Amidst the extreme heat of the Afghan summer, Masooda, a polio outreach worker, moves with confidence between houses. Her aim is to talk to families that refuse to vaccinate their children against polio. Her energy is endless and she tops that with a smile and a warm way of talking with women and men.
Masooda has an impressive range of skills. She works as a skilled midwife with passion for her community. She is also a District Communications Officer for the polio programme, leading a team of 56 community outreach workers in her neighbourhood.
“I want to help my people – polio is a danger to every child, and we should eradicate it”, says Masooda.
Masooda recalls her early days with the programme, “I faced tough refusal families who denied their children the polio vaccine. A woman refused to vaccinate her younger sister. After one year, the sister died of measles as she hadn’t been vaccinated against it. Now, the same woman has a baby girl and she frequently takes her baby to the health centre for vaccination. Sadly, she learnt her lesson the hard way”.
Masooda leaves her house at 6:30am during immunization campaigns, just as the sun rises. She checks the outreach plans with her teams before they disperse around the town. Through the day, she makes supervisory visits to her teams and obtains updates on vaccine uptake issues. When she receives reports on absent and missing children, she converses with families in order to encourage them to vaccinate their children.
To eradicate polio from Afghanistan, Masooda thinks there is a lot more to do. She says, “I will continue to work hard, for every child to be able to walk, attend school and grow healthy. It is the whole community cause for generations to come.”
In Karachi’s Gadap Town, many families lack basic health and municipal services. To fill the gap, the Polio Emergency Operations Centre in Pakistan’s Sindh province has recently renovated an abandoned hospital to create an Emergency Response Unit (ERU). The unit provides polio vaccination to communities alongside PolioPlus activities to improve overall health. The unit was built with the support of Rotary International, WHO, UNICEF and the Bill & Melinda Gates Foundation.
Click through the gallery to see how the Gadap Emergency Response Unit has changed health delivery:
Gadap Town is home to many informal doctors who are not sufficiently trained to provide basic health services to the community. Often, they put their patients at risk. Before the creation of the Emergency Response Unit (ERU), most people had no choice but to rely on them for basic healthcare.
Now, the PolioPlus programme has helped turn the once abandoned Jannat Gul Hospital into a vibrant health centre. The hospital was renovated in record time and was inaugurated by the Minister of Health for Sindh Dr. Azra Fazal Pechuho, EOC Coordinator Mr. Umer Farooq Bullo and Rotary Pakistan PolioPlus Committee Chair Mr. Aziz Memon.
The new ERU hosts essential immunization services for children, including polio vaccination. The site also houses equipment to keep vaccines cold and ready for use.
Outside, a lawn with play equipment has been set up. Gadap is one of Pakistan’s largest slums, and the provision of a rare child-friendly environment as part of the health facility is helping to build community trust and acceptance of the polio eradication programme.
One room is for use by children suffering Acute Flaccid Paralysis and is also used to monitor any child having a reaction to immunization. The room is managed by a Government Medical Officer, supported by WHO provincial and federal monitors during polio vaccination campaigns.
A multipurpose room is used for trainings and planning before and during polio vaccination campaigns.
The ERU also hosts a data support centre that allows staff to relay live updates on polio campaign performance to the Sindh Emergency Operations Centre.
Five health dispensaries have been set up Gadap Town as part of the project, whilst a local Maternity Home is also being renovated.
These facilities will improve essential immunization and provide basic primary health services. They will also provide gynecological and maternal health services, which are in extremely high demand in Gadap.
The Government envisages that the ERU will continue to provide vital health services to families long after polio is eradicated. Rather than resorting to the care of informal doctors and nurses, the community can now access better quality healthcare, funded by the public sector.
From an abandoned hospital to a successful community health project: This is what the ‘plus’ in PolioPlus looks like.
In November:
Two cases of wild poliovirus were reported
5.6 million children were vaccinated.
Permanent transit teams vaccinated 1,723,859 children and cross-border teams vaccinated 163 775 children
In October
190,909 million children were vaccinated during the October Case Response Campaigns.
2.2 million children were vaccinated at 377 Permanent Transit Points.
Q: Outbreaks of circulating Vaccine-Derived Poliovirus type 2 (cVDPV2) are popping up in a lot of countries. How do you explain this? Did the programme know this would happen after the oral polio vaccine ‘switch’?
