GPEI-50 Years of Impact: How Polio Eradication and EPI Demonstrate What Is Humanly Possible

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 50^th 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.

Women make up only 28% of the workforce in science, technology, engineering and math (STEM), and men vastly outnumber women majoring in most STEM fields in college globally. On March 2011, the Commission on the Status of Women adopted a report at its 55^th session to promote women’s equal access to full employment and decent work. Two years later, on 20 December 2013, the UN General Assembly adopted a resolution in which it was noted that it is imperative for women and girls to be involved in STEM.

On the International Day of the Women and Girls in Science on 11 February 2023, Rosemary Mukui Nzunza, the head of the Expanded Programme on Immunization (EPI) at the Centre for Virus Research, the Kenya Medical Research Institute, shared her story of pursuing a career in science. She is currently in the final stages of working towards earning her PHD in Molecular Medicine.

Rosemary explains she would like girls and women to know there is enough room for everyone in science; and women should maintain healthy competition in science and go as far as they can. It also helps to look for mentors and people you can admire and follow so they inspire you to keep growing, she says.

“Research has earned this name as it means you need to go back and search over and over again,” Rosemary says. “Besides, there are no ceilings in science – girls and women can go as far as they want to.”

As a child, Rosemary Nzunza spent her free time pounding leaves, roots and tubers, using thick wooden sticks to create “medicine”. Her creativity, curiosity, and love for finding explanations for how things work made her want to teach science − or at least work in the world of science.

Rosemary never has a dull day at work. She currently serves as Senior Research Scientist and Head of Division of the Expanded Programme on Immunization (EPI) at the Centre for Virus Research at KEMRI. Her role entails monitoring quality assurance in laboratory work and biosafety and overseeing the work of the different units at KEMRI. She also represents the laboratory in key national committees in Kenya: the National Committee on Containment of Polioviruses (NTF), National Polio Certification Committee (NPCC), National Measles and Rubella Technical Advisory Committee (MTAG) and the National Polio Experts Committee (NPEC).

Rosemary joined the Kenya Medical Research Institute (KEMRI) Laboratory 23 years ago, starting her career as a research officer with the US Army Medical Research Directorate (USAMRD). In 2006, Rosemary earned her Master’s in Applied Microbiology. Back then, she was one of just two women at the unit who had postgraduate degrees under their belts. She reflects on how her male colleagues looked up to the two women as mentors, which made them feel really proud. But she notes that this also meant they were in charge of all laboratory procedures, laboratory quality, and the troubleshooting, which was quite challenging at the time.

Polio still exists

When Rosemary joined KEMRI, she was surprised to learn that the institution was tasked with supporting polio eradication. She had thought polio had been wiped out from the world a long time ago.

Children wait to be vaccinated during house-to-house visits for a national polio vaccination campaign in Mogadishu, Somalia, on Tuesday 06 June 2022. Photo credits: ©WHO/ Ismail Taxta

Presently, Rosemary and her team at the KEMRI Laboratory work meticulously on testing samples of measles, polio and rubella. They know their work is integral to saving children from the harsh effects of preventable diseases, such as polio. Their work on polio is two-pronged: they have been testing samples for acute flaccid paralysis (AFP) since 2000 and environmental surveillance (ES) since 2013. AFP is defined by the acute onset of weakness or paralysis with reduced muscle tone in children. There are many infectious and non-infectious causes of AFP. Polio, caused by wild poliovirus (the naturally circulating strain) is one cause of AFP, and so early detection of AFP is critical in containing a potential outbreak. Respiratory and stool samples are optimal for enterovirus detection. Environmental surveillance complements AFP surveillance. It entails collecting and testing wastewater samples and can help in the early detection of and response to polioviruses. By identifying polioviruses swiftly, countries can stop their spread.

At times, the 17-member team receives an overwhelming number of samples at once from countries in the Region facing polio outbreaks. This presents a challenge, as it might mean the team needs more supplies for testing and needs to work longer hours to deliver timely results.

Once they have tested samples, they interpret results for each and send them back to the country to guide further and swift action. By 3 pm Eastern African Time every Friday, the KEMRI team works to send summaries of test results on measles, polio and rubella to the national surveillance office within Kenya’s Ministry of Health and other partners. These include the WHO Regional Office for Africa (AFRO); WHO Eastern Mediterranean Regional Office (EMRO); WHO headquarters; and the US Centers for Disease Control and Prevention (CDC).

