GPEI-Reaching the Hard-to-Reach: Dense Urban Environments

During polio vaccination campaigns in big cities such as Cairo, Egypt, vaccinators go above and beyond to find millions of doors to knock upon to find children who need to be vaccinated. © GPEI

Rising up into the sky, a tower block’s outline trembles in the heat haze, even in the early morning. It’s hard to count the number of floors from the ground as the concrete block stretches up so high. Inside the door, you look around for an elevator – but there is none. Taking a deep breath and hoisting the vaccine carrier higher onto your shoulder, you begin the long climb up the stairs through the heat. At the top, many pauses for breath later, you knock on the first door. As a mother holding her baby opens it, your work for the day really begins – but there is a long way to go. To vaccinate every child in the city against polio, you and your fellow vaccinators must knock on every door in this building; on this street; in this neighbourhood; and across the entire city. It is a monumental task – and one you take on several times a year.

Cities: Uniquely challenging environments

Often it is the ability of polio vaccinators to reach the most remote and inaccessible villages, hampered by challenging weather or conflict, that is the biggest challenge to eradication. But big cities, while more easily accessible, can pose an equal challenge.

Dr Mohammed Sibak Abouzeid, has been working to stop polio in Egypt since 1999, planning and organising polio eradication campaigns and evaluating whether enough children were reached in each campaign so that the next one can be better. Over 40% of Egypt’s population lives in urban environments.

“While my colleagues in the countryside are battling challenging terrain, weather and long journeys, we have a different set of barriers: slums, high rise buildings, marginalised communities and big populations that can change overnight,” says Dr Mohammed. “But our goal is the same: to reach every single child, no matter where they live.”

One critical tactical shift to ensure all floors of a tower block were covered was to ensure vaccinators first walked to the top floor, and then knocked on every door coming down, rather than the other way around, which meant the very top floors were missed.

A playground for polio

Cities provide an easy environment in which for polio to spread. The poliovirus spreads between humans through faeces, so wherever sanitation systems or hygiene practices are poor, or many people live in close quarters, the virus is able to spread rapidly.

Vaccination teams go door to door in urban slums such as this. This location is also used to collect sewage water which is tested for poliovirus as part of the country’s environmental surveillance network. UNICEF/S. Biswas

The city of Karachi is one of the remaining strongholds of the virus. People move in and out of Pakistan’s biggest city constantly: these ever changing populations make it difficult to know how many children need to be vaccinated and where they live. Many children are born every day, giving the virus many opportunities to hide in the unvaccinated guts of infants who have not received at least three doses of polio vaccine. Given the informal nature of many of the slums within this city, the lack of infrastructure such as health care centres can make it especially difficult to get vaccines to every child.

Slums have another consequence for polio eradication; with high levels of poverty, malnutrition and diarrhoea are regular threats. Malnutrition can damage the immune systems of children, meaning that even if they receive the vaccine, it might not be able to kick start the process of generating protection against the virus. Diarrhoea can lead to the vaccine leaving the body too quickly for it to begin creating antibodies; but it also can act as a vehicle to cause the poliovirus to spread further and faster.

Stopping polio in cities

Stopping polio even in these challenging environments takes ingenuity and creativity. Luckily, people like Dr Mohammed have the experience necessary to make a difference.

The city of Dhaka, Bangladesh, stretches off as far as the eye can see, hiding from view the millions of children who need to be vaccinated against polio. © Gavi

“To stop polio in urban environments, you need to train all vaccinators incredibly well, and give them the motivation they need to work in difficult environments. But the most important thing is to come to understand the networks that city inhabitants are a part of so that you can engage them, involve them in vaccination campaigns and find the right influencers from local communities to encourage parents to vaccinate their children.”

In cities like Cairo in Egypt and Mumbai in India, once thought to be the hardest places in the world to stop polio, such tactics were instrumental in stopping poliovirus. Indeed, they continue to be used even now in order to ensure high vaccination coverage and keep their populations protected. It may be a matter of getting the right neighbourhood religious leader to announce vaccination campaigns during a sermon, or the right midwife to tell new mothers about vaccination, but one thing is for sure: success against polio is ensured one person at a time, even in a city of millions.

Some of these girls have been practising for six years to master the skills they have. Being part of the circus enables them to also attend school. Children in the audience take great please watching other children perform with amazing skill. © UNICEF Afghanistan/Ashley Graham

“I am the king of this village! Every child belongs to me and I will spread my poison to a new person every day,” screams the snake, bursting onto the stage.

In the audience, children gasp and jump backwards, their eyes wide.

Hamid, clutching his precious box of vaccines, attacks the snake, managing to defeat him. The crowd cheers.

“Vaccinating your children will destroy this disease!” cries Hamid. “Make sure your whole village takes these droplets and you will see how strong you and your children can be.”

Clutching the precious box of vaccinations, the vaccinator (played by Hamid himself) finally manages to defeat the deadly polio threat. The crowd watches intently, you can see in their face that they are listening to the story about the danger of polio. © UNICEF Afghanistan/Ashley Graham

This poisonous snake – mor zaharia as it’s called in Dari – represents the dangerous threat of polio, a disease that Afghanistan is fighting hard to eradicate.

Hamid leads a touring youth circus group made up of children and teenagers from all across the capital, Kabul, who performs juggling, acrobatics and theatre routines for local audiences around the city and beyond.

Today the circus is in Qargha, Kabul, Afghanistan. It was started 14 years ago by Mobile Mini Circus for Children and is supported by UNICEF.

The circus enables the children who join – often from internally displaced communities around Kabul – to go to school every day and then practise circus skills at their centre after school and on weekends.

Part of their impressive performance includes passing on vital messages about healthcare and social issues to the audience, who may otherwise not have access to this information.

“Our circus is entertainment and it is so much fun for the performers and for the audience,” says Hamid.

The objective is to pass on a message about the importance of vaccinations against polio. “We pass on these important messages in a fun way which people listen to and they understand. Giving a message without fun means people will not take that message away,” says Hamid, who leads the circus. © UNICEF Afghanistan/Ashley Graham

“We pass on these important messages in a fun way which people listen to and they understand. Giving a message without fun means people will not take that message away.”

This is especially true of the children, who flock to the circus the moment they see youngsters their own ages pull out their juggling sticks and begin clowning around on the makeshift stage.

“We often perform in the internally displaced persons camps,” says Hamid. “These areas are not peaceful and the people have no proper shelters, no electricity and no running water.”

These conditions provide the perfect environment for communicable diseases like polio to spread; yet a simple oral vaccination, just two drops in the mouth, can bring a child closer to a life without polio. Children in Afghanistan will be vaccinated against polio multiple times, until the disease is stopped for good.

