever. By early January 2018, a total of 358 suspected cases had been reported in 16 states, with 45 deaths recorded for 2017. In Borno, the ongoing conflict means that the health infrastructure on the ground to respond to the outbreak is limited to local government and the polio eradication infrastructure.
At the camp gates, the polio vaccinators give two drops of vaccine into the mouth of every child; but they also tell the parents where to go to get their yellow fever vaccination. As Dr Terna, who works for the WHO Nigeria polio eradication programme, walks further into the camp, he catches sight of the distinctive blue that signifies the uniform of a polio volunteer community mobilizer. As she emerges from the door of a shelter, he hears her reminding the family within to get their children vaccinated against polio, but also for the whole family to be vaccinated against yellow fever.
With weakened health system in parts of north eastern northern Nigeria, the infrastructure that is already on the ground to stop polio is providing the volunteers needed to support the yellow fever vaccination campaign. More than eight million people are being targeted with yellow fever vaccines in the states of Borno, Zamfara Kwara and Kogi states in 2018.
Regular polio vaccination campaigns reach children under five years of age with polio vaccines, as this age group is the most vulnerable to the virus. But reaching everyone between nine months and 45 years to protect them against yellow fever takes creative thinking. People who would not usually be vaccinated have to be mobilised to come to health clinics where they can receive that one shot of yellow fever vaccine that infers life-long protection.
This is where the polio infrastructure comes in. To prepare for the launch of the yellow fever vaccination campaign that took place at the beginning of February, polio experts supported the preparations by developing detailed microplans, mapping each community so that every individual can be vaccinated. Volunteer community mobilisers, well versed in educating communities about the risks of infection, used their skills to warn populations of the high mortality rates associated with yellow fever.
The polio surveillance system in Borno is already on high alert to identify any case of polio, even in conflict affected areas. “Surveillance remains everyone’s number one priority,” says Dr Terna. “While the polio infrastructure is doing everything it can to find any trace of polio, it is killing two birds with one stone by keeping an eye out for yellow fever as well. This is a win-win situation to stop both diseases.”
While surveillance focal persons move house to house, they are also raising awareness about the symptoms of yellow fever. When a potential case is found, the polio infrastructure is being used to collect blood samples and transport them to the national laboratory down the reverse cold chain, keeping samples at the correct temperature for testing.
“What makes this campaign special is not just the fact that the strong polio infrastructure is helping to control other diseases, but also that it underscores what can be achieved with intersectoral collaboration and partnership,” said Dr Wondimagegnehu Alemu, WHO Country Representative to Nigeria. “Without the polio eradication infrastructure, a campaign of this scale would not have been able to take place.”
“Everyone is pulling in one direction – the government, partners and volunteers within communities – to protect any and every vulnerable person against polio and yellow fever,” says Dr Aliyu Shettima, Polio Incident Manager at the Emergency Operations Centre (EOC) in Maiduguri.
Support for immunization to the Federal Government of Nigeria through the World Health Organization is made possible by funding from the Bill & Melinda Gates Foundation (BMGF), Department for International Development (DFID), European Union (EU), Gavi, the Vaccine Alliance, Global Affairs Canada (GAC), Government of Germany through KfW Bank, Japan International Cooperation Agency (JICA), Korea Foundation for International Healthcare (KOFIH), Measles and Rubella Initiative (M&RI) through United Nations Foundation (UNF), Rotary International, United States Agency for International Development (USAID), United States Centers for Disease Control and Prevention (CDC) and World Bank.
In Afghanistan, frontline health workers explain to parents why the polio vaccine must be delivered multiple times
“It’s easy for the others, they are young and strong!” laughs Hamida. She has just climbed hundreds of steps to the top of a long and steep staircase on the side of one of Kabul’s many hills. Together with her colleagues Mohib and Khalid she works as a part of a polio team vaccinating children in their community. Today, the team started at 8 am, and they have now been walking up and down the hill for three hours. No wonder she is tired.
So far, the group has visited 50 families and vaccinated 110 children. They have 30 more to go today, and, in the next three days, they will visit a total of 233.
The team’s role is not only to vaccinate the children but to also to educate people about the life-saving polio vaccine and its importance. It is not always an easy job.
“Last time we visited was only two weeks ago, so some parents have been asking why we are visiting again. I have explained to everyone that the vaccine is beneficial for the children and that children need to be vaccinated every time we visit to be protected.”
It is the first day of a vaccination campaign, which aims to immunize over 6 million children against polio in Afghanistan.
Today, thankfully, all families have accepted the vaccine from this team.
Last push to eradicate polio in Afghanistan
Afghanistan is one of the last countries in the world where wild poliovirus still circulates, and has the highest number of children paralyzed by the virus.
In 2017, there were a total of 14 cases and, so far in 2018, there have been three confirmed cases. In recent months, the virus has been found circulating in southern and eastern regions.
WHO Afghanistan polio programme manager Dr Hemant Shukla is confident that with stepped-up efforts, the circulation can be stopped. “Afghanistan has stopped transmission in the past in all areas, but not at the same time. We are confident that by following correct strategies, focusing in the right areas and by coordinating our efforts with neighbouring Pakistan, we can stop the transmission”.
To answer to the challenge, the Polio Eradication Initiative has stepped up efforts to detect any viruses in the environment. The programme is taking special steps in the eastern and southern regions to reach all children with the vaccine every time the vaccinators pass by, as these are very high risk areas for polio transmission, with people moving in and out of neighbouring Pakistan. Special outreach tactics are concurrently aiming to reach and immunize ‘mobile populations’, such as nomadic people, who are at high risk of contracting polio.