Management during COVID-19 was a challenge

One of the most difficult times Rosemary has faced in her career was the response to the COVID-19 pandemic. During that period, she felt like health workers were carrying the weight of the entire world. In Kenya, her team was tasked with supporting the government in conducting COVID-19 tests. At the time, everything seemed so uncertain. Personal protective equipment (PPE) kits looked frightening, people all over the world were dying of COVID-19, and procedures and test kits still needed validation. She remembers thinking to herself, “Someone has to do this. And it’s us, here, now.”

Agnes Chepkurui, a lab technologist, preparing samples to determine what kind of poliovirus is present in the sample.
Photo credit: WHO/L. Dore

Similar to the situation health workers around the world faced, her team was also afraid of being infected with COVID-19, especially before vaccines were available. Rosemary recalls the team staying at work for long, tiring stretches, partially to avoid contact with their families, out of fear of inadvertently putting them at any risk of being infected with COVID-19. Teammates would huddle together and discuss their after-work protocol at home: slip in through the back door, disinfect clothes, clean up rigorously, take a shower, avoid all contact with loved ones, and set off on the same routine the next day before anyone woke up.

She split the team into two shifts to manage the immense workload. The aim was to prevent the team from burning out and ensuring their new work on COVID-19 didn’t slow down the other, crucial support to disease elimination that still needed to be carried out. Looking back now, Rosemary credits the support she and her team received from the management at KEMRI, colleagues, partners, friends and family with helping them stay focused and rise to the unprecedented challenges of that time.

She also attributes the success of the KEMRI EPI Division Laboratories to support from institutions across the world, including the Global Polio Eradication Initiative (GPEI) partners. She says she has always been impressed with the incredible support from WHO and the rest of the GPEI partnership, where diverse agencies come together to tackle one goal.

More mentors needed for girls to join and grow in science

The young lady who stepped foot out of her village in Machakos county – in Kenya – for the first time when she left for Eldoret to earn her Bachelor’s in Science Education has come a long way. She is keen to see other girls and women take their place at the forefront of science – but only if they have a passion for this field, she adds. Breaking into a laugh, she says there’s a lot to read and keep up with every single day. After all, science is about changing the world.

GENEVA/ NEW YORK, 6 November 2020 – UNICEF and the World Health Organization (WHO) today issued an urgent call to action to avert major measles and polio epidemics as COVID-19 continues to disrupt immunization services worldwide, leaving millions of vulnerable children at heightened risk of preventable childhood diseases.

The two organizations estimate that US$655 million (US$400 million for polio and US$255 million for measles) are needed to address dangerous immunity gaps in non-Gavi eligible countries and target age groups.

“COVID-19 has had a devastating effect on health services and in particular immunization services, worldwide,” commented Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “But unlike with COVID, we have the tools and knowledge to stop diseases such as polio and measles. What we need are the resources and commitments to put these tools and knowledge into action. If we do that, children’s lives will be saved.”

“We cannot allow the fight against one deadly disease to cause us to lose ground in the fight against other diseases,” said Henrietta Fore, UNICEF Executive Director. “Addressing the global COVID-19 pandemic is critical. However, other deadly diseases also threaten the lives of millions of children in some of the poorest areas of the world. That is why today we are urgently calling for global action from country leaders, donors and partners. We need additional financial resources to safely resume vaccination campaigns and prioritize immunization systems that are critical to protect children and avert other epidemics besides COVID-19.”

In recent years, there has been a global resurgence of measles with ongoing outbreaks in all parts of the world. Vaccination coverage gaps have been further exacerbated in 2020 by COVID-19. In 2019, measles climbed to the highest number of new infections in more than two decades. Annual measles mortality data for 2019 to be released next week will show the continued negative toll that sustained outbreaks are having in many countries around the world.

At the same time, poliovirus transmission is expected to increase in Pakistan and Afghanistan and in many under-immunized areas of Africa. Failure to eradicate polio now would lead to global resurgence of the disease, resulting in as many as 200,000 new cases annually, within 10 years.

New tools, including a next-generation novel oral polio vaccine and the forthcoming Measles Outbreak Strategic Response Plan are expected to be deployed over the coming months to help tackle these growing threats in a more effective and sustainable manner, and ultimately save lives. The Plan is a worldwide strategy to quickly and effectively prevent, detect and respond to measles outbreaks.

