A child is given two drops of oral polio vaccine on a vaccination campaign in Afghanistan
Afghanistan is reaching over 5.6 million children with vaccines against polio during large-scale campaign starting in January.
On 30 January, the Ministry of Public Health, WHO and UNICEF launched the first polio immunization campaign of 2017. Targeting over 5.6 million children, the campaign will be delivering vaccines in provinces in the southern and south-eastern regions, most districts in the eastern region, as well as selected high-risk districts across the country, including Kabul city.
“The campaign will build on strong progress seen in 2016. Last year Afghanistan had only 13 cases of polio nationwide, down from 20 in 2015. This was made possible through hard work by thousands of frontline health workers and a renewed emphasis on monitoring and oversight,” said Dr Maiwand Ahmadzai, Director of the National Emergency Operations Centre for Polio Eradication at the Ministry of Public Health, speaking at a joint press conference held in Kabul.
This week’s campaign is carried out by over 31,000 trained polio workers. These vaccinators and other polio workers are trusted members of the community and they have been chosen because they care about children.
“We have seen significant progress in our polio eradication efforts over the past year. Most of Afghanistan is now polio-free, the circulation of the poliovirus is restricted to small areas in the eastern, southern and southeastern parts of the country and we have seen huge improvements in vaccination campaign quality,” said Dr Hemant Shukla, Director of the Polio Programme at WHO. “Our focus is now on reaching every single child during every vaccination campaign to stop the transmission of polio.”
More than 31,000 trained polio workers have been chosen to work on campaigns because they are trusted by their communities and care about protecting children against polio.
“With our collective efforts, we will be able to eradicate polio from the world. Vaccines are the right of every child and no child should be missed during polio campaigns,” said Ms Melissa Corkum, UNICEF Polio Director in Afghanistan. “Thousands of frontline workers visit every house in the country during campaigns. That’s not an easy task. Due to the hard work of these dedicated frontline workers, we are closer to polio eradication than ever.”
In 2016, new initiatives have been implemented to strengthen the polio eradication programme in Afghanistan. All polio eradication activities have been brought under one leadership as Emergency Operations Centres have been established at the national and subnational level. The surveillance system has been strengthened and the circulation of wild poliovirus is unlikely to be missed in Afghanistan. The quality of campaigns, routine immunization and rapid response to polio cases have improved tremendously over the past year.
In 2016, 13 polio cases were registered: 7 cases in Paktika, 4 cases in Kunar, one case in Kandahar and one in Helmand province. Afghanistan remains one of 3 polio-endemic countries together with Pakistan and Nigeria.
140th session of WHO Executive Board, Geneva, Switzerland. Photo: WHO/C.Black
27 January 2017, Geneva, Switzerland – Ministries of health gathering at this week’s Executive Board of the World Health Organization (WHO) reviewed the latest global poliovirus epidemiology and concluded that the world has never had a better chance to complete the job. Amid discussions on Ebola, Zika and pre-elections for the new WHO Director-General, delegates stressed the urgent need to secure a lasting polio-free world, by fully implementing the Global Polio Eradication Initiative (GPEI) Polio Eradication Endgame Strategic Plan.
Endemic polio is now restricted to a handful of areas of Pakistan, Afghanistan and Nigeria, all of which are implementing regionally-coordinated emergency plans to reach and vaccinate the remaining pockets of under-immunized children.
Despite more children being reached in these traditional ‘reservoir’ areas for the virus, delegates cautioned that risks remained, as underscored by the detection of polio cases in Borno state of Nigeria, the first in two years anywhere in Africa. Countries are now focusing on making sure there are no surveillance gaps at a subnational level so that virus cannot circulate undetected, while working to increase population immunity levels.
Delegates commended the successful global switch from trivalent oral polio vaccine (OPV) to bivalent OPV in 2016, and emphasized that strong surveillance to detect any type 2 poliovirus from any source is now critical. A global stockpile of monovalent OPV type 2 (mOPV2) remains on hand for potential response as needed. A critical global supply shortage of inactivated polio vaccine (IPV) continues to pose a risk, but is being managed by prioritizing available supply to high-risk areas and implementing new measures to stretch available supply, notably use of fractional IPV, as recommended by the Strategic Advisory Group of Experts on immunization (SAGE).
