Islamabad – An announcement over a loudspeaker from the mosque captures the attention of parents and their children. The voice announces that a polio campaign is taking place in the settlement and vaccinators will be coming to give two drops to children under five. Eight teams of two vaccinators each are already on their way, each starting their day from the farthest house in the community and making their way to the center.

In January, when Pakistan detected a positive wild poliovirus from a sewage sample with genetic links to the virus circulating in Afghanistan, the polio teams jointly conducted a detailed epidemiological investigation to trace the routes of virus movement and identify infected populations. In a matter of weeks, a response was planned and implemented, vaccinating around 6.37 million children from 13 – 17 February. In this article we take you to an Afghan refugee settlement in Islamabad, one of the 30 districts that were covered partially and where the outbreak response focused on mobile and cross-border populations.

The story looks at three important components of a campaign: vaccinators, vaccines and tally sheets.

Vaccinators: the backbone of programme

“Who is there”, asks a man from inside the house, in Pushto.

“Polio team,” responds Salma who speaks Pushto. “We are here to give polio drops. Do you have children under five at home?”

Polio vaccinators. © WHO/EMRO

A tall man with a three-year-old boy in his arms, opens the door and welcomes the two vaccinators. Salma introduces herself and her team member Amina and asks the father if either of their children had received polio drops that day. The father confirms that in this round, his children did not receive any polio drops.

“Can I give them the polio drops?”, asks Salma.

The father responded back energetically, “Of course, you can! I want my child to grow up healthy!”

This is when Salma opens the blue box. Inside it are ice packs and vials of oral polio vaccine. She talks to the little daughter and asks her to open her mouth and gives her two drops from the vial.

After giving the drops, she marks the girl’s little finger. “You can show this incase anyone asks if you got the polio drops.”

Amina, on the other hand, fills out the tally sheet that she will later submit to her supervisor. If this information is incorrect, it can impact the overall operational coverage data for the campaign.

On leaving the house, Amina takes out her chalk and marks the door of the house with key information that will mention what day they visited, the number of children under five in the house and if there was any child with symptoms of acute flaccid paralysis.

One house done, now on to the next one.

Vaccines: two drops for every child 

“It is not always this straightforward,” says Amina. “Sometimes parents are skeptical about the vaccine and don’t want us to vaccinate their children. I often take the drops myself to show them how safe the vaccines are. When they see me taking these drops, it helps us build confidence with them.”

The polio programme has a long history of systematically listening to community concerns and addressing them, often engaging influencers such as religious leaders, to underscore the safety and efficacy of polio vaccines. This has helped address vaccine hesitancy and reached more children, building their immunity against this debilitating disease. At this settlement, occasional announcements were made through the mosque, informing people that a polio campaign was taking place and encouraging them to vaccinate their children. The result of these efforts has helped the programme significantly reduce the number of refusals across the country.

The blue box Amina carries with her has a large red “End Polio” sticker and it can carry up to 20 vaccine vials, nestled between the ice packs. Each vial contains 20 doses. She pays special attention to the box making sure the temperature is always maintained and the vaccines are kept out of direct sunlight. Vials that have been used, those that are unused and the ones in use are all kept in separate bags in the cold box.

Tally Sheets: supporting real-time corrective actions

The third important piece of a polio campaign is the tally sheet. In rudimentary terms, it is a piece of paper with many tiny boxes that deliver a telling story of number and ages of children, those who were vaccinated, those who were missed, location where the campaign is taking place and number of doses delivered. In case of any refusals, the vaccinator mentions the reason for refusal at the back of the tally sheet. It tells how well an area has been covered and the remaining gaps.

Markings on a house entrance after visitation by polio vaccinators. © WHO/EMRO

The authenticity of this data is a crucial component of operational coverage. It allows supervisors to identify gaps, present progress and advise corrective actions for vaccination teams. Each evening, this data is used to measure the campaign’s operational coverage.

In one of the houses where the vaccinators entered, the mother mentioned that the child had already been vaccinated. However,  no finger of the child was marked , while the others each had a blue mark on their pinky finger. Taking no chances, the vaccinator took out the vial and gave the child drops and then marked the finger. The tally sheet cannot be marked unless a child has been vaccinated and finger-marked.

Getting past the finish line

Up until April, Pakistan has conducted four polio vaccination campaigns. With the support of 390,000 polio workers, almost 43 million children under-five were vaccinated during a five-day nationwide vaccination campaign. There are multiple campaigns planned for the year ahead, requiring hours of strategic and evidence-based planning led by the national and provincial emergency operations centres.

Leaving nothing to chance during this last 100 meter dash towards eradication, the programme has also started implementing innovative interventions, such as the nomad population mapping and vaccination of high-risk mobile populations, engaging public health students for monitoring campaigns through the Lot Quality Assurance Sampling survey and the co-design initiative that engages women polio workers to develop solutions for improving campaigns and identifying potential livelihood opportunities for them in the future.

For Amina and Salma, the conclusion of the February round meant that children under five had received the vaccine to build strong immunity against the poliovirus. However, the journey to eradication continues. After a short break, the programme will begin working on validating the next set of microplans. All of this work is essential to ensure that the virus really finds no place left to hide and no child left to paralyze.

By Rimsha Qureshi,
Communications Officer, GPEI Hub Amman

Islamabad – As he rode his motorbike out of the relative safety of Bannu city on a September morning, Danyal Sikandri was nervous. It was his first day on a new assignment, and he was riding out into the district outskirts with colleague Yasir Shah in search of a reclusive group of people – nomads.

Their task was to find nomadic settlements and vaccinate the children there against polio and other vaccine-preventable diseases. Sikandri has been involved with the Pakistan Polio Eradication Programme since 2019, first as vaccinator and then area in-charge. Therefore, he was no stranger to interacting with people. But with this assignment, he didn’t know what to expect, since he would be travelling long distances to find people who might not speak the same language, might be unwelcoming or worse, he could end up in an area which may not be secure.

After travelling for about 36 kilometers, the team found a nomadic settlement in Domel. A group of families clustered together in makeshift tents made of plastic sheets and cloth. Sikandri approached the elders and explained why they were there. The nomads, who had come from Afghanistan and were temporarily camped in Domel, warmly welcomed the vaccinators in their midst.

As Sikandri vaccinated 14 children in the camp that day, his nervousness dissipated, and a resolve set in – to bring life-saving vaccines to as many nomadic children as he could.

“When I met them, I saw how different their lifestyle is, since they are constantly on the move and far from health facilities,” says Sikandri. “They want to protect their children from diseases too, so they are happy to see us. They tell us that it is the first time that vaccinators have come to their tents to vaccinate their children.”

Sikandri is one half of a two-member special mobile team which works under Pakistan Polio Programme’s latest initiative to reach segments of the population with polio and essential vaccines, which they would otherwise not have access to. The nomad vaccination initiative was launched in September 2022 in the seven endemic districts of southern Khyber-Pakhtunkhwa (KP) and expanded to four districts of Punjab neighboring these districts in October. The initiative was further expanded to include more districts from Punjab in January and Balochistan in early March. A total of 80 mobile teams in 22 districts have been deployed so far to reach nomadic children.

“With this initiative, we are filling a crucial gap. In the past, we were vaccinating children on the move, in buses, on train stations and other transit points, but the children that were being left out were from nomadic populations. This initiative is a product of extensive research, where we mapped out population movements and based on that information, made mobile vaccination teams to reach nomadic children with polio as well as all essential immunization necessary for their health and safety,” said Dr Zainul Abedin Khan, the National Team Lead for WHO’s Polio Operations in Pakistan.

“This is an excellent initiative of the Government of Pakistan, with support of polio partners, to protect children who had never been vaccinated before. This initiative will keep expanding based on the movement patterns. With this, we hope that population immunity is increased, and poliovirus is interrupted permanently,” he added.

“They want to protect their children from diseases too, so they are happy to see us. They tell us that it is the first time that vaccinators have come to their tents to vaccinate their children.”

Since nomads are highly mobile, the children in these communities are missed during routine vaccination campaigns or even at transit vaccination sites because they may not be passing through formal routes. This means their immunity remains weak, they are vulnerable to disease and can potentially transmit poliovirus as they travel across country and district borders.

In 2022, the program conducted a comprehensive survey of nomadic movement patterns in February and March in 14 districts of KP, Punjab and Balochistan. The survey found that nomadic movement begins in southern KP in September and ends in March, with the nomads setting up temporary camps as they pass through various districts.

“It is difficult for our door-to-door vaccination teams to reach them since a majority of nomads live on district borders or peripheries and it is not even known when they are coming,” said Muhammad Asif Javaid, who leads the program’s High-Risk and Mobile Population Unit (HRMU) and is spearheading this initiative. “They are frequently on the move, staying in places temporarily, never settling, so they miss the opportunity to receive polio and routine immunization.”

In the first phase of implementation, two special mobile teams – consisting of a trained vaccinator and a team assistant – were deployed in each of the seven districts of southern KP and four districts of Punjab. Subsequently, the project was expanded to cover 22 districts of the country.

Union council staff collect data on nomads visiting their areas. This information along with weekly micro-plans and targets are provided to vaccinators, who travel across their assigned UCs to visit these settlements. They provide polio and other essential vaccinations to children in the camps and issue vaccination cards to the families to ensure the data remains on record.

Javaid said that these teams are also helping with surveillance for cases of acute flaccid paralysis (AFP) by asking families and looking for any children who might have AFP, and then ensuring that it is reported to relevant authorities for further testing.

As of March 31, more than 114,600 children under the age of five had received the oral polio vaccine, 71,206 had received the inactivated polio vaccine, while nearly 20,000 routine immunization antigens have been administered to eligible children, under this initiative.

“Currently the program is actively working to vaccinate chronically missed children and is focusing on reaching missed populations rather than prioritizing geography alone,” Dr Zainul Abedin Khan added.

The task is challenging for vaccinators, who travel many kilometers out of urban centers to find nomadic settlements. They might run out of fuel, the settlement might have packed up and left by the time they arrive, or they may encounter hostility, but the vaccinators take it in their stride, happy to be safeguarding children’s futures.

For Sikandri, the experience has been rewarding. He has seen areas of his native district now that he had never seen before, and he feels his communication skills have improved since he began working on this project.

“We have received a lot of love from these people. When we vaccinate their children, they are thankful and pray for us. It feels good that people like them and their children are also being taken care of,” said Sikandri.

By Suzanna Masih,
Communications Officer, WHO Pakistan (Video by NEOC)

FATEHPUR – In Fatehpur, any mention of the month of August is followed by the word ‘qayamat’.

In Urdu, qayamat is used to express what the end of the world would look like. It could be a physical or metaphorical experience and is often used to describe a feeling, a feeling of utter devastation and destruction, when all is reduced to nothingness.

The world really did seem to end for the people here in Fatehpur, Rajanpur district, when the monsoons, once a celebrated time of the year in Pakistan, brought with them the climate’s wrath. Fatehpur was among the 90 calamity-hit districts in the country after the super floods and rains left a third of Pakistan under water and affected one in seven people in the country of over 220 million.

“We only had 25 minutes to leave the house. All I did was lock the door and run with my family after we heard the announcements to evacuate,” says Sughra Javed, a Lady Health Vaccinator, part of the polio immunization campaign.

But locks could provide little protection from the scale of the disaster that was to come. Shahida left for her mother’s house and came back two weeks later, only to find three-feet-deep water all around and the belongings she had gathered for years, old cotton blankets, a TV set, clothes folded in trunks, all gone.