Notes to editors:

Download photos and broll on vaccinations, including polio and measles vaccinations here

Generous support from Gavi, the Vaccine Alliance, has enabled previous access to funding for outbreak response, preventive campaigns and routine immunization strengthening, including additional support for catch-up vaccination for children who were missed due to COVID-19 disruptions in Gavi-eligible countries. However, significant financing gaps remain in middle-income countries which are not Gavi-eligible. This call for emergency action will go to support those middle-income countries that are not eligible for support from Gavi.

About UNICEF

UNICEF works in some of the world’s toughest places, to reach the world’s most disadvantaged children. Across 190 countries and territories, we work for every child, everywhere, to build a better world for everyone. For more information about UNICEF and its work for children, visit www.unicef.org. For more information about COVID-19, visit www.unicef.org/coronavirus. To know more about UNICEF’s work on immunization, visit https://www.unicef.org/immunization

Follow UNICEF on Twitter and Facebook

About the Global Polio Eradication Initiative

The Global Polio Eradication Initiative is spearheaded by WHO, Rotary International, the US Centers for Disease Control and Prevention (CDC), UNICEF, the Bill & Melinda Gates Foundation and Gavi, the Vaccine Alliance.

About the Measles & Rubella Initiative

The Measles & Rubella Initiative (M&RI) is a partnership between the American Red Cross, the U.S. Centers for Disease Control and Prevention (CDC), UNICEF, the United Nations Foundation and the World Health Organization. Working with Gavi, the Vaccine Alliance, and other stakeholders, the Initiative is committed to achieving and maintaining a world without measles, rubella and congenital rubella syndrome. Since 2000, M&RI has helped deliver over 5.5 billion doses of measles vaccine to children worldwide and saved over 23 million lives by increasing vaccination coverage, responding to outbreaks, monitoring and evaluation, and supporting demand for vaccine.

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Dr Rebecca Martin, Centers for Disease Control and Prevention, delivering the welcome address at the event ”To succeed by 2023—Reaching Every Last Child for a Polio-free World” to celebrate the launch of the Polio Endgame Strategy 2019-2023. ©WHO.

The 72^nd World Health Assembly, the governing body of the World Health Organization held by in Geneva, Switzerland is the biggest congregation of public health actors. Taking advantage of the critical mass of global leaders, the Global Polio Eradication Initiative hosted an event for polio eradicators, partners and stakeholders on 21 May 2019.

The event, To Succeed by 2023—Reaching Every Last Child, celebrated the GPEI’s new Polio Endgame Strategy 2019-2023. The five-year plan spells out the tactics and tools to wipe out the poliovirus from its last remaining reservoirs, including innovative strategies to vaccinate hard-to-reach children and expanded partnerships with the Expanded Programme on Immunization (EPI) community and health emergencies.

The informal event brought together a cross-section of stakeholders – partners, health actors, non-health actors, supporters, donors, Ministers of Health of endemic countries, WHO Regional Director for the Eastern Mediterranean, and Polio Oversight Board members – alluding to strengthened and systematic collaboration in areas of management, research and financing activities in the last mile.

Dr Zafar Mirza, Pakistan’s Minister of State,Ministry of National Health Services, Regulations, and Coordination, seen with Seth Berkley, CEO of Gavi, the Vaccine Alliance, at the GPEI informal event during the 72nd World Health Assembly. ©WHO

Dr Zafar Mirza, Pakistan’s Minister of State,Ministry of National Health Services, Regulations and Coordination, took the stage and gave insight into country-level polio eradication efforts and the need for coordinated action with Afghanistan: “20 years ago, 30 000 children were paralyzed by polio in Pakistan. This year, 15 cases have been reported. While we have done a lot, it is clearly not enough. We are resolute in this conviction. We, together with Afghanistan, must make sure we eradicate polio for the sake of our children. Our science is complete, only our efforts are lacking. Along with the polio programme, the donors and the Afghan government, we will get to the finish line.”

Echoing similar sentiments, Dr Ferozuddin Feroz, Minister of Public Health of Afghanistan, said, “I would like to start by expressing thanks to all the partners for their support. As you know, Afghanistan has a very challenging context due to inaccessibility, refusals, gaps in campaign quality, low routine immunization coverage, and extensive cross-border movement. But, Afghanistan has made progress—five out of seven regions continue to maintain immunization activities. We view polio as a neutral issue and have developed a robust National Emergency Action Plan 2019. We appreciate the Polio Endgame Strategy 2019-2023. We believe coordination with Pakistan will help us deliver a polio-free world. We look forward to your continued technical and financial support to achieve the goal of polio eradication.”