There have been 47 cVDPV2 outbreaks in 20 countries since the switch in April 2016. Some of these outbreaks are spreading over more than one country. Taking the three years before the switch as a frame of reference, there were 8 cVDPV2 outbreaks in five countries altogether in 2013, 2014 and 2015.
Based on epidemiological modelling studies, we anticipated cVDPV2 outbreaks following the removal of the type 2 component from oral polio vaccine in 2016, via the trivalent to bivalent OPV “switch”. And we anticipated that VDPV cases would outnumber wild poliovirus cases in the endgame. However, what the modelling did not predict was the number and scale of these outbreaks, some of which have proven very difficult to stop.
The reason we are seeing a growing number of cVDPV2 outbreaks, particularly in Africa, is the result of a growing cohort of children without mucosal immunity to type 2 poliovirus, while at the same time the [polio] programme uses monovalent oral polio vaccine type 2 (mOPV2) to respond to existing cVDPV2 outbreaks.
The monovalent vaccine [mOPV2] is currently our only tool to interrupt transmission of cVDPV2 and it is very effective when there is sufficient vaccination coverage in the communities we are targeting to avoid an outbreak. However, when campaign quality is poor and not enough children are reached with the vaccine, we run a risk of seeding new viruses among under-immunized populations. There has been evidence of this happening in and outside of outbreak response zones. We are currently developing a new strategy for stopping cVDPV2 outbreaks, and at the same time preventing new outbreaks.
Q: With a limited global stockpile of mOPV2, is there sufficient vaccine to respond to these and future outbreaks?
No. Current mOPV2 stock is insufficient to cater for the number of outbreaks and the sizes of populations requiring it. The GPEI is working with vaccine manufacturers to boost production of mOPV2 and we expect to meet targeted quantities in 2020.
The vaccine will continue to be used for cVDPV2 outbreak response until a new and more genetically stable oral polio vaccine, known as novel oral polio vaccine type 2 (nOPV2), currently under clinical development, is available.
Q. What does increased production of mOPV2 mean for vaccine manufacturers in terms of containment? On one hand, the polio programme is asking for more live type 2-containing OPV. And on the other, it’s pushing for strict containment of all type 2 wild and Sabin polioviruses.
It’s a balance. The world needs enough mOPV2 stocks to help with the elimination of cVDPV2, and type 2 live attenuated poliovirus is needed to produce this vaccine. Yes, we are asking vaccine manufacturers to make more vaccine, but [vaccine] production and containment of type 2 virus are not mutually exclusive pursuits. Polio vaccine manufacture is costly, particularly when demand calls for rapid scale-up of outputs. Containment is also costly. But this is not a reason to put it on hold and stop efforts to ensure safe and secure handling and storage of virus. Quite the opposite: the impetus for putting in place adequate biorisk management systems should be greater, given the higher level of risk of human exposure to poliovirus in and around these facilities.
Q. What about manufacturers of inactivated polio vaccine (IPV)? Can they afford to relax?
IPV is made with killed, or inactivated strains of wild poliovirus types 1, 2 and 3, or their Sabin counterparts. Any facility manufacturing polio vaccines using the type 2 serotype – be it wild or Sabin ̶ and type 3 wild poliovirus since the declaration of its global eradication in October, is required to implement containment measures set out by WHO. This of course also applies to any other type of facilities holding the viruses, for example, research or diagnostic labs.
Holding on to these viruses is a risk and responsibility, and appropriate measures must be taken to protect communities from reintroduction and resurgence.
The world needs IPV and will continue to need it for the foreseeable future. We need vaccine production to continue in well-managed facilities that incorporate GAPIII approaches to biorisk management.
Q. of Sabin 2 remains a priority, while simultaneously, mOPV2 made up of Sabin 2 is being used in countries around the world. What gives?
First, we must be clear that use of mOPV2 is not a decision that is taken lightly. A thorough risk-benefit analysis is conducted before an advisory committee makes a recommendation and it is submitted to the Director-General of WHO for his approval.
It is never ideal to use mOPV2 and reintroduce Sabin 2, which should be under containment. However, as I mentioned earlier, mOPV2 is currently the only tool available to stop outbreaks of cVDPV2 and we must use it.
The reason we continue to push for containment of Sabin 2 viruses in countries not experiencing cVDPV2 outbreaks is precisely to prevent further emergences of VDPV2, which can cause outbreaks of cVDPV2 more easily now because of the very low population mucosal immunity to type 2 poliovirus.