At the same time, countries expressed appreciation at the ongoing efforts to fully implement global laboratory containment activities. They also encouraged plans to transition the infrastructure of the GPEI for the long-term, to ensure the assets and infrastructure established to eradicate polio will continue to benefit broader public health efforts even after the disease is gone. At the World Health Assembly in May, the GPEI will present a strategic roadmap towards polio transition and the development of a post-certification strategy.
With all technical and programmatic building blocks in place to achieve success, ministries urged all stakeholders to ensure that the necessary financial resources to fully implement the Endgame Plan are rapidly mobilized.
Closing the discussion, partners from civil society addressed the ministries through Rotary International with a clear call to action: “We must protect hard won gains by sustaining immunity levels and careful monitoring of virus transmission. An additional US$1.3 billion is needed through 2019 to reach more than 400 million children in up to 60 countries and to ensure high quality surveillance. The eradication of polio will be a monumental achievement by a global partnership. Such achievements exemplify what we can do when united for a common purpose. Together we can end polio and forever build a better future for all children.”
More than 65,000 dedicated frontline workers are working tirelessly to eradicate polio from Afghanistan
Feroza and over 65,000 dedicated frontline workers are at the heart of efforts to eradicate polio from Afghanistan.
Feroza is one of the more than 65,000 dedicated frontline workers who are working tirelessly to eradicate polio from Afghanistan. For the past year, she has been working as a volunteer polio vaccinator, vaccinating children in her community during immunization campaigns.
“Polio is a very dangerous disease and people often underestimate how important and effective the vaccine is in preventing the irreversible consequences of the disease,” Feroza says. “I joined the polio programme because I want to raise awareness about the polio vaccine and its benefits to children in my community.”
Most of Afghanistan remains polio-free with the circulation of the virus confined to small areas in the southern, eastern and south-eastern parts of the country. In 2016, 12 wild poliovirus cases were reported, down from the 20 cases reported in 2015 and 28 in 2014. One case has been reported this year.
A number of new developments were implemented in 2016 to accelerate progress towards stopping polio transmission. This included the training of all polio field workers with a new curriculum to boost their skills and ensuring that frontline workers are kept motivated and committed.
Dedicated and brave vaccinators like Feroza are at the heart of the polio eradication effort. Female polio workers are particularly important in building trust in their communities and encouraging vaccination, ensuring more children are reached with life-saving vaccines.
“The best thing about my work is helping women and children and spreading awareness about the problems that are caused if children are not vaccinated. Sometimes mothers try to convince us to give them the vaccine as well since we are praising it so much – this is always amusing,” says Feroza smiling.
During vaccination campaigns, Feroza and her team visit houses to vaccinate all children under the age of 5 with the oral polio vaccine (OPV). “We work long and hectic days during the campaigns but I enjoy it.”
The work of volunteers like Feroza is crucial to reducing the number of children missed during immunization campaigns.
Afghanistan has a well-informed generation of parents who accept the polio vaccine every time it is offered to them. According to a study carried out in 2016, nearly 90% of Afghans recognize that vaccination is a way of preventing polio and there has been a reduction in the belief in preventing polio by using traditional medicine.
“We generally don’t face any problems during campaigns as most families are familiar with the vaccine and want to vaccinate their children. If families are hesitant, we try to encourage them by giving them information about the benefits of the vaccine. If they still reject the vaccine, we ask our supervisors to come and help convince them. I have never met a family who refused the vaccine in the end,” Feroza says.
A health worker prepares to administer a vaccine in northern Nigeria. WHO/L.Dore
A mass vaccination campaign to protect more than 4 million children from a measles outbreak in conflict-affected states in north-eastern Nigeria started on 13 January. The polio eradication infrastructure has been on hand to help with this feat of logistics. GPEI partners WHO, UNICEF and US Centres for Disease Control have been working with nongovernmental organizations to support the campaign in a range of areas including data management, training, social mobilization, monitoring and evaluation, supportive supervision and waste management.