During the August and September 2017 National Immunization Days 9.9 million children under five across Afghanistan were targeted with repeat doses of the oral polio vaccine.

Afghanistan is closer than ever to eradicating polio. Through this photo essay, discover 10 innovative approaches that are bringing Afghanistan closer to ending polio, for good.

It’s a clear, summer day in Safdarabad, in the Punjabi province of Pakistan, and Mr. Patras Maseeh Bhatti and his colleagues have just arrived at “work” for the day. Surrounded by brick buildings instead of the inside of laboratory, they might look out of place in their attire. Dressed from head to toe in bio-hazard lab coats, long black rubber boots, and thick industrial gloves and armed with a bucket, their mission is to collect enough sewage from the selected sample site to be transferred in a separate container to the laboratory in Islamabad. Once there, the sample will be tested for poliovirus.

This sampling is part of a system of disease surveillance, which underpins the entire global effort to eradicate poliovirus. Without surveillance, it would be impossible to pinpoint where and how wild poliovirus is still circulating, or to verify when the virus has been extinguished from the wild.

Across the Eastern Mediterranean Region, disease detectives like Mr. Bhatti are becoming more and more important in the fight to end polio. In addition to surveillance for Acute Flaccid Paralysis (AFP), which involves the detection and reporting of children with rapid-onset ‘floppy’ limbs, environmental surveillance involves testing sewage or other environmental samples for the presence of poliovirus.

“This is the only mechanism where you will be able to detect viruses that are circulating with the absence of paralytic polio cases,” Dr Humayun Asghar of WHO’s Regional Polio Programme explains. “As we get closer to eradicating polio even with very high [vaccination] coverage in the population, the virus can still circulate undetected in under-immunized children.”

The growing network of disease detectives

Although AFP surveillance remains the gold standard for surveillance for polio, only one in approximately 200 cases of polio actually show symptoms of paralysis. The World Health Organization has been working closely with a number of countries within the Eastern Mediterranean Region to expand environmental surveillance networks and build capacity in field and lab staff. In endemic areas, environmental surveillance is providing critical supplemental information and data, enabling epidemiologists to tailor the eradication strategies even further. In other parts of the Region, it is proving a critical additional tool to mitigate the risks of a potential virus importation, particularly given the challenges that some countries face, including large-scale population movements, inaccessibility or insecurity.

“In these situations, any additional tools to supplement our AFP surveillance are critically valuable,” he says, “and we need a robust system in place for countries to be able to manage this network.”

In countries like Pakistan and Afghanistan, Dr Asghar says rapid and extensive population movement is the biggest risk for the virus spreading. “The virus moves with the people, so we cannot be sure that the virus is staying where we detect the cases. Here, environmental surveillance has proven extremely valuable because in the absence of many paralytic cases, we continue to detect wild poliovirus in the environment which tells us a lot about how and where the virus might be continuing to hide.”

The detection of poliovirus in countries not recording paralytic cases is also very useful, Dr Humayun says. During the polio outbreak in the Middle East in 2013-2014 this helped to inform partners carrying out the multi-country regional response where to further concentrate efforts in order to close the outbreak and ensure it did not spread further.

In both Pakistan and Afghanistan, environmental surveillance has been one of the key strategies for narrowing in on where the virus continues to circulate, and the lessons learned through the establishment of environmental surveillance in these countries is informing the expansion across the region.

In Lebanon and Jordan, where environmental sampling has been established in 2017, staff have been trained to collect samples from specified collection sites and to ensure the samples reach the laboratory in Amman in the right condition for processing.

Efforts to build on existing health infrastructure and disease surveillance systems in Iran, Sudan, Somalia, Syria and Iraq are underway, with plans for the expansion of environmental surveillance systems and lab networks in 2017.

Leaving a lasting legacy for health systems

Since the Global Polio Eradication Initiative (GPEI) began in 1988, the programme has mobilized and trained millions of community health workers and volunteers for surveillance. A standardized, real-time global surveillance and response network exists and is being put to full use.

Dr Humayun says that this investment in people and infrastructure is not only of benefit during the last mile of polio eradication, but will be a lasting legacy that the polio programme will leave behind for health systems of countries across the region.

“Polio surveillance methods, techniques, facilities and knowledge are our biggest assets, but they have applications beyond our programme. So, these laboratories can be of great value then to countries who need to develop their capacity in other diseases of public health importance,” he says.

Learn more about disease surveillance

Africa’s last case? Two-year-old Yafanna Mamma, held by her mother, Yagamallam, in a photo captured by the polio case investigation team. Photo: GPEI

The photo shows a little girl in a blue dress, resting against her mother’s shawl, a tiny green heart hanging from her ear.

It is just over 12 months since two-year-old Yafanna Mamma became Nigeria’s most recently-reported case of wild poliovirus. But this anniversary provides little cause for cheer – last year, Nigeria was about to celebrate two years without any cases, only for four infants to arrive from deep inside conflict-affected territory, in the remote north-eastern state of Borno, paralyzed by polio. Yafanna was the last of them, arriving in the northern Nigerian outpost of Monguno malnourished and sickly.

The discovery of polio in these children underlines the challenges facing the polio eradication programme – and many other health and development initiatives – working in conflict zones. Amidst the ongoing humanitarian crisis in North-Eastern Nigeria, at least 200,000 children are estimated to still live in inaccessible areas, where insecurity is a constant threat. All humanitarian activity, including vaccination campaigns and disease surveillance, is made all the more difficult across these areas, and there is a significant risk that poliovirus continues to hide undetected, spreading among unvaccinated children in the area.

Yafanna’s paralysis was a lesson that when vaccination and disease surveillance efforts pose such a challenge, finding no polio cases does not mean that there is no virus.

Yafanna’s family – father Ali, mother Yagamallam and their two surviving sons – are a living example of the consequences of conflict on the health of families. Their small village, Zanari, is four hours’ walk into inaccessible territory north-east of Monguno, with no health centre and irregular access to vaccination campaigns.

“Since 2014, there is no health facility,” Ali says softly, seated beside his wife in the WHO-UNICEF joint office in Borno’s capital, Maiduguri. “The closest facility is in Monguno town and walking it takes many hours.”

They made that walk, carrying their infant daughter, two weeks after she had fallen sick with a high fever and they soon noticed she could no longer stand. When they arrived in Mongonu a worried doctor quickly referred them to Maiduguri, where they attended a health facility in a camp for internally displaced people.

“At the health facility they asked us to bring stool samples from our daughter, they gave us medicine, and after we went back home. The fever got better, but she stayed paralyzed.”

After two weeks, the military arrived, guarding a medical team which confirmed that little Yafanna, who had never received any doses of oral polio vaccine, had been found by the poliovirus.