Q. sounds like we are fighting fire with fire with mOPV2. Are we?
Many outbreaks have been stopped using mOPV2. However, in areas with low routine vaccination coverage, and thus low immunity, we are indeed reintroducing Sabin 2 in naïve populations and seeding new outbreaks. We are currently reviewing all aspects of our cVDPV2 approach and developing a new strategy that examines all options and tools ensuring we are using each for full impact. This includes improving our outbreak response so that it is appropriate in scope and effective, and accelerating the development and roll-out of a new vaccine that is less likely to seed outbreaks.
Q: When will nOPV2 be available?
Clinical trials are underway. There are numerous influencing factors but if all goes according to plan, our estimate is that approximately 100 million doses of the vaccine could be ready by mid-2020, with another 100 million by the end of the year. We are also working with the WHO prequalification team, which independently reviews all vaccine data to ensure a consistent quality in accordance with international standards to enable the vaccine to be used as quickly as possible by affected countries under an Emergency Use Listing (EUL), a risk-based procedure for assessing vaccines for use during public health emergencies—such as polio.
The vaccine is also being developed for types 1 and 3 polioviruses; however, this is further away in terms of production.
When we talk about PolioPlus, we know we are eradicating polio, but do we realize how many added benefits the programme brings? The ‘plus’ is something else that is provided as a part of the polio eradication campaign. It might be a hand-operated tricycle or access to water. It might be additional medical treatment, bed nets, or soap.
This series looks at the ‘pluses’ that Rotarians worldwide help to provide. Our first article looked at prevention of other diseases, and in part two we investigated how Rotary contributes to clean water provision. In our final article, we consider how Rotarians support those who have contracted polio, and who now live with permanent paralysis.
Creating jobs
Polio paralysis left Isiaku Musa Maaji, who lives in Nigeria, with few ways to make a living. At 24, he learned to build hand-operated tricycles designed to provide mobility for adults and children with physical disabilities, and later started his own business assembling them. His first break came, he says, when his local government placed a trial order. Officials were impressed with his product, and the orders continued.
Rotary’s Nigeria PolioPlus Committee recently ordered 150 tricycles from Maaji to distribute to polio survivors and others with mobility problems. The relationship he has built with local Rotarians has motivated him to take part in door-to-door polio vaccination campaigns.
“It is not easy to be physically challenged,” he says. “I go out to educate other people on the importance of polio vaccine because I don’t want any other person to fall victim to polio.”
Aliyu Issah, another polio survivor, feels lucky; he’s able to support himself running a small convenience store. He knows others with polio paralysis who have attended skills training programmes but lacked the money to start a similar business. In the absence of ready employment, some of them were forced to beg on the street.
He notes however that the polio eradication programme provides a job that is uniquely suited to polio survivors: educating others about the effects of the disease.
“Some of my friends who used to be street beggars now run their own small business with money they earn from working on the door-to-door immunization campaign,” Issah says.
Improving health care
In Maiduguri, Nigeria, Falmata Mustapha rides a hand-operated tricycle donated to her by Rotary’s Nigeria PolioPlus Committee. She is joined by several health workers for a door-to-door immunization campaign, bringing polio drops to areas without basic health care.
UNICEF data show that polio survivors like Mustapha have a remarkable success rate persuading reluctant parents to vaccinate their children — on average, survivors convince seven of every ten parents they talk to. In places where misinformation and rumours have left people hesitant to vaccinate, the survivors’ role in the final phase of the eradication effort is critical.
“Since working with the team, I have seen an increase in immunization compliance in the community,” Mustapha says. “I am well-regarded in the community because of my work, and I am happy about this.”
In September
97,081 million children were vaccinated during the August Case Response Campaigns.
1.7 million children were vaccinated at 377 Permanent Transit Points.
In October:
Four cases of wild poliovirus were reported
5.41 million children were vaccinated.
Permanent transit teams vaccinated 1 832 016 children and cross-border teams vaccinated 162 872 children
When we talk about PolioPlus, we know we are eradicating polio, but do we realize how many added benefits the programme brings? The ‘plus’ is something else that is provided as a part of the polio eradication campaign. It might be a hand-operated tricycle or access to water. It might be additional medical treatment, bed nets, or soap.
This series looks at the ‘pluses’ that Rotarians worldwide help to provide. Our first article looked at prevention of other diseases. In part two, we look at another lifechanging intervention: providing clean water for communities.