The oral polio vaccine is effective as it not only protects children from contracting the virus, it also prevents them from carrying it in their intestines. Several doses – spaced apart – need to be given to build sufficient immunity, especially in areas where poor nutrition can weaken immune systems.
During the low transmission season, the Polio Eradication Initiative conducted two campaigns – in January and February – in order to vaccinate children in high risk and very high risk districts in quick succession so that the vaccine would have a maximum effect.
In March, 10 million children across the whole country will be vaccinated – that’s every single child under the age of five years.
In Kabul, one by one the team marks their tally sheet with numbers and ages of the children and takes note whether all the children of the household were present.
One of the children vaccinated today is three-year-old Haroon, who stands outside his family’s home. His mother Nadia peeks through the gate. She has six children, and Haroon is her youngest.
“Haroon was just vaccinated two weeks ago, but I know it is important to vaccinate children every time”.
The team marks this household vaccinated for today.
In four weeks, Nadia will open up her door when the vaccinators knock again.
The Afghanistan polio snapshot gives a monthly update on key information and activities of the polio eradication initiative in Afghanistan.
In January:
For full update please click on pdf below.
The poliovirus remains in just a few small pockets around the world. However, these final hiding places are some of the most challenging settings on earth in which to eradicate a disease. Finding and stopping a virus whose special power is staying hidden is no mean feat, especially in remote or inaccessible places.
Disease detectives around the world are working tirelessly to find every last virus in these hard to reach places. Some areas are vast and sparsely populated, such as the broad plains and river beds making up areas of the Lake Chad region. Others are densely packed residential areas of Afghanistan, where security issues can sometimes make immunization difficult. In areas of Syria, civil war continues to rage through towns, communities, and families. Yet these challenges are not enough to stop the surveillance system.
In such difficult environments, the polio surveillance system must overcome numerous challenges to ensure that the poliovirus is tracked. Experts look for the virus in children with symptoms of acute flaccid paralysis and also in water samples from sewage systems in high risk areas.
For Dr Arshad Quddus, Coordinator for the detection and interruption of poliovirus at WHO headquarters, the key to overcoming the challenges facing polio surveillance is tapping into communities. Illustrating his point, he draws a circle on a piece of paper, placing a dot in the middle. In Afghanistan, he explains, that dot represents a surveillance focal point, based at a District Health Centre or hospital. The circle extending from them is their information network – a collection of mullahs, healers, health-care providers, teachers, parents and other surveillance recruits – who have been trained to spot cases of acute flaccid paralysis in their community that could turn out to be polio.
Each volunteer is given a book in which to write down the information they find, and a phone number to call. If they come across a case in their local community, they must ring their focal point, setting in action a series of events that will allow the child to be examined, stool samples to be taken from them to be tested in the laboratory for polio and their close contacts tested.
The system may seem simple, but insecurity, weather and challenging landscapes can be obstacles. In Afghanistan, the programme has developed creative ways to ensure that nothing stands in the way of the surveillance system being able to work as it needs to. In most cases, following the reporting of a case of acute flaccid paralysis, health workers will visit the child’s home to inspect them, and collect stool samples from the child to send for lab testing for the poliovirus. However, if the area is inaccessible, the child and their caregivers are transported to the nearest hospital in a safe area for inspection.
For Dr Quddus, the success of this system in Afghanistan is clear: “We have regular reports of where the poliovirus is circulating in difficult and hard-to-reach communities and this shows us we are being successful, despite tremendous challenges.”
These diverse methods also strengthen surveillance in countries where the security situation is rapidly changing. In Syria, the health-care system has been weakened due to conflict, with many of those at the heart of the polio surveillance system displaced. By building new networks in camps for internally displaced families where communities are created by proximity, and recruiting surveillance volunteers at the key points of entry and exit into the worst of the conflict zones, the polio surveillance system ensured that an outbreak of circulating vaccine-derived poliovirus in 2017 was rapidly identified and an outbreak response launched. The programme also thought outside of the box in Borno, Nigeria, by training medical corps being deployed to reach conflict-affected populations to spot signs of the virus.
The polio surveillance system is strengthened by a mixture of community, adaptability, and fierce commitment to finding every last trace of virus. These are the lessons learned that help find the virus everywhere, from urban districts of Afghanistan, to hard-to-reach areas of Nigeria. For Dr Quddus, “It is the individuals on the ground willing to give their all that will enable us to achieve eradication. The surveillance system is the eyes and ears of polio eradication, showing us where to focus our best efforts to vaccinate every last child.”
The Pakistan polio snapshot gives a monthly update on key information and activities of the polio eradication initiative in Pakistan.
In December:
The Afghanistan polio snapshot gives a monthly update on key information and activities of the polio eradication initiative in Afghanistan.
In December:
For full update please click on pdf below.
The Afghanistan polio snapshot gives a monthly update on key information and activities of the polio eradication initiative in Afghanistan.
In November:
For full update please click on pdf below.
The Pakistan polio snapshot gives a monthly update on key information and activities of the polio eradication initiative in Pakistan.
In November:
The year’s end offers the chance to reflect on the polio programme’s milestones and challenges in 2017, and look ahead to what we can achieve in the coming year. 2017 saw the fewest wild polio cases in history — a total of 17 cases, or a 50% reduction from the year before—with these cases occurring in just two countries: Afghanistan and Pakistan. Yet the need to reach every last child is more important than ever, as demonstrated by surveillance gaps in Nigeria and outbreaks of vaccine-derived polio in Syria and the Democratic Republic of the Congo.