There was little time here to process this loss. Around a week later, the health workers were back on the field serving at health camps that began in late August, nearly 10 days after Rajanpur experienced its worst floods in history.

 “I would be working, vaccinating, but it was so difficult to focus. Seeing the broken structure of my house made me want to run away when I was home, and when in the field at work, it was unbearable to see so many people suffering. One after the other, house after house was destroyed,” says Nasreen Faiz, who was among polio team members part of the September campaign.

“My entire village was finished. The crops were gone, the homes were gone, the animals were dead. But at least we had work, I would keep thinking of the people who didn’t even have work,” she adds.

Rajanpur was among districts where the nationwide immunization campaign was suspended as the calamity unfolded. But polio work continued a month after, in between the destroyed cotton crops and cracked land, still too soft to step on.

For Dr. Shahzad Baig, the Coordinator of the National Emergency Operations Centre (NEOC), it was painful to witness his country experience a humanitarian crisis of this scale.  “In the Polio Program, we are all part of one large family. When the floods came, it felt like I was sitting at a distance in Islamabad and witnessing my family members suffer. The very first thing I wanted us to do as a program was to find a way to support our people. On every forum, I would request for help to rebuild the homes of our frontline workers.”

The process of assessing the damage was an arduous one. There are over 350,000 health workers part of the program and to identify the people impacted as well as the extent of their loss, was challenging.

Dr Altaf Bosan, the National Technical Focal Person, explains the challenges of determining the impact of the floods with a workforce as large as that of the polio program.

“It was really a very difficult exercise. We went through multiple layers of verification to determine the number of people affected by the floods. This was done at three levels: through the Emergency Operation Centres at the district and province, and the NEOC,” says Dr Bosan.

Through a comprehensive assessment, the Polio Program determined that more than 12,500 polio workers across the country were affected, and funds were secured for the frontline workers who suffered full or partial damage to their homes. In total, cheques worth Rs216 million have been distributed among 10,500 polio workers so far.

On the first working day of the new year, January 2, Mr. Abdul Qadir Patel, the Federal Health Minister handed over cheques to the Provincial Coordinators of the Emergency Operations Centres (EOC). In Sindh, the process was completed at the end of last year following an inauguration by the Health Minister in Thatta district.

“I really commend the team working on it. It really was not an easy task to manage cheques for each individual and deliver them across the country,” Dr Bosan adds.

Nasreen has also received the cheque for financial support as have some of her other colleagues. It is a good time to receive it, she says, because “the winter is too harsh and the need for rebuilding so much greater.”

“I don’t know what can really compensate for their loss, if anything,” says Dr Baig. “Our purpose was to help support as much as we possibly could.”

By Zehra Abid,
Communications Officer, WHO Pakistan

WHO Representative in Afghanistan, Dr. Luo Dapeng, vaccinating children against measles in a mobile clinic in Baba Wali Village of Kandahar province. © WHO/Afghanistan

With more than twenty years’ experience on the ground in Afghanistan, WHO’s polio eradication programme continues to leverage its extensive operational capacity to deliver better health outcomes for all Afghans, including providing vital support to the recent nationwide measles vaccination campaign.

Measles outbreaks were reported across Afghanistan throughout 2022, with more than 5,000 cases and an estimated 300 deaths reported by November. Complications from the measles virus include severe diarrhea and dehydration, pneumonia, ear and eye complications, encephalitis or swelling of the brain, permanent disability and death. Most cases are children under the age of 5 years. There is no treatment for measles, the only reliable protection is vaccination.

While a series of sub national measles vaccination campaigns took place in 2022 reaching approximately three million children in 141 districts, the nationwide campaign from November 26 to December 5 represented the first national measles drive since the political transition in August 2021. The campaign covered 329 districts in all 34 provinces, vaccinating 5.36 million children aged between from 9 to 59 months against measles. 6.1 million children between 0 to 59 months received oral polio vaccine.

WHO’s polio eradication programme has significant reach in Afghanistan, with a presence in every district in the country. The polio programme leveraged this presence to recruit vaccinators, organize vaccination sites, and train campaign staff. With longstanding relationships with local authorities, the polio programme assisted in the selection of local schools, clinics, or mosques to serve as vaccinations sites. The programme’s established relationships with health institutions and communities enabled polio staff to recruit local health workers and other staff to fill the roles of measles vaccinators and provide training. Sharing their experience of implementing polio vaccination campaigns helped measles vaccinators prepare and plan for the task ahead.

The detection of measles cases and collection of data by WHO’s extensive polio surveillance network also played a crucial role in providing evidence-based planning for the campaign. WHO’s polio programme also provided logistical support, transporting measles and polio vaccines, ensuring the cold chain was maintained and vaccines were delivered to every district. Polio staff played additional roles in campaign monitoring and supervision.

“Measles is a highly contagious disease. WHO Afghanistan is very proud of its work immunizing and protecting children against both measles and polio in this campaign,” said Dr Luo Dapeng, WHO Representative in Afghanistan. “I am very grateful to all health workers, partners and donors who made this possible.”

© WHO/Pakistan

The meeting came at a time of contrasts for polio eradication efforts. On the one hand, the Region’s most recent case of wild poliovirus was reported almost 5 months ago, in Pakistan, and the footprint of the virus is the smallest it has ever been. Additionally, efforts to search for polioviruses have never been stronger and the polio programme has made significant progress in accessing under-immunized children across a number of high-risk countries in the last year. On the other hand, the Region hosts 4 of the world’s 7 ‘consequential geographies’ – low-resource, high-risk areas in Afghanistan, Pakistan, Somalia and Yemen that the programme has identified as carrying a significant risk of spread of polio.

WHO’s Regional Director for the Eastern Mediterranean Dr Ahmed Al-Mandhari, who convened this virtual meeting, set the tone for the event by coining 2023 as a “defining year” for polio eradication.

He urged all Member States and partners to leverage the opportunity and momentum of the current moment and scale up collective efforts to wipe out polio. “Going forward, our regional solidarity and concerted action will be even more important, as we move closer to making history and ending polio,” said Dr Al-Mandhari.

Leading the demonstration of regional support to polio were the Co-chairs, Minister of Public Health of Qatar, HE Dr Hanan Al Kuwari, and Minister of Health and Prevention United Arab Emirates, HE Mr Abdul Rahman Mohammed Al Owais. They urged participating Member States to strengthen routine immunization and consider polio as “all of our problem” until transmission ends everywhere. They also called on Member States to offer all they can – funding, advocacy or technical expertise – to reach every child with vaccines.

Participants at the meeting also included ministers of health and senior delegates from countries in the Region, in addition to representatives from the Bill & Melinda Gates Foundation (BMGF), the Centers for Disease Prevention and Control (CDC), Gavi, Rotary and UNICEF.

In his address, the Minister of National Health Services Regulations and Coordination of Pakistan updated the audience of the timely and robust programmatic actions the country has been taking to end polio. In the face of catastrophic floods, the country turned response efforts into an opportunity to offer polio vaccines to children wherever possible. Additionally, Pakistan is using creative ways, such as truck art, to reach out to vulnerable communities living in hard-to-reach areas.

During discussions, the delegate from Egypt and the Minister of Health of Yemen offered updates on their polio eradication efforts, while delegates from Iraq and Saudi Arabia proposed actions to prevent the spread of polio during mass religious gatherings in their countries.

Member States and partners acknowledged the immense efforts directed at ending polio in the 2 countries where it is still endemic – Afghanistan and Pakistan – particularly in the wake of the earthquake and catastrophic flooding that took place in 2022, and the extraordinary political will and engagement in both countries. They also noted the work ongoing in countries witnessing outbreaks of circulating vaccine-derived poliovirus type 2 (cVDPV2), and lauded health workers for their valour and dedication to their work.

Member States issued 2 statements following the meeting. One called for the international development and humanitarian communities and donors to scale up support to the National Emergency Action Plans for Afghanistan and Pakistan. A second statement called for international partners to provide essential services, including a robust vaccination response, to polio outbreaks in Somalia and Yemen.  In Yemen’s northern governorates, amidst a surge of anti-vaccine propaganda, a long-overdue outbreak response has still not been launched, and Somalia is experiencing the longest ever cVDPV2 outbreak.

Member States also reiterated the importance of focusing on zero-dose children, and strengthening routine immunization and surveillance in countries that are polio-free and those that currently have polioviruses. They also commended Regional Director Dr Al-Mandhari for his leadership and requested him to continue to support Member States in the Region to push towards ending polio and attaining Health for All by All.

While updating participants on a recent visit made by a high-level mission to Pakistan last year, a representative from the BMGF, on behalf of Dr Chris Elias, the Chair of the Polio Oversight Board, acknowledged the extraordinary and unmatched efforts made in Pakistan by the political and health leadership, law enforcement and security agencies, to prevent any further spread of polio. Despite the flooding and political changes the country has faced, the polio programme continued to “shift gears” and mount a swift and robust response to polio. This was one of several visits that high-level missions have been making to Pakistan in support of eradication efforts.

In closing remarks, WHO representatives recognized Iraq and Syria for the strides both countries have taken to maintain essential polio functions, including in polio surveillance, while concurrently transitioning away from funding from the Global Polio Eradication Initiative.

The seventh meeting of the Regional Subcommittee for Polio Eradication and Outbreaks demonstrated the high level of confidence that Member States and partners have in the 2 remaining polio-endemic countries, Afghanistan and Pakistan. As polio remains a Public Health Emergency of International Concern under the International Health Regulations (2005), the intensified regional- and international-level collaboration of Member States and partners at events like this will serve as a springboard for focused action in 2023.

Note for editors

The Polio Oversight Board is the highest decision-making body in the Global Polio Eradication Initiative (GPEI). It brings together senior leadership of the 6 GPEI partner agencies—the Bill & Melinda Gates Foundation (BMGF), U.S. Centers for Disease Control and Prevention (CDC), Gavi, Rotary International, UNICEF, and the World Health Organization (WHO)—along with a representative of the GPEI’s donor community.

Dr Tedros Adhanom Ghebreyesus, Director-General of WHO, visited Pakistan in his role as Chair of the Polio Oversight Board at the time. Following this, since mid-2021, the Polio Oversight Board* made 3 visits, and Mr Bill Gates of the BMGF visited in February 2022.

A moderator speaks in a workshop for the female frontline workers initiative. © BMGF/Sang-hee Min

ISLAMABAD – Poultry farming, EPI technicians, creative writing, midwifery, embroidery, online businesses: it’s a room filled with possibilities and dreams when women health workers come together to imagine their lives in a polio-free Pakistan.

These ambitions surface during the workshops the Pakistan Polio Programme initiated last year, as part of a unique project to actively listen to female frontline workers in the areas at highest risk for poliovirus transmission across the country.

The initiative used a bottom-up, data-informed approach to better understand the experiences of women on the frontlines and hear their ideas for how the programme can better support them to do their jobs safely and effectively. And came with a prior promise: leadership from all partners at the Emergency Operations Centres were to review – and implement – workable solutions.

This systematic listening process, which began in July 2022 and concluded last week, was done in two parts: First, an independent research company was brought on to conduct more than 2,600 randomized, anonymous surveys with polio frontline workers across Pakistan to understand their unique challenges and experiences in the field. After this, based on the results of these surveys, 14 workshops were designed to hear from women frontline workers themselves on what they think are the solutions to the challenges they face.