Dr Ferozuddin Feroz, Minister of Public Health, Afghanistan, talking about the remaining challenges for polio eradication and the need for continued partner support in the last mile. ©WHO

Recognizing the long-standing commitment of the United Arab Emirates, a video was played showing the on-ground efforts of the Emirates Polio Campaign, working with communities and families in Pakistan in collaboration with the Global Polio Eradication Initiative and partners, and the Government of Pakistan. Thanks to the Emirates Polio Campaign, 71 million Pakistani children have been reached with 410 million doses of polio vaccine.

Dr Abdullahi Garba, Director for Planning, Research and Statistics, National Primary Healthcare Development Agency spoke on behalf of Professor Isaac F Adewole, Federal Minister of Health of Nigeria. Dr Garba harked back to the past as the GPEI plans for the future: “Nigeria started actively working to eradicate polio in 1988, at a time when we used to have up to a thousand cases every year. With all our innovation and efforts, I am pleased to inform you today that no wild polio case has been detected for the past 33 months. This feat was achieved through continuous efforts between the government, GPEI and partners, having diligent incidence reporting, reaching inaccessible children, and improving the quality of the polio surveillance immunization activities through strong oversight mechanisms in Nigeria. I know I also speak on behalf of all countries across Africa – we will achieve success.”

Representing Nigeria, Dr Abdullahi Garba, Director for Planning, Research and Statistics, National Primary Healthcare Development Agency, talked about the challenges, innovations and tools used to bring Nigeria to the brink of polio eradication. ©WHO

Rounding off the evening, Dr Tedros Adhanom Ghebreyesus, the World Health Organization Director-General and Chair of the GPEI Polio Oversight Board, took the stage to recount his first visit of the year to the polio endemic countries of Afghanistan and Pakistan, the progress made over decades, and the need to re-commit to the cause of ending polio. “Together with Regional Director Ahmed Al-Mandhari and Chris Elias of the Gates Foundation, we travelled to Pakistan and Afghanistan. We saw first-hand the commitments by both public and civil society leaders, which gave us a lot of confidence. The other thing that gave us confidence was seeing our brave health workers trudging through deep snow. And of course, our partners: Rotary, United Arab Emirates, CDC, UNICEF, the Bill & Melinda Gates Foundation and Gavi. The last 30 years have brought us to the threshold of being polio-free…(which) lay out the roadmap that is the Polio Endgame Strategy 2019-2023. The Ministers of Afghanistan and Pakistan have also assured us that they will continue to work together in their shared corridor to finish polio once and for all.”

Dr Tedros Adhanom Ghebreyesus, the World Health Organization Director-General and Chair of the GPEI Polio Oversight Board, remains confident in continued political commitment in the endemic countries, the tireless support of partners, donors, and the Polio Endgame Strategy 2019-2023 to deliver a polio-free world. ©WHO

In 1988, the World Health Assembly passed a resolution to globally eradicate poliovirus, in what was meant to be “an appropriate gift…from the twentieth to the twenty-first century.”

As the GPEI plans for the future and its final push to ‘finish the job,’ it is clear that political and financial efforts need to ramp up in this increasingly steep last mile. As he concluded, Dr Tedros thanked committed partners like United Arab Emirates: “Global progress to end polio would not be possible without partners like the UAE. I would like to thank His Highness Sheikh Mohamed bin Zayed Al Nahyan, Crown Prince of Abu Dhabi, and the UAE – a long-time supporter of the polio programme – for agreeing to host the GPEI pledging event this November at the Reaching the Last Mile Forum, a gathering of leaders from across the global health space held once every two years…let us join together to end polio.”

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After concerted efforts spanning decades, polio eradication efforts are in the homestretch and experts are advising how to fast-track the last mile.

The SAGE convened in Geneva from 2-4 April 2019 to discuss all things related to vaccines and immunizations, including poliovirus and the global eradication efforts around it. SAGE reviewed the latest global polio epidemiology, the new Global Polio Eradication Endgame Strategy 2019-2023, and what the post-eradication world could look like.

Interruption of wild poliovirus continues to be a priority for the success of GPEI at the latest SAGE meeting. ©WHO

Double down and escalate the fight to end wild poliovirus

While SAGE noted the achievements and the progress of the Global Polio Eradication Initiative—reducing the incidence of polio by 99%, absence of wild polio virus type 3 cases, and evidence of Nigeria being wild poliovirus free for over two years—the group displayed cautious optimism about meeting the timeline set out for global eradication of wild poliovirus.

