GPEI-Raising immunity in northern Nigeria

Salamatu Kabir (right), a HTR team lead, travels with other health workers to vaccinate children across two local government districts. © UNICEF Nigeria

Three-year-old Ibrahim wouldn’t stop crying. Suffering from ringworm, a fungal infection, his leg had become badly infected. Left untreated, he risked developing fever and scarring wounds.

For Ali Musa, his father, it was hard to know where to turn for help. Where he lives, in the nomadic community of Daurawa Shazagi in the Nigerian state of Jigawa, there is little access to professional medical treatment.

From his home, it would take Ali a full day to trek to the nearest primary health centre. He does not recall the last time anyone in his community made this “practically unthinkable” journey.

Reaching all children with vaccines

“But when I heard in the market that a medical team was coming to us to treat sick people, especially women and children, I went with the hope to at least get him some relief from the pain,” Ali recalls.

There, Ali met members of the mobile health teams supported by the UNICEF Hard-to-Reach (HTR) project – funded by the Government of Canada’s Department of Foreign Affairs, Trade and Development. These teams are helping to ensure that children receive polio vaccinations, whilst also providing basic health services – including medications to fight infections like ringworm – in hard-to-reach areas of Nigeria.

A health worker wades across a shallow river to deliver polio vaccines and other health interventions. © UNICEF Nigeria

The teams vaccinate against measles, meningitis and other diseases, and provide vitamin A supplements and deworming tablets for children. They also carry out health promotion activities, teaching communities about important practices such as exclusive breastfeeding. During each clinic, members of the HTR team give two drops of polio vaccine to every child, ensuring that all are protected from the virus.

At the end of their visit, the team pack up the clinic, and travel home, taking hours to cross difficult terrain by foot, boat and motorbike.

2390 children vaccinated

The HTR project aims to reduce the immunity gap among children living in Nigeria. Since 2016, when cases of wild poliovirus last were detected in the country, determination and commitment have helped to strengthen eradication efforts, but many states still face an uphill task to increase historically low routine immunization rates. This is especially the case in rural areas, where there are few services, and communities have to travel far to the nearest health clinic.

So far in 2018, the project has reached thousands of previously unvaccinated children with the life-saving polio vaccine, including 2390 children in Ibrahim’s state, Jigawa.

“Why should I let anything stop me?”

Salamatu Kabir, who leads a HTR team assigned to take immunization and basic health care services across Jigawa, says “I look at it this way. If people from outside can come all the way to bring the hard-to-reach project to my country, why should I let anything stop me from delivering it to my own people who are most in need?”

A retired health worker, she says that she doesn’t think twice about the many hurdles that she will have to overcome to reach children in communities like Ali and Ibrahim’s.

Far more of a concern is planning meals for her four children whilst she is away, and packing all the equipment she will need for the journey. Experience over the years has taught her what items to add to her bag besides vaccines. She always carries an umbrella, an extra pair of clothes, insect repellant and depending on the season, either an additional pair of sandals or, most often, rain boots.

Salamatu asserts that for the team members, “visiting the settlements to administer health care is something we have come to love and look forward to”.

When the team finally does arrive at their destination they are greeted by an expectant community. Salamatu is motivated by the direct impact her work has on the lives of others.

Little Ibrahim is one of those to benefit. After treatment from the team, his condition improved quickly. His father Ali has since become a volunteer for the HTR project, and an avid advocate within his community for medical care.

“I will do my best to ensure every child in my village benefits from the help that is coming from far,” he says.

Dr Farzia Sadat manages over a thousand people in the polio programme. © WHO/T. Hongisto

A little girl giggles as she gets her finger marked with blue marker pen in front of a full classroom.

Eight-year old Pashton has joined her mother Shaima Ebrahimi in a training for polio vaccination campaign monitors a few days before a national campaign starts in Afghanistan.

Standing next to Pashton, Dr Farzia Sadat explains to her students how a blue marker is used properly, so that a mark stays on the children’s fingers. A blue fingertip is a confirmation that the child has been vaccinated against poliovirus.

This week, around 10 million children will receive two drops of polio and the blue mark. But first, polio workers need to be trained.

Six long years at home

Dr Farzia has been working for the polio eradication initiative for two years. Before each campaign, she trains the campaign staff and during the campaign she coordinates to the quality of work over 1,000 people.

On the first day of the campaign she gets up early, as she needs to get to a local mosque to meet vaccinators who are picking up their equipment for the day: blue vaccine carrier boxes with vials, pens, printed campaign plans and so on.

One of Dr Farzia Sadat’s vaccination teams at work. © WHO/T. Hongisto

At the mosque door, she takes her shoes off and steps in to greet one of her teams.

With four children and a busy career, she does not have much free time at her hands, but she would not have it any other way. “It was my dream to become a doctor from an early age, and my parents supported me. I was a bright kid and my parents saw my potential.”

Before starting to work in the polio eradication programme, she worked as a medical doctor and in different public health programmes in Herat. “I wanted to start working in public health to help many people instead of just one patient at a time.”

She doesn’t take her success for granted, as it was not always certain that she would be able to work at all.

“I started my studies in 1992, but a few years later, I was forced out of university because of the restrictions imposed on women. I stayed home for six long years,” she remembers.

She kept herself busy by volunteering in a local health facility pharmacy, doing tailoring work at home and helping at a local health centre. Although women were not allowed to study or work, they could help in health centres, as male doctors were not allowed to treat female patients.

Women were finally admitted back to universities in 2001. “All of my college classmates were so happy to start studying again”.