From programme strategies that helped protect progress and overcome obstacles, to commitments from donors and partners, 2017 demonstrated the resolve required to achieve a polio-free future. Accelerating progress in the new year and ending polio for good will require maintaining these political and financial commitments as well as building upon the programme’s efforts to find the virus wherever it exists.
Throughout 2017, developments in disease surveillance – both in humans and in the environment – allowed the programme to better hone in on the virus and identify its remaining hiding places.
For example, in Afghanistan, blood tests helped pinpoint which children have been reached and where gaps in immunity persist, allowing health workers to launch targeted vaccination responses. In Sudan, a pilot study used a new method of quality control to help ensure that stool samples arrive at the lab in the right condition for testing. And throughout the Eastern Mediterranean Region, environmental surveillance networks were expanded and strengthened.
These innovations are building robust, sensitive surveillance networks around the world that pick up every trace of the virus and enable the programme to develop targeted immunisation responses before polio has the chance to paralyse children.
The year also came with new challenges, including outbreaks of circulating vaccine-derived polio in Syria and the Democratic Republic of the Congo, where conflict has ravaged the health infrastructure. In these communities, and others where polio still exists, difficult terrain, conflict and highly mobile populations can all stand as hurdles to vaccinating children. Yet the polio programme continues to find new and effective ways of delivering vaccines.
For example, in Afghanistan, a collaboration with a mobile circus is sharing important messages about polio vaccination with hard-to-reach populations, including those living in camps for internally displaced persons. In Pakistan, campaigns based at border crossings and train stations vaccinated children on the move who might otherwise have been missed by traditional methods. And in Syria, dedicated workers are delivering vaccines at transit points and registration centres for internally displaced persons. Thanks to these strategies, more than 255,000 children have been vaccinated in Deir Ez-Zor, 140,000 were reached in Raqqa and the programme continues to work to reach every child.
Complementing these programmatic innovations were political and financial commitments that highlighted polio eradication as a priority for global health leaders. These included:
Next year, country programmes will need to continue working to ramp up surveillance, particularly in Nigeria, and reach children everywhere with vaccines. Cross-border coordination between Pakistan and Afghanistan, which has already had a huge impact in reducing cases, will continue to be critically important to stopping transmission.
At the same time, the global community is beginning to solidify plans for keeping the world polio-free once eradication is achieved. Countries are developing strategies for transitioning the infrastructure and tools that they currently use to fight polio. And the GPEI is working with global stakeholders and partners to develop the Polio Post-Certification Strategy, which will define the activities needed to keep polio from returning after the virus is eradicated.
If the remaining endemic countries continue to do all that they can to stop the virus, and if the global community continues to meet the level of political and financial commitment needed to make and keep children everywhere polio-free, 2018 will bring the world’s best opportunity yet to end the disease.
The Organization of Islamic Cooperation has celebrated the efforts of its Member States to eradicate polio and is working to ensure that eradication remains at the top of national health agendas. In a resolution passed at the sixth session of the Islamic Conference of Health Ministers, held in Jeddah in early December, the Organization of Islamic Cooperation recognized the importance of ensuring that all children are consistently reached and vaccinated with the polio vaccine. It also highlighted the critical roles of Government leaders and the Islamic Advisory Group in the effort to put an end to the crippling disease.
In the Jeddah Declaration, signed by representatives from all Member States, the Organization of Islamic Cooperation reiterated health as one of the basic rights of every human being and reaffirmed their belief that “… the right to health must be at the core of the global agenda.” They reiterated their support to polio eradication and to the full implementation of the Polio Eradication and Endgame Strategic Plan, and recognised the efforts of their Member States to stop transmission. In particular, members were called upon to support the work of the remaining polio endemic countries – Afghanistan, Nigeria and Pakistan – and for the Islamic Advisory Group to continue their work to support the Global Polio Eradication Initiative. The resolution issued at the end of the conference also called upon Member States and other donor entities to provide the necessary financial support that would allow the Islamic Advisory Group to continue its work.
Just days after the commitment of member states was reemphasised, the Minister of Health of Somalia Dr Fawziya Abikar Nor showed her commitment to eradication by attending a polio vaccination campaign, alongside Dr Ghulam Popal, WHO Representative for Somalia. High level government commitment has been one of the most important components of eradication in some of the most challenging countries around the world.
With polio at the lowest levels in history in Pakistan, the country is about to launch an all-out and hopefully final assault on the disease in 2018. To help these emergency efforts, the Government of Germany announced today an additional € 2 million in financial support, to Pakistan’s national emergency action plan. Germany is a longtime supporter of the Global Polio Eradication Initiative (GPEI) with contributions totaling more than US$ 550 million to the effort, not including a recently announced additional pledge of € 19.9 million to Nigeria’s polio eradication effort for 2018. For its engagement in polio eradication, including in fostering global commitment, Germany has on numerous occasions been internationally recognized at the highest levels. Chancellor Angela Merkel is a past recipient of Rotary International’s prestigious Polio Champion Award.
The Global Polio Eradication Initiative partners would like to extend their profound gratitude to both the Government of Pakistan and Germany for their collaboration and for their tremendous support and engagement in the effort to eradicate polio globally.
“I feel our collective productivity has improved manifold, ever since we started working together with the Community Based Vaccinators from the polio eradication programme,” says Syed Mussayab Shah, a tone of pride in his voice. Shah is a vaccinator with the Expanded Programme of Immunization, posted at Gulbahar Civil Dispensary, Peshawar district, Khyber Pakhtunkhwa. He is responsible for immunizing children against nine vaccine-preventable childhood diseases.