Providing clean water
Addressing a critical long-term need such as access to clean water helps build relationships and trust with community members. Within camps for displaced people in northern Nigeria, the polio vaccinators who regularly visit communities are sometimes met with frustration. “People say, ‘We don’t have water, and you’re giving us polio drops,’” Tunji Funsho explains. Rotary and its partners have responded by funding 31 solar-powered boreholes to provide clean water in northern Nigeria, and the effort is ongoing.
Supplying clean water to vulnerable communities is a priority of the PolioPlus programme not only in Nigeria, but also in Afghanistan and Pakistan — the only other remaining polio-endemic nations, where transmission of the virus has never been interrupted.
“Giving water is noble work also,” says Aziz Memon, chair of Rotary’s Pakistan PolioPlus Committee.
Access to safe drinking water is also an important aspect of the The Polio Endgame Strategy 2019-2023, which aims to “ensure populations reached for polio campaigns are also able to access much-needed basic services, such as clean water, sanitation, and nutrition.” The poliovirus spreads through human waste, so making sure people aren’t drinking or bathing in contaminated water is critical to eradicating the disease. Bunmi Lagunju, the PolioPlus project coordinator in Nigeria, says that installing the boreholes has helped prevent the spread of cholera and other diseases in the displaced persons camps.
Communities with a reliable source of clean water have a reduced rate of disease and a better quality of life. “When we came [to the camp], there was no borehole. We had to go to the nearby block factory to get water, and this was difficult because the factory only gave us limited amounts of water,” says Jumai Alhassan, as she gives her child a bucket-bath. “We are thankful for people who provided us with the water.”
By looking holistically at the needs of communities, Rotarians are ending polio, and making a significant contribution to overall health.
This story is part of the Broader Benefits of Polio Programme series on our website, which originally appeared in the October 2019 issue of The Rotarian magazine. Read part one.
The polio eradication campaign needs your help to reach every child. Thanks to the Bill & Melinda Gates Foundation, your contribution will be tripled. To donate, visit endpolio.org/donate.
In September:
One case of wild poliovirus was reported
6.1 million children were vaccinated.
Permanent transit teams vaccinated 1 428 845 children and cross-border teams vaccinated 164 692 children
In August:
The bi-annual Technical Advisory Group consultation was held. The report of the meeting is now available.
8.3 million children were vaccinated during the August Case Response Campaigns.
1.9 million children were vaccinated at 424 Permanent Transit Points.
Reposted with permission from Rotary.org When we talk about PolioPlus, we know we are eradicating polio, but do we realize how many added benefits the programme brings? The “plus” is something else that is provided as a part of the polio eradication campaign. It might be a hand-operated tricycle or access to water. It might be additional medical treatment, bed nets, or soap. This series takes a look at the ‘Pluses’, starting with prevention of other diseases. A 2010 study estimates that vitamin A drops given to children at the same time as the polio vaccine had at that time already prevented 1.25 million deaths by decreasing susceptibility to infectious diseases.
We take you to Nigeria, which could soon be declared free of wild poliovirus, to show you some of the many ways the polio eradication campaign is improving lives.
Polio vaccination campaigns are difficult to carry out in northern Nigeria, where insurgency has displaced millions of people, leading to malnutrition and spikes in disease. When security allows, health workers diligently work to bring the polio vaccine and other health services to every child, including going tent to tent in camps for displaced people.
The Global Polio Eradication Initiative (GPEI), of which Rotary is a spearheading partner, funds 91% of all immunization staff in the World Health Organization’s Africa region. These staff members are key figures in the fight against polio — and other diseases: 85% give half their time to immunization, surveillance, and outbreak response for other initiatives. For example, health workers in Borno use the polio surveillance system, which detects new cases of polio and determines where and how they originated, to find people with symptoms of yellow fever. During a 2018 yellow fever outbreak, this was one of many strategies that resulted in the vaccination of 8 million people. And during an outbreak of Ebola in Nigeria in 2014, health workers prevented that disease from spreading beyond 19 reported cases by using methods developed for the polio eradication campaign to find anyone who might have come in contact with an infected person.
Children protected from polio still face other illnesses. In Borno, malaria kills more people than all other diseases combined. To prevent its spread, insecticide-treated bed nets — such as the one Hurera Idris is pictured installing in her home above — are often distributed for free during polio immunization events. In 2017, the World Health Organization organized a campaign to deliver antimalarial medicines to children in Borno using polio eradication staff and infrastructure. It was the first time that antimalarial medicines were delivered on a large scale alongside the polio vaccine, and the effort reached 1.2 million children.