“Nigeria’s well-established polio vaccination programme provides a strong underpinning for the campaign,” says Dr Wondimagegnehu Alemu, WHO Representative in Nigeria. “Population data from the polio programme has been essential to guide planning for the measles campaign. We are also able to make use of staff that have vast experience in providing health services in very difficult and risky areas.”
One third of more than 700 health facilities in Borno State, north-eastern Nigeria, have been completely destroyed, according to a report released in December by WHO. Of those facilities remaining, one third are not functioning at all. This is leaving the health of communities vulnerable.
WHO has a strong presence in the community in these areas thanks to a well-established polio programme which includes teams of health workers trained to work in areas of high insecurity and reach communities that no other partner can reach.
With levels of malnutrition as high as 20% in some populations in Borno State, children are particularly vulnerable to diseases like measles, malaria, respiratory infections and diarrhoea.
Planning for the future
This measles campaign in northern Nigeria is by no means the only example of polio funded functions and infrastructure contributing to other critical functions. On average, polio-funded staff spend more than 50% of their time on non-polio activities, such as routine immunization, measles campaigns, maternal and child health initiatives, humanitarian emergencies and disease outbreak, sanitation and hygiene programmes and strengthening health systems. In Nigeria in 2015, the Emergency Operations Centres set up to tackle polio were repurposed instantly in response to the spread of Ebola to the country, which enabled the outbreak to be ended almost as soon as it began.
Polio is closer to eradication than it has ever been; and while we keep all efforts on rooting out the virus in its final hiding places, the Global Polio Eradication Initiative is also beginning to plan for the future. The 16 priority countries, including Nigeria, where 95% of the programmes assets are based are planning now so that some polio funded functions and infrastructure can continue to contribute to other critical health and development goals, as polio funding gradually decreases
Read more about the measles vaccination campaign in Nigeria.
In August 2016, hundreds of thousands of people fled their homes in Borno State, north-eastern Nigeria, where they had been living in areas under the control of the armed group Boko Haram. These areas had been inaccessible to any health programme, including polio vaccinators.
When health workers finally reached these families, they found thousands of severely malnourished children in need of treatment for a range of health conditions. They also found four children in three different locations within Borno paralyzed by polio. The virus had been spreading silently in these areas for the past two years, beyond the reach of the polio eradication programme.
The detection of polio in Nigeria was a serious setback for the polio eradication programme. With no cases detected in Nigeria or any other African country for two years, there was hope that Africa was polio-free.
The outbreak response was swift and comprehensive, with the Governments of Borno and Nigeria, the World Health Organization and UNICEF conducting an immediate emergency vaccination response.
From August, health authorities conducted five large-scale supplementary vaccination campaigns targeting every accessible child under five years of age in Borno State. Campaigns were also aimed at children in the bordering states of Nigeria, as well as the Lake Chad region of Niger, Chad, Cameroon and the Central African Republic in synchronized activities to rapidly raise childhood immunity to the poliovirus and protect against inter-state and international spread. Approximately 11 million children are being targeted across the region.
Multiple strategies were employed to reach as many children as possible. Additional health workers were hired and trained and detailed plans for each settlement and internally displaced persons camp were comprehensively reviewed to ensure all children were registered for immunization. Targeted media campaigns drew awareness to the upcoming vaccination campaigns. Health camps offered polio vaccination in addition to basic health care packages.
To accelerate community demand for vaccination, the Volunteer Community Mobilization Network was quickly scaled up to reach all highest-risk communities. These women, in their distinctive blue hijabs, move from house-to-house and through the internally displaced persons camps to ensure parents know about the risk of polio and the importance of full immunization for their children. Working for just a couple of dollars a day, they also connect pregnant women to available health services and encourage safe delivery practices, as well as identifying children with severe acute malnutrition and linking them to treatment facilities.