Reaching children with vaccines in dense urban environments can be a significant challenge. So the polio eradication programme and the team responsible for delivering routine vaccines – the Expanded Programme on Immunization – are working together to make sure that they do the job as best they can, explains Shah. “We are determined to reach and vaccinate every child in our area. And to ensure this, we exchange information and notes with the community based vaccinators twice every week.”
| “The synergy between the two programmes has been a blessing as we are reaching more children with vaccination every day, including those living in urban slums. Our spirits are high and we are determined to reach every last child.” Dr Akram Shah |
Where families live in concrete housing units in urban slums, access to health care is a persistent challenge. The urban slums are often unrecognized, lack essential infrastructure and are low priority for local health authorities. This translates into low and unequitable coverage of social services in urban areas – including vaccination.
Pakistan is the most urbanized country in South Asia and the population living in urban slums continues to increase. The urban population has risen from an estimated 43 million in 1998 to 73 million in 2014. In Peshawar, increased migration is an additional challenge, making it the sixth biggest city in the country.
The challenge of identifying and vaccinating children living in urban areas, especially those living in slums and migrant families, is demanding innovation and skill sharing. The teamwork between the polio eradication team and the Expanded Programme for Immunization is ensuring everyone benefits – especially children who urgently need the protection offered by vaccines.
The Civil Dispensary is the only government health facility in the area that caters not only to the residents of Gulbahar but also those living in adjoining slums. Community-based polio vaccinators from local areas come to this health facility to sit side by side with their colleagues from the broader vaccination programme to review their field books containing the housing maps and vaccination details of every single child under five in their areas. Microplans, containing this detailed information of local communities, are a valuable tool of the polio eradication programme. From this essential information, routine vaccinators make a list of unvaccinated children for follow-up who might be falling through the cracks. The polio vaccinators also refer clients from their communities to the health facility to receive their other routine vaccines. This collaboration is game changing for the drive to protect every last child against vaccine preventable disease.
UNICEF, with funding from Gavi, the Vaccine Alliance, is supporting the Government of Pakistan in improving routine immunization coverage in urban slums with a focus on seven major cities in Pakistan in collaboration with the polio eradication programme.Referring to the synergy initiative, Shah says, “Earlier we worked without defined plans and targets. Now, due to the information sharing from community based polio vaccinators, we have plans with identified areas and targets that help us monitor our own progress as well as the vaccination coverage.”
“Record keeping of families in urban slums is a very difficult job,” shares Tabassum Shuaib, a polio community-based vaccinator from Peera Gaib, Peshawar.
“Families are constantly moving in and out from here – and many of those that move in do not have a vaccination card. They can only recall the number of times their child has been vaccinated. However, now I have all the families, pregnant mothers and children under five from this community registered and their data is maintained at the Gulbahar Civil Dispensary, so we can keep track ourselves and make sure no child is missed.”
Dr Akram Shah, Director of the Expanded Programme of Immunization in the area, is pleased with the rewards of this teamwork: “Peshawar offers the same challenges as any other major city of Pakistan. With increased migrant population and urbanization during the past decade, the burden of ensuring access to basic life and health resources to all has also increased. The synergy between the two programmes has been a blessing as we are reaching more children with vaccination every day, including those living in urban slums. Our spirits are high and we are determined to reach every last child.”
Despite focused efforts to stop the transmission of wild poliovirus in 2017, to date this year 17 cases have been reported globally; six from Pakistan and 11 in Afghanistan. During a series of meetings to review progress in the two endemic countries, which make up one epidemiological block, members of the Technical Advisory Group (TAG) on polio eradication concurred that while both Pakistan and Afghanistan continue to make progress, continued transmission threatens gains already made towards interruption.
The TAG meetings, held in Islamabad and Kabul, recognized the efforts of both countries to coordinate activities closely, focusing on clearly identifying missed children, the reasons they have been missed, and putting in place operational plans to overcome these challenges. Efforts made to adjust national emergency action plans and build on the lessons learned from previous years and other countries have been commended by expert members of the TAG and hailed as key drivers behind the momentum.
TAG however reminded the country programmes of the remaining gaps and concluded that consistently reaching and vaccinating high-risk mobile population groups is essential if Afghanistan and Pakistan are to interrupt transmission over the coming months.
The greatest risk to polio eradication, according to TAG chair Jean Marc Olive, are the reservoirs that continue to harbor the virus: the northern corridor comprising of eastern Afghanistan and Greater Peshawar – Khyber in Pakistan, the southern corridor linking southern Afghanistan (Kandahar and Hilmand) with Quetta block, Balochistan province, in Pakistan and Pakistan’s economic hub, Karachi.
Recognizing the already high level of Government commitment from both countries, TAG insisted that sustained leadership at all levels in both countries would be essential for the implementation of recommendations, including maintaining coordination at the national, provincial and district levels, as well as among the bordering districts in the common corridors of transmission.
Specific recommendations for addressing areas with continued transmission included the development of joint Action Plans for the common reservoirs (northern and southern corridors) linking the two endemic countries ’ as well as to strategize for improving program implementation quality in other high risk areas as well as among the high risk mobile populations.
About the Technical Advisory Group
The Technical Advisory Group (TAG) was established to review progress towards polio eradication in specific countries, assess implementation of previous TAG recommendations, discuss planned activities and issue recommendations to address constraints facing national programmes in achieving their targets. TAG meetings are attended by country-specific TAG members, national representatives and partner organizations, both international and regional.
The Islamic Advisory Group for Polio Eradication has launched a new training manual for students of religious studies in support of polio eradication efforts. The manual provides practical guidance on how to engage with local communities to advocate for vaccination as well as other maternal and child health issues.