Female health workers from the polio endemic districts of Bannu, DI Khan, Lakki Marwat and Tank in southern Khyber Pakhtunkhwa to the geographically challenging terrains of Chaman, Quetta and Killa Abdullah in Balochistan to Punjab in central Pakistan to Sindh in the south of the country to the capital city of Islamabad were brought together in this series of workshops.

Participants during the workshops. © BMGF/Sang-hee Min

The workshops were also moderated by a third party to allow for open and honest discussions, and carefully curated to create spaces where, for the first time, the women were the chief guests, they were the people who mattered most, while everyone else had one job: to listen.

“When you get respect, you get everything. It’s the first time that we have talked, and other people have listened,” says Fauzia Naseem, an Area-In-Charge from Chaman.

As each of the two-day workshops finished, there was excitement, energy and almost a sense of disbelief that hours had been dedicated to listening to them. “I’ve been here since 2017 and no one has ever really asked us what we think. Otherwise we are only told where to go and what to do. Today I feel like what we say matters,” says Samreen, a polio worker, from Tank.

“This is a very special project – and a very insightful one too. It offers us the opportunity to gain from the wealth of knowledge of the polio programme’s frontline staff. For the very first time, the people who actually do the work of delivering the vaccine to a child have been systematically asked how they think it should be done. We are currently looking into their suggested solutions and seeing which are implementable and can be taken forward,” said Dr Shahzad Baig, the Coordinator of the National Emergency Operations Centre in Islamabad.

“For many women, this is the first time they are together to just talk to each other, hear from each other, take a selfie and be in a space where they have the right to simple joys that they otherwise may not have access to. The workshops for women from southern Khyber Pakhtunkhwa were particularly special. These were held in Islamabad and for many women, this was the first time they had visited the country’s capital city. Their excitement and sheer joy was infectious. It lit up the room,” said Dr Atiya Abro, Deputy Director Ministry of National Health Services.

Moderators guide the participants during a workshop for the female frontline workers initiative. © BMGF/Sang-hee Min

 

The last session in all workshops was dedicated to listening and understanding the women’s diverse interests in other career pathways after polio, and what skills or support the workers felt would be needed for them to transition into these jobs in the future.

This initiative was coordinated by the Pakistan Polio Programme’s National Gender Group, comprised of representatives from the government and partner agencies including WHO, UNICEF, BMGF and N-STOP.

“Having the opportunity to listen and give center stage to these women has been a true privilege. It’s encouraging to see such strong commitment from Pakistan programme leadership to support these female health workers – not only in their work toward our collective goal of eradicating polio, but also to facilitate transitions into other potential livelihood opportunities in the future. We look forward to the next phases of this exciting initiative as well,” said Sang-Hee Min, Senior Programme Officer, Bill & Melinda Gates Foundation and member of the National Gender Group.

“Polio teams are a valuable asset to our country,” said Dr Baig. “It is very important to me that when we finish polio from Pakistan, we don’t just pack up and leave but utilize this incredible workforce. We build systems and create opportunities to serve the workforce, a majority of them women, and find some way, however small, in giving back to the people who have worked tirelessly to protect the children of our country.”

By Zehra Abid,
Communications Officer, WHO Pakistan

©WHO
©WHO

Acknowledging that our common goal is to attain ‘Health for All by All’, which is a call for solidarity and action among all stakeholders;

Noting the progress achieved globally in eradicating wild poliovirus transmission since 1988, with endemic wild poliovirus transmission restricted to just two countries – Afghanistan and Pakistan;

Recalling that 2023 is the target year for interrupting all remaining poliovirus transmission globally, as per the Global Polio Eradication Initiative Strategy 2022–2026: Delivering on a Promise;

Appreciating the recent, intensified efforts made by both Afghanistan and Pakistan, resulting in a unique epidemiological window of opportunity to achieve success in 2023, as characterized by:

the geographic restriction of wild poliovirus transmission in 2022 to eastern Afghanistan and a few districts of north-western Pakistan;

the absence of any wild poliovirus case since September 2022;

the significant decline in genetic biodiversity of wild poliovirus to just a single lineage in each country; and

the successful interruption of circulating vaccine-derived polioviruses;

Emphasizing that the opportunity to interrupt wild poliovirus transmission must be seized now, given the unprecedented epidemiological progress and the inherent risks of delays in stopping polio, which would likely result in resurgence of polio;

Underscoring the ongoing risk of  transmission of wild poliovirus, with detection of wild poliovirus from environmental samples in both countries since January 2023,  confirming cross-border transmission ;

Highlighting that the key to success lies in reaching remaining zero-dose children (children who are un- or under-immunized) with oral polio vaccine in the most consequential geographies,1  operating within a broader humanitarian emergency response, including increasing access to all populations in some areas;

Underscoring the importance and heroic work of health workers at the forefront in insecure settings, especially women, whose support and participation is critical to the eradication effort;

Recognizing the sustained commitment by leaders at all levels, notably by political leaders and law enforcement agencies, community and religious leaders, civil society, Global Polio Eradication Initiative partners, especially Rotary International, parents, caregivers and all health workers;

Recalling that the international spread of poliovirus constitutes a Public Health Emergency of International Concern under the International Health Regulations (2005);

Appreciating the support provided by the GPEI in responding to the devastating floods affecting Pakistan and the tragic earthquake affecting Afghanistan in 2022;

Appreciating the commitment of the United Arab Emirates through the initiative of His Highness Sheikh Mohamed bin Zayed Al Nahyan, President of UAE, to promote and support polio eradication in Pakistan through the UAE Pakistan Assistance Programme;

Recognizing the longstanding support of donors like Rotary International and acknowledging the historical financial support of other Member States to the eradication effort, including the Kingdom of Saudi Arabia, Kuwait, Oman and Qatar;

Appreciating and supporting the decision of the WHO Regional Director for the Eastern Mediterranean to formally grade all polio emergencies and to apply relevant emergency standard operating procedures to WHO operations to address polio emergencies;

We, Member States of the Regional Subcommittee for Polio Eradication and Outbreaks for the Eastern Mediterranean,

DECLARE THAT:

1. We will focus all efforts on reaching remaining missed children with oral polio vaccine, within a broader humanitarian response context in the remaining most consequential geography of eastern Afghanistan and in north-western Pakistan;

COMMIT TO:

2. Mobilizing all necessary engagement and support by all political, community and civil society leaders and sectors across the Region, to fully achieve interruption of wild poliovirus transmission in the Region;

3. Facilitating the necessary support to fully implement all aspects of the Global Polio Eradication Initiative Strategy 2022–2026, including by ensuring rapid detection of and response to any poliovirus from any source, and implementing high-quality outbreak response;

4. Fostering coordination with other public health efforts, to ensure closer integration in particular with routine immunization efforts;

REQUEST THAT:

5. The international development and humanitarian communities and donors strengthen their support for full implementation of the National Emergency Action Plans to Eradicate Polio in Afghanistan and Pakistan; and

6. The Regional Director continue his strong leadership and efforts to achieve a Region free of all polioviruses for good, including by advocating for all necessary financial and technical support, reviewing progress, planning corrective actions as necessary and regularly informing Member States of the aforementioned and of any further action required through the World Health Organization Executive Board, World Health Assembly and Regional Committee for the Eastern Mediterranean.

@WHO

PAKISTAN marked a historic moment for polio eradication a year ago. On Jan 27, 2022, for the first time, we clocked in a year without polio paralysing a child. There was a euphoric feeling that the country had finally turned a corner. The long battle to end this disease was thought to be close to an end. But the virus had other ideas.

Despite aggressive vaccination efforts, polio was surviving and continuing to spr­ead in a small area in southern KP. First det­ected only in sewage water, the virus then paralysed a 15-month boy in North Waziristan. It was the first case of polio in nearly 15 months. I was in Karachi with sev­eral members of our team when the news came. Although not surprising given the circulation detected in the environm­ent, it was heartbreaking to hear that an­other child in Pakistan would never walk again because of an easily preventable disease.

Emergency responses were immediately finalised. While preparing for the work ahead, memories took me back to Borno in Nigeria, a country where I spent a decade fighting polio. After the ‘last case’ of polio in Nigeria was reported in 2014, I started to check my phone every morning, relieved that another day had passed without the virus resurfacing. Typically, it takes three years without any poliovirus for a country to be declared polio-free. But in August 2016, 30 months after the last detection of the virus, a child from a security-compromised area of Borno was found paralysed by polio. As there was poor surveillance and no ability to vaccinate, the virus had found its hiding place. One paralysed child became three. And the outbreak brought Nigeria back to square one.

I knew that the case in North Waziristan was following a familiar pattern, but it was greatly challenging, nonetheless. The year 2022 was excruciatingly demanding. It was a year of feeling the weight of huge challenges, but moving on and choosing courage, commitment and hope every time.

We have aggressively responded to any outbreak in the country, restricting the virus to just seven districts in southern KP. Our virus surveillance network has nearly doubled. We have charted the movement patterns of nomads to reach children otherwise deprived of essential immunisation. We have launched a novel project that allows us to listen to hundreds of front-line women health workers and hear their recommendations for reaching the end goal. And we are consistently working towards improving overall healthcare in areas most at risk from polio.

Polio eradication has had remarkable sup­port and remained a priority in one of the hardest years for the country. The prime minister holds quarterly meetings on polio eradication, bringing provincial and federal leadership together. The federal health minister has visited different provinces to encourage and support provincial health ministries. There is uniform consensus and commitment across all poli­tical parties that Pakistan must win this battle against polio, and now is the time.

This commitment is there at every level, from federal health secretaries, chief secretaries and chief ministers, to the deputy commissioners directly overseeing implementation. The military and law enforcement have given the programme their absolute support, making immunisation possible in some of the hardest areas to reach, while global advocates for polio eradication, including Bill Gates and the regional directors of WHO and Unicef, have made polio eradication a top priority in their visits to the country.

We have begun 2023 with great hope and greater commitment. The first nationwide campaign was recently concluded. Despite rain, cold, snow and ice, polio workers carried on with inspirational dedication. They are the face of Pakistan’s sincerity, perseverance and hard work.

The six months ahead are crucial to eradication. This is the closest Pakistan has ever been to interrupting transmission. But the risk of the virus continuing to circulate in the seven districts of KP’s south, and the risk of it exploding beyond and bringing the virus back to polio-free areas, is real.

Polio eradication now needs a renewed countrywide sense of urgency. It needs to be important to all of us to see this virus vanquished. After three decades of the polio programme in Pakistan, there is understandable fatigue. But this is not the time to tire. This is the time to believe. A world free of polio was the birth of a dream. In countless countries at countless times, it has felt like an impossible dream — until it was possible and actually happened.

Over 99 per cent of the world has made this dream come true. And it will come true for our children too if we take this as a collective fight and finish the job. Now is the time to strengthen that resolve, to come together and make the end of polio possible.

Written by Shahzad Baig, Lead, Pakistan Polio Eradication Initiative.

This article was originally published in Dawn on January 27, 2023.

© WHO/Afghanistan

3 February 2023, Geneva, Switzerland At this week’s WHO Executive Board in Geneva, Switzerland, global health and policy experts urged a razor-sharp focus on finishing polio in the remaining highest-burden areas, from where the virus would continue to spread if given the chance.

In his opening address to the Executive Board, WHO Director-General Dr Tedros Adhanom Ghebreyesus noted that no wild poliovirus cases had been reported anywhere since September 2022, and commended support for this effort globally, including through the pledging of US$2.6 billion to the effort in October.