Health camps have been set up in areas with a high number of internally displaced persons to offer much-needed health services than polio vaccines alone. These include de-worming tablets, zinc, oral rehydration salts for children with diarrhea as well as other routine vaccinations for children who may never have had contact with a health system. Polio survivors help to educate parents at these camps to the dangers of the current outbreak and the fact that there is no cure for polio, but that it can be prevented through vaccination.
To access the hardest-to-reach populations in newly-accessible areas, the Government of Nigeria with support from the United Nations is using helicopters to deliver vaccines and other health services. UNICEF has procured and delivered more than 150 million doses of oral polio vaccine to this outbreak response. The work remains dangerous, with ongoing attacks and active fighting in some areas.
After having access to so little for so long, the demand for services has been overwhelming from affected communities. The provision of soap and other basic ‘pluses’ has helped to meet some of these needs, and encouraged mothers to bring their children out for vaccination.
With so much at stake, strong monitoring and supervision has been key to ensuring as many children can be reached as possible. Wide-scale vaccination campaigns offering polio vaccination and other services will continue throughout the first quarter of 2017 in an effort to ensure this outbreak is stopped and the world can finally achieve a polio-free Africa, once and for all.
The border between Pakistan and Afghanistan is no barrier to the poliovirus. Close cultural and linguistic ties connect the two countries. Populations move fluidly across these borders. Each year, the virus moves with them.
Afghanistan and Pakistan have seen significant progress in the last 18 months in their efforts to stop polio. But both countries have been close before, and have been thwarted: the virus has found pockets of unvaccinated children where it can hide, regroup, and stage a comeback. Despite historically low levels of polio over the last few months, cases of paralysis and positive samples found through environmental surveillance show us that the virus has not yet been stopped.
A new approach
Armed with this knowledge, Pakistan and Afghanistan have taken a new approach. Since June 2015, the two have been coordinating major programme activities, as success in one country depends on success in the other. Monthly polio immunization campaigns have been synchronized so that no child on either side of the border can fall through the cracks, the Emergency Operations Centres (EOCs) of each country – which house the government and partners of the Global Polio Eradication Initiative to coordinate eradication activities – interact with one another on a weekly basis, and the highest level political and administrative leadership meet face to face every six months, to resolve challenges and to develop plans to address the remaining hurdles.
A common communications strategy has synchronized messaging at the border and – with radio being the main source of news for 70% of Afghans and 50% of Pakistanis in border areas – the programme has coordinated radio programming on the leading border channels, producing weekly health shows and using popular soap operas to create Pashto-language programming on polio and children’s health.
This innovative approach is paying dividends. The polio eradication programmes in both countries are working closely together to coordinate vaccination campaigns, surveillance, and to track population movements.
The three ‘corridors’ of polio transmission
Three ‘corridors’ are serving to allow the virus to travel with population movements between countries: via the Torkham border crossing from Peshawar and Khyber in Pakistan to Nangarhar, Kunar and Laghman in east Afghanistan, and via the Friendship Gate border crossing from Pakistan’s Quetta Block to the Greater Kandahar area in south Afghanistan. Population immunity in these transmission corridors have been gradually improving in the last year, shown by the vaccination status of non-polio AFP cases.
Wild polio increasingly seems to be travelling down a central corridor between southern Khyber Pakhtunkhwa and the Federally Administered Tribal Areas in Pakistan travelling across rugged, smaller border crossings to Paktika, Paktia and Khost provinces in the south east of Afghanistan.
Mobile populations
At the most recent Inter-Country Coordination Meeting in Islamabad, Pakistan, the Afghanistan National EOC Director underscored the importance of reaching and vaccinating populations on the move, whether at formal or informal locations.
While Torkham in the northwest and Friendship Gate in the south are the main border crossing points between the reservoirs – with more than one million children under 5 crossing these points each year – the smaller informal crossings are considerably more challenging to reach and vaccinate children.
Pakistan and Afghanistan are working to strengthen coordination on the communities moving through these locations, to ensure that all children under 5 are vaccinated wherever they are. The programmes are strengthening their disease surveillance at community level, mapping out mobile groups and ensuring they’re included in immunization microplans, and working with leaders and influential figures to understand their movements better.