Rotary and its partners also distribute soap and organize health camps to treat other conditions. “The pluses vary from one area to another. Depending on the environment and what is seen as a need, we try to bridge the gap,” says Tunji Funsho, chair of Rotary’s Nigeria PolioPlus Committee. “Part of the reason you get rejections when you immunize children is that we’ve been doing this for so long. In our part of the world, people look at things that are free and persistent with suspicion. When they know something else is coming, reluctant families will bring their children out to have them immunized.”
Rotarians’ contributions to PolioPlus help fund planning by technical experts, large-scale communication efforts to make people aware of the benefits of vaccinations, and support for volunteers who go door to door.
Volunteer community mobilizers are a critical part of vaccination campaigns in Nigeria’s hardest-to-reach communities. The volunteers are selected and trained by UNICEF, one of Rotary’s partners in the GPEI, and then deployed in the community or displaced persons camp where they live. They take advantage of the time they spend connecting with community members about polio to talk about other strategies to improve their families’ health.
Nigerian Rotarians have been at the forefront of raising support for Rotary’s polio efforts. For example, Sir Emeka Offor, a member of the Rotary Club of Abuja Ministers Hill, and his foundation collaborated with Rotary and UNICEF to produce an audiobook called Yes to Health, No to Polio that health workers use.
This story is part of the Broader Benefits of Polio Programme series on our website, which originally appeared in the October 2019 issue of The Rotarian magazine.
The polio eradication campaign needs your help to reach every child. Thanks to the Bill & Melinda Gates Foundation, your contribution will be tripled. To donate, visit endpolio.org/donate.
In August
3 cases of wild poliovirus were reported.
5.1 million children were vaccinated.
Permanent Transit Teams (PTTs) vaccinated 1 579 581 children, and cross-border teams vaccinated 160 046 children against polio.
At the undergird of the polio programme in Afghanistan are women — polio officers, health workers, frontline workers, mothers, sisters, daughters, and grandmothers— some are anonymous, and some are on the frontlines. But what he polio programme is driven by women on a mission. The milestones achieved in the global fight against polio eradication are in large part due to the female work force. They are able to step beyond the threshold of countless homes, and effectively, cross socio-cultural barriers
From field visits, to encouraging parents, vaccinating children to sitting in the Expert Review Committee, Afghan women put shoulder to the wheel in efforts to eradicate polio in Afghanistan.
Read their stories in their own words:
Dr Fariba — Provincial Polio Officer, Kabul
“I’ve been doing this job for over 13 years now. I’m married with two kids. I used to be working in Mazar in different local clinics, and gradually got promoted to where I am today,” said Dr. Fariba.
Dr. Fariba is a provincial polio officer in Kabul. Over the years, Dr fariba has criss-crossed across the neigbhourhoods of Kabul in scorching summers and unforgiving winters with a single-minded cause: to reach every last child with polio vaccines. Thanks to her profession, Dr Fariba has picked up exceptional navigation skills. Call it occupational hazard or just a woman with a purpose, Dr Fariba knows the back alleys and short cuts around all of Kabul.
“I’m on the selection panel to find good polio workers, and I try to get qualified females to join, because it’s really important to have more women in this programme. Parents usually talk to women more openly and respectfully, which makes our work easier. As a woman and a mother, I get easy access to speak to families, and sometimes, it helps to convince them to vaccinate their children…” Dr. Fariba added.
Dr Karima — Provincial Polio Officer, Kabul
“I started to work in polio 14 years ago … we really hope to eradicate polio from our country,” said Dr. Karima, a provincial polio officer in central Kabul.
Dr. Karima manages a bustling part in central Kabul. Dr Karima works hard and wants to make a difference in the lives of the Afghan children and would like to see polio eradicated in Afghanistan— hopefully, during her lifetime.
Her professional aspirations for a polio-free Afghanistan is also driven by her other full-time job: that of a mother. “I have a 17-year-old boy and a 13-year-old girl, my daughter wants to become a doctor just like me, so I have to set a good example for her…” Dr. Karima explained.