“We had heard of this disease,” Ali says, looking down at the table. “But we didn’t know what it could do. Before the insurgency, vaccinators would visit us with a motorcycle. But after the insurgents came the vaccination teams stopped coming.”

The polio eradication programme is working hard in Nigeria to reach every child with the vaccine, and to find the virus wherever it is hiding. Vaccinators are steadily reaching more children, using strategies such as engaging and collaborating with local communities, vaccinating in camps for internally displaced people, and in different locations like markets and transit points. But there is still much work to do.

Little Yafanna never walked again. Three short months later after her paralysis, she contracted another disease – possibly whooping cough – and on 27 December 2016 after three days of coughing and fever, she died.

Ali now has been engaged to talk with the community about the threat of polio, and the importance of vaccination. “I pray that we can honour her life by making her the last polio case in all of Africa. So that her name is remembered. So that her life is remembered.”

The Pakistan polio snapshot gives a monthly update on key information and activities of the polio eradication initiative in Pakistan.

July updates include:

No new cases of polio reported – the total for 2017 remains 3
The Federally Administered Tribal Areas marked one year without reporting a case – down from a high of 179 cases in 2014
Small-scale vaccination campaigns were carried out in July in the core polio reservoirs and other high risk areas, aiming to reach 10.1 million children

The Afghanistan polio snapshot gives a monthly update on key information and activities of the polio eradication initiative in Afghanistan.

July updates include:

One new case of wild poliovirus was reported, bringing the total number of cases to 5 in 2017
Vaccination campaigns were carried out across 28 provinces, aimed at reaching 6.5 million children under 5 with oral polio vaccine OPV
Smaller campaigns aimed to reach 104,000 children with IPV & OPV in Kabul City and Khak-e-Safed district of Farah province, and 43,000 children with OPV in Paktika province

Fifty-seven year-old Khalida, a striking figure on her four-wheeler motorbike, is a supervisor of one of the female vaccinators’ teams in Karachi, Pakistan’s largest city.

“I have been working as a supervisor for three years, but I have been associated with polio vaccination campaigns for many years as volunteer,” she explains. The community in the area where Khalida works is mostly from Pakistan’s tribal areas in the north-west of the country, and distrustful of outsiders. Traditionally, this mistrust involved not accepting vaccination. Today, all families in the area accept polio drops.

Khalida had worked in different jobs but wasn’t satisfied until she was offered a job of polio team supervisor. Her influence in the area has been critical to overcome myths about vaccination and build knowledge and trust.

Having women like Khalida working on the frontlines is a game changer for polio eradication. The fact that she is well known and trusted in her community means that mothers and fathers are more likely to allow her and her team to take the crucial step across the thresholds of their homes to vaccinate their children. The Pakistan Polio Programme’s emphasis on local, motivated, full-time, community-based female vaccinators has been improving immunization coverage figures. Across the country, the proportion of vaccinated children increased from 85% in August 2016 to 92% in May 2017, according to independent post-campaign monitoring.

In my community, the number of polio cases has decreased drastically. The progress is visible with the naked eye. We hold rigorous polio campaigns which are being carried out frequently in the area to reach every child multiple times with vaccines and keep them safe against paralysis. In this regard the contribution of the frontline health workers I supervise is remarkable, as they work hard to ensure each and every child is protected from this crippling disease.

Polio eradication is very important to have a healthy generation; as healthy generations, these children will be able to better serve the country – Khalida

For Khalida, vaccinating children against polio is a true mission. “Since I began working to end polio, I feel like I am a soldier. Just as an army fights to protect a country, similarly I fight against a virus which is disabling our beloved children. I will fight against this crippling disease until the virus is permanently eradicated and our beloved children are fully protected”.Khalida’s work spans a large area, with temperatures in the summer reaching 40°C, making the work of vaccinators very challenging. To provide supervision to the polio teams under her care, Khalida uses a motorbike specially designed for her for this very purpose – it has four wheels and is capable of crossing the rocky terrain and getting her where she needs to go at top speed. The sight of Khalida coming into a settlement on her motorbike has become a well-known, welcome sight.

Pakistan is one of only three last polio endemic countries, along with Afghanistan and Nigeria. The number of cases has declined dramatically in the past years: from 306 in 2014 to 20 in 2016. As of June 2017, the number of polio cases reported in Pakistan was three.

A child receives two drops of polio vaccine during the May vaccination campaigns in Lahore, Pakistan. WHO Pakistan/Anam Khan.

At the end of May 2017, more than 38 million children under the age of 5 were vaccinated against polio in Pakistan. During the campaign, over 250,000 trained polio workers went from house to house across the length and breadth of the country to vaccinate children against the crippling disease.

This was one of five country-wide vaccination campaigns that took place during the 2016/2017 “low season” for poliovirus transmission. From October to May when temperatures are low in Pakistan, the virus remains less active, giving polio eradication experts the opportunity to get ahead of the virus.

The end of the May polio campaign marked the start of the “high season” for poliovirus transmission. The ability of the poliovirus to infect children increases in high temperature and during heavy rainfall. As a result, viral circulation is expected to be higher from June to September.

Reaching more children

With steady gains in the proportion of children vaccinated during the 2016/2017 low season, the May campaign achieved an overall goal of vaccinating 92% of the targeted children, according to independent post-campaign monitoring. The highest vaccination coverage rates were observed in Khyber Pakhtunkhwa (KP), Sindh and the Federally Administered Tribal Areas (FATA), some of the highest risk areas of the country, with rates increasing from 84% to 95% in KP and 77% to 93% in Sindh in the last nine months.

A polio vaccinator marks the door of a house to show that the children living there were not home when he called, so that they can be vaccinated by campaign monitors the next day. WHO Pakistan /Anam Khan.

However, more work is needed to bring vaccination rates up to 95%, the level identified as that needed to stamp out the virus for good. FATA remains the only region consistently over 95% in the last three campaigns, with Balochistan, Islamabad, Azad Jammu, Kashmir and Gilgit Baltistan not reaching the benchmark.

With the high season underway, Pakistan is well-positioned to respond to these remaining gaps and challenges. The current situation remains the best we have ever seen in the country, with the virus geographically limited. The number of cases has declined from 306 in 2014 to 53 in 2015, and to 20 in 2016. So far this year, the number of polio cases reported in Pakistan is three (compared to 13 the same time last year). However, this progress means that there is more to lose than ever before. The low season campaigns put the polio programme in a better position with which to fight the virus through the high season.

Poliovirus in the environment

While the number of new wild poliovirus cases remains record low, the environmental surveillance system indicates the virus remains a serious threat to children, with the proportion of samples being tested positive for poliovirus reaching 18 per cent as of May this year compared to 10 per cent as of May 2016. In particular, the environmental presence of the virus has increased in the Quetta block, Karachi and the twin cities of Islamabad-Rawalpindi. The programme is systematically addressing and responding to these challenges by focusing on reaching missed children and continuously improving campaign quality to remove every last hiding place of the virus.