When she was allowed to continue her studies, she returned with a newfound energy and went on to graduate with top grades despite having a young daughter to care for.

Helping women enter the workforce

At the end of the first day of the campaign, the teams gather in a local health centre to debrief.

The monitors have walked around the city following vaccinators and checking whether the vaccine vials have been handled correctly, fingers marked properly, and numbers of vaccinated children marked accurately on tally sheets.

At the evening meeting, everyone gets a chance to tell management about any problems.

A team of two young women reports that they have been harassed on the streets, and Dr Farzia takes note.

“Every campaign we have one or two cases of harassment,” she sighs. “We have security in place to help the women, if something should happen.”

In Afghanistan, it is still relatively rare for women to work. The polio eradication initiative is accountable for possibly the largest female workforce in Afghanistan, employing thousands of front line workers in every campaign.

Dr Farzia hopes to hire more women. In vaccination campaigns, women have one overwhelming advantage over men: they can enter homes. This makes it easier for newborn and sleeping children to be vaccinated, and fewer children are missed in each campaign. “It improves our programme results, but it is not so easy to find more women. In some areas, people have never seen women work outside their homes.”

For the future, she hopes that life will become easier for Afghan women again. And for now, she will continue working for that goal.

The poliovirus takes a beating at WHA 2018. © Sini Ramo/WHO

28 May 2018, Geneva, Switzerland: ‘Eradicate first’ was the mantra at last week’s World Health Assembly (WHA). While holding detailed discussions to plan for a polio-free world, delegates emphasized the need to finish the job of eradication.

With wild poliovirus transmission levels lower than ever before, Ministers of Health and delegates reviewed progress being achieved through national emergency action plans in the remaining endemic countries. As at May 2018, only eight cases due to wild poliovirus had been reported globally, from just two countries: Afghanistan and Pakistan.

To prepare for a polio-free world, Member States adopted a landmark resolution on poliovirus containment. A limited number of facilities will retain poliovirus after eradication, to serve critical national and international functions such as the production of polio vaccine or research. It is crucial that these poliovirus materials are appropriately contained under strict biosafety and biosecurity handling and storage conditions, to ensure that virus is not released into the environment, either accidentally or intentionally, to again cause outbreaks of the disease in susceptible populations.

WHO and countries that are currently funded by the Global Polio Eradication Initiative (GPEI) face significant financial, human resource, and programmatic risks as a result of the scaling down of the GPEI budget (2017-2019) and its eventual closure. Hence, Member States requested the Director-General to develop a strategic action plan on polio transition that will mitigate these risks, as well as strengthen country health systems. Delegates considered the resulting 5-year strategic action plan on polio transition, which has 3 key objectives: (i) sustaining a polio-free world after eradication of polio virus; (ii) strengthening immunization systems, including surveillance for vaccine-preventable diseases; and (iii) strengthening emergency preparedness, detection and response capacity in countries to ensure full implementation of the International Health Regulations. The strategic action plan outlines how essential polio functions like surveillance, laboratory networks, and some core infrastructure can support the implementation of the Post Certification Strategy to sustain a polio-free world, and can be integrated into the immunization or health emergencies’ programme, or mainstreamed into national health systems. The plan provides detailed costing for the integration of essential polio functions into WHO’s Thirteenth General Programme of Work, and some financing options. The three polio-endemic countries (Afghanistan, Pakistan and Nigeria) and a few high-risk countries battling outbreaks have been excluded from transition planning until eradication. All other GPEI-funded countries are expected to plan for polio transition.

Member States expressed overwhelming commitment to fully implement and finance all strategies to secure a lasting polio-free world in the very near term. Rotary International, speaking on behalf of the GPEI, which includes WHO, Rotary, CDC, UNICEF and the Bill & Melinda Gates Foundation, offered an impassioned plea to the global community to eradicate a human disease for only the second time in history, and ensure that no child will ever again be paralysed by any form of poliovirus anywhere.

Dr Taj Muhammad interacts with children during a polio immunization campaign in Sadar Union Council, Killa Saifullah district, Balochistan, Pakistan. © S. Mughal/WHO Pakistan

Almost everyone in the Killa Saifullah district of Balochistan, Pakistan, knows and respects 35-year-old Taj Muhammad. A dedicated and passionate doctor by profession, Dr Taj spends his days working as a Union Council Medical Officer in his local public health facility, and his evenings running a free medical clinic for local residents.

In his capacity as Medical Officer, he coordinates polio eradication efforts at the Union Council level, which is the smallest administrative unit in Pakistan.

His role includes coordinating microplanning, training frontline health workers, and supervising polio vaccination campaign activities. Since the start of his medical career in 2007, he has supervised more than 100 polio vaccination campaigns.

Dr Taj says he became a doctor to fill the existing health care gap in his area. “During my childhood, my mother was seriously ill and she died because of the absence of medical facilities in our area. She often used to tell me that I must become a doctor to help poor people with their health. She died afterwards but her words are still in my heart,” he explains.

His hometown, Killa Saifullah, is located 135 kilometers away from Balochistan’s provincial capital Quetta. Economic and social deprivation is widespread, and the district lacks basic health facilities, particularly for women and children. “There is only one hospital, serving only 150 people per day in the district, whereas the current population is more than 200,000. In these conditions, working as a medical officer is quite challenging,” Dr Taj says.

His job is tiring, and the demands are huge, but Dr Taj perseveres. As well as supporting polio vaccination activities, and endorsing vaccination, each day he tends to the large crowd of people who gather outside his evening clinic, often desperately needing health care.