Stronger together
The new polio cases in the central corridor have reinforced the idea that neither Pakistan nor Afghanistan can eradicate polio alone, with the virus travelling between the two. At the Islamabad meeting, the National EOC coordinator for Pakistan highlighted the fact that neither programme was where it intended to be by this time in 2016, and these strategies tailored to addressing specific challenges were essential to end the virus for good.
The significant improvements in the programme quality in the southern and eastern corridors can be attributed to a relentless focus on improving campaign quality and the innovative approach of the two countries working as one team across the border.
Pakistan and Afghanistan are learning from the programme’s experiences in other countries. If this progress can be maintained in the traditional corridors between the long-time polio reservoirs, and the programme can move quickly to rapidly increase immunity in the new, central corridor, the programme has the opportunity to strike out polio in two countries with one blow, working together to ensure that no poliovirus can find a hiding place along the porous border between them.
The Global Polio Eradication Initiative (GPEI) is highlighting the innovations that are helping to bring us closer to a polio-free world. Find out about other new approaches driving the polio eradication efforts by reading more in theInnovation Series.
WHO Afghanistan/S.Ramo
The borders between Afghanistan and Pakistan are porous, with populations moving fluidly between the two countries despite challenging terrain. With both countries continuing to find cases of polio, ensuring that every child crossing the border receives polio vaccines is important to stop the virus in its tracks. Following a decision to repatriate Afghan refugees from Pakistan, the numbers of people moving across the border has risen dramatically in the last year.
WHO Afghanistan/S.Ramo
Children arriving from Pakistan are at risk of communicable diseases such as polio, pertussis and measles and many suffer from acute respiratory infections due to colder weather conditions. Many are also at risk of malnutrition. Afghanistan remains a polio-endemic country; this year there have been 12 confirmed polio cases to date in Afghanistan from the eastern, southern and south-eastern regions.
WHO Afghanistan/S.Ramo
Polio vaccinators climb onto a truck to vaccinate a child at the Torkham border in Nangarhar, the busiest border crossing in Afghanistan. Over 50,000 children have been vaccinated with the oral polio vaccine (OPV) at this border crossing since July this year by vaccination teams supported by the Ministry of Public Health, WHO and UNICEF.
Currently polio teams are working at 17 cross-border points to ensure that all children entering Afghanistan get immunized against polio. Over 280 Permanent Transit Teams (PTTs) vaccinate children who travel in and out of security-compromised areas and children traveling to other destinations to ensure that every child on the move receives two drops of the oral polio vaccine to grow up healthy.
WHO Afghanistan/S.Ramo
Polio social mobilizers talk to women who have just arrived from Haripur, Pakistan, about the different kinds of vaccinations children need and the benefits of immunization. They also describe to them the symptoms of acute flaccid paralysis (AFP), the symptoms of polio, asking the women to bring their children to the nearest health centre if they suffer from any floppy weakness of the limbs.
WHO Afghanistan/S.Ramo
Elina prepares the inactivated polio vaccine (IPV) to administer to Maryam, a three-year-old refugee, at the UNHCR encashment centre in east Kabul. “I am a mother of three daughters and really enjoy my job as a nurse and vaccinator. I want to help our children and make sure all Afghan children can be spared from polio paralysis by giving them the polio vaccine.”
WHO Afghanistan/S.Ramo
Wali Mohammad has lived in Pakistan for 25 years and is now returning with his seven daughters and five sons. He holds his 3-year-old-daughter Amina on his lap at an IOM transit centre near the border in Nangargar as she is given vaccines to protect her against measles and polio.
WHO Afghanistan/S.Ramo
Sardar has been a polio vaccinator for five years. “We vaccinate hundreds of children every day by giving them two drops of the oral polio vaccine. We often climb into the trucks as they cross the border if the children don’t come down. This way we know we reach all children,” said Sardar, one of the vaccinators immunizing children at the Torkham border crossing in eastern Nangarhar province. “I want to help our children. Our country needs to finish polio for good.”