A father and daughter proudly show off the purple dot of ink on her little finger to show that she has been vaccinated against polio in the May campaign. WHO Pakistan/Anam Khan.

Preparing for the next low season

Government leadership is fully committed to the National Emergency Action Plan (NEAP), implemented via focused Emergency Operations Centers at National and Provincial levels, with emphasis on evidence-based decision making, a one-team approach between all of the partners of the GPEI and the government, highlighting the essential role of front-line workers at the center of the polio eradication effort, effective oversight of performance management and accountability, and coordination across the common Afghanistan-Pakistan epidemiological block. As eradication moves into the final stage, seamless cross-border coordination with Afghanistan, that has had four polio cases so far this year, becomes ever more critical to success in both countries.

Late August marks the beginning of the Hajj season – the annual pilgrimage of Muslims to Mecca – bringing together people from all over the world. While a holy time of pilgrimage, this also presents health risks as people are coming together from many countries where they may have been exposed to different infectious diseases.

The Ministry of Health of Saudi Arabia has issued health requirements and recommendations for entry into Saudi Arabia during the Hajj season, including requirements relating to polio vaccination. Regardless of age, all travellers from certain, specified countries must show proof of vaccination against polio within the last twelve months, and at least four weeks before departure. All travellers from these countries will also receive one dose of oral polio vaccine on arrival in Saudi Arabia.

These requirements apply to travellers from the following countries:

WHO African Region	Cameroon, Central African Republic, Chad, Democratic Republic of the Congo, Equatorial Guinea, Ethiopia, Guinea, Kenya, Liberia, Madagascar, Nigeria, Niger, Sierra Leone, South Sudan
WHO Eastern Mediterranean Region	Afghanistan, Iraq, Pakistan, Somalia, Syrian Arab Republic, Yemen
WHO South-East Asian Region	Myanmar
WHO Western Pacific Region	Lao People’s Democratic Republic
WHO European Region	Ukraine

A doctor greets a Syrian child in a refugee camp, where children are vaccinated against polio and other diseases. Photo: WHO

In recent years, the global drive to eradicate polio has seen the virus cornered in fewer places than ever before. Yet polio’s final strongholds are some of the most complicated places in the world to deliver vaccination campaigns. Insecurity and conflict are some of the challenges to delivering vaccines, as well as populations on the move, testing terrain and weather, and weak health systems.

In 2013, polio outbreaks in Central Africa, the Horn of Africa and the Middle East paralysed hundreds of children. The Global Polio Eradication Initiative (GPEI) developed strategies to deliver vaccines and stop the virus, even when access seemed impossible. All three of these outbreaks were put to an end just a year later, by not letting the complexity of the situation undermine the quality of vaccination campaigns.

The valuable lessons learned by the GPEI in tackling these outbreaks are now being used to end polio in the final polio endemic countries – Afghanistan, Nigeria and Pakistan – as well as to stop a newly-detected circulating vaccine-derived polio outbreak in Syria.

Challenges to immunization in emergencies

Disruptions to routine immunization systems and mass displacement caused by conflict can rapidly reduce population immunity, making individuals much more vulnerable to polio outbreaks. Polio eradication relies on being able to repeatedly access over 95% of children with vaccines. Yet emergency settings can interrupt systems that gather data about a population, functioning health facilities, health care personnel, vaccine supplies, cold chains to keep vaccines safe, power supply, financial resources, population demand for vaccines, and disease surveillance. When these factors are at play, the GPEI calls on past experience and adopts new approaches to reach every last child.

Lessons learned in conflict zones

Community acceptance and trust

When there are barriers to access, the first step is to have community trust and acceptance of vaccination. Every community and context is different and calls for a targeted approach to communicate exactly why immunization campaigns need to take place. The polio eradication programme identifies and trains vaccinators from local communities, engages religious figures to support the campaign and gets local leaders on board to advocate for, plan and implement vaccination efforts. The polio programme has seen time and time again that when securing access is a challenge, the answer often lies in the very communities we are trying to reach.

In Pakistan, a number of Religious Support Persons have been recruited based on the guidance of the Islamic Advisory Group for polio eradication, to address concerns of local communities about polio vaccinations in some challenging areas of the country. This has resulted in enhanced community acceptance of immunization, with refusal rates of less than 1.5%, as well as broader child welfare interventions.

Opportunistic vaccination campaigns

When different forces make populations periodically inaccessible, vaccination schedules can be interrupted and leave pockets of people unprotected against polio. In these situations, health authorities try to reach children in whatever ways are possible. Transit points can be set up around insecure areas, to vaccinate children as they enter or leave; vaccinators work with local leaders to track and reach populations on the move; communities within the inaccessible areas can store and deliver vaccines themselves; and brief periods of calm can be used to bring vaccines and other essential health services into villages through a health camp.

In Pakistan, over 350 transit points have been set up in recent years along borders and near areas with access challenges. This is one of the innovative approaches that have reduced the percentage of children missed on vaccination campaigns from 25% in 2014 to 5% in 2017.

Negotiated access

In the most challenging situations, when all other approaches are not able to overcome the severity of vaccination challenges, the programme has negotiated access by engaging non-state actors, governments, religious figures and local leaders. Reiterating the humanitarian principle of “neutrality,” the GPEI works with all parties to a conflict to highlight the importance of vaccination campaigns, and secure agreements to access targeted communities for specific periods of time.

In the past, negotiating access to conflict zones was comparatively simple to today. In the 1980s, days of tranquillity were first used in the Americas, through negotiation with two groups – often the government and the opposition group. In many areas where polio persists, there are many different actors and groups engaged in conflict, so negotiation is more complex. It includes identifying who is appropriate to negotiate with in any given district or area, and, importantly, finding appropriate negotiators. Often, third party partners such as the International Committee for the Red Cross are engaged to negotiate operations of vaccination campaigns in security-compromised areas, and in areas where vaccination bans have been imposed by local authorities.

Conflict and insecurity continue to pose significant challenges to eradication. Our best chance of ending polio for good in conflict zones lies in learning from these lessons and adhering to the principles of neutrality in health.

New funding and political commitment will enable the GPEI to protect 450 million children from polio every single year. WHO/L.Dore

Atlanta, USA, 12 June – Public health leaders gathered at the Rotary Convention in Atlanta to unite in their commitment to securing a polio-free world. Endemic countries and donors together pledged US$ 1.2 billion to finance the polio endgame.