His work to serve his community is particularly important because Killa Saifullah lies close to Dukki, where the only case of polio in Pakistan so far in 2018 was reported. Nawabzada Dara Khan, who chairs the Killa Saifullah’s Municipal Committee, notes that the community feels “vulnerable” knowing that the virus is close by.

Since the first polio case of 2018 was detected, polio vaccination campaigns have been conducted in response in all neighboring districts, including Killa Saifullah. But whilst this has increased immunity to the virus, it has also caused vaccine hesitancy amongst some parents, who question the need for multiple vaccination campaigns.

“We are trying hard to vaccinate each and every child; however, repeated campaigns and misconceptions are posing a big challenge for us,” Dara Khan says.

Luckily, the efforts of dedicated doctors like Dr Taj are helping to remove misconceptions and doubt. With the immense trust and respect he enjoys from his community, he has been able to use his free evening clinic as a local platform to advocate for polio eradication and the safety of the vaccine, extending his critical role in the polio programme.

Dara Khan adds, “The contribution of Dr Taj in polio eradication is commendable. His goodwill is playing a very positive role within our community to remove these misconceptions.”

His impact is also wide ranging, reaching multiple different families.

The proof? In April, thanks to the intensive efforts of Dr Taj and others, no parents or caregivers in Killa Saifullah refused vaccination.

That’s 70,690 children who now have lifelong protection from polio.

Dr Taj monitoring the work of a vaccination team during a polio immunization campaign in his district. © S. Mughal/WHO Pakistan

Microplans guide the activities of polio vaccinators. © WHO Afghanistan/Amarkhil

How do vaccinators ensure that every child is reached?

Every child needs to be vaccinated to protect them from poliovirus. To achieve this, detailed plans are prepared for vaccination teams. The aim is to find each child under 5 years of age – in Afghanistan, that’s around 10 million – and to reach them with vaccines.

A heavy steel gate opens on a quiet suburban street in central Herat. The city lies in a fertile river valley in Afghanistan’s west, an area rich with history. Over the centuries, invaders from Genghis Khan’s army to the troops of the Timurid empire, the Mughals and the Safavids have opened the gates to rule the city once known as the Pearl of Khorasan.

Now, a far more peaceful group can be seen walking down the streets of Herat. Equipped with blue vaccine carrier boxes and drops of polio vaccine, the teams knock on one door after another to vaccinate any children they find inside. The aim is to eradicate polio in Afghanistan.

Four-year old girl Fariba peeks from behind the gate and steps out on the street, followed by her father Mashal.

Mashal encourages his daughter to open her mouth to receive two drops of polio vaccine, and a drop of vitamin A. Fariba looks at the vaccinators with suspicion, but follows her father’s guidance.

The vaccinators thank them and continue down the street.

Locating all children

In March, vaccinators in Herat gave oral polio drops to over 150 000 children.

In a country with one of the highest rates of population growth in the world and frequent population movement, it is no easy feat to tell how many children live in each province, district, village, block, house or tent.

How do vaccinators know where the children in each area are located then? Through a simple but elegant guide known as a ‘microplan’. This is what the vaccinator follows: Where to start the day, how many children live on that street, which is the next house to visit?

No coincidence: Who goes where

A few kilometres from Fariba and Malik’s home, Dr Khushal Khan Zaman is sifting through printed plans on his desk at the World Health Organization office.

Dr Khushal explains that once a year, health workers physically count the houses in their area. Then they check that the plans from the previous year still match the numbers.

Campaign supervisors know the approximate number of children in each house from the last campaign. But the data is complemented by their personal knowledge. As locals, they often know of any changes in the composition of their community – where new children have been born, or the location of nomadic groups who have settled in the area.

This helps keep the plans accurate. For instance, if a nomadic group has stayed in an area for a longer time, their tents may be added to the microplans. For shorter stays, a separate checklist is used instead to monitor nomadic population movement. This improves the programme’s ability to trace and reach every child with vaccines, even if they are on the move.

Once the plans have been updated, teams of vaccinators are assigned to visit specific homes on a particular day during the upcoming campaign.

The final plan indicates not only the numbers of houses and children, but also details on how many related items are needed for each team: vaccine vials, vaccine carriers, ice packs (to keep the vaccines at optimum temperature), chalk, tally sheets, pens, leaflets, finger markers, plastic bags and scissors.

This is a contrast to a few years ago, when the plans listed only the name of the area with the estimated number of children to be vaccinated. The newer plans include even the smallest houses, and information on the closest mosque and local elders.

“It needs to be clear to everyone, which team is responsible for which area. We mark where the teams start and which direction they take using arrows,” Dr Khushal explains.

And it is no coincidence who goes where. To ensure that parents allow their children to be vaccinated, vaccinators may be allocated parts of their community that they know well, to increase trust when they deliver the vaccine.

Children like Fariba might not understand yet why the vaccine is important, but their father does. When vaccinators knock, it is not chance that brings them, but care and commitment.

The Rotary National Chair gives a child oral polio vaccine, protecting her against the virus for life. © WHO Pakistan

Karachi, the capital of Sindh province, is Pakistan’s largest city, with an estimated population of more than 16 million people. It is also by far the most challenging place in Pakistan to eradicate polio. Difficulties include the large and frequent movement of people, poor water and sanitation conditions, and pockets of community resistance to vaccination.

In 2017, two of Pakistan’s eight total cases of polio were located in Karachi, and multiple environmental samples continue to test positive for the virus.