Elaha Barakzai — Cluster Supervisor, Farah Province
Even though she’s only 20-years old, Elaha Barakzai, cuts an impressive figure. She is a cluster supervisor in Farah Province and has been working for polio eradication for the past two years, right after high school. Within the programme she supervises six teams of vaccinators — about 12 people and all of them older men. “I have never had issues with my teams. They respectfully follow my instructions and do their work. I help them get access to families who might refuse to open their doors to male vaccinators. We work very smoothly as one big team”, said Elaha, contrary to popular belief.
Elaha is currently doing a Bachelor of Art degree in Pashto Language and Literature, however, after having a job in polio eradication programme, she is planning to start studies in public health. “I discovered my interest after I worked for polio programme, I am a health person and I will work in health and serve my people,” said Elaha.
Hanita Haghigi — polio data
Hanita Haghigi is working on polio data in western region in the country. She is also helping the western team with other technology issues. “I am proud that I am helping the polio eradication initiative in my country. Every bit of support counts, I would like to see polio eradicated in my country and I believe all Afghans should support us, especially the Afghan women.” said Hanita Haghigi.
In July
The Extension of the National Emergency Action Plan 2018-2019 was finalized in July.
3.25 million children were vaccinated during the July Case Response Campaigns.
1.8 million children were vaccinated at 387 Permanent Transit Points.
In Union Council Kechi Baig, Quetta district, Balochistan province of Pakistan, Asma needs no introduction. When she talks, people listen. First, when she was one of the few female religious scholars at her local madrassa (school), and of late, as a champion for the polio programme.
For Asma, the segue into community health sensitization was quite natural. Her religious vocation as a teacher, also known as an Alima, and her life-long aspiration to help her community, came full circle when she became a religious support person (RSP) for the polio programme.
“I always wanted to become a doctor… but (it just so happened) I joined a madrassa and became an Alima…when I heard that the polio programme is looking for female RSPs, I took the opportunity. Even though I did not become a doctor, I can workwith doctors to serve humanity,” said Asma about her motivations.
As one of three female RSPs out of a team of 118, she has given unique credence to the polio efforts in her community. Kechi Baig accounts for a significant number of refusals to vaccinate. Community health workers are sometimes unable to make headway with refusal families. In such cases, Asma plays an important role as a faith-based counsellor, drawing upon her knowledge and expertise on religious teachings with communication skills and personal friendships within the community. Asma convinces 15-20 ‘hard refusal’ families in each vaccination campaign.
“I visit the households and leave with grandmothers convinced. As a madrassa teacher, I have seen that most females are unaware of religious teachings of Islam and the role of women to improve society. The polio fatwa (Islamic rulings) book proves to be very helpful because it contains authentic fatwas from venerated religious scholars.”
Asma realizes that bringing an attitudinal change through one-off encounters with refusal households is not enough. She saw the need for a long-term counselling relationship. Now, the polio programme team also conducts community engagement sessions with a cross-section of women across the community — from mothers to grandmothers to young students to women training at Asma’s madrassa—to raise awareness about polio.
“It is a great achievement being part of the training sessions about polio and health where I get to talk about the fatwa book. In almost every campaign I work with community health workers and convince 15 to 20 hard refusals for vaccination. It’s a big opportunity to save children from polio,” explained Asma.
Religious support persons, particularly women RSPs like Asma, play a very important role in mediating how people consider their choices for and against polio vaccination through the religious interface. By incorporating educative, spiritual, and medical knowledge, faith-based counselling goes a long way in neutralizing any refusal predispositions within the community.
21 August 2019 marks three years since Nigeria last reported a case of wild poliovirus. This is an important public health milestone for the country and the entire Africa Region, which is now a step now closer to polio-free certification.
At the press conference in Abuja, the Executive Director of the National Primary Health Care Development Agency (NPHCDA), Dr Faisal Shuaib, acknowledged that the three-year mark is an important moment in the fight against polio but also emphasized the need for vigilance ̶ “one which we must delicately manage with cautious euphoria.”
“This achievement would certainly not have been possible without the novel strategies adopted in the consistent fight against polio and other vaccine preventable diseases. We commend the strong domestic and global financing and the commitment of government at all levels,” the Executive Director stated.
Innovation, partnership and resolve have all underpinned advancements made in Nigeria, together with the commitment of tens of thousands of health workers. “Since the last outbreak of wild polio in 2016 in the northeast, Nigeria has strengthened supplementary immunization activities and routine immunization, implemented innovative strategies to vaccinate hard-to-reach children and improved acute flaccid paralysis (AFP) and environmental surveillance. These efforts are all highly commendable,” said WHO’s Officer in Charge for Nigeria, Dr Peter Clement.