The Global Polio Eradication Initiative was launched in 1988, spearheaded by Rotary International. For the past three decades, Rotary has brought political commitment, funding and energy to the fight against polio. At this pledging event, Rotary committed a further US$ 150 million to the cause.

At a time when polio eradication has never been closer, new funding and political commitment is more important than ever. The poliovirus has been cornered to just three remaining countries – Afghanistan, Nigeria and Pakistan – but this progress is fragile. While polio continues to exist anywhere in the world, children everywhere remain at risk. Each year, the GPEI reaches 450 million children to vaccinate them against the virus, in polio endemic countries and elsewhere, and maintains disease surveillance systems in more than 70 countries to find and stop every last virus.

Today, 16 million people are walking who would have been paralysed if they had not been protected against polio thanks to the extraordinary efforts of public health workers. This new injection of funding and commitment will ensure that in the future, no child will ever again suffer from the consequences of this incurable, but preventable, disease.

Young mothers waiting to vaccinate their children receive information on exclusive breastfeeding from a polio-funded Volunteer Community Mobilizer. @ UNICEF/R. Curtis

“Are you watching me?” “Yes, ma’am.”

“Are you seeing me?” “Yes ma’am.”

Along two rows of benches under the awning of the Chikun Primary Health Centre in northern Nigeria’s Kaduna State, about 50 young mothers sit still, their babies swaying on their laps. All eyes are fixed on Lidia, the assured polio social mobilizer who is not delivering polio vaccine, but showing the women how to correctly breastfeed.

Lidia is a grandmother, a one-time community midwife now employed with Nigeria’s polio eradication programme as a UNICEF-supported Volunteer Community Mobilizer (VCM). During the monthly polio vaccination campaigns, she goes house to house with the vaccination team, opening doors through her trusted relationship with the mothers, tackling refusals where they occur and tracking any children missed in the campaigns through her field book containing the names and ages of all children in her area. But it is between campaigns where Lidia’s full worth is realized.

Trust

Helen Jatau, a supervisor in this Local Government Area, supervises 50 VCMs and five first-level supervisors. She is convinced the health care polio frontline workers provide between campaigns provides benefits beyond the surface value – it establishes trust. “When we bring different things to the mothers, it helps the community live better and even accept us more, because we are giving more than just polio vaccines.”

Between polio vaccination campaigns, mobilizers like Lidia track pregnant women and ensure the mothers undertake four Ante-Natal Care visits, including immunization against tetanus. They advise mothers-to-be to give birth at the government health facility, provide them with the first dose of oral polio vaccine, facilitate birth registration and connect them to the routine immunization system. In houses and at monthly community meetings, the mobilizers also provide information on exclusive breastfeeding, hand washing, the benefits of Insecticide Treated Bed Nets, Routine Immunization and the polio vaccination campaign.

Ante-Natal Care

VCM Charity Ogwuche stands before the mothers at the health centre and peels over the pages of a colourful flip book. “Breastmilk builds the soldiers inside your child,” she shouts. “It will save you money. You don’t need to find food for your child to eat. You don’t need to find water: 80% of breastmilk is water. It will protect your child.”

Adiza, a young mother holding her first child, Musa, carries a routine immunization card including messaging on breast feeding and birth registration. “Aminatu talked to me about antenatal care. She asked me to get the tetanus shot, and today she has brought me here to receive routine immunization for my baby. I am really grateful. If she wasn’t here I wouldn’t be here. I wouldn’t know about it. She is the only one who tells me about this.”

Charity is proud of her work. “The women are so familiar with me, it makes me happy. They call me Aunty. I provide most of the health information for them. Really there is no other in our community. They are very young mothers and they need me.”

Birth registration

Every Tuesday is birth registration day. Once, hardly a soul turned up to register their newborns, but today, a long line of VCMs are standing clutching handfuls of registration forms, waiting to register the newborns within their catchment area.

Aminatu Zubairu, wrapped in the trademark blue hijab of the VCM, explains how all social mobilizers must come from their own community, and how that familiarity breeds the trust that has enabled her to register hundreds of children in her area. “I go to their houses and ask if they had the birth registration. If they say no I take all the information. Now I will register them and get the certificate of birth and carry it to their house to give back to them. In a month I can do 50 of these. This year there are plenty of newborns.”

Danboyi Juma, the district’s Birth Registration Officer, believes birth registrations have increased by 95% since VCMs assumed responsibility for the service. “They are helping us so much because they go house to house,” he says. “They have increased the number of birth registrations in this area by so much – oh, that’s sure.”

Routine Immunization

Jamila and her baby Arjera, who was vaccinated for the first time, following the persistent efforts of her VCM Rashida Murtala. @ UNICEF/R.Curtis

Despite stifling heat, on this Tuesday, there are more than 50 mothers and several fathers sitting on benches, waiting for their turn to have their babies vaccinated. More than 80% of them carry the cardboard cards given to them by VCMs to remind them their baby is scheduled for routine immunization.

Jamila, a young mother wrapped in a white shawl around her orange head-dress, is bringing her six-month-old baby Arjera to be vaccinated for the first time. Her VCM, Rashida Murtala, badgered her for months before Jamila finally accepted.

“Oh, she refused and refused,” Rashida says. “She’s fed up with me visiting. I went to see her today and finally she followed me. I’m happy to see her here.”

Jamila smiles. “She has been disturbing me every day that I have to take this child to the health centre. I know she’s right, so today I followed her.”

Priscilla Francis, the Routine Immunization provider who vaccinates young Arjera, believes VCMs are key to strong vaccination coverage in Chikun district. “There is much improvement in attendance since the VCMs started. They are well trained. They do a good job of informing mothers to come. If we lost them we would lose our clients – no doubt. When they come we tell them to come back, but no one else is going to their house to bring them.”

Hassana Ibrahim, a Volunteer Ward Supervisor, knows her mobilizers are important. “I have 10 VCMs, five in this ward. Non-compliance used to be a big problem but not now. Now with the routine immunization, the community sees they are providing a package of health care and now people comply with the polio vaccination.”

Naming ceremonies

New mother Naima with newly named Jibrin and her friends and family was happy to welcome her VCM to immunize children at her son’s naming ceremony: “She is my friend.” @ UNICEF/R.Curtis

Following the routine immunization session, the VCMs fan out to attend the naming ceremonies of newborns in their catchment area. Naming ceremonies provide an important opportunity to vaccinate lots of children, as family gathers around to celebrate. On average, they attend 10 naming ceremonies a month. Today we visit Naima, the young mother of a 7-day-old boy, who as per tradition has just been named Jibrin by his grandfather. Naima is surrounded by her sisters, family and village friends, who cook and eat with them, and their 68 children under five. Within minutes, the VCM has walked among them all, vaccinating them as they sit waiting with their mouths open to the sky like little birds.