In the northwestern part of the city lies Orangi Town. The fifth largest slum in the world today, it is a tough place to live for the children who run around and play games in the streets outside their homes.

One of their most pressing needs is a supply of clean, drinkable water. In Orangi Town, the sewage system is basic, and poorly maintained. At many points, human waste mixes with drinking water lines. The quality of potable water is low and filled with pathogens including bacteria and viruses, and it is the main cause of many water-borne illnesses in adults and children, including hepatitis A, acute watery diarrhea and typhoid. Polio can also be spread through drinking water contaminated with the stools of an infected person.

Health workers for the polio eradication programme work tirelessly to immunize every child. But there are other ways to reduce the spread of the virus – and provision of uncontaminated drinking water is one of them.

The new water filtration plant will provide 55 000 people with clean water. © WHO Pakistan

Thanks to the efforts of Rotarians, who raised 50% of funds, 55 000 residents of Orangi now have access to a new water filtration plant. By ensuing that there are no viruses or bacteria present in the water, the plant will protect children from water-borne illness. As the plant runs using solar energy, it will work consistently through the regular power outages that affect the city, and won’t require expensive oil or electricity to run, placing fresh water within the reach of all.

Speaking on 8 May at the opening of the plant, Mr Aziz Memon, Chairman of Pakistan’s National Rotary PolioPlus Committee said: “This is the 15th water filtration plant installed in Pakistan, and the sixth in Karachi, and we will do all that we can with our partners to help raise the community’s standard of living including health.”

Dr Shafiq, a representative of Orangi Town, thanked Rotary International for its continuous support of polio eradication in the area. Combined with vaccination activities, children drinking the clean water provided by the new plant will now have an improved chance to grow up polio-free.

National Chair Aziz Memon said: “Orangi Town is one of the most underprivileged urban slums in Karachi and the supply of safe drinking water will improve health issues of the community and save children from water borne diseases.”

He added that “Rotary is making intensified efforts in this impoverished area and has established a Resource Center in Bijli Nagar Orangi Town.”

These extra steps towards ensuring that children are safe from disease also help to gain community trust, and form part of Rotary’s work to raise awareness of polio, and overcome vaccine hesitancy. In 2016, Rotary International contributed over US$ 106 million to polio eradication worldwide, and in Pakistan, Rotarians are at the forefront of the fight against the virus.

By chance, the opening ceremony of the plant coincided with the second day of this month’s subnational immunization days, when over 20 million children across different parts of the country were targeted with oral polio drops. Emphasizing the link between safer water, and polio eradication, children were given polio vaccine by high profile individuals attending the event.

Kicking off a safer future for some of Orangi’s children, Mr Memon and Rotary District Governor Ovais Kohari pushed a button at the plant to allow clear, safe water to flow from the taps. They then had a drink of water to test the quality and taste.

Simultaneously, polio vaccinators were going from house to house all over the city. For some families, Rotary was providing two life changing interventions in just one day – an effective vaccine, and water that they could finally trust.

By providing communities with clean water, Rotary International is helping to improve child health and reduce poliovirus spread. Those attending the opening of the sixth water filtration plant in Karachi included representatives from the World Health Organization, UNICEF, the Bill & Melinda Gates Foundation, Rotary International, Qatar Hospital, and community stakeholders. © WHO Pakistan

A female vaccinator administers polio vaccine during a campaign in Kabul, Afghanistan. © WHO/J Swan

Last month, Canada signed a generous pledge of Can$ 100 million to help eradicate polio in Afghanistan as well as in the two other endemic countries, Nigeria and Pakistan, and to continue to protect many polio-free countries. The pledge was announced by the Honourable Marie-Claude Bibeau, Minister of International Development and La Francophonie, at the 2017 Rotary International Convention in Atlanta.

In addition to previous donations of approximately Can$ 650 million, this most recent funding consists of Can$ 30 million to WHO and UNICEF to support programme activities in Afghanistan, and Can$ 70 million of flexible funding that can be used to support vaccination campaigns, rapid outbreak response, poliovirus surveillance and other critical eradication strategies and activities to reach every last child worldwide with a safe vaccine.

This latter funding is especially valuable to the programme, as it will help sustain the priority areas of work that make global polio eradication possible. In 2017, there were 22 cases of wild poliovirus reported worldwide, from only two countries, Afghanistan and Pakistan. In Nigeria, wild poliovirus was last detected in 2016. However, since 2001, there have been wild polio outbreaks in 41 countries that were previously polio-free.

Flexible funding, such as that provided by Canada, is critical to allow the programme to react quickly to the most urgent needs, successfully stopping each outbreak, and ensuring that every child is protected from polio worldwide.

Minister Marie-Claude Bibeau used the signing as an opportunity to underline Canada’s ongoing commitment. “Canada has been a supporter in the fight against polio from the very beginning and we are committed to seeing it through to the end,” she said. “Keeping the momentum is key, particularly in Afghanistan, Pakistan and Nigeria, where polio still exists. Canada remains committed to ensuring every child is immunized, particularly girls, who continue to face barriers.”

As a champion of feminist development, Canada has particularly emphasized the role played by women in the programme, from the front lines, to programme management and political leadership. Polio eradication moreover forms a crucial part of Canada’s “Right to Health” commitment, and has the potential to become one of the first tangible outcomes of the UN Sustainable Development Goals.