Experts noted the unique window of opportunity presenting itself to achieve success in 2023, the target year for stopping all remaining poliovirus transmission globally. They also provided guidance to develop a new vision for polio transition that will go beyond 2023, supported by tailored regional action plans to drive country progress.

Endemic wild poliovirus transmission is now limited to geographically-restricted areas of just two countries: Pakistan and Afghanistan.  Intensified efforts in both countries have resulted in a historically-low number of biologically-distinct virus lineages remaining in circulation.  Individual virus lineages are being successfully knocked out, demonstrating the effectiveness of strategies. Commenting on this current trend, Regional Director for WHO’s Eastern Mediterranean Dr Ahmed Al-Mandhari said:  “Never have we looked so hard for the virus and found so little of it.”

Poliovirus transmission, either due to wild poliovirus or circulating vaccine-derived poliovirus, is now primarily affecting just seven subnational geographic areas, which together now account for 90% of all new polio cases worldwide.  These “most consequential geographies” share certain key programmatic characteristics:  they are home to some of the largest populations  of “zero-dose” children, in other words, children who are either un- or under-vaccinated, and are affected by broader humanitarian, complex emergencies.

The overriding programmatic goal in particular in the first half of 2023 must be: to reach the remaining zero-dose children in each of these geographies by adapting operations to the nature of the complex humanitarian emergencies in each of these settings. This means operating effectively within the broader humanitarian context.  It means working with broader humanitarian partners, to deliver polio vaccine alongside other interventions, in the most culturally-relevant and appropriate manner.

The Board noted of course the re-emergence of polio in the past year in previously polio-free areas, and commended local public health authorities for successfully managing these events. But more than anything, these events are a stark reminder of what would occur if we did not achieve global eradication – a global resurgence of the disease.  Within that context, experts urged countries not to lose sight of the need to plan for securing a lasting polio-free world, including by fully implementing containment activities.

The meeting also noted that the capacities developed to eradicate polio underpin the health system in many places. As we move towards eradication, we must ensure that this expertise is not lost, and is instead integrated to strengthen national health systems, which are the backbone to prevent a future resurgence of polio. In 2022, ‘proof of concept’ was demonstrated, through the successful transition of over 50 polio-free countries out of Global Polio Eradication Initiative support. In these countries, the expertise and tools of the eradication programme have been repurposed to support essential immunization, primary health care, emergency preparedness and resilience and response capacities. The guidance provided by Member States at the Executive Board will be instrumental to shape the next stage of polio transition, through the development of a new global vision, guided by tailored action plans at the regional level, to ensure that transition efforts are fully aligned with global, regional and national health priorities.

For both polio eradication and transition, success depends on continued political and financial resources, and experts appreciate the tremendous show of support by the international development community demonstrated in the last quarter of 2022, including through the pledging of an additional US$2.6 billion in Berlin, Germany, in October 2022 at the World Health Summit, to the polio eradication effort. And while more resources must still be mobilized, in that context, the meeting especially appreciated the efforts of Rotary International, for their ongoing work in helping secure both public and civil society commitment to this effort.  Speaking on behalf of Rotarians worldwide, Judith Diment MBE, Chair of the Polio Advocacy Task Force, said:  “ Rotary proudly joined donors in Berlin to collectively pledge more than half of the funds needed for the GPEI’s strategy. We urge further investment by all sectors to overcome challenges and sustain these gains for future years.”

Dr Tedros, in closing the polio discussion, addressed the assembled delegates:  “We are in a much better situation now than we were previously.  But the last mile is the hardest.  There can be no room for complacency.  Now is actually the moment to double down on our efforts.  Let’s continue to push on.”

In conclusion:  there is a very real window of opportunity for success this year.  But this window will not remain open for long.  The virus will again gain in strength.  2023 is our chance.  Let us take it.  Let us keep the focus on our collective and clear objectives:  reaching zero dose children in the most consequential geographies, and taking steps towards a sustainable transition, to ensure that a polio-free world, once achieved, stays that way.  We all have a role to play in achieving this. We have a collective responsibility.

Experts urged therefore never to get distracted from that focus.  If we are razor-sharp in our focus, success will follow.

@WHO

In October 2022, the Technical Advisory Group (TAG) for Afghanistan and Pakistan met in Muscat, Oman, to conduct a thorough review of ongoing polio eradication efforts in the remaining polio endemic countries. During the 6-day meeting they also provided strategic technical guidance on steering efforts towards successful interruption of the poliovirus in both countries in 2023.

Polio programmes make significant progress, despite challenges

The TAG recognized the accomplishments of the polio programmes despite longstanding humanitarian crisis in Afghanistan and unprecedented levels of flooding across Pakistan that affected almost 33 million people. The progress comes due to concerted efforts by all stakeholders across all levels, intense vaccination schedule, timely programmatic pivots to changing epidemiology and the full support of law enforcement and security agencies in implementation of polio vaccination campaigns.

Members noted the high level of sustained political commitment to polio in both countries. In Afghanistan, since the political transition, nationwide campaigns have allowed the polio programme access to almost 10 million children, 3.5 million of whom were previously inaccessible. In Pakistan, intensified vaccination activities and strategic approaches were used to reach missed children.

The TAG also acknowledged the strategic role played by the Emergency Operations Centres (EOCs) in strengthening coordination and providing programmatic oversight at the national and regional levels.

Promising epidemiological trends provide a window of opportunity

Remarkable improvements in epidemiology in Afghanistan and Pakistan provide a window of opportunity for interrupting transmission of wild poliovirus. In Pakistan, the virus is endemic only in the southern districts of Khyber Pakhtunkhwa province, and in Afghanistan both cases have been reported from the eastern region. However, no cross-border transmission was recorded in 2022.

In addition to the limited geographical spread, the biodiversity of the genetic clusters is also at an all-time low: down from 8 in 2020 to 2 in 2022 in Afghanistan and from 11 in 2020 to one in 2022 in Pakistan.

Moreover, there has been no detection of circulating vaccine-derived poliovirus type 2 (cVDPV2) in either country in the last year. The last cVDPV2 case in Afghanistan had onset of paralysis on 9 July 2021, and the last cVDPV2 case in Pakistan had onset of paralysis on 23 April 2021.

Given the promising epidemiological trends seen in 2022, the TAG noted the possibility of full interruption of polioviruses this year. However, for the 2 programmes to succeed, the TAG proposed major strategic shifts in categorization of risks based on the epidemiological trends. The group of experts’ recommendations include context-specific tactics and technical guidance on activities to prioritize until mid-2023, when the TAGs for Afghanistan and Pakistan will meet again.

This new categorization redefines and re-demarcates the endemic zones in Afghanistan and Pakistan from the outbreak districts and the rest of the country where it is important to maintain children’s immunity. Additionally, it identifies highly vulnerable and consequential areas that are an additional risk category for Pakistan, where historically core reservoirs may play a role in establishing circulation in an event of reinfection.

The TAG also endorsed the 2023 polio supplementary immunization activities’ calendars for Afghanistan and Pakistan and emphasized continued cross-border coordination between the 2 countries, particularly in the key corridors. Finally, the TAG encouraged the continued use of strategies to integrate gender and social behavioural change communication into the programme’s activities, to reach every last child.

To read the reports from the Technical Advisory Group meeting on Afghanistan and Pakistan, click here.

“The mother was complaining that her son was weak and that the weakness had happened suddenly, so I examined his leg,” said Spogmai. “I saw that the limb was paralysed and immediately notified the clinic’s AFP focal point.”

AFP stands for Acute Flaccid Paralysis. Surveillance for AFP – keeping an eye out for the signs of paralysis among children – is the cornerstone of polio eradication in one of the last countries where the virus is endemic. To eradicate polio, every last child must be vaccinated and, importantly, every last virus must be traced. A sign that the virus may be circulating in the community, every case of AFP is tested to confirm or rule out presence of poliovirus.

Details of all AFP cases are copiously recorded in Surveillance Registry books. © WHO/AFG

Afghanistan is closer to interrupting polio transmission than ever before. In 2020, 56 children were paralysed by the virus, to date in 2022, the number has been reduced to two. Vigilance is key and highly sensitive surveillance enables the polio programme to quickly detect presence of polio and guide rapid targeted responses.

Like all staff at the clinic – doctors, nurses, cleaners, guards, administrative staff – Spogmai was trained to look out for signs of the virus.

“I had never seen a case of polio before, but I know how to watch out for it because I was trained to detect these things by the clinic’s medical officer. We have refresher training regularly to make sure we know.”

Orientation sessions for AFP surveillance are straightforward: what are the signs of polio, what to look for and what to do next. Participants form part of a vast jigsaw of community-based surveillance across Afghanistan. Beyond the clinic’s doors is a network of more than 46,000 volunteers comprising of religious leaders, hospital staff, private practitioners, physical rehabilitation centres, mid-level health workers, community health workers, community volunteers, traditional healers, pharmacists, drug store staff and others working in health care, all looking out for signs of paralysis in children in their communities.

“Sudden onset paralysis in cases is more compatible with polio,” says WHO’s Dr Khushhal Khan Zaman, Medical Officer, Polio. “We don’t want any case of polio to be missed and spreading the virus. Every case of AFP is notified, investigated, followed up and documented.”

The local Provincial Polio Officer visits Spogmai’s clinic regularly to check on documentation and discuss cases with clinic staff. Details of all AFP cases are copiously recorded. Binders line the shelves of the surgery, holding details of cases going back more than a decade.

The scene in Paghman is repeated across the country in all of Afghanistan’s 34 provinces, all part of the network of surveillance across the country. Spogmai’s clinic is a ‘CHC Plus’ (a comprehensive health centre that provides additional services) and serves a large population in the district. Other health facilities such as Basic Health Centres are smaller but regardless of their size, all staff are trained to look out for AFP cases and to report them to the designated focal point for further investigation.

Afghanistan’s AFP surveillance network was established in 1997 and the system is complemented by an environmental surveillance network consisting of 32 sites across the country. In June, the first review of the polio surveillance system in six years took place with WHO hosting a 16-strong team of national and international experts who visited 76 districts across 25 provinces. The review determined the likelihood of undetected poliovirus transmission in Afghanistan to be low. Recommendations, including upscaling surveillance in the country’s south and southeast, are being implemented.

For Spogmai’s young patient, the next steps involved collecting two stool samples 24 hours apart which were sent to a WHO accredited polio laboratory for testing. The results were negative for polio and the young boy is living a healthy life with his family in the community, that same community that continues to ensure cases of AFP are spotted, recorded and tested.

The site at Pezand Pana Dafter in Nangarhar province has produced three positive environmental samples since coming online in September. © WHO/Afghanistan 

The review team, comprising of experts including virologists and epidemiologists, visited Afghanistan in June, conducting a comprehensive nationwide assessment of the country’s polio surveillance system. Among their recommendations was the need to address gaps in environmental surveillance and expand the number of environmental surveillance sites in areas deemed high risk for polio, including the country’s east, southeast, south and west regions, to ensure any presence of the virus is quickly detected.

Afghanistan’s AFP surveillance system – monitoring for signs of Acute Flaccid Paralysis in children under 15 years of age – is complemented by environmental surveillance – the collection of sewage samples at designated sites to check for the presence of the virus in the community. Together, they enable the programme to detect where the virus may be circulating and, importantly, mount a timely response.