Naima is happy to see her trusted VCM, and encourages her to vaccinate the children. “I know her well,” she says. “She taught me to go for ante-natal care, to deliver at the hospital and to go for immunization. She is the only health care worker who comes. We are from the same community. She is my friend.”

At the 70^th World Health Assembly in Geneva, global health leaders have reiterated their commitment to polio eradication, discussing progress made and challenges ahead and emphasising the critical need for effective transition planning for the post-polio era.

Member States spoke of the continuing steady progress towards eradication, and the importance of supporting the remaining endemic countries in finishing the job. With only 37 cases in three countries in 2016, achieving eradication is closer than ever before.

Delegates from Afghanistan, Pakistan, and Nigeria, the last three endemic countries, outlined their key strategies for ending transmission as a matter of priority. The Pakistani delegate underscored the need for continued support from the global community: “Last miles are difficult, but we need to stay the course and reach a significant public health landmark of our time.”

Michel Zaffran, Director of Polio Eradication at WHO, spoke of the impressive decline in cases, achieved through the commitment of Member States, and stressed the critical need to continue to support the endemic countries in their efforts to stop the virus.

“We stand on the brink of making history, but progress is fragile… We cannot lower our guard. We must redouble our efforts to support Nigeria, Pakistan and Afghanistan to implement their national emergency action plans, and ensure they have the resources to do so.”

Member States also addressed the challenge of the scale down of the polio programme as eradication comes closer, including the potential impact on achieving and sustaining a polio-free world, on health programmes and systems currently supported by polio assets, and on WHO itself. They welcomed existing efforts to plan for the post-polio world, and stressed the importance of careful, considered, and strategic approaches to the transition of polio assets, requesting the WHO Director-General to prepare a detailed transition action plan.

Many delegates expressed concern about the ongoing shortage of inactivated polio vaccine, and noted the need to implement containment measures to ensure the safe and secure storage and handling of materials containing polioviruses, and destroy unneeded materials.

Rotary International reaffirmed the commitment of their 1.2 million volunteers to the global polio eradication effort, and expressed cautious optimism about the low levels of transmission in 2017. The Rotarian speaker called for the support of all countries to achieve eradication. “The support of every country is needed now more than ever. Passive support is not enough; we will not succeed without political and financial commitment… Let’s make history and end polio together.”

Reactive vaccination in Sokoto
Photo: WHO AFRO

In early May 2017, polio programme staff from across Nigeria joined efforts to combat a meningitis outbreak in Sokoto, providing support and expertise in outbreak response to help Sokoto State in controlling the outbreak.

Almost 200 WHO polio officers worked with state and national government agencies and other partners to plan and implement a state-wide vaccination campaign aimed at reaching almost 800 000 young people at risk of contracting the disease.

With considerable experience in delivering large-scale vaccination campaigns, polio staff played an important role in the planning, coordination and delivery of the meningitis response. Almost thirty years of fighting polio has equipped GPEI with valuable expertise in outbreak response that can be applied beyond the polio programme.

Working as part of a national support team, they supported the campaign in a number of areas, including the development of a detailed campaign strategy, coordination and logistics, planning, coordination and supervision of trainings, and vaccine management activities.

The broader benefits of the polio programme

This support for meningitis outbreak response is but one example of how the infrastructure and expertise of the Global Polio Eradication Initiative (GPEI) is helping to achieve positive health outcomes beyond polio eradication and can offer significant benefits for broader health efforts. In Nigeria alone, polio staff and infrastructure have contributed to multiple outbreak response and vaccination activities, including the response to Ebola and large-scale measles vaccination campaigns.

Polio-funded workers at country level spend on average 50% of their time supporting non-polio activities, including routine immunization, maternal and child health programmes, humanitarian emergencies and disease outbreak, and sanitation and hygiene programmes.

Skills and infrastructure of the programme in areas like healthcare delivery, disease surveillance and outbreak preparedness and response can be successfully applied to non-polio health priorities and programmes.

Planning for the future

While we remain focused on ending polio for good, GPEI is also beginning to plan for a world after polio – looking at how we can maintain some of this infrastructure, knowledge and expertise once the programme comes to an end. In 16 countries, including Nigeria, with the highest levels of GPEI-funded staff and infrastructure, GPEI partners are supporting national governments and other health partners to plan for the transition some of these critical assets in to existing health systems and initiatives, so they can continue to contribute to positive health outcomes around the world.

A child in west Africa receives polio vaccine. Photo: WHO.

More than 190 000 polio vaccinators in 13 countries across west and central Africa will immunize over 116 million children over the next week, to tackle the last remaining stronghold of polio on the continent.

The synchronized vaccination campaign, one of the largest of its kind ever implemented in Africa, is part of urgent measures to permanently stop polio on the continent. All children under five years of age in the 13 countries – Benin, Cameroon, Central African Republic, Chad, Côte d’Ivoire, Democratic Republic of Congo, Guinea, Liberia, Mali, Mauritania, Niger, Nigeria and Sierra Leone – will be simultaneously immunized in a coordinated effort to raise childhood immunity to polio across the continent. In August 2016, four children were paralysed by the disease in security-compromised areas in Borno state, north-eastern Nigeria, widely considered to be the only place on the continent where the virus maintains its grip.

“Twenty years ago, Nelson Mandela launched the pan-African ‘Kick Polio Out of Africa’ campaign,” said Dr Matshidiso Moeti, WHO Regional Director for Africa. “At that time, every single country on the continent was endemic to polio, and every year, more than 75 000 children were paralysed for life by this terrible disease. Thanks to the dedication of governments, communities, parents and health workers, this disease is now beaten back to this final reservoir.”

Dr Moeti cautioned, however, that progress was fragile, given the epidemic-prone nature of the virus. Although confined to a comparatively small region of the continent, experts warned that the virus could easily spread to under-protected areas of neighbouring countries. That is why regional public health ministers from five Lake Chad Basin countries – Cameroon, Central African Republic, Chad, Niger and Nigeria – declared the outbreak a regional public health emergency and have committed to multiple synchronized immunization campaigns.

UNICEF Regional Director for West and Central Africa, Ms Marie-Pierre Poirier, stated that with the strong commitment of Africa’s leaders, there was confidence that this last remaining polio reservoir could be wiped out, hereby protecting all future generations of African children from the crippling effects of this disease once and for all. “Polio eradication will be an unparalleled victory, which will not only save all future generations of children from the grip of a disease that is entirely preventable – but will show the world what Africa can do when it unites behind a common goal.”

To stop the potentially dangerous spread of the disease as soon as possible, volunteers will deliver bivalent oral polio vaccine (bOPV) to every house across all cities, towns and villages of the 13 countries. To succeed, this army of volunteers and health workers will work up to 12 hours per day, travelling on foot or bicycle, in often stifling humidity and temperatures in excess of 40°C. Each vaccination team will carry the vaccine in special carrier bags, filled with ice packs to ensure the vaccine remains below the required 8°C.