Akhil Iyer, Director of the Polio Eradication Programme at UNICEF said, “Whilst polio exists in the smallest geographic area in history, this includes some of the most dangerous and difficult-to-reach parts of the world. Canada’s long-standing political and financial commitment helps our dedicated health workers, mostly women, go the extra mile and vaccinate every child to build a polio-free world.”

With this funding and ongoing support, Canada is striving to protect every girl and boy child. In doing so, Canada is making history.

The funding is also a testament to the major role played by the Canadian people at every level of the polio eradication programme. To date, Canadian Rotarians have raised and contributed more than US$ 52 million to eradication efforts, whilst Canada’s citizens have played an important role in tracking progress and publically voicing their support to end polio through the Scientific Declaration on Polio Eradication, and the One Last Push Campaign.

Michel Zaffran, Director of the Polio Eradication Programme at the World Health Organization said, “The ongoing support of Canada is fundamental to the programme’s success. With their global advocacy in international forums such as the G20 and G7 and their strategic and high quality support in Afghanistan and across the world, we can ensure that polio is eradicated forever.”

Canada’s contribution comes at an important time for the programme, in the run up to the 2018 G7 Summit. Previous summits have recognized polio eradication efforts, noting that programme assets also help to strengthen other aspects of health and development. This year, the Presidency is held by Canada, the first country to place polio eradication on the G7 agenda.

The Global Polio Eradication Initiative partners extend their profound gratitude to the Government and to the citizens of Canada for their tremendous support and engagement to end polio globally.

Minister Marie-Claude Bibeau announced Canada’s generous commitment at the 2017 Rotary International Convention in Atlanta. This latest funding comes on top of significant and long term support from the Canadian people. © Global Polio Eradication Initiative

Binta marks a girl’s finger with indelible ink after vaccinating her in Kano State, Nigeria. © WHO Nigeria

Binta Tijjani works to eradicate polio in her native Kano state of Nigeria. She is one of the over 360 000 frontline workers dedicated to ending polio in her country, the vast majority of whom are women. Nigeria is one of only three countries in the world yet to stop poliovirus circulation, together with Afghanistan and Pakistan.

Binta has worked in polio eradication for over 14 years. Starting as a house-to-house vaccination recorder, she was soon promoted to the role of polio campaign supervisor and now works as an independent polio campaign monitor.

“My biggest strength is my ability to work closely with our teams to ensure we reach every last child with vaccines, and advising teams so they can ask the right questions and raise important issues in each household they visit,” Binta says.

Working with the polio programme often opens up other opportunities for women to enter the workforce and utilize their skills to contribute to their communities, leading to positive investments beyond polio eradication.

“My work with the polio programme has enabled me to buy land and take care of my children’s school fees and our household needs. Currently I’ve enrolled in a course to get a certificate in catering. My dream is one day to open a restaurant,” Binta says.

Halima administers the oral polio vaccine to a child at a pharmacy where she works as a polio surveillance focal point. © WHO Nigeria

Similar to Binta, Halima Waziri has been serving the polio eradication cause in different roles since 2005. Currently Halima works as a lot quality assurance sampling interpreter in Kano state, assessing the quality of vaccination coverage after immunization campaigns in her area.

“I am most proud of engaging in many productive dialogues about polio vaccination in remote and hard-to-reach areas and high-risk communities in Nigeria. This has helped me to improve my interpersonal communication skills and given me confidence in public speaking and influencing people,” Halima says.

With the money she has earned as a polio worker, Halima has opened a medicine store where she sells medicines and also acts as a community informant and focal point for disease surveillance.

Nigeria was on the brink of eradicating polio when a new wild poliovirus case was reported in 2016 after two years without any confirmed cases. Low overall routine immunization coverage is a key stumbling block to eradication, combined with ongoing violent conflict in the northeast where over 100 000 children remain inaccessible for vaccination teams.

Nigeria continues to implement an emergency response to vaccinate all children under the age of 5 to ensure they are immunized and protected, including implementing vaccination campaigns whenever security permits, vaccinating children at markets and cross-border points, and conducting active outreach to internally displaced people.

Without the critical participation of women as vaccinators, surveillance officers and social mobilizers, Nigeria would not be as close to eradicating polio as it is today. The latest nationwide immunization campaign, synchronized with countries in the Lake Chad basin, aimed to reach over 30 million children in Nigeria in April.

No wild poliovirus cases have been reported in 2017 or 2018. Binta and Halima, together with an army of frontline workers, are determined to keep it this way and secure a polio-free future for Nigeria.

Auta works as a Vaccine Security and Logistics facilitator in Borno State, Nigeria. © UNICEF Nigeria

Forty-year-old Auta A. Kawu says the only thing predictable about working in the conflict-affected northeastern Nigerian State of Borno is its unpredictability.

“No two days in my week are alike,” he says.

As a Vaccine Security and Logistics facilitator, Auta is one of 44 specialists working with the Government, UNICEF and partners in Nigeria, who strive to ensure sufficient vaccine stock, appropriate distribution and overall accountability for vaccines in the country. Through careful management, Auta works to give every accessible child in Borno protection from vaccine-preventable diseases, including polio.

Describing a typical week in his life, he explains that if on Monday he is arranging for the vaccination of eligible children among a group of Nigerians returning back from neighbouring countries where they had fled due to fear of violence, by Tuesday he could be speaking with government personnel to find a way to safely send vaccines to security compromised areas. On Wednesday, he may find himself rushing extra vaccines to an internally displaced persons (IDP) camp, where more people have arrived than initially expected, whilst on Thursday you may find him trying to locate a cold chain technician to fix a fridge where the heat-sensitive polio vaccine must be stored.