The remaining challenges to fill vaccination coverage gaps—including restricted access, socio-political challenges, and large mobile populations—complicate the efforts to rid the world of poliovirus. However, the GPEI has developed a clear-cut five- year plan to secure a decisive win, the GPEI Polio Endgame Strategy 2019-2023, developed in broad consultation with stakeholders, including SAGE members.

Inactivated Polio Vaccine (IPV)—progress in roll-out continues

From the public health standpoint, Inactivated Polio Vaccine (IPV) can be used indefinitely even after polio eradication. As of April 2019, all 33 countries which had not yet introduced IPV into their routine immunization activities have now done so.

The projected IPV supply is thought to be sufficient enough for the introduction of a two-dose IPV schedule in all countries by 2022, and to catch-up all children missed due to earlier supply shortages, by 2020/2021.

Guidelines Endorsed

As per SAGE recommendations made in October 2016, GPEI developed guidelines for poliovirus surveillance among persons with primary immunodeficiency. After reviewing the guidelines, the SAGE endorsed the guidelines for implementation in high priority countries.

The meeting report will be published in the WHO Weekly Epidemiological Record by May 2019.

Strategic Advisory Group of Experts

The Strategic Advisory Group of Experts (SAGE) on Immunization was established by the Director-General of the World Health Organization in 1999 to provide guidance on the work of WHO. SAGE is the principal advisory group to WHO for vaccines and immunization. It is charged with advising WHO on overall global policies and strategies, ranging from vaccines and technology, research and development, to delivery of immunization and its linkages with other health interventions. SAGE is concerned not just with childhood vaccines and immunization, but all vaccine-preventable diseases.

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Pakistan’s routine immunization programme Expanded Programme on Immunization will carry out a nationwide measles vaccination campaign targeting around 31.8 million children aged 9-59 months from 15 to 27 October to respond to an ongoing measles outbreak in Pakistan. Over 30 000 measles cases have been reported this year, compared with around 24 000 cases in 2017.

Pakistan typically encounters a measles outbreak every 8 to 10 years, and the Federal Ministry of Health works proactively to stop these outbreaks with regular vaccination campaigns. Although the Polio Eradication Initiative and the Expanded Programme on Immunization are separate entities, they work together to improve immunization outcomes in Pakistan. Achieving strong essential immunization coverage is a critical step in bringing Pakistan closer to ending polio, and once this goal is reached, in maintaining polio-free status.

Many of the areas at highest risk for polio are also at high risk for measles. During the upcoming measles campaign, the polio programme will lend its human, physical and operational resources, knowledge and expertise to achieve the highest possible measles immunization coverage across the country.

Reaching more children through stronger collaboration

The collaboration between polio and routine immunization programmes has made a significant difference in vaccination efforts across dense urban environments as well as scattered rural settings. A key factor for success has been the polio programme’s highly-skilled workforce of community vaccinators, front-line health workers and social mobilizers.

During every round of country-wide polio vaccination campaigns, around 260 000 front-line health workers vaccinate more than 38 million children under the age of 5 across Pakistan. With vital on-the-ground experience in some of the most challenging settings, they are determined to ensure that the lessons learned in polio are transferred to other health interventions.

“Our front-line workers have built strong rapport in their respective communities,” said Dr. Rana Safdar, coordinator of the National Emergency Operation Centre (NEOC) for polio eradication and member of the National Measles Steering Committee.

“They understand the dynamics of the population, even as they relate to children, not only at the district level but also at the Union Council and village level. This indigenous knowledge coupled with community trust can definitely play an instrumental role for other health interventions.”

Unlike polio eradication activities, measles immunization is not carried out from door-to-door but at fixed centres at health facilities as well as through outreach sessions within communities. Children are mobilized to the vaccination sites where trained healthcare professionals administer the injectable measles vaccine. The deep local knowledge polio workers have developed and the trust they have built with their communities is vital in mobilizing caregivers to take their children for measles immunizations at nearby vaccination sites.

“The strong collaboration between the two programmes has helped us vaccinate more children. Our joint efforts are geared towards reaching every last child and they have shown significant progress so far. We hope that our synergized efforts during the upcoming measles campaign will lead us to reach every child in the target population with measles vaccine,” said Dr. Tahir Abbas Malik, from the Pakistan polio programme.

“For polio, these coordinated efforts have paved the way for increasing the coverage of persistently missed children, especially those who are on the move or reside in hard-to-reach areas. Similarly, integrated micro planning, monitoring and reporting of children who have not received essential immunization have been instrumental for achieving gains for routine immunization through enhanced coverage,” said Dr. Tahir Abbas Malik.