Following the review’s recommendations, three new environmental surveillance sites have now come online, bringing the total number of sites in Afghanistan to 32. One of those sites, at Pezand Pana Dafter in Nangarhar province has produced three positive environmental samples since coming online in September. The programme quickly mounted a response targeting 1.4 million children under 5 years of age in all four eastern provinces – Nangarhar, Kunar, Laghman and Nuristan.

“Surveillance is the eyes and ears of the polio programme, and environmental surveillance plays an important part in eradicating polio because it enables the programme to detect the presence of the virus,” says Dr. Khushhal Khan Zaman, who oversees polio surveillance for WHO Afghanistan. “Environmental surveillance tells us very plainly where transmission is likely happening.”

WHO guidelines stipulate that an environmental site be located in areas with substantial populations, and with flowing sewage water. In Afghanistan, sites are established in major cities and larger population centres with existing wastewater and drainage systems. Communities with mobile populations are also a focus. Samples are regularly taken and sent to a WHO-accredited polio laboratory for testing.

Afghanistan has made significant progress in interrupting transmission of the virus. From 56 children paralysed by WPV1 in 2020, so far this year there have been two cases, in Paktika and Kunar provinces. Seventeen positive environmental samples have been detected in 2022, all in the country’s east region.

Further environmental surveillance sites are planned as WHO Afghanistan continues to implement recommendations from the surveillance review.

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

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

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

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

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

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

Pakistan’s polio team supporting flood relief efforts © NEOC

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

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

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

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

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

Expert groups focus on outbreaks…

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

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

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

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

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

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

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

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

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

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

A child in Karachi receiving the polio vaccine. @WHO
A child in Karachi receiving the polio vaccine. @WHO

There is unprecedented support and commitment to ending polio in Pakistan by 2023, and with the current momentum maintained, the country will be able to interrupt transmission in the coming year, a high-level global delegation on polio concluded at the end of its visit to the country on Thursday.

The delegation was led by Chair of the Polio Oversight Board (POB) Dr Chris Elias, WHO Regional Director Dr Ahmed Al-Mandhari and UNICEF Regional Director George Laryea-Adjei.

“The last steps to ending polio are the toughest but eradication is within reach thanks to the hard work happening in Pakistan,” Dr Elias said.

“During my three-day visit, I was again impressed by the resolve of the government and community, especially frontline workers, to ensure polio is gone forever,” he added. “Reaching every child during the upcoming polio campaigns and strengthening the routine immunization system are now critical to success.”

The Polio Oversight Board is the highest decision-making body of the Global Polio Eradication Initiative. This is the delegation’s second visit together to Pakistan this year. The earlier visit was in May following the detection of a polio case in Pakistan after nearly 15 months. The recent visit comes following the destruction of several health facilities and mass displacement due to catastrophic floods, which increased the risk of polio transmission.

WHO Regional Director Dr Ahmed Al-Mandhari reaffirmed that Pakistan is in the “final stretch” of the road to eradication.

“The progress this year has well-positioned the country to end all poliovirus transmission in 2023. However, ensuring that we reach our goal will require sustained political and administrative commitment during 2023, a year of elections and political transition,” he said. “Under our regional vision of health for all by all, we all have a role to play in ending polio through our collective solidarity and action.”

UNICEF Regional Director for South Asia George Laryea-Adjei said that Pakistan’s success in containing the spread of polio through joint efforts by the government, donors, frontline health workers and partners is truly commendable.

 “The recent flooding has exacerbated health risks for millions of children, especially those living in districts historically at the highest risk for polio, so we must redouble efforts to engage parents and caregivers to protect these children,” he said. “The end of polio is near, and we must now go the last mile to ensure every child is protected against this debilitating disease.”

During the visit, the delegation met the prime minister, federal health minister, Pakistan Army’s engineer-in-chief and the heads of provincial governments of Balochistan, Khyber Pakhtunkhwa and Sindh, and reiterated support to help Pakistan end poliovirus transmission by 2023.

Both were exceptionally talented researchers, so united in their desire to rid the world of polio that they inoculated themselves and their families with disabled versions of the virus. Yet the rivalry between Jonas Salk and Albert Sabin was intense, with Sabin once suggesting that Salk’s efforts could be achieved in a kitchen sink.

The source of their hostility was a disagreement about the best way to immunise people against polio. Salk believed the answer lay in a “killed” virus vaccine – where the virus particles had been chemically inactivated, so they could no longer replicate or cause disease. Sabin favoured using a “live” oral vaccine – one containing live, but weakened, virus particles that could replicate but couldn’t cause paralysis.

The incidence of polio has reduced by 99.9% and GPEI and its partners have achieved what many had assumed would be impossible: the eradication of polio from all but a handful of countries.

Salk’s inactivated polio vaccine (IPV) entered human trials and was approved first. But it was Sabin’s oral polio vaccine (OPV) that became the global workhorse in polio eradication efforts and has been largely responsible for driving polio to the brink of extinction. However, polio isn’t gone, and the combination of COVID-19, ongoing conflict and political turmoil, has given polio the space it needed to fight back. Now, as polio eradication approaches its endgame, it is a combination of Salk’s and Sabin’s approaches that experts are hoping will prove to be humanity’s winning hand.

War on polio

Before the COVID-19 pandemic hit, progress towards eradicating polio was proceeding at a remarkable rate. During the 1940s and ’50s, when polio outbreaks were a common scourge of the summer months, the disease killed or paralysed more than half a million people worldwide each year – mostly children. The introduction of inactivated poliovirus vaccine (IPV) and, later, live attenuated oral poliovirus vaccine (OPV) led to a dramatic reduction in the incidence of polio in higher-income countries during the 1960s and ’70s.

But it wasn’t until the 1980s that the battle against polio really commenced. At that time, community- and school-based surveys revealed that polio was the leading cause of paralysis in lower-income countries, with one in every 200 polio infections causing paralysis. In 1988, the World Health Assembly adopted a resolution for the worldwide eradication of the disease, and a public-private partnership called the Global Polio Eradication Initiative (GPEI) was launched. Led by national governments, together with the World Health Organization (WHO), Rotary International, the US Centers for Disease Control and Prevention, UNICEF, and later joined by the Bill & Melinda Gates Foundation and Gavi, The Vaccine Alliance, GPEI has made huge progress in protecting countries’ populations against polio through widespread OPV campaigns.

During this time, the incidence of polio has reduced by 99.9%, and GPEI and its partners have achieved what many had assumed would be impossible: the eradication of polio from all but a handful of countries.

Eradication endgame

In 2019, an independent commission of experts announced that wild poliovirus type 3 (WPV3) – one of three forms of the virus – had been eradicated worldwide. Type 2 poliovirus was declared eradicated in September 2015 – with the last virus detected in India in 1999 – leaving only Type 1 wild poliovirus at large in two endemic countries: Pakistan and Afghanistan.

In August 2020, when most people were preoccupied with fighting COVID-19, the WHO announced that all 47 countries in its Africa Region had been certified wild poliovirus-free following a long programme of vaccination and surveillance. Afghanistan and Pakistan were now the only places where wild poliovirus remained endemic, meaning it continued to circulate naturally in the environment.

“The past two years have demonstrated very clearly that there’s a very finite window to interrupt polio transmission and finish the job. Because if we do not eradicate polio, this virus will resurge globally.”

However, between 2019 and 2020, outbreaks of circulating vaccine-derived poliovirus (cVDPV) – a rare form of polio that occurs only in areas of low vaccination coverage – tripled, resulting in more than 1,100 children becoming paralysed. This year, cVDPVs have also been detected in the UK, US, and Israel, with some signs of limited community transmission. Wild poliovirus has also reappeared in south-east Africa, with a case detected in Malawi and seven cases in Mozambique.

“The new detections of polio this year in previously polio-free countries are a stark reminder that if we do not deliver our goal of ending polio everywhere, it may resurge globally,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “We must remember the significant challenges we have overcome to get this far against polio, stay the course and finish the job once and for all.”

Disheartening as these setbacks are, they have provided a wake-up call to GPEI and its partners, and invigorated efforts to push polio eradication across the line. “I think the past two years have demonstrated very clearly that there’s a very finite window to interrupt polio transmission and finish the job,” said Aidan O’Leary, Director for Polio Eradication at the WHO. “Because if we do not eradicate polio, this virus will resurge globally.”

In 2020, GPEI launched a new roadmap to polio eradication, which set out two ambitious targets: firstly to permanently interrupt all poliovirus transmission in Pakistan and Afghanistan, stop transmission of cVDPV and prevent outbreaks in non-endemic countries by 2023. The second target is to certify the world free from polio – meaning no cases have been detected for three years – by 2026.

Achieving these goals will require a massive and concerted effort – with both OPV and IPV playing an integral role.

Polio vaccines

Polio is caused by a highly infectious virus that initially replicates in the nose or throat, before moving to the intestines and multiplying. From here, it can enter the bloodstream and invade the central nervous system, causing nerve damage and paralysis in around one in 200 people. Some survivors also develop post-polio syndrome, a disorder characterised by progressive muscle weakness and fatigue, which can severely impair their quality of life. However, around 70% of infected individuals are asymptomatic or have only mild symptoms, such as headache, fever and neck stiffness.

The development of vaccines against poliovirus has had a huge impact on its ability to circulate and cause disease, but OPV and IPV work in slightly different ways. IPV contains inactivated viral particles from all three poliovirus strains. Injected into the arm or leg, it is extremely effective at triggering antibodies against poliovirus in the blood, preventing the virus from travelling to the nerves and causing paralysis. However, it is less effective at triggering antibodies in the intestines, meaning vaccinated people can still become infected with poliovirus and transmit it to other people.

OPV, on the other hand, contains a mixture of poliovirus strains that have been weakened, meaning they can still replicate, but are not strong enough to cause paralysis. Because OPV is given via the mouth, it triggers the production of antibodies in both the intestines and the blood. This means that if a vaccinated person is exposed to poliovirus in the future, the virus won’t be able to replicate and infect other people.

This ability to block transmission, as well as being cheaper and easier to administer than IPV, led to the widespread adoption of OPV in most countries, and it has played a crucial role in eradicating wild poliovirus from all but a handful of places. However, because OPV contains weakened viruses that can replicate, some of them may be excreted by vaccinated individuals and transmitted to unvaccinated ones – particularly in areas with poor sanitation. This can be beneficial because exposure to weakened polioviruses helps to protect them against future infection.

However, it can also be problematic. In communities with high vaccine coverage, any onward transmission of vaccine-derived virus quickly fizzles out. But in those where fewer people have been vaccinated, weakened poliovirus may continue to circulate for months or years. Very rarely, these viruses can accumulate genetic changes that enable them to cause paralysis once more. If these strains continue to circulate, they can trigger outbreaks of what are called circulating vaccine-derived polio.

Under-immunised

Vaccine-derived polio is extremely rare, and only emerges in under-immunised populations. Between 2000 and 2021, more than 20 billion doses of OPV were given to nearly three billion children worldwide, and only 2,299 cases of cVDPV paralysis were registered during that period.

In the past decade, new types of OPV have been developed that reduce the risk of future cVDPVs emerging. Whereas earlier forms of OPV contained weakened forms of type 1, 2 and 3 polioviruses, since April 2016, all countries have switched to using bivalent OPV, which contains just types 1 and 3. This is helpful, because the weakened type 2 strain is responsible for nearly 90% of all cVDPVs.

“In all the areas where we face challenges, it’s due to a combination of issues around inaccessibility and security, non-functioning health systems, and communities that have become marginalised from the state, for a whole variety of reasons.”