The launch of the training manual follows Islamic Advisory Group’s efforts to prepare students of religious studies at key universities in predominantly Muslim countries to act as advocates for critical health initiatives particularly in high-risk areas where marginalized and underserved populations reside. As future religious leaders and scholars the students will be well placed within their local communities to promote healthy behaviour and dispel rumours and misinformation that hamper the work of vaccination teams and deprive their community members of protection against polio and other vaccine preventable diseases.
Nine-year old Adil Khan comes from Peshawar, Pakistan’s sixth largest city and capital of Khyber Pakhtunkhwa province. He is the oldest of the four children of Shami Ullah, a local laborer who often struggles to make ends meet. Together with his wife and four children, he lives in Wahid Ghari, a poor area of Peshawar, where many other underprivileged families reside.
If Shami Ullah’s life wasn’t difficult enough already, Adil was diagnosed with polio in 2008, only 5 months after he was born. After a couple of days of high fever followed by weakness in his left leg, Shami Ullah rushed his baby to the hospital where Adil was tested for polio. Unfortunately, the test came back positive. “We had heard about polio before, so when we learnt our son had it, we were very worried,” Shami Ullahsaid. “I just didn’t want to accept that Adil would not be able to walk his entire life.”
Adil’s story is not unique. In 2008, 21 children in Peshawar were diagnosed with polio, while there were a total of 117 cases reported that year in Pakistan. So far this year, there have been only five cases of wild poliovirus reported in Pakistan, down from 20 last year and 54 in 2015. The recent progress has been the result of strong government commitment, support and oversight at every level, strengthened programme performance and broad community acceptance.
Polio is a crippling and potentially deadly infectious disease caused by the virus which invades the nervous system and can cause irreversible paralysis. For polio victims, this has often meant lifelong social exclusion. However, Adil can walk and goes to school, thanks to the support of orthotic devices and physiotherapy. “We are so happy to see our eldest son run. He is just like other children,” Adil’s father said.
The rehabilitation story of Adil is one of almost 700 stories of children who have been provided with rehabilitation services by Pakistan’s Polio Rehabilitation Initiative. The initiative, which started in 2007, initially provided support to children from Pakistan’s province of Khyber Pakhtunkhwa and Federally Administered Tribal Areas. In November 2011, the programme increased its span to almost all parts of Pakistan.
“This initiative of provision of rehabilitation services to polio affected children is an important combination of medical and social rehabilitation,” said Dr Maryam Mallick who heads the Polio Rehabilitation Initiative with WHO Pakistan. When a child is paralyzed with polio, a rehabilitation officer visits the home of the polio patient to assess the needs. On the basis of this assessment, rehabilitation plans for both medical and social rehabilitation are being developed. The medical services include provision of orthotic devices, surgical procedures, physiotherapy, as well as regular follow-up services.
There are many benefits to rehabilitation to these children – with the right treatment children not only improve mobility, but they gain independence and allow them to enroll in school. “To ensure the regular attendance of the child, the educational expenses for the yearly tuition fee, uniform, books, shoes, and even a small amount for pocket money is being given to the principal of the respective school instead of being given to the parents,” Dr. Mallick said.
Adil is currently a second grade student at the Peshawar Cambridge Public School. He likes to study, which makes his father proud. “When he grows up, I would like him to become a doctor so that he can help people in need,” said Shami Ullah, who is also now a strong advocate of the Polio Eradication Initiative.
“I was told that if the child was vaccinated against polio, he could one day become a great footballer like Drogba and Yaya Toure…Today, they have not yet become like Drogba and Yaya, but they are in good health.”
– Awa B., mother of five children, Côte d’Ivoire
Today, the countries most vulnerable to poliovirus outbreaks are those where the barriers to effective immunization are most acute. In high-risk countries like the Central African Republic and Côte d’Ivoire, populations are hard to access and persuading communities of the need to vaccinate can be difficult.
For polio workers in these countries, it is important to reduce outbreak risk through strategies that involve local people, and which are receptive to the local surroundings and culture. Not every child will grow up to be a champion footballer, but by persuading parents of the importance of immunization, they can grow up active and healthy, protected from the debilitating effects of polio.
The Central African Republic and Côte d’Ivoire are both considered outbreak risk countries due to their difficult political and security situations, weak health-care systems, and regular cross-border population movement.
Geographically close to Nigeria, one of the last three polio endemic countries, the Central African Republic is currently at risk of virus spread from Borno state where there was a poliovirus outbreak in 2016. In 2011, Côte d’Ivoire experienced an outbreak of wild poliovirus type 3, also originating from Nigeria.
Outbreak prevention is a central part of the strategy to end polio, as the spread of the poliovirus through under-immunized populations could make eradication more of a challenge. In high risk countries where delivering vaccine can be difficult, different methods must be used to comprehensively immunize every last child.
In Côte d’Ivoire, a round of National Polio Vaccination Days officially began on October 28th in Ebimpé, marked by a ceremonial gathering of vaccination partners alongside key members of the local community. Speaking at the event, the Minister of Health and Public Hygiene, Dr Raymonde Goudou Coffie, described the need to vaccinate every last child as a mission for everyone: “Traditional leaders, heads of households and communities need to be involved in this initiative.”
This is a powerful method of engagement – making sure that parents and local leaders, as well as health workers and volunteer vaccinators, are involved in the fight against poliovirus.
Vaccinators also understand that no single approach will fit every situation. Instead, the Global Polio Eradication Initiative partners and field workers must work hard to understand how best to communicate the risk of polio outbreaks to different communities.
For instance, to reach parents working in Nana Mambere prefecture of the Central African Republic, local radio station SIRIRI hosted a panel based radio discussion to mark the recent vaccination campaign. Featuring medical professionals and local politicians, the panel addressed community worries around vaccine, urging every parent listening to take their young children to be immunized.