Routine vaccination is one of the only health services available to internally displaced people living in Mélea camp for internally displaced persons. © WHO/D. Levison

The environment

Dar es Salam refugee camp, in Bagassola district, Chad, is home to thousands of refugees. 95% of the population is Nigerian, displaced by years of violent insurgency, drought and insecurity in the Lake Chad basin. Some have lived in the camp since 2014.

Here, temperatures soar to 45 degree Celsius nearly every day. Dust is inescapable, colouring everything a shade of yellow. Houses are constructed from tents, tarpaulins and reeds, pitched onto sand. There is no employment, few shops, and no green areas.

A health worker sets out to conduct house-to-house polio vaccination activities in Dar es Salam. © WHO/D. Levison

Kilometers from the lake, residents have no access to the water around which their livelihoods revolved, as fishing people, as traders at the markets located around the island network, or as cattle farmers. This renders them almost entirely reliant on aid. The edge of the camp is an enormous parking lot, filled with trucks loaded with donations. Signs interrupt the landscape, attributing the camp’s schools, football pitches, and water stations to different funding sources.

Polio immunization is a core health intervention offered by the health centre here, with monthly house to house vaccination protecting every child from the virus.

“We vaccinate to keep them healthy”

In return for their work, vaccinators receive a small payment, one of the few ways of earning money in the camp. In Dar es Salam, there are thirty positions, currently filled by 24 men and six women, and applications are very competitive. Those chosen for the role are talented vaccinators, who really know their community.

Laurence (centre) explains why vaccination is so important, whilst his colleague marks the finger of a child just vaccinated. © WHO/D. Levison

Laurence speaks multiple languages, adeptly communicating with virtually everyone in the camp. He is a fatherly figure, engaging parents in conversations about the importance of vaccination whilst his colleague gives vaccine drops to siblings. Their mother is a seamstress, constructing garments on a table under one of the few leafy trees. Laurence engages her in conversation, explaining why the polio vaccine is so important.

Describing his work, he says, “I tell parents that the vaccine protects children from disease, especially in this sun, and that we vaccinate every month to keep them healthy.”

A precious document in a plastic bag

Chadian nationals living in nearby internally displaced persons camps don’t have the same entitlements as international refugees. Several hours’ drive from Dar es Salam, children lack access to even a basic health centre.

A UNICEF health worker inspects the baby’s vaccination card. © WHO/D. Levison

At a camp in Mélea, vaccinators perform routine immunization against measles and other diseases under a shelter made from branches. Cross-legged on the ground, they fill in paperwork, carefully administer injections, sooth babies, and dispose safely of needles. Other vaccinators give the oral polio vaccine to every child under the age of ten. These children are mostly from the islands, displaced by insurgency. Their vaccination history is patchy at best, and it is critical that they are protected.

One father arrives accompanied by his small, bouncy son. As the baby looks curiously at the scene in front of him, his dad draws out a tied plastic bag. Within is his son’s vaccination card, carefully protected from the temperatures and difficult physical environment of the camp.

A UNICEF health worker reads it, and realizes that the child is due another dose of polio vaccine. Squealing with confusion, the baby is laid back in his sibling’s arms, and two drops administered. The shock over, he is quickly back to smiling, rocked up and down as his dad folds up the card, and ties it up in the bag once more.

A child living in Dar es Salam is vaccinated against the polio virus. © WHO/D. Levison

“Our biggest challenge”

Back in Dar es Salam, DJórané Celestin, the responsible officer for the health centre explains the wider challenges of vaccination in this environment.

“We don’t just vaccinate within Dar es Salam in our campaigns. We are also responsible for 27 villages in the nearby surroundings. Reaching these places proves our biggest challenge.”

Away from the main route to Dar es Salam, there are no roads or signs, and many tracks are unpassable. To reach the 539 children known to live in the villages, vaccinators walk, or rent motorbikes, travelling for many hours.

This month, another round of vaccination in the Lake Chad island region concluded. Hundreds more refugee and internally displaced children are protected, in some of the most challenging and under-resourced places to grow up.

A mother and her child wait for routine immunization services in Mélea camp for internally displaced persons. © WHO/D. Levison

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

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

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

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

Reaching all children with vaccines

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

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

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

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

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

2390 children vaccinated

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

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

“Why should I let anything stop me?”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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