Even so, vaccine-derived polio has emerged as a key challenge in the final stage of polio eradication. Three geographical locations, in particular, currently account for more than 90% of all global cases of cVDPV caused by the type 2 strain: northern Yemen, eastern Democratic Republic of the Congo, and northern Nigeria. Ongoing conflict in south central Somalia is another concern.

“In all the areas where we face challenges, it’s due to a combination of issues around inaccessibility and security, non-functioning health systems, and communities that have become marginalised from the state, for a whole variety of reasons,” said O’Leary.

The situation in Yemen is particularly worrying, because of ongoing restrictions on childhood vaccination imposed by the Houthi administration in Sanaa, Yemen’s largest city. “We understand that a lifting of these restrictions may be imminent, but a delay of more than 12 months has allowed the virus to continue to spread in a situation where the essential immunisation system is either non-existent, or very poorly performing. And it has wreaked havoc with more than 200 children being paralysed over the course of this period,” O’Leary said.

These pockets of cVDPV are bad enough, but international travel also means that infections can be seeded elsewhere – which is thought to explain recent detections of cVDPV in London, New York and Israel. The good news is that such outbreaks can be stopped using the same tactics that have so successfully stamped out wild poliovirus – strengthening polio surveillance and ensuring high vaccination coverage.

Race against the clock

In an outbreak scenario, time is of the essence, making OPV the vaccine of choice. “The key with OPV is that it’s safe, effective, cheap and very easy to use,” said O’Leary. “Particularly the children that we’re most concerned about, which is infants under the age of one or two, it is not an easy task to bring them – sometimes very extensive distances – to receive an injectable vaccine in a clinic. So, we flip it, and bring the vaccine directly to households to make immunisation as simple and straightforward as possible, while maximising the coverage that can be achieved.”

The risk of new cVDPVs emerging during these emergency campaigns should be further reduced through the recent introduction of another new OPV, called type 2 novel oral polio vaccine (nOPV2), which is specifically designed to extinguish cVDPV2 outbreaks in a more sustainable way. Like earlier OPVs, it contains weakened type 2 polioviruses, but they have been further modified to make them more stable, meaning they are significantly less likely to revert into a threatening form.

To eliminate the primary risk of emergence of all types of vaccine-derived polio cases, the Polio Eradication and Endgame Strategic Plan (PEESP) called for the phased removal of the current Sabin-strain oral polio vaccine (OPV) – a critical and necessary step towards polio eradication. It’s important to clarify that the risk is not associated with the vaccine itself but rather low vaccination coverage. If a population is fully immunised, they will be protected against both vaccine-derived and wild polioviruses.

Endgame strategy

Ultimately though, the plan is to phase out OPV altogether. The problem lies not with the vaccine itself, but rather low vaccination coverage and the possibility of new cVDPVs emerging.

⌈If OPV has been the artillery in the war against polio, then IPV provides the cavalry needed to finish the job.⌉

Enter IPV. With polio eradicated from most continents and countries, the key to keeping it that way is maintaining high levels of population immunity – not just in adults and children who have previously been vaccinated against polio, but in children being born today and in the coming years – through routine childhood immunisation with IPV.

If OPV has been the artillery in the war against polio, then IPV provides the cavalry needed to finish the job, said O’Leary: “It needs to be significantly bolstered up everywhere, to sustain the gains that have been made. That ultimately means strengthening essential immunisation systems across the board.”

Until the COVID-19 pandemic hit, these efforts had been proceeding at pace. Nepal became the first country to introduce routine immunisation with IPV with Gavi support in 2014. Within five years all Gavi-supported countries had successfully completed their introductions – collectively immunising more than 112 million children.

However, the COVID-19 pandemic has set back the delivery of all routine childhood immunisations. “The big area of concern has been the jump from just under 19 million children who were categorised as zero-dose – meaning they are not receiving a single dose of routine vaccines – to more than 25 million,” said O’ Leary.

The final mile

Contained within GPEI’s new roadmap, The Polio Eradication Strategy 2022–2026, is a commitment to reverse this trend by rapidly rebuilding coverage rates in those areas where shortfalls are being recorded.

Whether GPEI and its partners can really make up enough ground to stop the transmission of wild poliovirus globally by the end of 2023, remains to be seen, but their resolve and commitment to go the final mile is unwavering.

“It’s not the first time such targets have been offered. But what’s different this time around is that, in addition to mass vaccination campaigns, the initiative’s new strategy will be intensely focused on finding targeted ways to reach missed communities and take advantage of opportunities to become more integrated with other essential services.” said Seth Berkley, Gavi’s CEO. “In these communities, children are not just consistently missing out on protection from polio, they are also missing out on a whole range of other critical health interventions and other vaccines.”

If the eradication of polio is successful, it would only be the second human disease, after smallpox, to have been scrubbed from the face of Earth. “Notwithstanding all the doom and gloom with the COVID-19 pandemic and other challenges, it really is feasible – if we remain very focused on that goal,” said O’Leary. “And it absolutely requires both types of vaccine.”

Re-posted with permission from GAVI.

BERLIN, 18 October 2022 – Today, global leaders confirmed US$ 2.6 billion in funding toward the Global Polio Eradication Initiative’s (GPEI) 2022-2026 Strategy to end polio at a pledging moment co-hosted by Germany’s Federal Ministry for Economic Cooperation and Development (BMZ) at the World Health Summit in Berlin.

The funding will support global efforts to overcome the final hurdles to polio eradication, vaccinate 370 million children annually over the next five years and continue disease surveillance across 50 countries.

“No place is safe until polio has been eradicated everywhere. As long as the virus still exists somewhere in the world, it can spread – including in our own country. We now have a realistic chance to eradicate polio completely, and we want to jointly seize that chance,” said Svenja Schulze, Federal Minister for Economic Cooperation and Development, Germany. “Germany will remain a strong and committed partner in the global fight against polio. This year, it is providing EUR 35 million for this cause. And next year we plan to further strengthen our efforts and support GPEI with EUR 37 million – pending parliamentary approval. By supporting the GPEI, we are also strengthening national health systems. That leads to healthier societies, far beyond the polio response.”

Wild poliovirus is endemic in just two countries – Pakistan and Afghanistan. However, after just six cases were recorded in 2021, 29 cases have been recorded so far this year, including a small number of new detections in southeast Africa linked to a strain originating in Pakistan. Additionally, outbreaks of cVDPV, variants of the poliovirus that can emerge in places where not enough people have been immunized, continue to spread across parts of Africa, Asia and Europe, with new outbreaks detected in the United States, Israel and the United Kingdom in recent months.

“The new detections of polio this year in previously polio-free countries are a stark reminder that if we do not deliver our goal of ending polio everywhere, it may resurge globally,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “We are grateful for donors’ new and continued support for eradication, but there is further work to do to fully fund the 2022-2026 Strategy. We must remember the significant challenges we have overcome to get this far against polio, stay the course and finish the job once and for all.”

At a challenging time for countries around the world, governments and partners have stepped forward to demonstrate their collective resolve to eradicate the second human disease ever. In addition to existing pledges, new commitments to the 2022-2026 Strategy this fall include:

  • Australia pledged AUD 43.55 million
  • France pledged EUR 50 million
  • Germany pledged EUR 72 million
  • Japan pledged USD 11 million
  • Republic of Korea pledged KRW 4.5 billion
  • Liechtenstein pledged Sw.fr. 25 000
  • Luxembourg pledged EUR 1.7 million
  • Malta pledged EUR 30 000
  • Monaco pledged EUR 450 000
  • Spain pledged EUR 100 000
  • Turkey pledged USD 20 000
  • United States pledged USD 114 million
  • Bill & Melinda Gates Foundation pledged USD 1.2 billion
  • Bloomberg Philanthropies pledged USD 50 million
  • Islamic Food and Nutrition Council of America pledged USD 1.8 million
  • Latter-day Saint Charities pledged USD 400 000
  • Rotary International pledged USD 150 million
  • UNICEF pledged USD 5 million

The pledging moment in Berlin marked the first major opportunity to pledge support toward the USD 4.8 billion needed to fully implement the 2022-2026 Strategy. If the Strategy is fully funded and eradication achieved, it is estimated that it would result in USD 33.1 billion in health cost savings this century compared to the price of controlling outbreaks. Further, continued support for GPEI will enable it to deliver additional health services and immunizations alongside polio vaccines to underserved communities.

“Children deserve to live in a polio-free world, but as we have seen this year with painful clarity, until we reach every community and vaccinate every child, the threat of polio will persist,” said UNICEF Executive Director Catherine Russell. “UNICEF is grateful for the generosity of our donors and the pledges made today, which will help us finish the job of eradicating polio. When we invest in immunization and health systems, we are investing in a safer, healthier future for everyone, everywhere.”

In addition to the funding for GPEI announced today, a group of more than 3000 influential scientists, physicians, and public health experts from around the world released a declaration endorsing the 2022-2026 Strategy and calling on donors to stay committed to eradication and ensure GPEI is fully funded. The group points to new tactics contained in the program’s strategy, like the continued roll-out of the novel oral polio vaccine type 2 (nOPV2), that make them confident in GPEI’s ability to end polio. Five hundred million doses of nOPV2 have already been administered across 23 countries, and field data continue to show its promise as a tool to more sustainably stop outbreaks of type 2 cVDPV. The group further asserts that support for eradication significantly strengthens immunization systems and pandemic preparedness around the world—pointing to GPEI’s support for the COVID-19 response—and urges endemic and polio-affected country leadership to stay committed to expanded vaccination and disease surveillance activities.

“Pakistan has made incredible progress against polio, but recent challenges have allowed the virus to persist,” says Dr Zulfi Bhutta (Chair of Child Global Health, Hospital for Sick Children, Canada, and Distinguished University Professor, Aga Khan University, Pakistan). “Polio, like any virus, knows no borders; its continued transmission threatens children everywhere. Stopping this disease is not just urgently needed now, it’s within our grasp. That’s why I’ve joined more than three thousand health experts from around the world to launch the 2022 Scientific Declaration on Polio Eradication. With strong financial and political commitments, our long-awaited vision of a polio-free world can become a reality.”

Additional quotes from the pledging moment:

Mark Suzman, CEO, Bill & Melinda Gates Foundation, said: “The question is not whether it’s possible to eradicate polio—it’s whether we can summon the will and the resources to finish the job. The Bill & Melinda Gates Foundation is grateful to Germany, Rotarians, donors, countries, scientists, and partners who stood together today to show that we are united in this goal. We look forward to working together to create a polio-free future and build more equitable and resilient health systems for all.”

Seth Berkley, CEO, Gavi, the Vaccine Alliance, said: “As we work together to stop the transmission of all polioviruses globally, we are more grateful than ever for the generosity of our donors, the leadership of governments and the mobilization of communities. Today’s pledges will support GPEI’s new strategy which correctly focuses on mass vaccination campaigns, concerted efforts by partners to strengthen essential immunization and integration with other critical health interventions and a further roll out of next-generation oral polio vaccines. These three measures combined are essential if we are to eradicate polio once and for all.”

Franz Fayot, Minister for Development Cooperation and Humanitarian Affairs, Luxembourg, said: “Luxembourg is proud to be a longstanding supporter of global efforts to eradicate polio. Building on the remarkable progress achieved so far, Luxembourg will continue to support the fight against polio until we ensure the protection of every child.”