WHO Afghanistan/S.Ramo
Razi Khan holds his daughter Asma as she gets the injectable inactivated polio vaccine (IPV) at the IOM transit centre near the Torkham border. Razi Khan has five daughters and four sons and he has lived in Pakistan for the last 30 years after moving there from Laghman province. Receiving IPV alongside OPV boosts immunity against polio.
WHO Afghanistan/S.Ramo
Vaccinator Jawad calls out for children under the age of 10 at the Torkham border to get a polio vaccination if they have not yet received it from teams climbing into trucks.
With transmission limited to small geographic areas this year, Afghanistan is closer to stopping the circulation of wild poliovirus than ever before. To eradicate the debilitating disease for good, vaccination teams must continue to reach every single child, everywhere.
In the last stages of polio eradication, a sensitive surveillance system that can detect every single poliovirus is indispensable to find it in its last hiding places. In Pakistan, surveillance for cases of acute flaccid paralysis (AFP), subsequent testing and supplementary environmental sampling from the environment are informing the progress made towards eradication.
The poliovirus has proven to be a constant and resilient foe, continuing to show up in several areas of Pakistan. However, transmission is the lowest it has ever been. So far in 2016, fewer children have been paralysed by polio than at any other year in history, with the virus limited to a few areas in just three countries – Pakistan, Afghanistan and Nigeria. Pakistan has made strong progress in identifying and vaccinating missed children in the country’s most challenging areas, resulting in historical low numbers of cases this year. This remarkable achievement is especially visible in the core reservoir districts where persistent transmission has been the norm.
Training surveillance officers
The training of dedicated surveillance officers is key to ensuring Pakistan’s surveillance system is built strongly for eradication. A recent training for 32 district surveillance officers from across Pakistan highlighted the importance of effective AFP and environmental surveillance in tracking down the virus. World Health Organization’s National Surveillance Coordinator, Dr Tahir Malik said the training is essential to ensure surveillance officers down to the district level are highly skilled in identifying and investigating cases. “This is critical not only to orient new surveillance officers but also for old officers to bring alignment in surveillance procedures”. He further explained, “After training we expect from the participants to fully understand poliovirus epidemiology, AFP surveillance, but also in detail its components and mechanics in Pakistan.”
“The training, which also covered specifics on the role of laboratory, surveillance indicators, healthy children sampling and environmental surveillance, aims to bring all officers on one page in terms of programme priorities,” Dr Tahir said.
Constantly improving
Supported by contributions from the Canadian Government, the training is part of the programmes surveillance improvement plan that was recommended by the Technical Advisory Group (TAG) for Polio Eradication in Pakistan, to place a greater emphasis on disease surveillance including scaling up the workforce of dedicated staff, realigning environmental surveillance sites and ensuring surveillance targets are met by including private and informal health sectors, pushing for timely investigation, and reprioritizing reporting sites to focus on silent UCs and Tehsils.
The Chairman of the TAG Jean-Marc Olive, who was visiting Pakistan during the training, addressed the Surveillance officers from Punjab, Balochistan, FATA and KP. “Make the paediatrician your friend, talk continuously to the community, walk, move, sensitise, orient, visit facilities and care providers. Surveillance is not beautiful graphs on a laptop, it is hard field work,” he said. “Be proud of what you do for the children of Pakistan.”
The 2016-2017 National Emergency Action Plan for polio eradication also highlights the intensification of surveillance as a critical activity so that virus signal are picked up as early as possible and response initiated rapidly and aggressively. In response, the programme is working to engage private clinics, traditional healers and pharmacies to make it more likely that all cases of polio will be reported and immediate case response can be launched when needed.
Environmental surveillance
In addition, there has been an increase in the work being done for environmental surveillance. The number of sites that test for presence of the virus in sewage water has been increased to 43 sites across Pakistan’s highest risk areas and environmental samples are being taken more frequently, which is proving to support the programme to detect and track the virus, a critical step as the country edges closer to stopping transmission.