The day before the October campaign in Côte d’Ivoire, an advance team of volunteer vaccinators in Grand-Bassam began vaccinating at the local weekly market. Knowing the routine of local women, they anticipated that there would be some children visiting the market with their mothers who might not be reached later in the week – making this gathering of the community too good an opportunity to miss.
Having an understanding of the communities targeted in campaigns, whether of their worries around vaccination, or even parents’ weekly schedules, is crucial to effectively reduce the risk of a polio outbreak.
In Côte d’Ivoire, Dr Bamba Souleymane, Departmental Director of Health in Grand-Bassam, noted the quantity of different health interventions that his team was attempting to successfully deliver. Alongside the polio vaccine, the volunteers were distributing impregnated mosquito nets, de-worming medication, and vitamins.
Such combined efforts use the GPEI’s well-established infrastructure to deliver a variety of desirable health benefits in communities, not polio vaccine alone. In places where the health infrastructure can be weak, the polio programme’s ability to reach remote children can be a big advantage for many reasons.
For Awa, the dream of her son becoming a champion footballer was a persuasive reason to take him to be vaccinated. For others, receiving different health benefits or hearing information via radio are compelling reasons to vaccinate their children.
Lowering the chance of an outbreak is never a straightforward process, but instead requires understanding parents, children, and communities.
The best vaccinators and campaign planners are able to spot opportunities to keep campaigns relevant, access groups in different ways, and ensure that coverage is sustained.
This way, we can successfully protect every last child.
In Afghanistan this year, staff from the non-governmental organization Care of Afghan Families collected 420 blood samples from children under 4 at the Mirwais Regional Hospital in Kandahar province. The aim? To find out whether polio vaccination campaigns have been reaching enough children, and whether the vaccines have been generating full protection against this paralysing disease. These ‘serosurveys’ showed that immunity in Afghanistan is high – and also identified where vaccination campaigns need to reach out further.
Whenever a polio vaccination campaign takes place, a purple dot of ink is painted onto the little finger nail of every immunised child to show that they have received the lifesaving vaccine. This data is collected and allows people to monitor the campaign and know exactly where children have been reached.
Now, with more children being vaccinated than ever before, the polio eradication programme needs to know more than how many children are being reached: we need specific data on where children are being missed.
Serosurveys are simple tests of the serum in a child’s blood, which measures their immunity (or seroprevalence) to different diseases. The polio eradication programme uses this test to see what level of protection a child has against wild poliovirus types 1, 2 and 3, allowing them to assess whether the vaccination campaigns are reaching enough children, enough times, to give them immunity.
At the Mirwais Regional Hospital, the children tested were from a diverse range of provinces. Their results were sent to Aga Khan University for initial testing, and then sent for further analysis to one of the Global Polio Eradication Initiative partners, the US Centers for Disease Control and Prevention in Atlanta. Through mapping both where they live and their immunity results, scientists at both institutions helped polio eradicators to discover the areas where a child is at most risk of being missed by vaccination campaigns.
Serosurvey results can be crucial for planning campaign strategies – making sure that every last child is reached, no matter where they live.
For Ondrej Mach, team lead for clinical trials and research in the WHO’s Polio Eradication Department, serosurveys “… are increasingly important for eradication efforts, allowing us to form an accurate picture of our progress so far, and the locations where we are being most effective.”
The Mirwais serosurvey proved that Afghanistan is closer than ever to eradicating polio, with more than 95% of children surveyed immune to wild poliovirus type 1, the virus type still circulating in some areas of Afghanistan, Pakistan and Nigeria, and more than 90% immune to type 3, which hasn’t been found anywhere in the world since November 2012. The tests also pointed to where gaps in immunity are, so that missed children can be found and protected.
These results are a strong reflection of the devoted work of polio vaccinators and community workers throughout the country, using their expertise to reach into every family, and spread awareness of the importance of polio vaccination.
As in Afghanistan, serosurveys are increasingly used in other countries where polio remains or poses a threat, to help identify the last remaining pockets of under-immunized children in high risk areas. This is especially important because with polio in fewer places than ever before, it is these unreached children that will take us over the finishing line.
By getting an increasingly accurate picture of where vaccination campaigns are operating successfully, as well as where the programme needs to renew efforts, we can move further towards the goal of reaching every child.
This helps us reach our ultimate goal – ensuring that every last child, everywhere, can be polio free.
The Afghanistan polio snapshot gives a monthly update on key information and activities of the polio eradication initiative in Afghanistan.
In October:
The Pakistan polio snapshot gives a monthly update on key information and activities of the polio eradication initiative in Pakistan.
October updates include:
In Nigeria’s north-eastern Borno state, children displaced by ongoing conflict are being reached with essential immunization and health care services, thanks to a strong network of Volunteer Community Mobilisers established by the polio eradication programme.
Two-year-old Hafsat Khalifa waits patiently in line with her mother, Hadiza. Hadiza is one of many women who’ve brought their young children to receive vital immunization at the local health camp in Maiduguri. Hafsat knows she needs to open her mouth wide when it’s her turn to receive the oral cholera vaccine just like she did when vaccinated with the Oral Polio Vaccine. She displays the confidence of a seasoned pro, although in reality this is the first year she has received any health services, having been born into an area of conflict. Along with these two vaccines, Hafsat will receive other much-needed health care during today’s visit.
Hafsat is one of many thousands of children affected by the humanitarian crisis in north-eastern Nigeria. The conflict has resulted in a surge in internally displaced persons, with limited access to medical care, leaving millions at risk of life-threatening diseases. Since four cases of wild poliovirus type 1 were detected in Borno in August 2016, an outbreak response for polio has been a top priority. But it has been carried out hand in hand with broader humanitarian efforts to meet the health needs of vulnerable populations.