However, despite progress, there is still much left to be done. Continued work to reach every last child with the polio vaccine, as well as strengthening surveillance and routine immunization across the region, will be key to keeping wild polio at bay and protecting the gains achieved.
Should there be no more cases in Nigeria or from countries in the Africa Region, and surveillance data submitted by countries meets evaluation criteria, the Africa Regional Certification Committee (ARCC) could certify the Region as wild polio-free as early as mid-2020.
The press briefing was attended by country representatives of all GPEI partners: WHO, UNICEF, CDC, Rotary and the Bill & Melinda Gates Foundation; as well as USAID, Government of Germany, EU and Canada. The Emir of Jiwa, representing the Northern Traditional Leaders Committee was also in attendance.
On the long road to global polio eradication, the programme has achieved four important milestones, representing four out of six WHO regions that have been certified as having interrupted transmission of wild poliovirus (WPVs): Region of the Americas (1994), the Western Pacific Region (2000), the European Region (2002), and the South-East Asia Region (2014).
At present, only the Eastern Mediterranean and African regions— no WPV reported in Africa since 2016, the African region may be eligible for regional certification as early as late 2019—remain to be certified in the path towards global eradication and hence constitute a key priority.
But who decides that a region is free of WPV?
The Eastern Mediterranean Regional Commission for Certification of Poliomyelitis Eradication (ERCC) is an independent body appointed in 1995 by the WHO Regional Director for Eastern Mediterranean to oversee the certification and containment processes in the region. It is the only body with the power to certify the Region free from wild polio, which convenes annually. Here are the outcomes of the recent ERCC meeting:
Urgent need to address regional priorities
The Commission noted with concern the need to stop the ongoing wild poliovirus type 1 transmission in the only two remaining polio-endemic countries in the Region: Afghanistan and Pakistan. The RCC acknowledged the on-going eradication efforts but strongly recommended the full implementation of the respective national emergency polio programmes through complete political and programmatic support to tackle the WPV1 transmission in the common Pak-Afghan epidemiological corridor, which remains unabated. The Commission also expressed concern about the current circulating vaccine-derived poliovirus type 2 and 3 transmissions in Somalia.
Wild poliovirus type 3certification prospects
The Commission, however, marked the good progress made towards curbing wild poliovirus type 3 (WPV3). Extensive analyses of the stool and environmental surveillance samples provided evidence that no WPV3 is in transmission in the Region. Based on the epidemiology, EMRO – along with the rest of the world – may be up for global WPV3-free certification by the GCC, potentially certifying two of three poliovirus strains eradicated—WPV2 strain was certified as globally eradicated in 2015.
Stepping-up is the need of the hour
So far, sixty cases of WPV1 are reported from two countries (Pakistan and Afghanistan) in 2019. Given the existing WPV1 transmission in the two remaining endemic countries of the Region, the RCC asked that the Member States undertake a firm commitment necessary for reaching zero.
Eastern Mediterranean Regional Commission for Certification of Polio Eradication (ERCC)
The Thirty-third meeting of the EMRO RCC was held in Muscat, Oman, to discuss the Regional progress towards a polio-free certification. The meeting brought together members of the RCC, chairpersons of the National Certification Committees, polio programme representatives of 21 countries, and WHO staff from the headquarters, regional, and the endemic countries. Representatives from Rotary International and the Centers for Disease Control and Prevention were also in attendance.
Comprised of public health and scientific experts, the regional certification commissions are independent of the WHO and national polio programmes. Global certification will follow the successful certification of all six WHO regions and will be conducted by the Global Certification Committee (GCC).
“Our area is a pretty difficult terrain because we live in the water and it is not easy for the teams coming from outside the community to gain access. So, the (hand-drawn) maps make it possible for us to identify areas we have yet to reach during the immunization exercise”, says Peter Idowu, a veteran community mobilizer and team supervisor in Makoko — a riverine shanty town located on the coast of mainland Lagos city, southwest Nigeria. Native to the village, Peter is the man to go to whenever the polio immunization teams face challenges navigating the waterways or the community.