Ian Riseley, Chair, Rotary Foundation, said: “While polio exists anywhere, it is a threat everywhere. This is an opportune moment for the global community to recommit to the goal and ensure the resources and political will are fully available to protect children from polio paralysis while building stronger health systems. That is why today, Rotary is reaffirming its commitment of an additional USD 150 million to the global effort to eradicate polio.”

His Excellency Abdul Rahman Al Owais, Minister of Health and Prevention, United Arab Emirates, said: “Polio outbreaks this year have emphasized that polio anywhere is a threat to communities everywhere. While we are encouraged by steady progress in Pakistan and Afghanistan in the drive towards polio eradication, and we know that there is a ways to go to finish the job. We also know that this progress would not have been possible without the courageous contributions of frontline health workers, who have remained steadfast in their commitment to protecting their communities from polio in the face of the pandemic, natural disasters and threats to their physical safety. Under the leadership of His Highness Sheikh Mohamed bin Zayed Al Nahyan, President of the UAE, we join our international partners in reiterating our commitment to a polio free world.”

For photos from the pledging moment at World Health Summit, please see here

Pledging table

Media contacts:

Oliver Rosenbauer
Communications Officer, World Health Organization
Email: rosenbauero@who.int
Tel: +41 79 500 6536

Tess Ingram
Media Officer, United Nations Children Fund
Email: tingram@unicef.org
Tel: +1 347 593 2593

Ben Winkel
Communications Director, Global Health Strategies
Email: bwinkel@globalhealthstrategies.com
Tel: +1 323 382 2290


Notes for editors:

The Global Polio Eradication Initiative is a public-private partnership led by national governments with six core partners – Rotary International, the World Health Organization (WHO), the US Centers for Disease Control and Prevention (CDC), UNICEF, the Bill & Melinda Gates Foundation and Gavi, the Vaccine Alliance. For more information on the global effort to end polio, visit polioeradication.org.

Related links

Polio https://www.who.int/health-topics/poliomyelitis#tab=tab_1

Fact sheet

Polio https://www.who.int/news-room/fact-sheets/detail/poliomyelitis

Dr Hamid Jafari, EMRO Director for Polio Eradication. © WHO/EMRO

Members of the Regional Subcommittee for Polio Eradication and Outbreaks in the Eastern Mediterranean reviewed recent progress during the 69th session of the Regional Committee. It was the sixth meeting of the subcommittee since it was formed during the 67th Regional Committee.

During the meeting Member States and partners reiterated their commitment to freeing current and future generations of children from polio and called for sustained efforts to end polio once and for all, including the pockets of wild poliovirus that linger in Afghanistan and Pakistan.

Visit the EMRO website for the full story.

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

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

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

© NEOC

As Pakistan continues to struggle from the effects of the devastating floods affecting parts of the country, polio staff on the ground continue to assist emergency relief efforts.

In flood-affected districts, the polio effort is supporting establishment of critical health camps, to provide basic clinical services, particularly ensuring treatment of water-borne and vector-borne diseases, and distributing water purification tablets.  All routine immunization antigens are also provided to target children and pregnant women.  Staff are actively conducting surveillance for communicable diseases, identifying nutrition needs of displaced populations, and collecting and analysing life-saving data to help target response strategies.  Polio programmes around the world have a long history of supporting broader public health and humanitarian emergencies, as was the situation earlier this year in Afghanistan, following the devasting earthquake there.

At the same time, the polio programme is adapting its operations, to ensure polio eradication efforts can continue unabated, even amid the tragedy.  The programme is at a critical juncture – intensive response is ongoing to stop this year’s outbreak in southern Khyber Pakhtunkhwa.  Virus linked to this outbreak was this month detected in an environmental sample from Karachi, in the south of the country.  At the same time, the high transmission season for polio transmission is now starting and this transmission risks being particularly intense given the floods.

But despite these challenges, polio staff are working double-time:  adapting polio approaches, while supporting life-saving flood relief efforts.

“I have been fortunate enough to be present when a number of countries successfully eradicated polio,” commented Dr Hamid Jafari, Director for Polio Eradication at the World Health Organization’s Regional Office for the Eastern Mediterranean.  “Rarely have I seen such commitment and dedication than I have seen in Pakistan – from national political leaders, to health workers, right to the mother and father on the ground.  To all who are involved, all I can say is:  Thank you!  You are making a huge difference to people’s lives, which goes far beyond the effort to eradicate polio.”

While detection of virus in Karachi is not unexpected, given the large-scale and frequent population movements between Karachi and the rest of the country, in particular Khyber Pakhtunkhwa. urgent efforts are underway, coordinated by the national and provincial Emergency Operations Centres (NEOC and PEOC), to continue surveillance efforts in greater Karachi and further boost immunity levels through health camps, to prevent polio from establishing a foothold in Pakistan’s largest city which has historically been a major polio reservoir.

© NEOC

Despite the extraordinary climatic conditions and consequent operational challenges aggravated by the collapse of infrastructure, the programme continued with the August polio campaign – including across Karachi – and re-adjusted the schedule in all accessible areas. While the immunization campaign could not be conducted in Balochistan and parts of Sindh, the effort managed to reach nearly 32 million children in the country, with health workers wading through deep water to reach children with the life-saving vaccine.

At the same time, the programme has undertaken contingency planning to resume intensified vaccination activities in southern Khyber Pakhtunkhwa to stop the outbreak, as soon as the situation allows. The programme continues to innovate, adapt, and find opportunities to build children’s immunity through vaccination at health camps, at transit points, in settlements for displaced persons.

And, of course, national and subnational authorities are coordinating activities with neighbouring Afghanistan, particularly in border regions, given that both countries represent a single epidemiological block.  Confirmation this month of Afghanistan’s second case this year, from Kunar province, confirms the risk any residual transmission on either side of the border continues to pose to children across this block.

Kunar, along with the rest of the country’s Eastern Region, is part of one of three, critical cross-border epidemiological corridors with Pakistan, the northern corridor specifically comprising of Eastern Region and central Khyber Pakhtunkhwa in Pakistan.  Case response is currently being planned in the immediate area and the broader corridor.  The other two cross-border epidemiological corridors are the southern corridor, comprising Quetta Block of Pakistan and Southern Region, Afghanistan; and, the central corridor, comprising southern Khyber Pakhtunkhwa and South-East Region in Afghanistan.

Districts along the border of Pakistan and Afghanistan in the three epidemiological corridors are at high-risk for poliovirus transmission, given the high proportion of zero-dose children and inconsistent quality of polio vaccination campaigns in some areas.

The Pakistan and Afghanistan polio programmes continue to coordinate on surveillance and vaccination activities through the Global Polio Eradication Initiative Support Hub, based in Amman, Jordan.

A polio worker administers the oral polio vaccine to a child in Karachi. Credit: @SalmanMahar

Polio is one of the world’s most devastating diseases. It mainly affects children under five and in one in 200 cases it results in lifelong paralysis. Amazing progress has been made in fighting polio globally: according to UNICEF, there were a reported 20,000 children paralysed by polio in Pakistan in 1994. By 2021, new paralysis cases had dropped to just one child. However, as long as just one child remains infected, all children are at risk.

Identifying and reaching unvaccinated children has been a challenge, but big data startups like Zenysis, in partnership with Pakistan government partners, are making inroads.

Vaccination data is only useful if it’s accurate

Abid Hasan is the project manager for Zenysis – a Gavi INFUSE pacesetter since 2017 – in Pakistan, and he explains the barriers to a more effective vaccination programme in the country:

“Data is like people, in that if data sets don’t talk to each other then they won’t work well. Zenysis gets data and data sets talking.”

Community health workers employed through Pakistan’s Polio Eradication Programme and the Expanded Programme of Immunisation go door to door to collect vaccination data, sometimes using datasheets, sometimes paper, sometimes recording data through WhatsApp. It can be difficult to track families with no formal address, or mobile communities with no fixed address. With 14 million children requiring a polio vaccination every two months, recording accurate data is a mammoth task.

The resulting data can be imperfect, with duplication a particular challenge. This is where Zenysis’s platform comes in. Zenysis software integrates, de-deplicates and harmonises more than 20 siloed datasets, including polio data, immunisation registries and population data.

Combined, the data can be used far more effectively for analysis and, importantly, action on the ground. The result? A new and improved vaccination plan, personalised for each vaccinator’s district – known as a microplan.

A Community Health Worker goes door to door during the August polio campaign to give children the oral polio vaccine. She finds a newborn zero-dose child and records that data into her register. Credit: @SalmanMahar
A Community Health Worker goes door to door during the August polio campaign to give children the oral polio vaccine. She finds a newborn zero-dose child and records that data into her register.
Credit: @SalmanMahar

Microplans help health workers target zero-dose children

The enhanced microplans provide health workers with granular information on each child in a region, including their vaccination status, age and address. This information can be used to identify individual children and highlight neighbourhoods where there are clusters of unvaccinated (zero-dose) children. This in turn means better use of time and energy, and better outcomes for communities.

The effect, explains Hasan, is seen in three key areas. “Firstly, the newmicroplans give community health workers the real picture. Second, frontline workers now have a plan to follow and are no longer using broad or inflated data that is hard to actionize. Third, this approach is measurable – when you reach a target, that goes into the system. With accurate data, you can really see the impact.”

Health workers on the ground have seen the difference. Sadaf, a community health worker for Polio, in Karachi, says: “Before the microplans the vaccinators were given a long list of children with duplicate entries in them, and they were extremely difficult to track. After receiving these microplans we can easily decide where to set up our outreach sites and mobilise children to bring them there for vaccination in a systematic manner.”

The impact has been impressive. Since January 2022, the Expanded Programme on Immunisation in the Sindh region has used the Zenysis platform to identify over 28,500 true zero-dose children in the region and vaccinate 12,724 of them with the aid of microplans. In March to June of this year, 3,854 zero-dose children were vaccinated with the help of the new microplans in the regions where they have been implemented.

Community Health Workers using Zenysis provided microplans to identify houses with zero-dose children in high risk areas of Karachi. Credit: @SalmanMahar
Community Health Workers using Zenysis provided microplans to identify houses with zero-dose children in high risk areas of Karachi.
Credit: @SalmanMahar

Gavi support has been vital in creating goals and driving change

Zenysis was part of Gavi’s INFUSE programme, which connects high-impact innovations with the countries that need them most. Hasan explains that for countries like Pakistan, the investment from Gavi is vital to enhance healthcare budgets, but also to help provide momentum and set goals for vaccination programmes.

Looking ahead, Zenysis is collaborating closely with government partners to expand the platform and vaccination approach throughout Sindh province, tackle other vaccine-preventable diseases, and improve the government’s technical platform management capacity.

As Hasan says, “Not everyone is a data expert – but if you can go on a platform, go into a dashboard, and see all your data into one workspace then you can reach a zero-dose child and their family, and get them vaccinated.”

And with each child vaccinated, we get a step closer to a world where infection by wild poliovirus is a thing of the past.

Reposted with permission from gavi.org

Examining Terms of Reference for AFP Focal Points. ©WHO
Examining Terms of Reference for AFP Focal Points. ©WHO

Monday 6 June

Arrive Kabul at 9.30am, my first visit in two years and the city has lost none of its bustle.

A review team last visited here in 2016 but access was limited. Much has changed – both within Afghanistan and for polio – since then. The programme now has access across the country and the epidemiological picture has changed dramatically. In 2020, 56 children were paralysed by the virus. So far this year only one child has been paralysed giving Afghanistan its strongest chance yet of interrupting polio transmission.