Evidencing the energy and commitment required to work on the frontline of vaccination, Auta notes that the work never lets up. Despite an exhausting week, on a typical Friday, you might find him on the road again, travelling to a remote location where health workers have just been given access. When he gets there, he will help out once more – trying to ensure that vaccines are distributed as effectively as possible to maximize the number of children reached.

He recounts a recent story of reaching the reception area of an IDP camp in Dalori, which is located in a highly volatile area of the state. Arriving with 300 doses of oral polio vaccine, and 200 doses of measles vaccine, he was told that new arrivals were expected later that day. Many of the people coming had been under siege by non-state armed groups since 2016, and had taken the opportunity of improved security and mobility to flee to the nearest town. Very few of the young children arriving had ever been reached with vaccines.

With the screening of children eligible for measles and polio vaccines starting around 9 am, and plenty more children yet to arrive, it was quickly clear that the available doses would not be enough.

Springing into action, Auta notified the head of the security team accompanying him of the need to go to nearest health facility to bring additional doses. Once clearance was given, he rushed to Jere Local Government, a district nearby, to collect more vaccines.

In the meantime, however, there were sudden changes in the security environment. The return journey to Dalori was not cleared until late noon.

Luckily, giving up isn’t in Auta’s nature.

By the end of the day, he had successfully delivered 580 doses of oral polio vaccine and 460 doses of measles vaccines for the children in the camp, providing some of them with their first ever interaction with a health system.

The crucial role of Vaccine Security and Logistics facilitators like Auta cannot be over-emphasized. In addition to his central work, Auta also conducts advocacy visits to traditional and religious leaders and supports the planning and implementation of vaccination campaigns in inaccessible areas.

Vaccine facilitation may be unpredictable work, but Auta is secure on one thing. Thanks to the work of him, and thousands of other determined health workers, community mobilizers and with support from donors and partners including the Bill & Melinda Gates Foundation, the Government of Canada, the Dangote Foundation, the European Union, Gavi – The Vaccine Alliance, the Government of Germany, the Government of Japan, the Japan International Cooperation Agency (JICA), Rotary International, the US Centers for Disease Control and Prevention, the World Bank and others, Nigeria is steadily on its way to being declared polio-free.

“No two days in my week are alike.” © UNICEF Nigeria

On top of the US$ 120 million committed in 2013, last year, HH Sheikh Mohamed bin Zayed pledged an additional US$ 30 million towards polio eradication, and the UAE is active on the ground in Pakistan through the UAE-Pakistan Assistance Program
UAE support also funded more than 5000 committed full-time vaccinators in highest-risk districts of Pakistan
Last year saw the lowest number of wild poliovirus cases in history (22 worldwide); Pakistan reported a 97 percent decline in cases between 2014 and 2017

GENEVA (16 April 2018) – The Global Polio Eradication Initiative (GPEI) announced today that the UAE has completed the US$ 120 million commitment made by His Highness Sheikh Mohamed bin Zayed Al Nahyan at the 2013 Global Vaccine Summit in Abu Dhabi.

“We thank the UAE for their long-term generous support and unwavering dedication to polio eradication, and particularly the personal commitment of His Highness Sheikh Mohamed bin Zayed Al Nahyan, Crown Prince of Abu Dhabi,” WHO Director General Dr Tedros Adhanom Ghebreyesus said. “This is the kind of support that will ensure we reach every last child to complete the job and to show the way to delivering health to all.”

Polio is a highly infectious disease that can cause lifelong paralysis, but it is entirely preventable with vaccines. Only three countries remain which have never stopped polio: Afghanistan, Pakistan and Nigeria. When the polio eradication effort was launched in 1988, 350 000 children were paralyzed by polio every year across 125 countries.

Polio eradication efforts have since made remarkable progress and there were only 22 cases in 2017 – the lowest ever recorded number. However, a number of key challenges remain. Reaching the most vulnerable children with the polio vaccine is hampered by a range of hurdles including difficult terrain, insecurity, and large-scale population movements.

Following the Global Vaccine Summit, the UAE expanded its role through the UAE Pakistan Assistance Program (UAE-PAP) to ensure that further gains would be made where it was needed the most. Through the “Emirates Polio Campaign” initiative, the UAE has helped drive on-the-ground eradication efforts within the most vulnerable communities in Pakistan.

Speaking about the UAE’s work, His Excellency Mohamed Mazrouei, Undersecretary of the Crown Prince Court of Abu Dhabi said: “The UAE’s pivotal role in eradicating polio completely is not limited to being a donor only, but extends to include its capacity to convene key groups and provide on-ground support to deliver vaccines in the highest risk areas of Pakistan.

“The UAE’s support – both as a leading donor and passionate advocate – has been critical for getting as close as we’ve ever been to making history by eradicating polio,” UNICEF Director of Polio Eradication Akhil Iyer said. “This is a gift not only to the children of Pakistan but to all future generations of children, everywhere, who are so close to the goal of being able to be born and be raised in a polio-free world.”

Dr. Chris Elias, President of the Global Development Program, Bill & Melinda Gates Foundation, said: “The UAE and His Highness Sheikh Mohamed bin Zayed Al Nahyan have shown an unwavering commitment to end polio, and we are delighted to partner with them in this effort. Without their involvement, achieving a record low number of polio cases in 2017 would not have been possible.”

The UAE is a longtime supporter of the polio eradication program. In addition to the US$ 120 million that His Highness Sheikh Mohamed bin Zayed Al Nahyan pledged in 2013, he pledged a further US$ 30 million to polio eradication, announced by Bill Gates at the Rotary International Convention in Atlanta, USA in June 2017. With additional commitments in 2011 and 2014, in total, the UAE has contributed US$ 167.8 million since 2011 to help end polio, with direct support to Pakistan, Afghanistan, Somalia, Ethiopia, Kenya, and Sudan.

About GPEI

The Global Polio Eradication Initiative (GPEI) is led by national governments and spearheaded by the World Health Organization (WHO), Rotary International, the US Centers for Disease Control and Prevention (CDC), and the United Nations Children’s Fund (UNICEF), with the support of the Bill & Melinda Gates Foundation. Since its launch at the World Health Assembly in 1988, the GPEI has reduced the global incidence of polio by more than 99%.

The GPEI receives financial support from governments of countries affected by polio, private sector foundations, donor governments, multilateral organizations, private individuals, humanitarian and non-governmental organizations and corporate partners. A full list of all contributors is available on the GPEI website, http://polioeradication.org/financing/donors/

Bill Gates and Aliko Dangote underlined their commitment to polio eradication, alongside other health interventions. © UNICEF Nigeria

A unique group of people gathered last month in Sokoto state to commit to the twin goals of eradicating polio, and working to rapidly strengthen routine immunization. Bill Gates, and Africa’s richest man, Alhaji Aliko Dangote, joined traditional leaders from across northern Nigeria, Federal Ministry of Health officials, representatives from several State governments, and partners including UNICEF and WHO.

The two billionaires play a significant role in the fight to eliminate polio in Nigeria, where no wild virus has been detected since 2016. The Bill & Melinda Gates Foundation has committed US$1.6 billion in the country to date to fund pilot projects targeted at health care, agriculture and financial inclusion, a contribution which makes up their biggest investment in Africa. Aliko Dangote, who is Nigerian, has previously worked with Mr Gates to help interrupt transmission of the poliovirus in his country, and helps fund other health programmes as president of the Dangote Foundation.

During their visit, Mr Gates and Mr Dangote witnessed first-hand the progress Nigeria is making in polio eradication, routine immunization and primary health care provision.

At meetings held at the Sultan’s Palace and Governor’s House, Mr Gates highlighted the commitment of traditional leaders and reiterated the importance of engaging communities to reach every child with vaccines. Expressing his concern over the high infant mortality rate in Nigeria, he noted that vaccination is a cost effective way to save children’s lives.

Mr Gates also talked about the need to plan for the future of a polio-free Nigeria. Looking to how the polio eradication infrastructure can be used to help meet other health needs, Mr Gates said that the strong existing polio infrastructure – including vaccine supply chains, disease surveillance, laboratory systems and social mobilization networks – can be used to develop and improve routine immunization coverage for other diseases.

“We can prevent millions of deaths through routine immunization,” Mr Gates said. “We will not relent in our commitment towards this.”

Mr Dangote further highlighted that the fight against polio requires commitment from all stakeholders.

Drawing attention to malnutrition as one of the biggest factors undermining Nigeria’s progress, Mr Dangote urged the government and partners to reach out to private sector companies and ask them to donate at minimum 1% of their profits to financing the health sector.

At the meeting, the governors of Bauchi, Borno, Kebbi, Kaduna, Kano, and Sokoto States signed extensions of their Memorandum of Understanding on routine immunization. In doing so they reaffirmed their commitment to maximizing immunization coverage in their respective states, helping to protect every child against polio and other vaccine-preventable diseases.

Surveillance is one of the main pillars of the polio eradication initiative. By testing stool samples collected from children suffering acute flaccid paralysis – the clearest symptom of the virus – as well as samples taken from sewage water, we are able to find the poliovirus wherever it is hiding.

Pakistan’s polio surveillance system is one of the largest ever established in the world. Click through these pictures to learn about the journey of a stool sample there: From a child with suspected polio to the laboratory.

In March, the Afghanistan polio eradication initiative conducted its first nation-wide immunization campaign for polio eradication in 2018. In just under a week, around 70 000 workers knocked on doors and stopped families in health centres, city streets and at border crossings to vaccinate almost ten million children. What an incredible achievement.

But what does a huge campaign like this take?

We had a look behind the scenes and followed the week in Herat, western Afghanistan. See what the campaign looked like from beginning to end through this photo essay.

Polio personnel are keeping children safe from polio, and are also helping to strengthen outbreak response for other diseases. © WHO Nigeria

“When I received the confirmation of the first case of Lassa fever…nothing prepared me for the tasks ahead other than my work in polio eradication” – Mrs Faith Ireye, WHO State Coordinator in Edo state.

In the first two months of 2018, there were 110 deaths in Nigeria from suspected Lassa fever. Outbreak response, led by the Nigerian government and WHO, is focused on detecting every case, and tracing the virus wherever it is hiding.

Bolstering this effort are individuals with experience of guarding against a different disease – polio.

Ms Ireye, who has worked with the Global Polio Eradication Initiative for over ten years, is currently helping to coordinate the Lassa fever outbreak response in Edo State, one of the hardest hit by the outbreak.

“My experiences in polio eradication activities allowed me to immediately swing into action. So, when the [Lassa fever] outbreak was confirmed, I realized the need to use my expertise to serve communities at risk,” she says.

Part of her job is to help coordinate surveillance, specifically ensuring that everyone who has come into contact with someone with Lassa fever is found, and tested for the virus.

Her work is critical to help prevent further fever cases. Deputy Governor of Edo State, His Excellency Philip Shaibu said, “WHO…is one of the pillars that have helped lead surveillance in Edo state… In this particular outbreak, WHO was the first to draw attention to the fact that we need to galvanize resources from all partners, from other parts of the country, to ensure that things get done.”

The polio infrastructure

When outbreaks of other diseases happen, the knowledge and experience of polio personnel like Ms Ireye can make a significant difference to outbreak response. For example, polio workers were essential to containing the Ebola virus outbreak in 2014. For the Lassa fever response, 271 polio workers are involved in active case search, 235 in contact tracing, and 320 in community sensitization activities across the 18 at-risk states.

“The polio infrastructure was originally designed towards achieving the polio eradication goals,” said Dr Wondimagegnehu Alemu, WHO Country Representative to Nigeria. “Now polio infrastructure has expanded its support to broader disease surveillance strengthening, outbreak response and basic health care services including immunization.”

The benefits of experienced personnel

WHO staff gather with clinicians from the Jos University Teaching Hospital, Nigeria, after training them on active case search. © WHO Nigeria

Other activities carried out by polio workers include data collation and analysis, and case reporting.

“The polio teams on ground in the states were crucial for mounting the initial response to the Lassa fever outbreak, and have continued to be WHO’s frontline technical support to the NCDC, States Ministry of Health and local government area teams,” Dr Emmanuel Musa, WHO Incident Manager for Lassa fever Management Team in Nigeria observed.

A legacy for posterity

Investments by donors and partners have gone far beyond polio eradication. Reflecting the positive impact that polio infrastructure and knowledge has had on other health priorities such as Lassa fever, WHO and other partners are currently supporting the development of a national transition plan. This will ensure that the investments that have brought the world to the brink of eradication are made available to support other national public health efforts, long after polio has been defeated.

“We must carefully consider how we transition many of the polio workers and the polio infrastructure to help with managing other health needs,” Dr Alemu said. “Future funding and partnerships will be a key part of this work.”

For now, experienced polio personnel continue their work to end the Lassa fever outbreak. Thanks to them, and the support of governments, partners and donors, we are ending polio, and are also helping to strengthen other health interventions.

Support for immunization to the Federal Government of Nigeria through the World Health Organization is made possible by funding from the Bill & Melinda Gates Foundation (BMGF), the United Kingdom, the European Union (EU), Gavi, Global Affairs Canada (GAC), the Government of Germany, the Japan International Cooperation Agency (JICA), the Korea Foundation for International Healthcare (KOFIH), the Measles and Rubella Initiative (M&RI) through the United Nations Foundation (UNF), Rotary International, the United States Agency for International Development (USAID), the United States Centers for Disease Control and Prevention (CDC) and the World Bank.

Deputy Governor of Edo State speaks with the WHO State Coordinator, as part of efforts to implement strong outbreak response. © WHO Nigeria

Zulaihatu Abdullahi, a volunteer community mobilizer in Kaduna State, goes door-to-door to ensure that every child is vaccinated against polio. © UNICEF Nigeria / Jasmine Pittenger

Zulaihatu Abdullahi is well known in her community, particularly to the mothers. As a volunteer community mobilizer in Kaduna state, northern Nigeria, her mission is to ensure that no child contracts polio, or any other preventable childhood disease.

This is difficult, as immunization programmes are sometimes treated with suspicion in her part of Nigeria. As a ‘change agent’, Zulaihatu’s job is to go door to door, counselling parents about the importance of the polio vaccine.

This particular lunchtime, she is visiting an 18 year-old mother living in a compound in a densely-populated, urban district of Kaduna State.

The young mother puts down the pole she is using to pound millet and welcomes Zulaihatu, recognising her royal-blue UNICEF hijab. She sits, and pulls on a hijab for cover as she settles down to breastfeed her baby. She has three other small children at home, a fifth on the way and she is new to the area.

“Before I came here I was rejecting all vaccines,” she says, “but because of this woman, Zulaihatu, I decided to accept. She told me the usefulness and I was convinced to do it.”

Thanks to Zulaihatu’s patience, and her work to build trust with the younger woman through regular visits, four more children are now protected against polio who might otherwise still be at risk. The mother has also been encouraged to seek anti-natal care, and the youngest child has just received his routine immunization shots.

“Sister Zulaihatu was one of the first women I met when we moved here,” the mother recalls. “She came here every day. She told me how she takes care of her own children. What she feeds them. How they all take vaccines. Little by little I started to change my thinking.”

Zulaihatu is trained to make her community aware of important household and parenting practices to keep their children thriving. The list is extensive and includes tips to treat diarrhoea, the importance of basic hygiene and sanitation, how to protect the family from malaria, the benefits of neonatal care and breastfeeding for infants, and the importance of registering their births.

She is one of nearly 20 000 UNICEF-trained community mobilizers, influencers and communication experts spread across 14 northern ‘high risk’ Nigerian states. With the support of donor and partners including the Bill and Melinda Gates Foundation, CDC, Dangote Foundation, European Union, Rotary, GAVI, JICA, the World Bank and the Governments of Canada, Germany, Japan, and others, the mobilizers are a key part of UNICEF’s ongoing support to the Government of Nigeria’s immunization programme.

Despite their achievements, Zulaihatu and other mobilizers know that there is much is still left to be done in their communities. Tomorrow, Zulaihatu will continue her work, going from household to household to keep every child safe.