Leaving no stone unturned
Once Pakistan is able to demonstrate that no poliovirus is present, both from AFP surveillance and supplementary environmental surveillance, for three consecutive years, the country will be declared polio-free. Until that time Pakistan will continue to leave no stone unturned in pursuit of the virus and no child unvaccinated and vulnerable.
A child in northern Nigeria receives a dose of the oral polio vaccine. Vaccination teams are going to great lengths to protect every last child against polio. UNICEF/T.Moran
Experts from across the Global Polio Eradication Initiative (GPEI) partnership convened an emergency meeting in Abuja, Nigeria, from 3 – 5 November. Led by senior epidemiologists from the governments of Nigeria and neighbouring countries, the group examined a detailed review of the current impact of the outbreak response, and identified area-specific challenges and prioritized operational plans accordingly.
The detection of new wild poliovirus type 1 (WPV1) cases in Borno, Nigeria, in August – the first detected on the African continent in more than two years – has prompted an unprecedented response. The outbreak was immediately declared by both the Government of Nigeria and governments of surrounding countries to be national and regional public health emergency. This opened the way for a regional outbreak response, mobilizing emergency resources from across the public and civil society sectors.
Thousands of health workers across the region have been mobilized and trained, and in Borno alone more than 1.7 million children have been vaccinated. But many more continue to be un- or under-immunized, either due to operational deficits in outbreak response implementation, hampered access due to insecurity or large-scale population movements within countries.
Unless these missed children are rapidly reached, the risk remains that the current outbreak could spread further, including internationally, and cause more preventable, incurable paralysis.
Access and reaching populations everywhere
Insecurity, geographical challenges and difficulties with communication in some of the hardest to reach areas are providing barriers to reaching all children. Internally displaced persons (IDPs), refugees and nomads are particularly vulnerable groups, with insecurity blocking transit routes and the ability to accurately predict population size ahead of vaccination campaigns reduced. Due to population displacement, detailed micro-plans are frequently disrupted.
Children across northern Nigeria and other countries in the Lake Chad region must be protected rapidly against polio to end the outbreak. UNICEF/T.Moran
Cross-border coordination, embedding the response within the broader humanitarian emergency context, and innovating rapidly to adapt strategies to local challenges is what has stopped similar outbreaks with similar challenges elsewhere in the world.
Yet despite these challenges, the GPEI can draw on a vast array of experience from running outbreak responses in similar settings, most recently in the Middle East, Central Africa and the Horn of Africa from 2013-2015. These existing, proven strategies are rapidly adapted to the evolving environment. Permanent vaccination teams are now in place, as and when an area becomes accessible, to rapidly implement ‘mini’ vaccination campaigns in between larger-planned activities. Such teams are also critical to reach populations as they leave inaccessible areas. Children in both formal and informal IDP camps are a particular focus for the delivery of the polio vaccine alongside other humanitarian and basic health needs.
Assuming that many children living in conflict-affected areas will not have been vaccinated for several years, the target age group has been raised to protect children over 5 years of age.
The Volunteer Communication Network of vaccination advocates within communities has been expanded to cover Internally Displaced Populations living in camps and host populations, while Koranic School teachers have been engaged to address non-compliance and the mobilization of women and youth to ensure local protection for vaccination teams.
Volunteer community mobilizers wearing distinctive blue hijabs are working in IDP camps and host communities to identify unvaccinated children, pregnant women and those with severe acute malnutrition. UNICEF/T.Moran
Coordinating across borders
While cases of polio have only been found in Borno, extensive population movement, insecurity and previous cross border population movements require the outbreak response to cover the entire Lake Chad region. Cameroon, the Central African Republic (CAR), Chad, Nigeria and Niger are working together to track population movements and addressing the challenges inherent in accessing some hard-to-reach areas in each country, including sourcing communication equipment to operate where there is a lack of telecommunication network, closed borders in some places and language barriers. Efforts are being intensified to map out the seasonal movement of nomads, identifying resting places and water points with the support of nomadic community leaders in order to improve micro-planning to inform the response. In Chad, vaccination campaigns are providing livestock vaccines alongside polio vaccines to children in order to increase uptake in nomadic communities.