The sprawling water city Makoko is a slum located across the Third Mainland Bridge on the lagoon. It is a largely low-income community with half the population on water and the other half on land. Informal, makeshift houses with corrugated iron roofs sit precariously atop stilts. Down below, narrow wooden boats act as a form of aquatic taxi ferrying goods and people around the bustling community. Nobody knows the exact population of this slum district of Lagos, but it is estimated to be as high as 100 000. It is mostly a fishing community inhabited by the Egun people.
“My goal is to see that all the kids in our community are immunized and live healthy lives. That is why I engage our teams in sensitizing parents all the time on the importance of routine immunization and the dangers of polio. As a member of the community and with a passion of becoming a health worker myself, I kept on mobilizing our people for easy accessibility, because our language is different from Yoruba and most of the Polio teams can’t speak the language. It is always easy with me being in the Polio team as our people will readily accept the vaccine without rejecting,” says Peter.
Nigeria is the only country in Africa and one of the only three in the world endemic to wild poliovirus, alongside Afghanistan and Pakistan. Nigeria is also affected by circulating vaccine-derived poliovirus type 2 (cVDPV2) outbreaks.
UNICEF works closely together with Global Polio Eradication Initiative (GPEI), key polio partners and the Nigerian government. There is a vast network of over 20 000 community mobilizers focusing on demand creation and improving health-seeking behaviors of caregivers.
In May:
1 case of wild poliovirus was reported.
1 million children were vaccinated.
Permanent Transit Teams (PTTs) vaccinated 971 281 children, and cross-border teams vaccinated 72 614 children against polio.
“We had not seen vaccination teams in our community for a very long time. Sometimes we go for months without vaccinating our children, if we don’t take our children to the mainland to get them vaccinated”, says Mr. Atebakuro Oton George, a fisherman and father of five, residing in Minibie ward of Nigeria’s Bayelsa State.
A largely riverine state, Bayelsa accounts for over 60% of the delta mangrove of the Niger Delta. Many children here continue to miss their chances at life-saving vaccination, as transport is precarious in the tangle of creeks and rivers that crisscross the state. In 2018 a number of innovative strategies such as, immunization boats at sea and community engagement through the traditional hierarchy and sensitization activities, supported by World Health Organization (WHO) through the Government of Bayelsa were introduced to reach a wider net of children.
“Now on weekly basis, health workers brave the seas and visit our communities to vaccinate our children”, an elated Mr. George continues.
Subsistence farming and fishing are the mainstay of the local population’s economy and diet. Health services are provided by primary health care centers located within the island communities.
“The difficulty of accessing healthcare services is due to suboptimal and expensive coastal and waterway transportation from the distant communities to healthcare centers, hence, innovative strategies are being employed to reach the underserved and vulnerable population with vaccination and other health interventions especially during Supplemental Immunization Activities (SIAs)”, says Dr Edmund Egbe, WHO State Coordinator in Bayelsa.
To reach ‘missed’ children, community engagement activities to increase demand for immunization have been initiated to bolster willingness of caregivers to readily access the interventions even when in the middle of the river or the ocean. The successful implementation of the community engagement framework has resulted in high-level acceptance of immunization services in the State. From April 2018 to April 2019, over 169 836 children received vaccination.
Routine immunization coverage has improved remarkably: the first quarter RI Lot Quality Assurance Survey (LQAS)— a quarterly activity organized by the National Emergency Routine Immunization Coordinator Centre (NERICC) to assess routine immunization performance, reasons for non-immunization as well as efforts to improve uptake and utilization of RI in Nigeria—conducted in April 2019 indicate that the State is second best in the country. Previously, the State was ranked amongst others in the country as poor-performing from the last National Immunization Coverage Survey (NICS) conducted in 2016; this led to the inauguration of an emergency response committee in March 2018.
King Diete-Spiff, the Chairman and the ‘Amanayanbo’ of Town-Brass, in his meeting with the State Traditional Rulers Council said, “Sustaining the innovative strategies of vaccinating vulnerable populations will undoubtedly increase immunity against vaccine preventable diseases and reduce the mortality and morbidity rate in difficult to access communities”. He described the polio infrastructure in Bayelsa, supported by WHO and partners, as the bedrock of driving successful healthcare intervention at the grassroots.
Support for polio eradication and routine immunization to Nigeria through WHO is made possible by funding from the Bill & Melinda Gates Foundation, the Department for International Development (DFID – UK), the European Union, Gavi, the Vaccine Alliance, the Government of Germany through KfW Bank, Global Affairs Canada, the United States Agency for International Development (USAID), Rotary International and the World Bank.