UNICEF’s vast network of volunteer community mobilisers have not only played a vital role in ensuring that children like Hafsat receive OPV and other health services every time they are offered, but are leveraging the skill-set they’ve gained from their expanded training to impact child and maternal health far beyond polio.
In addition to receiving the oral cholera vaccine today, Hafsat’s nutrition status will be assessed at the health camp, and children identified as malnourished will be referred for receiving therapeutic food. This important network of polio vaccinators, with years of experience in reaching children with polio vaccines, has made a huge difference in halting the spread of cholera and meningitis outbreaks in Nigeria in 2017. They are also helping create awareness and generate demand for the upcoming campaign against measles.
The reach of this network even extends to protecting children before they are born. Volunteer community mobilisers provide critical antenatal care for pregnant women that can save the lives of mothers and babies alike. And this year, for the first time ever in an emergency humanitarian setting, antimalarial medicines have been delivered on a mass scale alongside the polio vaccine, reaching 1.2 million children in a campaign in August.
For families in Nigeria’s north-east, many who have fled their homes in the face of ongoing violence, this life-line to access essential services is critical to ensuring their children can grow up protected from vaccine-preventable diseases.
Dressed in a blue uniform, carrying a vaccine carrier on his shoulder, Imran Khan is a polio vaccinator working at Karachi Cantonment Railway station. “I make sure no child under five travelling by train is missed during the immunization campaign,” he says. Apart from vaccinating children, Imran also sensitizes their parents on the importance of vaccination and threats posed by the crippling disease.
Vaccinating children inside trains is a unique initiative introduced in Pakistan’s Sindh province which is connected with the rest of country through a railway network that transports millions of people every day. Passengers include people travelling to visit family and communities living on the border between Pakistan and Afghanistan as well as seasonal migrants and displaced populations. With many of these people moving between areas where polio continues to circulate, the threat of the virus continuing to survive as it moves from place to place via this human network is one of the biggest challenges the programme is facing. Reaching children on the move with the polio vaccine is therefore critical for stopping the virus.
Currently there are more than 500 permanent transit points across the country, where vaccination teams work to vaccinate all children under the age of five as they cross district, provincial and national borders. The strategy to vaccinate children inside trains themselves was started in Pakistan’s Sindh province in January 2017. Since then, during each vaccination campaign, polio workers vaccinate children travelling on the popular rail route between Karachi and Hyderabad, Sindh’s two biggest cities, which was selected for the project implementation.
“During campaign days, I travel from Karachi to Hyderabad on a daily basis. Along with other team members, we visit all the train compartments to vaccinate each and every eligible child”, says Imran Khan with passion in his voice.
According to Dr Nawab Khan, High Risk Mobile Population coordinator with Pakistan’s Polio Eradication Initiative: “To maintain and increase population immunity against polio in Pakistan, reaching children through public transport routes is an effective outreach strategy. It plays an important role in interrupting the transmission of poliovirus and represents a great opportunity to vaccinate children missed during door-to-door immunization campaigns.”
More than 24 thousand children have been vaccinated inside trains running between Karachi and Hyderabad since the project started.
It is thanks to the use of innovative strategies such as this one that the Pakistan Eradication Polio Programme has come so close towards achieving a future in which polio no longer endangers children, families, and communities. The progress can be seen in the declining number of wild poliovirus (WPV) cases in Pakistan: from 306 cases in 2014, to 54 in 2015, and 20 in 2016. As of October 2017, the total number of WPV cases reported in Pakistan stands at five.
The people working to end polio are helping broader humanitarian response efforts in north-eastern Nigeria. With malaria currently claiming more lives than all other diseases put together, a campaign was launched in October to reduce the malaria burden among young children in Borno state by delivering antimalarial medicines. At the same time, community health workers protected children against polio.
“The current campaign marks the first time that antimalarial medicines have been delivered on a mass scale alongside the polio vaccine in an emergency humanitarian setting,” said Dr Pedro Alonso, Director of the Global Malaria Programme, in an interview with WHO on the campaign and the broader humanitarian situation in Borno. “This integrated campaign with WHO’s polio and health emergency teams is an example of unprecedented collaboration to tackle the leading cause of death in a displaced population.”
The humanitarian crisis in north-eastern Nigeria has resulted in a surge in internally displaced persons, with limited access to medical care, leaving millions at risk of life-threatening diseases. In August 2016, four cases of wild poliovirus type 1 were detected in Borno; the outbreak response has been carried out hand in hand with broader humanitarian efforts to meet the health needs of vulnerable populations.
WHO’s well developed network of polio vaccinators, with their years of experience in reaching children with polio vaccines, is making a real difference to the drive against malaria. The polio programme in Nigeria has a vast infrastructure and hundreds of staff on the ground and they are coordinating efforts to make sure that families affected by the crisis have access to other healthcare services.
As a result, the campaigns have reached 1.2 million children with polio vaccines and antimalarial medicines, as shown through a WHO photo story. “I think we will imminently be able to show significant impact,” said Dr Matshidiso Moeti, Regional Director for Africa, reflecting on the encouraging results of the joint campaign.
Photo story: Integrated campaign tackles malaria and polio in north-eastern Nigeria
Malik is one of the hardworking vaccinators making sure that even children on the move are protected against polio.
The poliovirus knows no borders, making children on both sides of the border between Afghanistan and Pakistan vulnerable to contracting the debilitating disease. This is why, placed strategically along the border, 19 WHO-supported vaccination posts reach children on the move as they cross between countries, ensuring that all children under the age of 10 receive two drops of the oral polio vaccine to protect them from polio.