“This extraordinary coordinated response is precisely what is needed to stop this polio outbreak,” said Michael K McGovern, Chair of Rotary’s International PolioPlus Committee . “Every aspect of civil society in these African countries is coming together, every community, every parent and every community leader, to achieve one common goal: to protect their children from life-long paralysis caused by this deadly disease.”

The full engagement of political and community leaders at every level – right down to the district – is considered critical to the success of the campaign. It is only through the full participation of this leadership that all sectors of civil society are mobilized to ensure every child is reached.

More information

Kobra Ibrahim, 22, a monitor for the polio campaign poses for a picture during the polio vaccination campaign in Mazar on October 22, 2016. Photo: WHO Afghanistan/Rada Akbar

Thousands of remarkable female vaccinators, supervisors, campaign coordinators, surveillance volunteers and social mobilizers play a critical role in Afghanistan’s efforts to eradicate polio. The progress the polio programme has witnessed in the past years would not have been possible without the hard work and commitment of courageous women who are dedicated to protecting children and making polio history.

Through this series of photographs, meet some of the brave and hard-working Afghan women who are leading the battle against this paralyzing disease, bringing Afghanistan, and the world, closer to eradicating polio for good.

Acute flaccid paralysis (AFP) focal point Dr Siddiqui examines a child at Mirwais Regional Hospital in Kandahar. © WHO Afghanistan/S. Ramo

A strong surveillance system is the backbone of Afghanistan’s polio eradication effort. It ensures that every single poliovirus is detected and analysed, enabling a quick and effective response to stop every strain of the debilitating virus.

Afghanistan is closer than ever to stopping polio. The year 2016 ended with only 13 cases, down from 20 in 2015 and 28 in 2014. Most of Afghanistan remains polio-free, with transmission limited to the southern, eastern and southeastern parts of the country. Surveillance is key to ensuring that the virus is tracked and stopped wherever it circulates.

Together with partners of the Global Polio Eradication Initiative, WHO is further strengthening Afghanistan’s surveillance system to accelerate progress towards a polio-free Afghanistan.

Active volunteers track down the virus

Afghanistan currently has a network of 21 000 acute flaccid paralysis (AFP) reporting volunteers, including health workers in health facilities as well as community volunteers such as traditional healers, mullahs, shrine keepers and pharmacists, supported by over 700 AFP focal points. These volunteers actively find and report children who have symptoms that could be polio: floppy, rapid-onset paralysis with no apparent cause. Stool samples are collected from each child with suspected polio, and sent for further laboratory testing and analysis.

A child with AFP is examined at a health centre in Kandahar. © WHO Afghanistan/J. Jalali

“As a doctor I feel it is my responsibility to work for polio eradication in my country. Polio is a devastating disease that can cause permanent paralysis so everyone should play their part in ending this disease,” said Dr Saifurrahman, AFP reporting volunteer from Shah Wali Kot district of Kandahar. “When a patient with floppiness or paralysis comes to the clinic, I examine the child properly and if the signs point to polio, I immediately inform the Provincial Polio Officer, after which we’ll collect stool samples for further testing.”

In 2016, the polio surveillance network reported a total of 2903 AFP cases, of which 13 were confirmed polio cases and 2858 were discarded as non-polio AFP. As of mid-February, 31 cases are pending classification.

An external review conducted in 2016 concluded that Afghanistan’s polio surveillance surpassed global standards and the circulation of wild poliovirus is unlikely to be missed.

With the support of WHO, Afghanistan continues to step up its surveillance system. In last year alone, 458 new surveillance reporting sites have been introduced and the AFP reporting volunteer network expanded by 18%.

Dr Saifurahman works as an AFP reporting volunteer in Shah Wali Kot district of Kandahar where one polio case was reporded in 2016. © WHO Afghanistan/J. Jalali

When vaccinators go around communities during immunization campaigns and transit teams vaccinate children on the move, they also conduct active AFP case search to further boost AFP surveillance. Active AFP case search has also been incorporated into trainings led by the Ministry of Public Health and WHO ahead of every national immunization campaign.

Strong polio surveillance relies on Afghans who are close to their communities and trusted by them. Saheeb Jaan, a shrinekeeper in Bamyan province, has been a volunteer AFP reporter for 8 years.

“If I see a family come to the shrine with a sick child having weakness or paralysis, I report it to the doctors. WHO has given me a referral notebook so that I can get their information and convince them to call the doctors to make sure their child does not have polio,” she said. “I became a volunteer because it is a good cause and helps save children’s lives. I am happy and proud to be a part of the polio campaign.”

Every single AFP reporting volunteer receives comprehensive training from WHO at least once a year, reviewing key aspects of surveillance such as AFP case definition, clinical signs and symptoms of polio, proper check-up procedures and the protocol for notifying AFP cases to the focal point.

Stepping up environmental surveillance

Environmental sample collection from sewage water in Matun city of Khost province. © WHO Afghanistan/A.Zahed

Environmental surveillance, the collection and laboratory analysis of sewage samples, further increases the sensitivity of surveillance in critical areas.

Afghanistan’s environmental surveillance was set up in Kandahar City in 2013 and samples are now regularly collected from 17 active surveillance sites. WHO and partners conducted a thorough assessment of existing sites in December 2016, leading to three new additional surveillance sites being selected in Kandahar, Nangarhar and Khost, in addition to existing sites in Kabul, Kunar and Helmand. Environmental samples are collected monthly, but sampling frequency has recently been doubled in the south.

In 2016, two poliovirus isolates were reported from environmental samples, down from 19 in 2015.

The road ahead

Afghanistan’s strong surveillance system ensures that the programme continues to find every strain of the virus in its hiding places, accelerating the road ahead to a country free of polio.

Saheeb Jaan, a shrinekeeper from Bamyan province, is one of the 21,000 AFP reporting volunteers around Afghanistan. © WHO Afghanistan/R. Akbar

Vigorous training of AFP reporting volunteers and focal points remains crucial in order to guarantee that no AFP case is missed and that samples are collected, stored and transported properly. WHO continues to support the training and orientation of new and existing AFP focal points and volunteers to ensure each volunteer is trained at least once a year.

The programme is engaging more private health facilities to further strengthen the AFP reporting network. Currently almost 1400 private practitioners are involved as reporting volunteers around the country, making up 6% of the network, and the number is increasing. Engaging more private clinics will further improve the programme’s ability to find children with paralysis.

