Actress Grace Kelly distributed March of Dimes literature to leaders of the Mothers’ march on Polio. © Yale School of Medicine

Even long before the GPEI was formed, Monaco played a leading role in early initiatives to develop a polio vaccine. In the 1950s, Her Serene Highness Princess Grace was an advocate for the National Foundation for Infantile Paralysis in the United States of America, founded by President Franklin D. Roosevelt (himself a polio survivor).

The Foundation became known as the “March of Dimes”, so called because of its far-reaching call for funds to research a cure for polio, which at the time was one of the most serious communicable diseases in the USA. Grants from the NFIP facilitated the work of researchers such as Dr. Jonas Salk, creator of the first successful vaccine against poliovirus. But it also facilitated the work of unsung heroes, such as Dr. Leone Farrell at the University of Toronto’s Connaught Medical Research Laboratories. Farrell devised the “Toronto method” for mass production of vaccines, which made the massive field trials of Salk’s vaccine possible, paving the way for the mass vaccination campaigns which have brought us so far in eradicating polio.

Leone Farrell, PhD, was a key figure in the successful mass production of the polio vaccine, enabling Jonas Salk and his team enough serum to perform the initial polio vaccine trials in 1954. © