News Category: Eradication

Each year at the end of April, the global community commemorates World Immunization Week, reminding us of what humanity can achieve when we come together and take action for our collective health. Given that I began my career working in a national immunization programme, known as the Expanded Programme on Immunization, also commonly known as the Essential Programme on Immunization or EPI, I am encouraged to see the world mark another, related milestone this year: the 50th anniversary of EPI.  Building on the success of the global smallpox eradication effort, EPI was launched in 1974 to expand national routine immunization services around the world and reduce the deaths and disabilities caused by common vaccine preventable diseases. Over the last 50 years, EPI has saved 154 million lives, reduced infant deaths by more than 40 percent, and protected millions from disability. While WHO now recommends 13 vaccines across the life course for the EPI programme, six were recommended at its inception: Bacillus Calmette-Guérin (BCG), diphtheria, measles, pertussis, tetanus, and polio.

Polio has been a part of EPI from the very beginning, and it will be essential for the polio eradication and EPI programmes to continue working together within the Eastern Mediterranean Region and globally as we aim to achieve another eradication goal: ending polio once and for all.

Only one serotype of the wild poliovirus remains (WPV1), and it exists in limited geographic areas within just two countries in the world, Afghanistan and Pakistan. While many national, regional, and global factors have contributed to this progress, a key element has been collaboration between the polio eradication and EPI programmes. Countries in the Eastern Mediterranean Region such as Egypt and Iran have built strong national EPI programmes that maintain high levels of routine immunization coverage to ward off outbreaks, eliminate measles, collaborate with the polio eradication programme to stop outbreaks quickly when detected, and prevent transmission. In countries like Iraq, Libya, Sudan, and Syria, where immunization coverage is lower due to more complex operating environments, polio assets are being transitioned and integrated into the broader EPI programme so that polio programme capabilities in emergency operations and disease surveillance can be applied to controlling other diseases. Additionally, the efforts of the Regional Subcommittee for Polio Eradication and Outbreaks have not only helped make this transition of polio assets a reality, but have also brought Member States together to help both the EPI and polio eradication programmes access more children across the Region.

Global Polio Eradication Initiative partners in Afghanistan and Pakistan, the last two polio-endemic countries, have jointly established health centres and vaccination facilities that provide routine immunization, health check-ups, and polio vaccines in areas lacking facilities. In areas with weak or absent health facilities, health camps are conducted to vaccinate all children. Programmes routinely  implement integrated polio and measles campaigns to control both diseases. In Afghanistan, the polio programme began a strategic partnership with humanitarian organizations in 12 high-risk provinces to add routine vaccines including polio into their portfolios of basic health services. More than 1 million polio vaccinations have been delivered through this engagement with humanitarian groups between January and October 2023. And in February 2024 alone, biker teams under the Nomads Vaccination Initiative launched in late 2022 in Pakistan gave polio drops to more than 30,000 children in nomadic settlements in 17 districts, delivered over 11,000 doses of the inactivated polio vaccine (IPV), and administered 12,000 doses of routine vaccines. The biker teams continue to expand the scope of their vaccination efforts.

The planning, operational and monitoring intensity of the polio eradication programmes helps EPI through use of common microplanning tools to map and reach all children, identify zero-dose children, and shine a light on areas with weak or absent immunization delivery.  Joint advocacy efforts foster greater political commitment and funding support to improve EPI.

Polio Eradication in the Eastern Mediterranean Region has learned important lessons and gained valuable experiences through ongoing innovations to vaccinate children in countries affected by conflict, insecurity and inaccessibility, fragile health systems and highly vulnerable populations.  These experiences have helped EPI programmes in countries like Afghanistan, Pakistan, Somalia, and Sudan. Certainly, more can and should done to leverage the capacities of both the polio eradication and the EPI programmes in such countries.

One of the most critical success factors in polio-endemic countries, across our Region, and around the world has been the exchange of workers between the polio and EPI programmes. Like me, many health workers have started their careers in a national EPI programme and then moved to the polio eradication programme, or vice versa. This exchange of human resources between programmes has led to a sharing of knowledge and experiences that has contributed to the achievements that we have seen in both programmes over the last half-century.

While polio eradication has very specific targets to achieve, the goals of the Global Polio Eradication Initiative (GPEI)and those linked to the Essential Programme on Immunization such as the Immunization Agenda 2030 share many similarities and ultimately depend on establishing and maintaining access to children who have not been regularly reached with any vaccines. I am confident that we can continue to strengthen both the polio eradication and EPI programmes, end polio, and achieve the IA2030 goals and more over the next 50 years. We will accomplish this by advocating for the continued investments needed to end polio and reduce the burden of vaccine-preventable diseases, and by continuing to collaborate and share our expertise and lessons learned, both in the Eastern Mediterranean and globally.

Countries around the world are grappling with an alarming rise in measles, a deadly, yet vaccine-preventable disease. Last month, the US CDC issued a health alert over rising cases across the US, where 113 measles cases have been reported this year, already exceeding the total number of cases last year. And across European and Central Asian countries, measles cases went from under a thousand in 2022 to more than 30,000 in 2023. 

As a survivor of a vaccine-preventable disease, I understand more than most just how important it is to reverse this trend. Six months after I was born in Bombay, India, I contracted polio, which left me paralyzed from the hips down. At the time, polio vaccines weren’t widely available in India, and as a result, I never received the life-saving drops that could have protected me from this crippling disease.

I wasn’t alone – in the 1970’s when I was born, India struggled with almost 200,000 polio cases each year. This isn’t surprising—before vaccines became common, diseases we hardly think about now, like polio, plagued the world and caused unnecessary death and immense suffering. Before the measles vaccine was introduced in the early 1960’s, the disease used to kill an estimated 2.6 million people annually.

To ensure all children benefit from the power of vaccines and are protected from the ravages of preventable diseases like measles, we must heed the lessons of successful vaccination efforts, such as the global push to eradicate polio.

Since a global effort to eradicate the disease through vaccination began in 1988, polio cases have been reduced by 99.9%. And a decade ago last week, one of the seemingly insurmountable challenges to the eradication effort was achieved: India, a country with limited means and facing unlimited challenges, was certified as polio-free, along with the entire South-East Asia Region.

Today, countries are pushing to replicate India’s success in the virus’s remaining strongholds, particularly in Pakistan and Afghanistan, where only 12 cases were recorded last year. I believe we can get to zero cases anywhere in the world by fully harnessing the power of vaccines, learning from India’s remarkable story, and refusing to concede defeat.

India was once deemed the most difficult country in the world to end polio. Poor sanitation and overcrowded living spaces allowed the virus to spread easily, infecting hundreds of thousands of children each year, making it nearly impossible to control.

Strong support from the Indian government coupled with a new global push to eradicate the disease in the late 1980s marked a turning point. Soon after, vaccination campaigns led by millions of dedicated vaccinators and community mobilizers on the frontlines resulted in the repeated distribution of life-saving vaccines to nearly every child in the country. In the years leading up to the last case, a staggering 1 billion doses of the polio vaccine were distributed to 172 million children annually. Mass vaccination campaigns, requiring over 2 million vaccinators at a time, reached every household.

After the last case, India was determined to keep the country polio-free. Impressive surveillance networks and immunization campaigns continued on, which I got to witness in 2015 when I returned to India with Rotary International. Administering two drops of the vaccine to babies in the backstreets of New Delhi was a profound, full-circle moment for me – from my mother’s lack of access to the vaccine, to my own struggle with polio, to ensuring my daughter received the necessary immunization.

Today, strategies pioneered in India are being used to eliminate wild polio from Pakistan and Afghanistan, the final two endemic countries for wild poliovirus. And in both countries, promising trends that were seen in India, such as fewer strains of the virus and smaller outbreaks, suggest that the virus may be permanently on its way out.

There’s no denying that there are still serious challenges to vaccinating all children in areas where the virus is still a threat – from complex humanitarian emergencies, ongoing conflicts, a lack of trust in governments and science, to difficulties reaching remote populations.

The push to end polio today has relied on continuing to innovate. Strategies started in India have continued to be refined to meet today’s challenges – from vaccinating hard-to-reach populations through community microplanning and empowering women health workers to address vaccine hesitancy have been refined and improved. And in particularly fragile settings, recent collaborations with humanitarian organizations have demonstrated the value of integrating polio initiatives with broader health services.

What gives me hope is that today, we have the tools and strategies needed to end needless suffering caused by polio and other preventable diseases around the world. What we still need is the continued resolve to get us there. As India’s blueprint showed us, unwavering support from donors and global organizations, coupled with the ongoing determination from communities, local leaders, and national governments will be essential.

With more countries around the world heading into elections this year than ever before, I hope to see policymakers in the US and abroad continue to commit to eradicating polio and strengthening access to other life-saving vaccines. With the right level of commitment and resources, we can end polio everywhere and protect children against other preventable diseases.

By Minda Dentler

Minda Dentler, a 2017 Aspen Institute New Voices Fellow, is a polio survivor, a global health advocate, author, and the first female wheelchair athlete to complete the Ironman World Championship in Kona, Hawaii.

On 27 March 2014, India was officially certified wild polio-free. This pivotal moment not only marked a triumph for the country itself, but as the last country battling the virus in the WHO South-East Asia Region (SEARO), it also paved the way for the entire SEARO region to be certified wild polio-free—a massive undertaking for the world’s largest region, spanning from India to Indonesia.

As we celebrate the 10-year anniversary of this triumph, we catch up with a few experts who worked on polio eradication India – Deepak Kapur (Chairman, Rotary International’s Polio Plus Committee), Dr. Roma Solomon (Former Executive Director, CORE Group Partners Project India Secretariat), Dr. Jay Wenger (Director, Polio, Bill & Melinda Gates Foundation), and Dr. Naveen Thacker (President, The International Pediatric Association). Their reflections serve to remind us of the collective will and commitment that made overcoming a seemingly insurmountable health challenge possible.

What was your role in the fight to end wild polio in Southeast Asia/your country?

As a young pediatrician in 1994, I witnessed the devastating effects of a polio outbreak. Motivated to make a difference, I embarked on what became a lifelong mission to combat polio. I advocated for polio eradication by authoring informative booklets and books that were distributed across the country and collaborated with my fellow Rotarians to raise awareness and resources however we could, which once included sending handwritten postcards to pediatricians and Rotary clubs. Following over a decade of these kinds of grassroots efforts, I then began working to shape the policies that would eventually help India eliminate wild polio.

Describe a time you felt up against immense barriers in the fight to end wild polio in your area, and what helped you remain optimistic.

We were facing fierce resistance against vaccination in Uttar Pradesh, when I recalled meeting Moosa Kaka. Moosa Kaka came to me when I was working in his hometown of Kandla to ask about vaccinating his children, instead of relying solely on religious leaders from his mosque. Remembering his heartfelt plea for reassurance, it dawned on me that healthcare providers play a pivotal role in addressing vaccine hesitancy and instilling trust in communities. This realization spurred us to establish a network of pediatricians and medical professionals. Once we saw how successful this was in Uttar Pradesh and Bihar, I knew it was only a matter of time and refining our strategy before the whole country would be wild polio-free.

What is a key lesson from the fight to end wild polio in your area that the rest of the world can learn to help stop the virus globally?

While it is hard to pick one, a crucial lesson from India’s fight against wild polio is the power of partnerships. At a global level, India ensured their strategies were aligned with the global effort to fight polio, from new innovations to timely disease surveillance to involving female staff in vaccination teams. In the country, coordination with the private sector was critical to our success. Even at a local level, we actively engaged the community and worked with socioreligious leaders to address social resistance.

What does it mean to you that your area is still wild polio-free 10 years later?

This holds significant meaning for me because of the years of dedication we’ve put into our work. While we acknowledge the ongoing risks, we are committed to maintaining vigilant surveillance, which is of great importance to me.

What was your role in the fight to end wild polio in Southeast Asia/your country?

This holds significant meaning for me because of the years of dedication we’ve put into our work. While we acknowledge the ongoing risks, we are committed to maintaining vigilant surveillance, which is of great importance to me.

Describe a time you felt up against immense barriers in the fight to end wild polio in your area, and what helped you remain optimistic.

Ensuring accurate surveillance systems throughout all parts of India, including places where there was not a strong healthcare infrastructure, presented formidable challenges. The tireless workers of NPSP – Indian physicians, drivers, administrative support staff and other – were essential to overcoming these barriers. This was all supported by the unwavering dedication of our advocacy partners like Rotary, as well as by the Government of India. Their commitment played a pivotal role in overcoming obstacles, increasing support for the polio program and advancing our surveillance efforts to every corner of the country.

What is a key lesson from the fight to end wild polio in your area that the rest of the world can learn to help stop the virus globally?

Commitment from government partners at all levels was crucial to success. Government commitment that consistently translated into action at the operational level – from country-level officers to district administrators – identifying programmatic gaps and challenges and then committing to urgent evidence-based course-corrections was a critical characteristic of the final stages of polio eradication.

What does it mean to you that your area is still wild polio-free 10 years later?

Knowing that countless children have been spared from this debilitating disease is a remarkable feeling, and I feel fortunate to be a small part of the global community that contributed to a polio-free India. In the past decade, the infrastructure built by the polio program has evolved to strengthen health systems for a number of issues – for example, responses to diseases like measles, rubella and COVID-19 utilized surveillance systems built out by the NPSP. Seeing what we were able to accomplish in India motivates me to work to stop polio transmission globally, so no child has to live in fear of paralysis from this preventable disease.

What was your role in the fight to end wild polio in Southeast Asia/your country?

I led the CORE Group Polio (Now known as ‘Partners’) Project (CGPP) India Secretariat from its inception in 1999 until retiring last year. My work with CORE focused on community engagement to achieve polio elimination in India.

Describe a time you felt up against immense barriers in the fight to end wild polio in your area, and what helped you remain optimistic.

On one of my field visits, the community mobilizer led me to what we called a refusal household. I saw a woman my age washing clothes in the open veranda. As soon as she saw me, she ran inside and picked up a little girl and asked me to leave. I sat down beside her and started a conversation with her, trying to find out the reason why she did not want her grandchild to get vaccinated. To my surprise she started crying and told me that she had just lost a grandson because he was given some injection by a local ‘doctor’ for ‘fever’ and she didn’t want to lose this child too. The community mobilizer and I spent the next half hour with her, explaining how the polio vaccine works and how it would protect this child and not harm her. She agreed to not only vaccinate the little one but also spread the word among her friends and neighbors.

What is a key lesson from the fight to end wild polio in your area that the rest of the world can learn to help stop the virus globally?

As medical professionals, it’s vital that we must leave our egos at the door and keep compassion, empathy, and social justice at the forefront of our minds. Mothers who deny interventions that would benefit their children often come from a different background than our own. It is our failure if we cannot convince them or understand the reason behind their refusal. Refusals need time to change toward acceptance.CGPP India served as a liaison between the government and civil society, so we saw firsthand how polio work brought a certain sense of unity among all development partners. The virus brought us together with one single purpose: to work together to protect our children from it. We were forced to look at the disease from a human angle and from the parents’ point of view. This helped us realize that unless we involve people for whom this program is intended, it will not work. It is a people’s program.

What does it mean to you that your area is still wild polio-free 10 years later?

While I am thrilled to have reached this milestone, I am both fulfilled and unfulfilled in seeing how far this work has come. The world needs to work harder and faster before the virus re-emerges in polio-free areas. It can spread like wildfire and threaten years of hard work. Somehow, I feel that the world is not very aware of the progress made and the efforts that have gone into the program so far. This fight needs to be won as soon as possible.

What was your role in the fight to end wild polio in Southeast Asia/your country?

My fight against polio in India started way back in 1995 during the first immunization drive (NID). Back then, Rotary played a key role in convincing the Indian government to adopt the National Immunization Day which was inspired by successful programs in Brazil and other countries. My involvement with the polio eradication efforts of Rotary further intensified in the year 2001 when I was appointed as the chair of Rotary International’s India Polio Plus Committee (INPPC). I’ve held this position for 23 years now and I hope that not only our region, but the entire world will be completely free of the wild poliovirus (WPV).

Describe a time you felt up against immense barriers in the fight to end wild polio in your area, and what helped you remain optimistic.

There were many occasions over the years where the partnership consisted of WHO, UNICEF, CDC, and Rotary was literally up against the wall, as there were immense barriers on the way. One such challenge arose when we were alternating supplementary immunization rounds between the monovalent oral polio vaccine type 1 (mOPV1) and monovalent oral polio vaccine type 3 (mOPV3). After these campaigns, we started to notice a seesaw effect: focusing on one type of polio would lead to a rise in cases of the other. When we were concentrating on the rounds of the mOPV1, WPV3 cases would rise and vice versa. However, this issue was eventually resolved with the introduction of the bivalent Oral Polio Vaccine (bOPV) which contains only two components: attenuated live viruses of the WPV1 strain and the WPV3 strain. This formulation eliminated the WPV2 strain from the vaccine which had previously reduced its efficacy. With the bOPV, we were able to simultaneously address the outbreaks of WPV1 and WPV3, particularly in the northern states of India.

What is a key lesson from the fight to end wild polio in your area that the rest of the world can learn to help stop the virus globally?

The battle against polio in India has provided us with numerous invaluable lessons. One of the key lessons is the never-say-die attitude. Another one is the power of partnership and what it can achieve, as demonstrated collectively by WHO, UNICEF, Rotary, and the Government of India. Perhaps, the most important lesson that we have learned and that can be used for other health and social endeavors not only within our country or our region but across the world, is that all movements must be converted into people’s movements. When the beneficiaries themselves start demanding immunization or vaccines and when they recognize and appreciate the value of what we’re offering for free- that’s when a program transforms into a people’s movement and then the success is assured.

What does it mean to you that your area is still wild polio-free 10 years later?

Leading global experts had predicted that India would be the last country to eradicate polio. However, we proved them wrong, recording our last case of the wild poliovirus on January 13th, 2011 and maintaining our polio-free status for three years to achieve our certification as a polio-free nation on March 27th, 2014. The key to our decade-long success in remaining polio-free lies in two basic strategies. First, our intense immunization efforts ensured nearly every child under the age of five received either the polio drops or the injectable polio vaccine. Second, our exceptional surveillance system, conducted by the National Polio Surveillance Project (NPSP), a joint venture between the Government of India and WHO, provides world-class monitoring and surveillance for polio cases. These strategies have been instrumental in not only achieving but also maintaining our polio-free status till date.

To strengthen the fight against polio, health ministers from across the WHO Eastern Mediterranean Region gathered virtually for the 10th meeting of the Regional Subcommittee on Polio Eradication and Outbreaks. It was the first meeting of the Subcommittee convened by the new WHO Regional Director for the Eastern Mediterranean, Dr Hanan Balhky.

Her Excellency Dr Hanan Al-Kuwari, Minister of Public Health, Qatar, and Subcommittee Co-chair, welcomed Dr Balhky’s determination to end polio during her tenure. His Excellency Mr Abdul Rahman Mohammed Al Oweis, Minister of Health and Prevention of the United Arab Emirates, and Subcommittee Co-chair, represented by His Excellency Dr Hussain Al Rand, also expressed enthusiasm that Dr Balkhy’s vision and expertise promise to propel regional efforts, bringing the world closer to eradication.

Read more on the WHO EMRO website

In Nangahar, eastern Afghanistan, Lailuma, a female mobiliser vaccinator (FMV), facilitating a session on polio, vaccine preventable diseases and child health with women in the locality. FMVs organize these kind of awareness sessions for women every day in hundreds of locations across the country – their role is crucial in reaching mothers and their children with vital health services and immunization against polio and other deadly diseases. © UNICEF/UNI530951/Karimi
In Nangahar, eastern Afghanistan, Lailuma, a female mobiliser vaccinator (FMV), facilitating a session on polio, vaccine preventable diseases and child health with women in the locality. FMVs organize these kind of awareness sessions for women every day in hundreds of locations across the country – their role is crucial in reaching mothers and their children with vital health services and immunization against polio and other deadly diseases. © UNICEF/UNI530951/Karimi

It’s midmorning in Lashkar Gah, the capital of Helmand Province in south Afghanistan. The sun, climbing rapidly, has already burned through the wintry dawn. Inside the maternity ward of the Bost Provincial Hospital – the second biggest health care facility in the Southern Region – seven women nurse their newborn babies. The mother of the youngest bathes her just-born son’s face with a warm cloth. The eldest, at two hours’ old, is getting her first childhood vaccinations – BCG, hepatitis B and polio.

Here in Bost hospital, like every maternity facility in Afghanistan, babies are vaccinated in their first few hours of life. In any 24-hour period, the UNICEF-backed female vaccinators will vaccinate dozens of babies in this hospital alone. Some are medically trained to administer intravenous vaccinations, and others – known as female mobilizer vaccinators, or FMVs – are women from the local community, who administer polio drops and run health education sessions.  FMVs are not just vaccinators: they are the first line advocates for polio eradication. They are a familiar face to the local community who provides sound advice and information for good health of their children and family members.

Introduced in 2020 as a pilot in three provinces, the FMV programme has since then expanded to 20 out of the country’s 34 provinces. Today, there are over 650 FMVs reaching thousands of women and children every day in hundreds of locations countrywide. The FMV programme also helps alleviate some of the burden on the national health system: the pastoral care service the FMVs provide frees up doctors, nurses and midwives to concentrate on their life-saving work. Some of the FMVs are trained nurses or midwives, and pitch in to help when an extra pair of hands are needed.

A child receives polio drops as part of the routine immunization service at a temporary health facility near the Torkham border crossing in Eastern Afghanistan. © UNICEF/UNI530949/Karimi
A child receives polio drops as part of the routine immunization service at a temporary health facility near the Torkham border crossing in Eastern Afghanistan. © UNICEF/UNI530949/Karimi

The FMVs are a unique group when it comes to reaching women. In the eastern part of the country where the polio virus persists, communities are also historically culturally conservative: here it really is a woman’s work to inform other women. Women are usually the primary caregivers, reaching more women means reaching more children, reducing missed vaccinations and broadening the cohort of fully immunized children. Moreover, they can reach all women, even getting the message to those who are unable to leave the house because they do not have a mahram– a male family member who acts as a chaperone, usually a husband, father, or brother.

Health education sessions run by FMVs include all important components for mothers and children’s health -– from nutrition to childhood diseases, breastfeeding, general hygiene and the importance of vaccination to protect children deadly diseases like measles and polio. Four times a day in hospitals and clinics from Kandahar to Mazar, women crowd into spaces transformed into temporary classrooms, presided over by an FMV with a handheld flipchart. Every session is packed.

One such session, on the importance of sanitation to prevent the spread of polio, is going on in a sunny courtyard of a health facility in Jalalabad, in eastern Afghanistan. Rows of women listen attentively to Lailuma, an FMV who lives in the locality, while children play at their feet. The occasional burst of children’s laughter break the rapt silence.

At a temporary health facility in Eastern Afghanistan, near the Torkham border crossing point with Pakistan, a female mobiliser vaccinator marks the finger after administering the polio vaccine to an Afghan boy who has recently returned from Pakistan. © UNICEF/UNI530950/Karimi
At a temporary health facility in Eastern Afghanistan, near the Torkham border crossing point with Pakistan, a female mobiliser vaccinator marks the finger after administering the polio vaccine to an Afghan boy who has recently returned from Pakistan. © UNICEF/UNI530950/Karimi

This is a unique programme, tailored for the complex realities of Afghanistan. Attitudes toward vaccination and healthcare differ between regions, provinces, and even between families. There is no single approach that would suit a country as culturally complex as Afghanistan. The FMVs are deeply embedded in the community that they serve, and their patients are family members, friends and neighbours. They have their trust, which is half the battle won.

“Women in our culture are more responsive to a certain approach,” Hadiya, the FMV supervisor in Lashkar Gah, explains. “They need privacy, politeness, a relaxed atmosphere, before they can settle down to listen.”

Since the FMV programme began, vaccination rates, community awareness levels and, by extension, general trust in the healthcare system, have increased across Afghanistan.[1] The FMVs are the community’s first and trusted source of health information, who also play a pivotal role in identifying children  missing vaccinations. Health seeking behaviour and visit to health facilities have  also risen as a direct result of women’s increased levels of knowledge.

Despite challenges, the FMVs are driving the polio eradication programme forward, one family at a time. In Jalalabad, Lailuma remains positive: “Inshallah polio will be eradicated. Achievements feel small, but if we keep going we will succeed, and it will be gone from Afghanistan forever.”

(All names have been changed.)

By Kate Pond, UNICEF Afghanistan 

[1] UNICEF, Formative Assessment on the Effectiveness of the Deployment of Female Mobiliser Vaccinators (FMV) in Polio High-Risk Locations, May 2023.

The sound of drums is enough to rouse even the sun, prompting it to wrestle the early morning smog for a front-row seat in a local Pashtun community in Rawalpindi, Pakistan. As tea stall owners set up shop for the day, curious women peek out of their windows, and excited children rush out of their houses to flock around the mysterious drummer. And as he moves from street to street, they run alongside him. Flushed with excitement, they start dancing to the familiar local tunes, some of them falling over each other. All smiling. It is a welcome distraction on a cold January morning.

This lively scene, however, is no accident. A banner draped around the drummer carries a powerful message: “Let’s vaccinate our children regularly to eradicate polio. The upcoming vaccination campaign begins on 8th January. Help us vaccinate your children whenever a health team visits your house.” This ‘attention-grabbing’ approach, blending cultural traditions with polio awareness campaigns, is the brainchild of UNICEF’s Social Behavior Change team working with the government’s Provincial Polio Emergency Operations Centre in Punjab.

Leading this creative team is Sajida Mansoor, who understands that information overload on polio vaccination can overwhelm parents, at times to the point of inaction.

“Out-of-the-box thinking was required to respond to the challenge. That’s how we came up with this unconventional but fun idea of using drums to spread awareness and highlight key immunization dates to reach children, especially those who were consistently missing polio vaccination,” says Sajida, a long time UNICEF staffer supporting polio eradication efforts in the country.

Zafar, the drummer, uses his rhythmic beats to attract a crowd of children and adults to share information about the upcoming polio campaign, in a neighborhood in Rawalpindi, Punjab, Pakistan. © UNICEF/Pakistan
Zafar, the drummer, uses his rhythmic beats to attract a crowd of children and adults to share information about the upcoming polio campaign, in a neighborhood in Rawalpindi, Punjab, Pakistan. © UNICEF/Pakistan

Zafar Iqbal, the drummer, suddenly stops playing, to allow the call for prayers from the local mosque to be heard in the community. Zafar is a seasoned professional musician who sustains his livelihood by showcasing his talent at various cultural events when he is not engaged with the polio eradication programme.

But the polio percussion show isn’t over yet. Joining Zafar at center-stage is seven-year-old Gul Bahisht. She confidently delivers a brief speech she has composed: “Do you know Pakistan is very close to finishing off polio? But I learnt that the virus is still spreading in our area and can paralyze children. We must vaccinate all children and protect them from being hurt and disabled from polio. I have been vaccinated. Why not vaccinate your child too. It’s easy and simple. Just two drops for your child in every campaign and we will all be free from polio forever.”

Zafar picks up where he left off and the rhythmic beat of his drums resume, bringing immense laughter and joy to the delighted children and their families in the neighborhood.

This engaging strategy has struck a chord with local communities. In neighborhoods where the initiative was first introduced, parents became more receptive. Mother and fathers happily opened their doors to polio vaccination teams. It enabled them to vaccinate a large cohort of children who had consistently missed vaccination due to reasons cited as ‘not available,’ which often meant the parents did not open their doors to vaccinators.   Children embraced the teams without distrust, resulting in more efficient vaccination coverage.

This achievement underscores the importance of extending the initiative to other neighborhoods in future campaigns, particularly in communities where some children consistently miss their vaccinations.

A polio worker, Shazia Bibi (right) vaccinates a seven month old boy held by his mother in a neighborhood in Rawalpindi, Pakistan. © UNICEF/Pakistan/Bokhari.
A polio worker, Shazia Bibi (right) vaccinates a seven month old boy held by his mother in a neighborhood in Rawalpindi, Pakistan. © UNICEF/Pakistan/Bokhari.

“This approach has helped us break down the barriers with caregivers and they are more receptive to communicating with us.  We are dedicated to ensuring that our teams on the ground actively respect the religious and cultural norms of the local community. For instance, drummers like Zafar pause their beats during calls for prayer, demonstrating social and religious sensitivity. Additionally, the musical elements are in accordance with the cultural norms of the community,” adds Sajida.

In communities across Lahore and Rawalpindi where the ‘drummer’ strategy was introduced, polio teams managed to vaccinate every single available child. This was a significant contribution to the 96 per cent vaccination coverage achieved in the Punjab province during the recent campaign.

Meanwhile, back in Rawalpindi, Zafar’s percussion jam for polio eradication continues to reverberate in the neighborhood. A father himself, he made sure his youngest two-month-old daughter was vaccinated during the recent vaccination campaign.

“I feel very happy and blessed that the beats from my drums bring joy to people, and at the same time support an important cause that protects our children in Pakistan from deadly diseases like polio,” says Zafar with a smile.

By Wasif Mahmood,
UNICEF Polio Communication Officer, Provincial Emergency Operations Center, Punjab

Adapted from the Annual Letter

The story of wild poliovirus is one powerful example of how philanthropy can catalyze progress. At one point, 7,000 children were paralyzed from wild poliovirus every week. Philanthropists, like Rotarians—who are able to take risks and dedicate resources that others could not—organized efforts to support eradication solutions, government efforts in polio-affected countries, and frontline heroes to reach children in even the most remote parts of the world. As a result of these global efforts, in 2023, the number of people infected by wild poliovirus dropped to 12 for the entire year.In the case of polio, philanthropy helped make the seemingly impossible possible. Many more of the greatest challenges that face our world today already have solutions—existing and emerging—that can save lives. As I share in my letter, philanthropy now has a chance to step forward and turn those solutions into real impact for people.There’s already so much generosity in the world, and together, we can tap into it and make certain everyone has the opportunity to live a healthy and productive life. Find out what we can achieve in my 2024 annual letter.

Mark Suzman,
CEO, Bill & Melinda Gates Foundation

Geneva, Switzerland, January 2024 – Convening this week at the World Health Organization (WHO) headquarters, global health leaders and Ministers of Health at the WHO Executive Board (EB) reaffirmed their commitment to eradicate polio once and for all and use the polio investments to build strong, equitable and resilient health systems.

Opening the EB amid a wide array of public health topics on the agenda, WHO Director-General Dr Tedros Adhanom Ghebreyesus told assembled delegates:  “We continue to intensify our efforts to eradicate polio. Last year, six cases of wild poliovirus were reported in Pakistan, and six in Afghanistan, the second-lowest number of cases reported in a calendar year. Our target is to interrupt transmission of wild poliovirus this year.”

Member States noted the unique opportunity to eradicate remaining wild poliovirus type 1 endemic transmission, which is now limited to just a handful of areas of eastern Afghanistan and three districts of southern Khyber Pakhtunkhwa, Pakistan, and urged for continued intensified efforts to reaching all remaining un- or under-immunized children in those areas.  Delegates also reiterated the importance of intensifying efforts to combat variant poliovirus outbreaks (circulating vaccine-derived polioviruses), including through strengthened outbreak response and the continued roll-out of novel oral polio vaccine type 2, which became the first vaccine used under Emergency Use Listing (EUL) to be pre-qualified by WHO.  The engines of transmission for such strains are in clearly-identified and known most consequential geographies, namely north-western Nigeria, eastern Democratic Republic of the Congo, south-central Somalia and northern Yemen.

Speaking on behalf of WHO Regional Director for the Eastern Mediterranean Dr Ahmed Al Mandhari, Dr Hamid Jafari, Director for Polio Eradication in the Eastern Mediterranean said:  “In Afghanistan and Pakistan, the national programmes deployed innovative strategies and strengthened partnerships with humanitarian actors to reach more children. And across the region, the programme also identified pathways for sustaining essential polio functions, through integration with existing programmes. In particular, I am proud of the work of the Regional Subcommittee for Polio Eradication and Outbreaks that we started back in 2021. Their advocacy and support have successfully carved out clear pathways towards protecting children in the Region from polio and other vaccine-preventable diseases.”

Within this context, delegates thanked current Regional Director Dr Ahmed Al Mandhari, for his personal engagement and leadership in bringing the region to the threshold of success; and welcomed his successor, Dr Hanan H Balkhy, who committed to leading the region across the finish line.

“On behalf of the core partners of the Global Polio Eradication Initiative, Rotary International, the US Centers for Disease Control and Prevention (CDC), UNICEF, the Bill & Melinda Gates Foundation and Gavi, the Vaccine Alliance, we would like to thank all Member States for their tremendous efforts,” said Aidan O’Leary, WHO Director for Polio Eradication and Chair of the Global Polio Eradication Initiative Strategy Committee.  “Last year, thanks to your efforts, upwards of 800 million children were immunized, many in areas with protracted and complex emergencies.  The reality is that it is precisely in such areas of complex emergencies where polio persists, and unfortunately those emergencies are becoming even more complex.  We need the continued political will of Member States to overcoming whatever geo-political challenges might currently stand in the way of reaching that remaining last unreached child in these areas.  Be assured that together with our partners, we stand ready to support you in your incredible efforts.”  Underscoring WHO’s commitment to the effort, O’Leary reminded the EB that WHO now considered the effort to eradicate polio as its only Public Health Emergency of International Concern (PHEIC), under the International Health Regulations (IHR).

O’Leary also reminded delegates of our collective duty to prepare for a lasting polio-free world. He referenced specifically the new approach to polio transition, which draws upon lessons-learned, and puts countries at the forefront, as solutions need to be country-specific, tailored to each country’s own context.  Within that context, delegates emphasized the importance of implementing all activities to not only achieve a polio-free world, but also to sustain it through strengthening essential immunization, surveillance, integration and transition, reiterating their support and commitment to fully finance the Global Polio Eradication Initiative Strategy and the WHO base budget.

Speaking on behalf of Rotarians around the world and civil society as a whole, Judith Diment of Rotary International’s PolioPlus Committee, congratulated delegates on ongoing efforts to protect children from devastating diseases such as polio.  “The Global Polio Eradication Initiative is closing in on zero, with fewer cases in fewer places in 2023, reaching more children through tailored approaches to increase public demand and identifying missed children.  We applaud the use of targeted, integrated activities.”

In late December 2023, the World Health Organization issued its first-ever prequalification approval for a vaccine being used under its Emergency Use Listing (EUL) regulatory pathway – novel oral polio vaccine type 2 (nOPV2). Since rollout of this next-generation vaccine began in March 2021, the Global Polio Eradication Initiative (GPEI) has administered nearly 1 billion doses of nOPV2 across 35 countries, protecting millions of children against illness and paralysis. Prequalification will enable additional countries to access the vaccine more easily for more sustainable response to outbreaks of type 2 variant poliovirus (cVDPV2). 

“This is a historic milestone for polio eradication and for public health,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “Novel oral polio vaccine type 2 has blazed a trail for other new vaccines that address critical health emergencies, and its use demonstrates the utility of the EUL mechanism in helping to rapidly get new products to where they’re needed most.” 

The EUL to PQ pathway 

WHO EUL is reserved for the use of yet-to-be-licensed vaccines, medicines and diagnostic tools during public health emergencies like polio outbreaks. Following rigorous assessments of existing quality, safety and efficacy data from completed clinical trials, the pathway enables expedited availability of products to the places impacted by these emergencies. The vaccine’s manufacturer, Bio Farma Indonesia, has been instrumental in ensuring supply and enabling nOPV2 to earn full licensure from the Indonesian regulatory authority, Badan POM. WHO Prequalification (PQ) is the final step of the process, allowing for streamlined regulatory approval for nOPV2 use in countries that need it. 

“This key step illustrates how innovation can help protect children against the variant poliovirus type 2, with thanks to the support of donors and partners, and the commitment of governments and community health workers,” said UNICEF Executive Director Catherine Russell. “UNICEF is committed to helping ensure the safe and adequate supply of vaccines to countries, while working with communities to build trust in vaccines. We need to keep going till we reach every child, and eradicate polio once and for all.”

nOPV2’s performance and the power of innovation 

To date, nOPV2 has been used in 35 countries under EUL, predominantly in the African region which is most affected by cVDPV2 outbreaks. Throughout its clinical development and field use, nOPV2 has proven to be as safe to use and effective at stopping outbreaks as its predecessor, monovalent type 2 oral vaccine (mOPV2), but, importantly, is more genetically stable. After nearly three years of use, estimates show that nOPV2 is 80% less likely to seed new variant polio outbreaks, making it the tool of choice to stop these outbreaks for good.  

Nigeria has played an outsized role in nOPV2 rollout in the leadup to WHO Prequalification, administering nearly half a billion doses to children across the country to date. The vaccine has helped bring about an 85% reduction in variant poliovirus cases in Nigeria since 2021, and its impact is visible through this and other data in a new story from the GPEI. 

Development of the vaccine began in 2011 through a consortium of experts led by the Bill & Melinda Gates Foundation, including the UK National Institute for Biological Standards and Controls (NIBSC), the U.S. Centers for Disease Control and Prevention (US-CDC), the US Food and Drug Administration, PATH and the University of California at San Francisco. 

“Supporting the development of new vaccines is one of the most important investments we can make to protect people against preventable diseases like polio,” said Mark Suzman, CEO of the Bill & Melinda Gates Foundation. “With easier access to nOPV2 for more countries, this vaccine will keep even more children safe in areas still grappling with poliovirus. We look forward to working with partners across sectors to support more groundbreaking innovations.” 

Next steps in the fight against type 2 variant poliovirus 

As of 3 January 2024, 325 cases of cVDPV2 had been reported in 2023, compared to 689 cases in 2022. While nOPV2 has played a key part in this reduction, its success, like any polio vaccine, depends on the ability to rapidly implement high-quality immunization campaigns that reach every child.   

To overcome the final challenges that remain in polio eradication, the GPEI is finding new ways to access children living in hard-to-reach areas, promote community acceptance of vaccines, and improve early detection and response to outbreaks. These efforts are being prioritized in the places where children are at the highest risk of encountering and spreading the virus. 

“It is critical to protect all children against polio with timely administration of vaccines. Along with our global partners, CDC is committed to ensuring rapid detection of type 2 polio outbreaks and response with the novel oral vaccine,” said Dr. Mandy Cohen, Director of the US-CDC.  

A prequalified nOPV2 will help to make important headway against cVDPV2 outbreaks, and with renewed support from global partners, donors and leaders of polio-affected countries to fully implement the program’s strategy, we can stop all forms of polio for good. 

 

END 

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About the GPEI:
The Global Polio Eradication Initiative is a public-private partnership led by national governments with six partners – the World Health Organization (WHO), Rotary International, the US Centers for Disease Control and Prevention (CDC), the United Nations Children’s Fund (UNICEF), Bill & Melinda Gates Foundation and Gavi, the vaccine alliance. Its goal is to eradicate polio worldwide.

For media enquiries:
WHO
For prequalification specific enquiries:
Sarah Sheppard – Communications Officer sheppards@who.int
For polio and nOPV2 enquiries:
Joseph Swan – Communications Officer swanj@who.int

UNICEF
Helen Wylie, Communications Specialist hwylie@unicef.org

Bill & Melinda Gates Foundation
Amber Zeddies, Senior Program Officer amber.zeddies@gatesfoundation.org

US CDC
Chelsea Toledo, Health Communications Specialist rnv8@cdc.gov  

The Global Polio Eradication Initiative has two goals laid out in its current strategy: to interrupt all remaining transmission of endemic wild poliovirus type 1 (WPV1) and to stop all outbreaks of variant poliovirus type 2 (cVDPV2). 2023 was a critical year for progressing on each of these, and while our urgent and diligent work to end polio must continue into 2024, the GPEI achieved incredible things in the past twelve months.

Continuing work in endemic countries

Despite significant geo-political and environmental challenges in the two remaining WPV1-endemic countries, Pakistan and Afghanistan, the polio programme has continued to reach greater numbers of children with polio vaccines.

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

Wild polio transmission was beaten back to just a handful of districts in eastern Afghanistan and the southern area of Khyber Pakhtunkhwa province in Pakistan. In both countries, efforts are increasingly focused on reaching and vaccinating the last remaining ‘zero dose’ children – children who have received no vaccines of any kind. The number of these missed children continues to dwindle, with the success of improved collaboration with the national immunisation program, new efforts like Pakistan’s Nomad Vaccination Initiative and focused vaccination activities at border crossings between the two countries. Just one family of the virus remains endemic in each country, and coupled with this increasing geographic restriction, the situation resembles the end of wild polio eradication efforts in former virus hotspots like India, Nigeria and Egypt.

In addition, after a wild poliovirus outbreak that was confirmed in southeast Africa in early 2022, neither Malawi nor Mozambique has reported a WPV case since August 2022 thanks to a concerted subregional emergency response across five neighbouring countries. We are hopeful that this outbreak will be officially closed in the coming months, affirming that countries have what it takes to protect children from this devastating disease and keep wild polio out of Africa.

Progress on variant polio outbreaks

Thanks to the novel oral polio vaccine type 2 (nOPV2), strong political commitment and community-based efforts to reach more children with the vaccine, the number of cases of variant poliovirus type 2 (cVDPV2) continued to decline in 2023.

Nearly 1 billion doses of nOPV2, a comparably safe, effective, but more genetically stable version of the existing type 2 oral polio vaccine (mOPV2), have now been administered across 35 countries, protecting millions of children from illness and paralysis.

Emergency response to variant polio outbreaks is continuing, notably in the most consequential geographies for the programme—where children are at the highest risk of encountering and spreading poliovirus. In northern Nigeria, for example, variant polio cases have fallen by 90% since a peak in 2021, thanks to concerted commitment from government, unique community programs to improve the reach of vaccines and the extensive rollout of nOPV2. Across these consequential geographies, the programme will continue to focus on increasing access, acceptance and campaign quality, which have helped make incredible progress in Nigeria, and continue to innovate until we end polio for good everywhere.

Finally, In September 2023, after a massive vaccination response in the shadow of ongoing war, Ukraine officially stopped its outbreak of type 2 variant polio that began in 2021. New York, London and Jerusalem, where high-profile outbreaks began in 2022, have not detected the virus in recent months. Still, the emergence of polio in these areas is a reminder that as long as poliovirus exists anywhere, it is a threat to people everywhere.

nOPV2 Vaccination at Guilding Angel School Tunga, Minna, Niger. © WHO/AFRO

A global effort

Most importantly, thanks to the efforts of the GPEI and its partners, health workers vaccinated more than 400 million children in 2023, preventing an estimated 650,000 cases of paralysis from polio and saving the lives of up to 60,000 children. Building full, healthy futures was at the core of Rotary International’s mission when it began this fight to end polio for good in 1985, and when the GPEI was launched in 1988—35 years ago.

This year, the Independent Monitoring Board (IMB) conducted a rigorous mid-term review of the GPEI’s progress towards its strategic goals. This welcome counsel is already helping inform and guide the GPEI’s own ongoing analysis and strengthening of its strategic approaches to achieve a polio-free world, as the programme published its initial response to the mid-term review, under the guidance of the Polio Oversight Board (POB).

Achieving and sustaining a polio-free world has proven harder – and taken longer – than anyone could have imagined. But making history is never easy, and we are confident that together we can eradicate a second human disease from this earth, and build stronger, more resilient health systems along the way.

2023 has firmly set the stage for success. With the complexities of the world today, this programme still inspires to bring about the very best in our humanity.

Thank you to all who have contributed to this effort so far and continue to do so. Let us double down and make the dream of a polio-free world a reality.

DUBAI, UAE, 3 December 2023 – The Islamic Development Bank (IsDB), together with the Government of Pakistan, announced a US$100 million loan to support Pakistan’s polio eradication efforts, today, at the Reaching the Last Mile Forum held on the sidelines of the ongoing COP28 events in Dubai, UAE.

This loan builds on a previous support from the IsDB and includes a US$35 million principal buy-down from the Bill & Melinda Gates Foundation. The new funding complements previous loans and will be used to secure and deliver the millions of polio vaccines needed to protect all children across Pakistan against this debilitating yet preventable virus.

“I am very pleased to announce that the IsDB approved US$100 million financing in the 4th Phase of Polio Eradication Program for Pakistan in April 2023, which brings the IsDB total financing for Polio eradication in Pakistan to US$ 587 million, making the Bank one of the largest providers of finance to the national polio eradication program in Pakistan. Under this latest phase, I am happy to note that US$ 60 million of this amount was disbursed in mid-November 2023. We and our partners remain committed and are working hard to win this battle against this disease. We really are at the last mile in this long journey as only 5 cases of wild poliovirus have been reported in the country in 2023,” IsDB President and Group Chairman, H.E. Dr. Muhammad Al Jasser, reiterated in his statement read out by IsDB Vice President Finance, Dr. Zamir Iqbal, at the Forum. “I would like to thank the Government of Pakistan, as well as our partners, the Bill and Melinda Gates Foundation, UNICEF and WHO for their steadfast commitment,” added the statement.

Today, Pakistan and Afghanistan are the only countries where wild poliovirus remains endemic.

“We welcome the support of the IsDB and the Bill & Melinda Gates Foundation in contributing to the critical effort of ending polio in Pakistan,” said H.E. Dr. Nadeem Jan, Minister of National Health Services Regulations and Coordination. “Interrupting poliovirus transmission remains a core focus for the Government of Pakistan, and thanks to the heroic efforts of community health workers, global partners and contributors like the IsDB and the foundation, we have pushed the virus to the brink of eradication,” the Minister added.

The Bill & Melinda Gates Foundation sees this loan as an important step forward for eradication efforts in Pakistan. “We are pleased to partner again with the IsDB and the Government of Pakistan to ensure funding opportunities to provide the needed resources to reach every child with polio vaccines. I remain inspired by the strong commitment from leaders across Pakistan to ending polio at both the provincial and national levels,” said Chris Elias, President of the Global Development Division at the Bill & Melinda Gates Foundation and Chair of the Global Polio Eradication Initiative Polio Oversight Board. “With continued support to health workers and the efforts from partners like the IsDB, I am confident we will end polio in Pakistan,” he reiterated.

On the occasion, WHO Director General, Dr. Tedros Adhanom Ghebreyesus, stated: “WHO remains committed to working with our partners to support Pakistan’s effort to end polio for good.” He added: “These funds will allow Pakistan to raise immunization coverage, improve its ability to find and respond to this virus, and make polio history for children in Pakistan and around the world.”

This loan will enable the Pakistan polio program to reach all children and communities with this life-saving vaccine to ensure no one suffers from this debilitating disease in the future. It will also help meet the country’s commitment of US$155 million towards its national polio program supported by the partners of the Global Polio Eradication Initiative (GPEI).

As one of the two implementing partners of the GPEI in Pakistan, UNICEF will support the government to procure and deliver vaccines to children, protect communities from polio and reach families with other essential health services. “We are at a critical moment in Pakistan, and we cannot ease up the fight against polio until every child is protected,” UNICEF Deputy Executive Director Omar Abdi said, adding: “UNICEF is committed to ending polio in Pakistan because we know it is possible. We have seen polio disappear from country after country across the globe. Today there are only two countries where it persists. Together, we can reach every child with polio vaccines, especially those who have not been vaccinated before, and we can end wild poliovirus transmission in Pakistan for good.”

Originally published by the Islamic Development Bank on 3 December 2023

Manzoor (second right, pictured here with his uncle, brothers and sisters) will make a full recovery from polio paralysis. ©UNICEF/Karimi

By Kate Pond, UNICEF Afghanistan

“Manzoor is our miracle child!” exclaims the young man, face shining. Two-and-a-half-year-old Manzoor is unmoved by his uncle’s excitement; he is busy eyeing the boiled sweet in the outstretched hand of a village elder on the other side of the room. The boy gets up decisively, and trots across the carpet. He grabs the candy in a pudgy hand and gobbles it down with relish.

Just a few months ago, Manzoor could not walk. His left leg was paralyzed by the polio virus.

In a neighbouring district, Saima, fidgets with her hennaed fingers while her father pours tea. Small for her 11 years, Saima still favours her right side, although the paralysis caused by the virus is easing. As her father tells the story of her recent illness, her grandfather puts his arm around the girl’s shoulders, embracing her warmly.

Polio is still endemic in Afghanistan – one of the last two countries in the world. Since the start of 2023, six children have been diagnosed with the disease, all of them in Nangarhar Province, a rural area in the east of the country. Saima and Manzoor are lucky: six months after the onset of symptoms, it looks like they will make a full recovery. Two of the six were not so lucky; one boy remains very weak in the limbs affected, and one girl died.

The national polio vaccination campaign, led by the National Emergency Operations Centre in coordination with UNICEF and WHO, is in full swing. Last year, 9.4 million children were vaccinated under the campaign, and the target for 2023 is 10 million. The monthly campaigns are boosted by educational campaigns for mothers and other caregivers, run by UNICEF and partners.

Saima and Manzoor received vaccine drops in recent campaigns, and their parents were well aware of the signs and symptoms of polio, how it is caught, and the importance of vaccination as the only preventative measure. In fact, the speed at which their parents acted to get tests and treatment for their children are testament to the commitment and hard work of over 30,000 polio social mobilisers and influencers building public trust in the programme, and the deep-seated desire of the Afghan community to eradicate the virus once and for all.

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©UNICEF/Karimi

Manzoor lives in Niazan district, Nangarhar Province, where only 30% of residents have a piped water supply.

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©UNICEF/Karimi

Saima will make a full recovery from polio, thanks in part to the vaccination programme, and her parents’ swift action when she fell ill.

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©UNICEF/Karimi

11-year-old Saima and her father walk through their village in Kot district, Nangarhar. In April, polio paralysed Saima’s left arm and leg, but she has since regained their use.

The combination of vaccination campaigns and regular routine vaccination is the gold standard to eradicate polio forever. Nangarhar ranks above the national average for full childhood vaccinations, with 27 per cent of children fully covered, although it is also slightly higher than average for children in the same age bracket to be unvaccinated (Ref: UNICEF MICS 2022-23). In each of the six new polio cases, the children had missed one vital vaccination – usually the intravenous jab given to babies and toddlers – which left a gap in their immunity, and the virus was able to break through.

Nothing happens in a vacuum. For a vaccine to work effectively, the child receiving it needs to be healthy, adequately nourished, and living in a sanitary environment. The polio virus is contracted from water sources that are contaminated by raw sewage infected with the virus. Wild polio is detected in the samples WHO collects in regions across Afghanistan, including in the east.

Less than half the population of Afghanistan has access to basic sanitation, and a third do not have access to clean drinking water. In rural areas, like Saima and Manzoor’s districts, the streams the children play in are often the same streams that household waste and effluent flow into. Nangarhar residents benefit from higher-than-average access to clean drinking water, but sanitation is considerably lower than average, and 20 per cent practice open defecation. In Manzoor’s district, for example, only 30 per cent of the population benefit from a piped water supply. Without the necessary infrastructure in place to provide these services, children will continue to be exposed to the virus in their living environment and run the risk of contracting the disease.

The polio vaccination campaign is striding forward in Afghanistan, and the virus is fighting to survive. But while the water in which children play is contaminated, the risk of them catching the virus hangs heavily over communities. Winning the battle involves recognizing the interconnectedness of health and nutrition, clean water and sanitation, community education and vaccination, and responding with a comprehensive package of services. As Saima’s father put it: “Mashallah my daughter is lucky. She will make a full recovery. But without better sanitation we will continue to live in fear of the virus.”

To celebrate this year’s World Polio Day, supporters from over 30 countries, across every region of the world, joined the Make Polio History campaign to tell global partners, donors, and polio-affected country governments that eradication is possible and urgently needed now. 

The Global Polio Eradication Initiative (GPEI) has the knowledge and tools to end polio for good, but we cannot do it alone. Throughout the campaign, polio champions around the world built a long list of some of the greatest wins for humanity—from the creation of the first vaccine to the harnessing of electricity—and shared why polio eradication can and must be added to this list.  

Well-known figures like Bill Nye, Adina Porter, Prue Leith and Itzhak Perlman voiced their support for a healthier future for children everywhere. Health workers in Afghanistan and Cameroon joined in as well, along with Fiocruz President Mario Moreira, Dr. Naveen Thacker of the International Pediatric Association, GPEI Gender Champion Minister Andrew Mitchell, and other doctors and researchers from India, Brazil and the United Kingdom.  

We know that eradicating polio is not easy, but making history never is. The polio eradication effort—from global partners to country governments to local frontline health workers—has a long history of innovating and adapting in the face of adversity. 

GPEI partners know this well, from WHO leadership in the Eastern Mediterranean and African Regional Offices to UNICEF teams in Sudan and Ethiopia, who also participated in the campaign. Rotary International has been there since the beginning, as CEO John Hewko was proud to share, and will continue to be until the end. And finally, members of the GPEI’s Polio Oversight Board recognized the global support shown throughout the campaign, and committed their efforts to delivering a polio-free world. 

Today, there are proven strategies and new tools to deliver vaccines in the highest-risk areas for polio, which are also some of the world’s most challenging and hard-to-reach settings. Promising trends in polio-affected countries that have been seen in other places now polio-free suggest that today, the virus is truly on its last leg. With continued attention and support from donors, partners and affected country governments, polio eradication is within reach. 

It will take all of us, but together, we can make history again and end polio for good. 

Visit the Make Polio History website to hear more perspectives from polio champions from around the world, and to lend your voice to the effort.  

The Global Polio Eradication Initiative (GPEI) welcomes the latest report from the Independent Monitoring Board (IMB), which presents a rigorous independent review of the programme’s progress toward its goals — aiming to interrupt all remaining wild poliovirus type 1 (WPV1) transmission and circulating variant poliovirus type 2 (cVDPV2) transmission by the end of 2023. The IMB concludes that despite recent progress toward eradication, remaining challenges make stopping transmission of WPV1 this year unlikely, while ending all variant poliovirus outbreaks will take even more time.

The IMB notes the encouraging restriction of WPV1 transmission in the two remaining endemic countries, Afghanistan and Pakistan, the continuous work to reach every child with polio vaccines, and the political commitment to maintaining the progress that has been made. The IMB also noted improvements in combating variant poliovirus outbreaks, including the GPEI’s targeted efforts to implement large-scale campaigns that protect more children and strengthen surveillance systems. The report underscores the urgent need to stop all forms of the virus – because polio anywhere remains a threat to people everywhere.

The GPEI understands that recent progress against poliovirus is fragile and serious challenges remain. Many of the challenges outlined by the IMB are recognized barriers in the areas most vital to the success of eradication, including complex security and humanitarian situations, operational issues hindering campaign performance, and hurdles to effective integration of the polio programme with other health efforts. The GPEI remains confident that it can innovate and adapt in the face of this adversity to reach all children in the world’s most challenging settings. Still, the IMB notes that without adequate financial resources and political commitment at all levels, the programme will not be able to fully implement needed solutions.

The GPEI appreciates the IMB’s continued scrutiny and shared commitment to ending polio. In October 2023, the GPEI Polio Oversight Board will meet to analyse the IMB’s recommendations along with input from Technical Advisory Groups and country teams to adopt corrective actions that ensure the programme’s strategic goals are met. 

The GPEI will continue working closely with the IMB, polio-affected countries, donors, and partners to optimize the polio programme’s response, improve immunization campaigns and disease surveillance, and ultimately overcome the remaining hurdles to deliver a world in which no child is paralyzed by this deadly disease. 

Related Documents:

22nd Report of The Independent Monitoring Board (IMB)
Polio Eradication Strategy: GPEI response to the midterm review (pre-final draft)
Dr Nadeem Jan, newly-appointed interim Federal Health Minister Pakistan, and Aidan O’Leary, Chair of the GPEI Strategy Committee. © NEOC Pakistan

4 September 2023 – Recognising the importance of Pakistan in the global polio eradication effort, as one of the last two WPV1-endemic countries, the operational polio leadership of WHO and the US Centers for Disease Control and Prevention (CDC) travelled this week to Pakistan to observe first-hand operations, latest developments and innovations, and meet with newly-appointed political leadership.  The delegation, which was in-country from 29 August to 1 September, consisted of Director of Polio Eradication at WHO Headquarters and Chair of the Global Polio Eradication Initiative (GPEI) Strategy Committee Aidan O’Leary from WHO and Richard Franka, Team Lead of the Pakistan Team at Polio Eradication Branch, CDC.

The GPEI leaders noted the unprecedented historic opportunity to achieve success in the country this year, with WPV1 transmission at record-low levels.  At the same time, the group noted the high level of engagement and political will for the effort, at all levels.  Meeting with Dr Nadeem Jan, newly-appointed interim Federal Health Minister who visited the polio National Emergency Operations Centre (NEOC) on his very first day in office last month, the delegation received assurance that polio eradication is a key operational priority for Dr Jan’s tenure.

Provincial caretaker Health Minister Dr Saad Niaz and Aidan O’Leary discuss steps the programme is taking to keep track of polio cases in Karachi. © NEOC Pakistan

Dr Jan stated:  “It is important for us that our country and global partners and donors stand together in this final leg of the eradication journey.  I am a polio worker at heart.  I will ensure that not only does polio remain a priority at all tiers of governance, but efforts are more targeted and intensified.”

This level of commitment was further mirrored at meetings with other national and provincial political and health leaders, including the Engineer-in-Chief at the General Headquarters in Islamabad, provincial health ministers of Khyber Pakhtunkhwa and Sindh, and the Chief Secretary of Sindh, to ensure the new interim administration in the country carries the positive momentum forward.  Together, concrete ways to capitalize on the current epidemiological opportunity were discussed, including in fully implementing recommendations by the recent Technical Advisory Group (TAG) for Polio Eradication in Pakistan and Afghanistan, in particular in implementing area-specific and tailored tactics to overcome area-specific challenges to reaching remaining un- or under-vaccinated children.  The delegation also visited field activities and witnessed first-hand the tremendous efforts, innovations and commitments undertaken by polio workers and local communities, including in the remaining WPV1-endemic districts of the southern area of Khyber Pakhtunkhwa.

Speaking on behalf of the delegation, Aidan O’Leary commented:  “Rarely have I seen this level of commitment to achieve success.  On behalf of the GPEI, and on behalf of children and parents everywhere, I would like to thank and commend authorities at all levels in Pakistan for their tremendous engagement, leadership and commitment to reaching every last child.  Literally no stone is being left unturned to find and vaccinate all remaining unvaccinated children, in particular in the remaining endemic areas of the southern area of Khyber Pakhtunkhwa province.  With this level of commitment, I am confident a polio-free Pakistan will soon be achieved, and GPEI partners of course remain committed in supporting Pakistan’s authorities in this quest.”

The delegation was also attended by members of the international development community, including local representatives of Rotary International.

ISLAMABAD, JULY 21, 2023 – A high-level delegation of the Global Polio Eradication Initiative (GPEI), including the Polio Oversight Board, visited Pakistan to discuss the impact of political transition on eradication efforts and the strategies in place to vaccinate children that remain unreached in the polio-endemic districts of southern Khyber Pakhtunkhwa.

Led by Dr Chris Elias, Chair of the Polio Oversight Board and President Global Development, Bill & Melinda Gates Foundation, the delegation included WHO Regional Director for the Eastern Mediterranean Region Dr Ahmad Al-Mandhari, UNICEF South Asia’s Deputy Regional Director Noala Skinner, CDC’s Polio Eradication Branch Chief Dr Omotayo Bolu, Chief Programme Strategy Officer from Gavi-the Vaccine Alliance, Aurelia Nguyen, Trustee of Rotary International Foundation Aziz Memon, and High Commissioner of Canada in Pakistan Leslie Scanlon, who represented all donors to the GPEI.

This was the first visit by the POB and representatives from all GPEI partners to Pakistan in 2023. The POB is the highest decision-making and oversight body of the GPEI.

During the four-day visit from 16 – 20 July that included Lahore, Peshawar and Islamabad, the delegates visited the National and Provincial Emergency Operations Centers, attended a meeting of the National Task Force on Polio Eradication, and held separate meetings with the leadership of the Pakistan Army, Health Minister Abdul Qadir Patel and Foreign Minister Bilawal Bhutto Zardari.

“Pakistan continues to make important progress in the fight to eradicate polio. I’m impressed by the commitment I’ve seen again this week from the federal and provincial governments in getting the job done,” said POB Chair Dr Chris Elias. “The experience globally is that strong government leadership is key in the final push to defeat polio.”

The delegation also met the Governor of Punjab, Chief Minister of Khyber Pakhtunkhwa and provincial chief secretaries, health secretaries, commissioners and deputy commissioners of priority districts of Punjab and Khyber Pakhtunkhwa in Lahore and Peshawar, respectively, and met with the Chief Secretary of Balochistan.

“While the challenges before us are formidable and complex, I remain cautiously optimistic about the goal of interrupting transmission of poliovirus in Pakistan by the end of this year. This will require solidarity and collective action at all levels to enable rigorous implementation of the strategy, that must be fully supported by communities and the political, administrative and security leadership,” said WHO Regional Director Dr Ahmed Al-Mandhari.

Endemic transmission of wild poliovirus remains restricted to seven districts in the south of Khyber Pakhtunkhwa province, namely Tank, Bannu, North Waziristan, South Waziristan Upper, South Waziristan Lower, DI Khan and Lakki Marwat.

A vaccination campaign is ongoing in the seven endemic districts named “Reaching the Unreached.” The campaign specifically targets over 270,000 children under five in 69 low-performing union councils where vaccine coverage for polio and other essential immunization has been inadequate.

 “Under our regional vision of health for all by all, WHO will continue supporting Pakistan’s polio programme to give our future generations a world free from polio,” Dr Al-Mandhari added.

UNICEF’s Deputy Regional Director Noala Skinner appreciated the leadership. “We applaud the leadership of Pakistan and the dedication of frontline workers, including thousands of women, who tirelessly vaccinate and protect millions of children from the deadly poliovirus,” she said, adding, “The next six months are critical for Pakistan’s efforts to eradicate polio.  We are so close to our goal of reaching all children with polio vaccines. Together, we must ensure that the programme is able to reach every child in Pakistan, regardless of where they live.”

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Dr Omotayo Bolu

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Leslie Scanlon

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Mr. Aziz Memon

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Ms. Aurélia Nguyen

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Dr Chris Elias

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Ms. Noala Skinner

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Dr Ahmed Al-Mandhari

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Mr. Shahzad Baig

Dr Humayun Asghar. © WHO/EMRO

The vast machinery of the global polio eradication programme is much like the inner workings of a clock – a network of interconnected people, organizations and programmes that together are more powerful than the sum of their parts. Collaboration is foundational to eradication, and every eradicator plays a part in edging the programme closer to its goals.

But in some cases, individual eradicators develop capacities or practices that enable programmatic leaps. Dr Humayun Asghar is one of those outsize drivers of progress. His initiatives around early laboratory testing of stool samples of children with acute flaccid paralysis (AFP), his efforts to create  a cross-regional network of labs, and his efforts to set up a large pioneering network of environmental surveillance sites in Egypt are innovations that today power the programme’s surveillance capacity. We know where the virus is, even in the absence of paralytic polio cases, largely thanks to his work.

In 1988, when Dr Humayun joined the National Institute of Health (NIH) in Pakistan’s capital city of Islamabad, polio was paralysing more than 1000 children worldwide every day and the Global Polio Eradication Initiative (GPEI) was just being set up. Dr Humayun spotted an opportunity to stop the spread of poliovirus by tracking it – which meant identifying which children with AFP were infected with poliovirus and which children were experiencing paralysis for other reasons. In 1991, Dr Humayun began to contact pediatricians and, later, vaccinators, to collect stool samples from children who presented with AFP to test them for poliovirus infection. In a nod to the doctors’ and vaccinators’ contribution, Dr Humayun shared the results immediately with the reporting individual, regardless of their location.

The information filled a gap for physicians who wanted to know why their patients were unwell, and it provided a new level of detail on the virus’ whereabouts. Word got around and soon, more and more doctors started sending in their AFP patients’ stool samples. As the practice grew, processes needed to be formalized: Dr Humayun and his colleagues had to ensure stool samples were reaching them in the right conditions for testing, which led to the establishment of a set of criteria and standard operating procedures around the transportation of stool samples – something known today as the reverse cold chain.

The dawn of AFP surveillance in Pakistan

This new system unveiled the dawn of an era of detailed, systematic surveillance for AFP, the most common, tell-tale symptom of poliovirus infection. That it grew out of mutual trust and collaboration with focal points in the community reaffirmed Dr Humayun’s belief, “If you offer service to the community, the community serves you.”

Site selection during establishment of polio environmental surveillance in Pakistan. © WHO/EMRO

In their quest to fill in gaps in disease surveillance and formalize a practice of testing samples from AFP patients, Dr Humayun and his colleagues succeeded in establishing the first poliovirus laboratory in Pakistan.

Dr Hamid Jafari, WHO Polio Director for the Eastern Mediterranean Region, says this contribution to eradication cannot be  overstated.

“Dr Humayun has sowed the seeds of AFP surveillance in Pakistan all through his own initiative and drive and nurtured and supported the lab network in the Eastern Mediterranean Region; as one of the architects of the regional and global laboratory network, he has contributed to building a great legacy.”

Advancing the Region’s work

Over the intervening decades, Dr Humayun has helped the Region’s laboratory network grow in size and skill, bringing in new practices such as testing for poliovirus in sewage water (environmental surveillance) and then harnessing this new practice to test for the presence of other diseases – most recently, COVID-19. He also took the practice out of the Eastern Mediterranean Region and into the African Region, supporting the polio laboratory in Nigeria to introduce environmental surveillance.

Collecting the first sample for polio environmental surveillance while training health workers, Nigeria. © WHO

Testing for and tracking the virus in stool samples and sewage water enabled the programme to identify different types of poliovirus, and by building on this, a practice was developed to conduct nucleotide sequencing, which provides a fuller picture of viruses’ lineage and allows scientists to identify which family any given poliovirus belongs to. Dr Humayun attributes these accomplishments to laboratory staff, who strengthened their own capacity to diagnose polio without waiting for results from other global specialized laboratories.

Supporting others to grow

Since he joined WHO’s Eastern Mediterranean Region in February 2002, Dr Humayun has served in several capacities – as Scientist Virologist, Regional Advisor for Public Health Laboratories, and finally as the Coordinator for the Region’s Poliovirus surveillance, Laboratory support and Data management. He credits two mentors in particular for inspiring his career – the late Dr Helmy Wahdan, former Polio Director for WHO’s Eastern Mediterranean Region, and Dr Olen Kew, a poliovirus scientist – and, over the course of his career, has tried to pay that inspiration forwards.

“Dr Humayun has mentored and supported young scientists and laboratory specialists across the Region to advance their skills and careers,” said Dr Nima Saeed Abid, WHO Representative for Sudan. “He has been a true leader in his field.”

Perhaps unsurprisingly, Dr Humayun believes one of the keys to eradicating polio lies not in the lab, but in people: in empowering and engaging the workforce by incentivizing them with education, training and promotion.

On the occasion of his retirement in May 2023, Dr Humayun expressed gratitude that he was able to witness and contribute to two important milestones: the eradication of wild poliovirus types 2 and 3.

And when the eradication of WPV1 does happen, he says, “I will be cheering from the sidelines, alongside so many other vital contributors to the programme’s legacy.”

©WHO

Global leaders and stakeholders have been unanimously declaring their solidarity to achieving a lasting world free of all forms of polioviruses.

Convening this week at the World Health Assembly in Geneva, Switzerland, Ministers of Health from around the globe evaluated the unique epidemiological opportunity which currently exists, in particular in eradicating all remaining chains of endemic wild poliovirus in a handful of districts of just two countries – Pakistan and Afghanistan.  As a record number of Member States and civil society partners took to the floor, key to success, all experts agreed, must be on adapting operations and reaching remaining un- or under-immunized children in just seven subnational most consequential geographies, with collectively account for 90% of all new polio cases, including in a gender-equitable and integrated manner.  To ensure lasting success, delegates urged country-specific solutions for polio transition.  In response to both a wild poliovirus outbreak in south-eastern Africa and multi-country circulating vaccine-derived poliovirus outbreaks, extraordinary special sessions were led by WHO and its Regional Office for Africa between affected Member States and partners, to discuss concrete steps to stopping all outbreaks affecting the Region by end of year.

The World Health Assembly comes on the heels of last week’s G7 Leaders and G7 Health Ministers meetings in Japan, where both meetings highlighted the urgent need to ensure a world free of polio can be rapidly achieved. Next week, Rotarians from around the world are convening at the Rotary International Convention in Melbourne, Australia, to ensure civil society support for the effort will go hand-in-hand with public sector engagement.

Speaking on behalf of both Pakistan and the entire Eastern Mediterranean, Mr A.Q. Patel, Pakistan Federal Minister for National Health Services, Regulations and Coordination, said:  “We are in the final leg of eradication and we are doing everything we have to do to achieve success.  The virus is restricted to its smallest-ever geographical footprint, and the (polio) programmes in both Pakistan and Afghanistan continue to vastly expand their hunt for the virus and mount robust campaigns to reach all children, not just with polio vaccine, but indeed other antigens as well.  We could not have come this far without the strong support and goodwill of all Member States, however there is still more to be done at the heart of all our work, and for the future of all generations of children.  We need continued and sustained financial and political support from all Member States and partners, in order to give every child, no matter where they live, the promise of a polio-free world.”

H.E. Dr Hanan Mohammad Al-Kuwari, Minister of Public Health of Qatar, and Co-Chair of the Eastern Mediterranean Regional Subcommittee for Polio Eradication and Outbreaks, commented:  “In our Region, we have made significant progress in both containing the spread of wild poliovirus and closing outbreaks of vaccine variant polio.  Afghanistan and Pakistan have restricted the virus to the smallest geographical footprint in history and are now doubling up efforts to fully interrupt the remaining transmission.  The engines fueling this progress are manifold, but the two most powerful, and the two I truly believe will get us across the line, are improved immunity and better surveillance. We are reaching and vaccinating more children, more often, and we are using the most sensitive and robust surveillance measures in history to ensure that if the virus is there, we are not missing it.  Excellencies, partners and colleagues, I ask this as clearly as I can: Stay the course. Dig deep to do what needs to be done. Stand with us and be part of history.”

Noting the global commitments being made, Jean-Luc Perrin, Rotary International’s Representative to the United Nations in Geneva, told the global health community at the Assembly:  “Polio eradication is a rare example of enduring, truly global collaboration toward a goal whose achievement will benefit all nations in perpetuity, while contributing toward broader global health priorities.  We cannot take progress or possible victory for granted. Let us make collective history and End Polio Now!”

In conclusion: global leaders continue to note the very real window of opportunity for success this year, but that this window will not remain open for long.  The virus will again gain in strength. Only collective and global collaboration will result in ultimate success, and delegates and leaders urge all stakeholders to keep the focus firmly on one overriding objective:  reaching remaining un- or under-vaccinated children in the most consequential geographies.  A collective responsibility, but if achieved, will result in success in 2023.

Additional quotes from the World Health Assembly:

“WHO and our partners remain steadfastly committed to finishing the job of consigning polio to history.  Last year, three million children previously inaccessible in Afghanistan received polio vaccines for the first time.  And in October, donors pledged US$2.6 billion to support the push for eradication.  At the same time, as part of the polio transition, more than 50 countries have integrated polio assets to support immunization, disease detection and emergency response.  We must make sure that the significant investments in polio eradication do not die with polio, but are used to build the health systems to deliver the services that these communities so badly need.”- Dr Tedros Adhanom Ghebreyesus, Director-General, World Health Organization

“Wild poliovirus transmission has been cornered to the smallest ever geographic locations in the Eastern Region of Afghanistan and seven districts in southern part of Khyber Pakhtunkhwa in Pakistan.  However, the last 100-metre dash presents its own challenges and we must do all we can to achieve success.” Dr Hamid Jafari, Director for Polio Eradication for the Eastern Mediterranean, on behalf of Dr Ahmed Al-Mandhari, Regional Director, World Health Organization Eastern Mediterranean Region

“The African Region, which was certified free of wild poliovirus in 2020, has set itself the objective of stopping the transmission of all types of 2 polioviruses by the end of 2023 and integrating polio assets into activities that strengthen broader disease surveillance. It is also deploying integrated public health teams to respond to other emergencies, building on experiences from past poliovirus outbreaks and leveraging the polio network and infrastructure for response activities.” – Delegation of Burkina Faso, speaking on behalf of the entire African Region.

Representatives from regions and countries share lessons learned from transition. © WHO/HQ

In Somalia, integrated public health teams, built on the polio network, deliver a broad range of health services, despite challenges posed by ongoing polio outbreaks and the impact of the COVID-19 pandemic. In the Central African Republic, thanks to strong advocacy by the civil society, sustaining polio eradication remains on the health agenda. Meanwhile, India’s significant progress, builds on transforming the networks built initially to eradicate polio to strengthen the country’s essential immunization programme.

From 25 – 26 April, national, regional and global stakeholders, including country representatives, global health partners and donors, and members of civil society, gathered in Geneva to share their experiences of polio transition. The objective of the two-day forum was to agree on the future direction of polio transition, including adjustments that are needed, building on lessons learned.

In his opening remarks at the forum, Dr. Tedros Adhanom Ghebreyesus, the Director General of the World Health Organization (WHO), underscored the rationale for the transition process, “As we move closer to a polio-free world, we must work to sustain the incredible infrastructure that has been set up to eradicate polio.”

“A transformation of this scale and complexity has never been done in public health. We have a huge challenge, and a huge opportunity.”

The challenges and opportunities of a successful transition were recurring themes during the forum. Although much progress has been made since 2018, the COVID-19 pandemic, political and economic instability and a more constrained fiscal environment have complicated transition efforts and strained health systems in many countries. To overcome this, countries have continually adapted transition planning for their contexts, guided by national health priorities, towards strengthening health outcomes, especially in the areas of essential immunization, health emergencies, and primary health care.

Reflecting on these lessons, stakeholders agreed that the renewed global vision for transition should be inspiring, actionable, practical and relevant to all countries. They emphasized that providing coordinated technical and financial support, aligned with country priorities, is critical for success. At the national level, countries should adapt flexible strategies, with realistic milestones.

Strong essential immunization programmes were recognized as crucial for achieving and sustaining polio eradication. Meanwhile, maintaining the poliovirus surveillance system and laboratory network was identified as a critical priority to protect a polio-free world and strengthen broader disease surveillance efforts. It was recognized that there is scope to systematically integrate gender, equity, human rights and the health of refugees and migrants into transition planning, aligned with the country context. Stakeholders also discussed the potential ‘enabling factors’ to make transition a success, and ‘risks’ that need to be mitigated during transition, as well as the specific responsibilities of different stakeholders.

The outcomes of the forum will inform the new Global Vision for Polio Transition that will be shaped by the end of 2023. The vision is an essential component of the post-2023 strategic framework, alongside Regional Strategic Plans, tailored to regional and national context, and a Monitoring and Evaluation Framework to track progress and ensure transparency and accountability.

Dr Tedros concluded his remarks by noting the potential to strengthen health systems through a successful transition.

“Eradicating polio and safeguarding its legacy with stronger health systems will be a gift for our children, and our children’s children.”

Following the forum, Member States offered further guidance on transition during the 76th World Health Assembly, building on interventions made during the 152nd Executive Board meeting. Member States highlighted that the polio transition strategic framework should aim to integrate polio functions into Primary Health Care towards Universal Health Coverage, align with WHO’s evolving work on pandemic preparedness, resilience and response, and focus on strengthening routine immunization, surveillance, outbreak management and response, national capacity building and partnerships. Considering the ongoing risk of spread of polio, Member States emphasized to have a risk-based approach to transition, backed up by realistic timelines and clear milestones.

The strategic framework will be developed through a consultative process to ensure that the next phase of transition is fit for purpose.

A doctor and surveillance volunteer checks a child for signs of paralysis in a clinic in Shawalikot district, Afghanistan. ©WHO / Jawad Jalali
A doctor and surveillance volunteer checks a child for signs of paralysis in a clinic in Shawalikot district, Afghanistan. ©WHO / Jawad Jalali

In May 2014, the WHO Director-General declared the international spread of poliovirus a Public Health Emergency of International Concern (PHEIC) under the International Health Regulations (IHR 2005), a designation that allows for accelerated response, emergency disbursement of funding and mitigation measures, such as vaccination of international travellers, to reduce the risk of spread of poliovirus. Nine years and several expert-led reviews later, polio retains its PHEIC status. COVID-19 and mpox have joined and recently left the list of diseases with this designation, but poliovirus still poses a risk of international spread. As noted with detections of variant poliovirus around the world in several previously polio-free countries, including Canada, Israel, the United Kingdom of Great Britain and Northern Ireland and the United States of America, poliovirus anywhere is a threat to children everywhere.

Despite retaining its PHEIC status, the polio eradication programme has made tremendous strides in the last 3 and a half decades. These efforts have brought the world to the best yet position in terms of achieving our goal of eradication.

In WHO’s Eastern Mediterranean Region, home to constantly brewing humanitarian crises and the last 2 countries endemic for wild poliovirus – Afghanistan and Pakistan – transmission has been cornered to the smallest ever geographical location. Up until now, in 2023, 2 cases of wild poliovirus have been reported from Afghanistan and one from Pakistan – all from the endemic zone in the East Region of Afghanistan and southern districts of Khyber Pakhtunkhwa, Pakistan. Both countries have also cut down the genetic diversity of the virus since 2020 – from 8 to one in Afghanistan and 11 to one in Pakistan.

Years of extraordinary efforts by frontline workers, national and local authorities, the partners of the Global Polio Eradication Initiative (GPEI) and donors the world over have led us to our best yet opportunity to snuff out this virus once and forever.

The footprint of circulating variant poliovirus in the Region has also reduced considerably in recent years. The Region has fewer outbreaks today than it had a year ago. Last year, Sudan closed its 2020 cVDPV2 outbreak and Islamic Republic of Iran closed a poliovirus event, while both Djibouti and Egypt are no longer detecting any poliovirus in environmental samples and are poised to formally close their outbreaks in a few weeks.

Polio surveillance systems have never been more sensitive. 18 of the Region’s 22 countries have established environmental surveillance systems to complement the networks of surveillance workers and health care providers actively searching for acute flaccid paralysis in children. In addition to countries at high risk of polio, the list also includes longstanding polio-free countries, such as Bahrain and Saudi Arabia, underscoring the importance of surveillance in all countries as the Region moves towards certification.

Investments made in polio have demonstrated their value for broader healthcare, such as during COVID-19 when the polio assets supported testing, vaccination and risk communication. The Region is making progress with polio transition to ensure countries maintain much-needed essential functions, even as funding transitions away from GPEI financing to national domestic resources or WHO base budget. These efforts will strengthen disease surveillance, routine immunization for children, and outbreak preparedness and response capacities.

The polio programme regularly engages with Member States through governing bodies such as the Regional Subcommittee for Polio Eradication and Outbreaks and uses expert advice by technical advisory groups of experts to review progress in the Region and support countries to stop transmission and maintain robust surveillance and immunization programmes. But to deliver on the promise of a polio-free world for future generations, there is still more work to be done. Across the Region, we are in a race against time to intensify surveillance, enhance the quality of immunization campaigns, and strengthen preparedness for and response to polio outbreaks, while ensuring any gender-related barriers are mitigated across all levels of the programme.

As WHO Member States gather in Geneva for the 76th annual World Health Assembly, now is the time to dig deep, draw on our strength as a partnership and the strength of donors and host governments, and achieve the goal we declared more than 3 decades ago.

Originally published on WHO’s EMRO website.

On 17 May, GPEI held a high-level influencer briefing with polio experts from around the world in which over 200 attendees from 63 countries took part.

Watch the recording of the event.

 

Meeting in Japan this month, leaders of the G7 urged for global support to the Global Polio Eradication Initiative (GPEI). In their official Communiqué issued at their Summit, G7 Health Ministers “recognize the value-added contribution of the global polio eradication infrastructure and workforce towards global surveillance capacity, national pandemic preparedness and response capacity, and the wider global health architecture. We call for continued support to the GPEI to fully leverage this vital resource for public health emergencies and to stay on track for polio eradication by 2026.”

This call was subsequently echoed by the G7 Leaders, following the group’s Summit, who called for “continued support to the GPEI to stay on track for polio eradication by 2026.”

The G7 forum and leaders have a long history of supporting the global effort to eradicate polio, and this reiterated support is further testimony to their commitment to the GPEI.  These latest commitments come ahead of this week’s World Health Assembly (WHA), where global health leaders from around the world are convening at the World Health Organization (WHO) in Geneva, Switzerland, to discuss global public health issues, including polio eradication.

A child receiving the life-saving polio drops. © WHO

A key priority in 2023 is to end both wild- and variant polio transmission around the world is focusing on the most consequential geographies where children are at the highest risk of encountering and spreading the virus, and which collectively accounted for 90% of all new polio cases worldwide in 2022. Northern Nigeria is one of these seven subnational areas that now hold the key to a polio-free world. 

In Nigeria increased vaccination and surveillance efforts have yielded positive results in 2022: No isolates from the country’s main historical transmission chain, the Jigawa lineage, which was responsible for most cases and international spread to many neighbouring countries in West Africa, have been detected since February 2022.  There was a decline from 1028 cases as on 31st December 2021 to 168 cases as on the 31st December 2022. As a result, the virus is currently confined primarily to two states in the northwest zone of the country, namely Sokoto and Zamfara.  This presents a distinctive opportunity for Nigeria to interrupt transmission by December 2023, according to the Expert Review Committee for Polio Eradication and Routine Immunization (ERC), the independent technical group advising the country on its eradication efforts.   

In February 2023, the ERC convened its 39th meeting in Nigeria to make recommendations aimed at interrupting transmission of variant type 2 polio and maintaining its indigenous wild poliovirus-free certification status along with the entire African Region. Led by the Ministry of Health’s National Primary Healthcare Development Agency and supported by GPEI partners, Nigerian civil society and Rotarians across the country, efforts are intensifying to fully implement the National Polio Emergency Action Plan (NPEAP).  

The country has developed a comprehensive National Polio Emergency Action Plan (NPEAP) to address the risks of all poliovirus types in order to ensure Nigeria and the entire Region’s certification status is maintained, within the context of the political transitioning process, the impact of COVID-19 on the national health systems and economy as well as the increasing concerns of insecurity affecting surveillance and vaccination reach. All recommendations made by the ERC are aimed at aligning the NPEAP with the 2022-2026 Global Polio Eradication Initiative (GPEI) Polio Eradication Strategy. 

Marking the finger with indelible ink, an-all important part of the polio immunization activity. ©WHO/Nigeria
Marking the finger with indelible ink, an-all important part of the polio immunization activity. ©WHO/Nigeria

The ERC noted that the proposed activities for 2023 are contingent on three critical enablers, namely the global stockpile of novel oral polio vaccines (nOPV2) and bivalent oral polio vaccines (bOPV), constraints in financial resources, and a smooth political transition to drive political commitments at sub-national levels. Given the impact of variant type 2 poliovirus over the last few years, there should be limited room for complacency to reach the finish line for the interruption of these strains. The ERC, therefore, called on all partners to support the implementation of the NPEAP for 2023. 

The conference also highlighted some of the achievements made in the fight against polio in Nigeria. The conference also highlighted some of the achievements made in the fight against polio in Nigeria. In 2022, there was an 84% decline in variant type 2 poliovirus cases, reduced from 415 cases in 2021 to 48 in 2022. The quality of Supplemental Immunization Activities (SIAs) improved, especially in the last quarter of 2022, and there were narrowed surveillance gaps at sub-national levels. Routine immunization (RI) coverage also improved from 33% in 2016 to 57% in 2022, and COVID-19 vaccination was also optimized to improve demand generation and delivery of other essential immunization vaccines. 

The ERC made recommendations in nine thematic areas to fully implement the National Polio Emergency Action Plan, including by continuing to strengthen surveillance, mitigate risks due to inaccessibility and insecurity, build a more resilient routine immunization programme, assure solid vaccine management and advocate for a polio-free Nigeria.   

In conclusion, 2023 is a critical year for polio eradication efforts in northern Nigeria and the other most consequential geographies for poliovirus transmission. The global community must continue to support these efforts to ensure that no child is left behind, and we can finally achieve a polio-free world. 

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

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

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

Vaccinators: the backbone of programme

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

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

Polio vaccinators. © WHO/EMRO

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

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

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

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

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

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

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

One house done, now on to the next one.

Vaccines: two drops for every child 

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

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

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

Tally Sheets: supporting real-time corrective actions

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

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

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

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

Getting past the finish line

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

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

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

By Rimsha Qureshi,
Communications Officer, GPEI Hub Amman

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

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

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

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

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

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

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

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

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WHO/Pakistan

Health worker Shahida Saleem sits outside her house in Fatehpur, Rajanpur district during a polio campaign in September 2022.

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WHO/Pakistan

“Our hearts and minds were elsewhere, but we managed to reach the children,” says Shahida Saleem, talking about the first polio campaign a month after the floods hit Rajanpur in August 2022.

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WHO/Pakistan

Amidst the destruction, the first thing Sughra Javed restored in her house was the board that marks her identity as a health worker.

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WHO/Pakistan

As the health workers travelled around Rajanpur in September, the impact of the floods was all around them, in the broken-down homes, furniture and blankets left out to dry in the sun.

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WHO/Pakistan

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

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

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

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

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

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

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

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

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

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

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

By Zehra Abid,
Communications Officer, WHO Pakistan