One of these teams is led by Malik, who has worked for the polio eradication programme for 14 years.
“I wanted to join the eradication programme when I heard that polio is a contagious disease that affects children. I wanted to serve children and our community. I learned about polio on the TV and radio and the health workers who came to our home to share information about the virus.”
Protecting children on the move
Malik started working as a vaccinator and has now worked as a team supervisor for the past 10 years.
“I am proud when we can reach every child and when I see my team vaccinating children, making sure that no child is missed. This makes me very happy,” he says.
Cross-border vaccination teams are crucial in the fight against polio. The Torkham border between Afghanistan and Pakistan, in eastern Nangarhar province, is one of the busiest border crossings in Afghanistan. Currently 38 WHO-supported vaccinators work in three shifts, operating 24 hours a day, 7 days a week.
“Today I started my work at 5.30 am. When we arrive at work in the morning, I gather the team together and we go through any issues that arose in the previous shift. We revise the schedule of the day and I assign teams to their specific locations. We have three locations at this border where we vaccinate all children coming to Afghanistan and those who are leaving.”
Checking for signs of polio
Since January 2017, WHO and partners have vaccinated over 44 000 Afghan children under the age of 10 crossing the border to Afghanistan from Iran and Pakistan. Over 25 000 of these have been vaccinated at the Torkham border’s so called “zero point” – the first point where Afghan refugees and returnees returning from Pakistan arrive.
“We focus a lot of finding cases of acute flaccid paralysis, sudden onset of floppiness in the limbs that is a sign of polio. We check children in all the vehicles that arrive at the border and work hard not to miss any potential polio cases,” Malik says. “When the trucks park here, we talk to the parents and ask about any possible cases of paralysis in the family. We also educate them about the importance of vaccines and tell them about the routine immunization services that are available free-of-charge in Afghanistan’s health facilities.”
Building trust
Most caregivers crossing the border to Afghanistan accept the polio vaccine but challenges remain.
“Sometimes we see parents who refuse to vaccinate children. We try our best to convince them to vaccinate by telling them more about the benefits of the polio vaccine and how polio cannot be cured. Those who refuse to vaccinate their children often don’t understand what the vaccine is or how it is essential for protecting their children,” Malik says.
Despite difficulties and his demanding work in a challenging environment where the security situation can shift quickly, Malik and his team are determined to continue the fight against polio.
“Afghanistan is still polio-endemic and the virus is deadly,” he says as he leads his team to approach another truck that crossed the border into Afghanistan. “I want to deliver these crucial services, serve my community and protect vulnerable children.
Read the original interview here.
Volunteers have been and continue to be the backbone of the eradication effort. Local Rotarians are raising critically-needed funds, and members of the community conduct the actual administration of the vaccines on the ground and report cases of paralysis. Without this vast network of volunteers – approximately 20 million strong worldwide – polio cannot be eradicated. They are the true unsung heroes of this effort.
Those are precisely the main hurdles: reaching children who remain unreached by health systems, because of difficult terrain, conflict, security compromised access, urban sprawl, or large-scale population movements. These are all reasons some children are not vaccinated. The poliovirus is very effective at finding vulnerable children, so we have to be better than the poliovirus at finding that last unvaccinated child. And that is what we are doing with local authorities and partners. Identifying – area by area – the real reasons why children in that area are missed, and then putting in place operational action plans, at the community level, to overcome those reasons. We’re making strong progress: never before has polio been as geographically restricted as it is today. But we are not there yet, and we need to pursue our efforts.
This is a key issue, particularly at this late stage of the effort, where we really have to focus on reaching the last one or two percent of children who we have so far missed. It is not good enough to achieve 95% coverage nationally, if sub-nationally we are still missing 5%-10% of children somewhere. So we need to be extremely rigorous in the monitoring of our activities, in particular when we assess population immunity levels. We have introduced a number of innovative approaches to address this challenge, such as Lot Quality Assessment sampling, to identify areas which fail to achieve campaign coverage targets; third party monitoring, to get an external view on data quality; and seroprevalence surveys, which show actual immunity levels of children in key areas or high-risk population groups. These tools provide the clearest and most reliable picture of immunity levels.
Polio eradication has always been about more than polio. Rotary International calls this effort ‘PolioPlus’, with the ‘plus’ standing for more than polio. Polio-funded staff on the ground have been busy helping address other public health emergencies, from the Ebola outbreak in West Africa, the recent drought in the Horn of Africa, to the devastating earthquake in Nepal a few years ago.
Polio-funded staff have also supported Gavi’s immunization efforts, including assisting countries in their implementation of Gavi-funded vaccine and health system strengthening activities. As a concrete example, the proportion of children who have been fully immunized against all vaccine-preventable diseases in some of the most marginalised areas of India increased from less than 20% ten years ago, to more than 80% today.
These broader benefits of the polio eradication effort, however, require that countries and the international
community make sure that the momentum is maintained when polio is eradicated. Indeed, unless this is well planned, the loss of funding coming through the Global Polio Eradication Initiative could negatively impact immunization programmes and other health interventions which have benefited from the large network of staff deployed to eradicate polio. Discussions with partners and countries are underway to map out this process for the post-polio world.
Polio eradication has indeed shown that all children – no matter where they live – can be reached with health interventions. The premise of this programme has been that every child has a right to be protected from lifelong polio paralysis, whether they live in Switzerland, or whether they live in conflict-affected areas of Somalia or areas with limited healthcare infrastructure of Afghanistan. And the lessons and experiences can be – and are being – applied to other disease control programmes.