Surveillance underpins the eradication of any virus. For polio, it consists of monitoring for signs of Acute Flaccid Paralysis or AFP in children under 15 years, and collecting samples of sewage, what we call environmental surveillance, to check for the presence of the virus in the community.

We’re here to apply a magnifying glass to Afghanistan’s surveillance system, to see if there’s anywhere the virus might still be hiding and recommend adjustments to make sure the system is capable of catching it.

If polio surveillance is about gathering data and documenting it meticulously, it’s even more so for a surveillance review. Our job includes checking documents and records, interviewing health workers and families of children with AFP, reviewing guidelines and standard operating procedures – checking and rechecking data.

Wednesday 8 June

Dr Abdinoor reviewing documents at a health facility. All major health facilities in Afghanistan have an AFP focal point who acts as the link between the facility and the broader polio surveillance system. © WHO
Dr Abdinoor reviewing documents at a health facility. All major health facilities in Afghanistan have an AFP focal point who acts as the link between the facility and the broader polio surveillance system. © WHO

After meetings yesterday, including briefing the National Emergency Operation Center (EOC), the operational heart of the polio programme here, I head to Herat in the country’s west where my first stop is the WHO office. I meet the polio team before moving on to the Regional EOC where we discuss the objectives of my mission. I review records before checking the cold room where vaccines are kept. There’s a corner for stool specimens that come in from the western region. Part of the process of checking children with signs of AFP is collecting stool samples that are then sent to the regional laboratory in Pakistan for testing. Reviewing the collection, storage and shipping of these samples is part of my remit as a reviewer.

Thursday 9 June

At a hospital in Herat city, I meet with the AFP focal point – a pediatrician. All major health facilities have an AFP focal point who acts as the link between the facility and the broader surveillance system. I ask him about his background, the facility’s stool handling, preparation and shipment, and the work of the hospital.

In the afternoon, I examine two children affected by AFP earlier in the year. I talk to their parents and ask them the same questions they were asked by the initial investigating surveillance officer. I do this to check the accuracy of the information collected during the original case investigation and to see if there are any discrepancies.

Friday 10 June

Friday – the only holiday of the week. I spend it at the WHO office going through documents including AFP case files and data. It’s also a good opportunity to enter all the information I collected over the previous two days into the online tool developed specifically for this review.

Saturday 11 June

We set out early to a district near the border with Iran, two hours’ drive away. First stop is a very busy Comprehensive Health Center (CHC). It’s reported six out of the eight AFP cases from this district this year. I meet with the director, doctors, nurses, and other staff. Beneath their facemasks, their smiles are beaming. They speak with pride of their clinic and, like all the health facilities I visit, it’s spotlessly clean.

In the afternoon, I meet with the community health supervisor who oversees 16 community health workers (CHWs) working in village health posts nearby. Village health posts play an important role in community-based polio surveillance.  I review the curriculum and training agenda to check what information is captured.

Sunday 12 June

I spend the day in the districts surrounding Herat city. My meetings include a visit to a traditional healer who fixes broken bones among other ailments, and a CHW who is an imam at a local mosque. Both are reporting volunteers in the 46,000-strong community-based surveillance network that keeps an eye out for polio among their communities.

Going through referral notes. The 16-strong review team visited 67 districts in 25 of Afghanistan’s 34 provinces, checking documents and records, interviewing health workers and families of children with AFP, and reviewing guidelines and standard operating procedures. © WHO
Going through referral notes. The 16-strong review team visited 67 districts in 25 of Afghanistan’s 34 provinces, checking documents and records, interviewing health workers and families of children with AFP, and reviewing guidelines and standard operating procedures. © WHO

Monday 13 June

I visit an environmental surveillance site in Herat city. Samples are taken from sewage on a regular basis and shipped to the lab in Pakistan to determine the presence of poliovirus.  I assess the site to see if it meets quality standards, check its location to make sure it’s in the right place to catch a good enough sample, the flow of the water and its appearance. I watch as trained staff from the local municipality collect a sample to determine whether the SOPs are adhered to.

Tuesday 14 June

To neighbouring Farah province, a round trip of about eight hours. At a CHC, a boy is brought in who was referred by a local faith healer. I observe the staff examine the child, and then visit the faith healer who tells me he inherited the knowledge of healing from his father and has been doing it now for over 20 years. It was heartening to hear him talk of his collaboration with the polio team for both AFP surveillance and immunization campaigns.

Wednesday 15 June

Last day in Herat city and I debrief the team in the REOC. Our flight back to Kabul departs late and we stop in Bamyan in the central highlands to collect two other passengers, including my fellow reviewer assigned to the Central Region.

The rest of the review team makes its way back to Kabul in the remaining days. We’ve all been doing the same thing – verifying, checking, interviewing, collating data. Our next task is to compile our report and provide any recommendations to the programme to make sure Afghanistan’s polio surveillance system catches every last virus, no matter where it may be hiding.

Nomina Akhtar © WHO/Muhammad Shoaib
Nomina Akhtar © WHO/Muhammad Shoaib

In 2021, when the news of cancer hit, Nomina Akhtar felt her world collapsing. It was discovered too late. By the time she knew, it was already stage-3 breast cancer.

Since 2015, Akhtar has been part of Pakistan’s polio programme as a community health worker. During these six years, she has found friends and well-wishers among her team members who have given her the support to carry on.

Akhtar, 43 and a mother of three continues to work for polio eradication as she undergoes treatment for cancer. “I gathered my courage and promised that I will fight till the end and live for my children. All my family, colleagues and seniors were with me whenever I needed support. That gave me courage and made me believe that I could, in fact, beat cancer.”

Based in Peshawar, Nomina’s husband and her three children, aged six, seven and 18, rely solely on her income. The lockdowns due to the pandemic caused her husband, a motorcycle mechanic, to close down his shop that has yet to reopen.

A life with cancer has been both physically and emotionally exhausting. She is undergoing both radiation and chemotherapy in Peshawar. This means a commute of almost 20 kilometers after a whole day of work.

“When I have to go for chemotherapy after work, it becomes very draining. I have to take public transport and wait at the hospital for hours. There are times when I have to return without treatment because either the machine is faulty or something else comes up. This treatment regime along with the medicine will continue for at least five years. It’s excruciatingly painful,” she says.

Polio programme: a great source of strength for Akhtar

“My colleagues are like my extended family, and I am like a sister to them. When I found out about my cancer, they wept with me. They have stood by my children and myself every step of the way.”

The supervisor of her area, Uzma Mansoor, says that when they first heard the news, they were devastated. “But it’s great to see that she has not lost hope and is fighting the disease like a champion,” she said.

The community she works in has also been incredibly supportive. “Some of the people in my work area came to know about my illness and they appreciated the fact that despite fighting cancer, I come to their doorstep during every polio campaign. Irrespective of extreme temperatures and illness, I am there to vaccinate their children and protect them from this life-threatening disease. Their support has increased manifold after this.”

Sahibullah, the Union Council Polio Officer of her area, says not only does Nomina continue to vaccinate children, but she is a role model for all other polio workers.

“It was God’s will, and we will face it with courage,” says her husband Aurangzeb Akhtar. “Despite being ill, Nomina is the one who keeps us going. She is working and earning for our family as well as motivating us to not lose hope. My children and I are so proud of her. Inshallah she will get well very soon.”

Nomina has strong conviction. She is fighting cancer and polio simultaneously, and is determined that she will defeat both very soon. “At least cancer has treatment,” she says. “Polio is incurable and the sooner we end this disease forever, the better.”

By Mohammad Shoaib,
Provincial Communications Officer KP, WHO Pakistan

 

A child is vaccinated during a nationwide vaccination campaign in Jabuary 2022. Seven national and one sub national campaigns have taken place since 15 August last year. © WHO/Afghanistan
A child is vaccinated during a nationwide vaccination campaign in Jabuary 2022. Seven national and one sub national campaigns have taken place since 15 August last year. © WHO/Afghanistan

Wild poliovirus transmission in Afghanistan is currently at its lowest level in history. Fifty six children were paralysed by wild polio in 2020. In 2021, the number fell to four. This year to date, only one child has been paralysed, giving the country an extraordinary opportunity to end polio.

The resumption of nationwide polio vaccination campaigns targeting 9.9 million children has been a critical step. Since 2018, local-level bans on polio vaccination activities in some districts controlled by the Taliban had significantly reduced the programme’s ability to vaccinate every child across the country. With access to the entire country following the August transition, seven nationwide vaccination campaigns took place between November 2021 and June 2022, and a sub national campaign targeting 6.7 million children in 28 provinces took place in July. Of the 3.6 million children who had been inaccessible to the programme, 2.6 million were reached during the November, December and January campaigns. With improved reach to previously inaccessible children throughout the February to July campaigns, the number children has been reduced to 0.7 million. Further campaigns are planned for the remainder of the year.

With Afghanistan and Pakistan sharing one epidemiological block, the two countries continue to coordinate cross border activities. December and May’s campaigns were synchronized with Pakistan’s national campaigns, focusing on high risk populations including nomadic groups, seasonal workers and communities straddling both borders.

Improved access also had a significant impact on polio surveillance activities. Afghanistan’s surveillance indicators remained above global standards throughout the transition. With access to all districts since August, the quality of activities has improved significantly including early case detection and reporting.

In June, the first review of the polio surveillance system in six years took place with WHO hosting a team of technical experts including epidemiologists and virologists. A small team visited in 2016 but insecurity and lack of access to much of the country limited the visitors’ movements to Kabul, Herat, Kandahar, Jalalabad, Mazar-e-sharif and Kunduz. This year, the 16-strong team visited 76 districts across 25 of the country’s 34 provinces. The review determined the likelihood of undetected poliovirus transmission in Afghanistan to be low. Recommendations, including upscaling surveillance in the country’s south and south east, are being implemented.

With more than twenty years on the ground in Afghanistan, the polio programme continues to leverage its extensive operational capacity to deliver better health outcomes for all Afghans. In the face of an unprecedented humanitarian crisis, in addition to day-to-day polio activities, polio staff continue to regularly monitor the functionality of health facilities across the country as well as support ongoing vaccination campaigns including measles and COVID 19. WHO’s polio team in the southeast were among the first responders following the devastating earthquake in Paktika and Khost provinces in June. In addition to providing critical health care, the team’s experience working among local communities provided the foundations of an assessment tool that mapped affected communities and ensured accurate data guided a focused response in the immediate aftermath.

Although the number of children paralysed by polio has reduced significantly in Afghanistan, the threat is far from gone and the programme faces significant challenges. While access has improved across the country, accessing every child though house to house vaccination remains a challenge in some areas leaving immunity gaps and, with them, children at risk.

On 24 February, eight polio workers were killed in targeted attacks in the country’s north, not the first time polio workers had come under attack in the course of their life saving work. Four of those killed were women. Female polio workers play a critical role in the programme, building community trust and reaching all children.

The sharp rise in the number of wild polio cases in Pakistan is a cause for concern, and the detection of one case each in Malawi and Mozambique is a reminder of the continued risks of poliovirus and the urgencyrequired to permanently interrupt transmission in both Afghanistan and Pakistan.

While the polio programme has made important progress in the last 12 months, sustaining those gains with high quality campaigns that vaccinate all children and build enough immunity to end circulation of the virus for good is critical. A polio free Afghanistan is within reach – but there is still a long way to go.