It is not insecurity alone that leads to hampered access. Sometimes it is simply a more natural phenomenon: the rains! The rainy season in the region typically runs from June to mid-October. Some areas are completely cut off from roads and other transport networks as a result of the associated flooding. With the rainy season now over, many areas and populations will be able to be reached with polio vaccine and other urgent health services.
Stopping outbreaks in such challenges settings is possible
There is no doubt that running an outbreak response with such challenges is far more complex, dangerous, costly and slower than under normal circumstances. However, what is equally clear is that the plans being intensified and implemented across the region are having an impact, and will continue to have an impact. Cross-border coordination, embedding the response within the broader humanitarian emergency context, and innovating rapidly to adapt strategies to local challenges is what has stopped similar outbreaks with similar challenges elsewhere in the world.
The groundwork set by this first phase of the outbreak response has set for reaching previously missed children in late 2016 and throughout 2017.
With continued leadership of political, health and community leaders at the local, national and regional levels alongside the international development community, this outbreak will be stopped and children across Africa protected against polio.
WHO
Last week, global political commitment to eradicating polio was affirmed at the World Health Assembly (WHA) in Geneva. During the polio agenda item, member states discussed progress made in the last year and the remaining hurdles that stand in the way of polio eradication.
In her opening address to the WHA, Dr Margaret Chan, Director General of WHO, said polio eradication has never been so close to the finish line. “During the short span of 2 weeks in April, 155 countries successfully switched from trivalent to bivalent oral polio vaccine, marking the largest coordinated vaccine withdrawal in history. I thank you and your country teams for this marvellous feat,” she said.
Member states reviewed the latest global epidemiology, noting the strong progress made across Africa with no case of wild poliovirus in approaching two years. Delegates from Afghanistan and Pakistan, the final remaining polio endemic countries, outlined the steps they are taking to ensure that transmission is interrupted as a matter of urgency. With fewer missed children than ever before and just 74 cases across the two in 2015, achieving eradication has never appeared to be such an achievable target.
Many member states spoke to reaffirm their commitments to fulfilling the objectives of the resolution passed at the last WHA to commit to ending polio once and for all. Michel Zaffran, Director of Polio Eradication at WHO, stated that strong progress had been made against all four objectives of the Polio Eradication and Endgame Strategic Plan.
Delegates also commended the historic achievement of the switch, warning that shortages of the inactivated polio vaccine and potential outbreaks of type 2 vaccine-derived polioviruses would be some of the major challenges of the coming year. They also expressed appreciation for the global contingency plans put in place to adequately manage the risks associated with the supply shortage, notably the availability of the stockpile of monovalent oral polio vaccine type 2.
Gavi, the Vaccine Alliance, supported the interjections of several member states highlighting the importance of ramping up transition planning in countries to prepare for the end of the polio infrastructure after eradication. “To be sustainable, the decision on which polio assets to sustain must be fully led and driven by countries themselves, based on national ownership, national plans and investments,” said the Gavi spokesperson.
Rotary international spoke to affirm that their 1.2 million volunteers worldwide remain fully committed to polio eradication. “We have three key challenges remaining,” said the Rotarian speaker. “First, we have to interrupt polio in Pakistan and Afghanistan. Second, we must avoid complacency. An additional US $1.5 billion is needed through 2019 to sustain high levels of immunity, repeatedly reaching more than 400,000,000 children in up to 60 countries and carrying out high quality surveillance to protect progress. Finally we must fully leverage the physical and intellectual assets of polio eradication so that they can benefit broader public health priorities.”
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Delivery of the Global Polio Eradication Initiative’s 2011-12 strategic plan is currently threatened by a $590 million funding gap, The End of Polio campaign is working to build public support for eradication efforts.
Three of the four countries in which polio remains endemic are members of the Commonwealth of Nations, and the campaign is working to make polio a priority issue at this year’s Commonwealth Heads of Government Meeting in Perth, before building global advocacy efforts to secure additional funding commitments from donor countries.
With more than 2,000 supporters signed on already, the campaign is off to a very successful start! Please add your voice at www.theendofpolio.com