“Afghanistan’s surveillance system exceeds global standards but we must continue to stay vigilant and continuously review and expand the system where necessary,” said Dr Hemant Shukla, head of the polio programme at WHO Afghanistan. “Constantly improving the quality and sensitivity of the surveillance system is critical for securing a polio-free future for Afghanistan.”

Nigerian Minister of Health (left) and EU Ambassador signing the documents for the €70 million grant

At an event in Abuja on 16 February 2017, the Government of Nigeria and the European Union signed a historic partnership to support health systems and polio eradication efforts in the country. Attended by key ministries and partners such as WHO and UNICEF, a €70 million grant agreement was signed targeted at improving maternal, newborn and child health, strengthening Nigeria’s health system and supporting ongoing efforts to eradicate polio.

The project is the first phase of support from the European Union to the Nigerian health sector under the 11th European Development Fund, and will be jointly implemented by United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO) in partnership with the Federal Government of Nigeria and key target states in the country.

Fifty million euro of the grant aims to ensure that by 2020, Adamawa, Bauchi and Kebbi states of Nigeria have functional primary health care centers, providing round-the-clock services to three million children under the age of ﬁve years as well as to almost a million pregnant women and lactating mothers.

Twenty million euro, to be dispersed by WHO, will go specifically towards health systems strengthening to achieve universal health coverage and support the push to eradicate polio from Nigeria for good. The grant comes at a critical time for polio eradication in Nigeria, with emergency efforts underway to stop the virus in the last remaining polio reservoir on the African continent.

Michel Arrion, the EU Ambassador to Nigeria and ECOWAS, said at the event, “The European Union is working together with the Nigerian authorities to address developmental challenges in key priority areas under its 11th European Development Fund. This project will help to improve access to eﬀective health and nutrition in the prioritized states and support the ﬁnal push to eradicate polio in Nigeria”.

The EU has been major supporter of polio eradication efforts worldwide and in particular Nigeria, providing €45 million to the country between 2011 and 2017. Additionally, the EU has provided significant emergency funding to help successfully stop past outbreaks in the Horn of Africa and the Middle East, and supported the eradication effort in other parts of the world.

Thanking the EU for on-going commitment, Dr Wondimagegnehu Alemu, WHO Country Representative, said, “Our partnership with the EU will enable the organization to continue providing the necessary technical support to the government of Nigeria towards strengthening health systems and enhancing timely interventions during supplemental immunization activities, including reaching children in areas with insecurity in the northeast.”

Polio eradication efforts have always played an important role in health systems strengthening. The polio network routinely conducts surveillance for other diseases of public health importance, including measles, yellow fever, neonatal tetanus and avian influenza. With local knowledge of communities, health systems and government structures, the polio network’s technical capacity in disease surveillance and planning of large-scale operations often helps sustain international and national relief efforts. At the country level, polio staff spend, on average, 50% of their time working on broader public health efforts, over and beyond polio eradication, providing a critical contribution to strengthening of health systems.

WS20170207_Afghanistan — © WHO Afghanistan/ S. Ramo

Afghanistan’s long struggle to eradicate polio is showing strong signs that the country is closer than it has ever been to finally stopping the disease, once and for all.

The year 2016 ended with only 13 cases, down from 20 in 2015 and 28 in 2014. Notably, 99% of all districts ended the year polio-free, with transmission cornered in small geographical areas in the south, east and south-east of the country.

While Afghanistan this week will announce its first case of wild poliovirus for 2017 – an 11-month-old girl in Kandahar District of Kandahar Province – the country has made substantial gains that make eradication in the short term a realistic goal. Monthly campaigns will be held through the end of May during the traditional ‘low season’ for polio transmission, which provides the best opportunity to stop transmission country-wide.

Every last child vaccinated

There is reason to be cautiously confident about 2017. Last year saw notable improvements in the quality of immunization campaigns across the country – particularly in high-risk areas – with significantly more children being reached and protected than ever before. The proportion of areas achieving required coverage standards in post-campaign Lot Quality Assessment Surveys has increased over the 12 months to December 2016 from 68% to 93%. Concurrently, the quality of campaign monitoring has improved with new approaches including remote monitoring through mobile phone technology and independent third-party monitoring.

Strategic district-specific plans for 2016-2017 are focused on 47 high-risk districts responsible for 84% of polio cases in the past 7 years. An intensified community engagement communication network has been established in these districts to ensure parents and caregivers are aware of the benefits of the polio vaccine and vaccinate their children during campaigns.

A National Islamic Advisory Group for Polio Eradication has been established in 2016 and Afghan religious scholars, the Ulama, issued a Declaration calling on all Afghans to vaccinate their children. Religious leaders are now strongly involved in supporting polio eradication efforts.

A strategy to revisit homes where children were missed was introduced in 2016. By the end of the year, in areas where the Immunization Communication Network was present, teams of mobilizers were successful in vaccinating 75% of missed children in very high-risk districts.

A single block

Afghanistan and Pakistan form one epidemiological block – reaching children on the move is another priority. Coordination and joint planning between the two countries is strong. Currently, 294 Permanent Transit Teams vaccinate children who travel in and out of security-compromised areas, special campaigns target nomadic populations and 49 cross-border teams at 18 cross-border vaccination points vaccinate children when they cross into or from Pakistan and Iran. In 2016, these border teams vaccinated over 122,000 returnee children with oral polio vaccine and over 32,000 with the injectable inactivated polio vaccine.

Surveillance is king

Underpinning all eradication efforts is a surveillance system which is able to pinpoint any virus. An external surveillance review concluded in 2016 that Afghanistan’s disease surveillance surpassed global standards and circulation of the virus is unlikely to be missed. In the past 12 months, an additional 458 disease surveillance reporting sites have been introduced and the number of reporting volunteers has increased by 18% to 21,000. Three additional environmental sewage surveillance sites have been added, in Kandahar, Nangarhar and Khost, and sampling frequency has been doubled in the south.

The road ahead: neutrality

Significant challenges remain: routine immunization coverage remains weak in many areas and insecurity and active fighting has hampered vaccination teams’ access. In this complex and challenging environment, the programme continues to maintain its neutrality. Maintaining dialogue with communities remains essential.

Now more than ever, Afghanistan has all the systems in place and tools it needs to achieve eradication: high-quality immunization campaigns, strong monitoring and supervision of vaccinators, vigorous communications platforms, a strong community engagement strategy creating an enabling environment for vaccination campaigns, national and regional Emergency Operations Centres to oversee and manage the programme, a supportive civil society, religious leadership and media and – most importantly – a committed network of local health workers who are trusted and supported by their communities.

In the coming months, Afghanistan has a unique opportunity to take the world over the finishing line for polio eradication. If all elements of the polio programme are accountable for reaching and immunizing every child in high-quality monthly polio vaccination campaigns, eradication is possible.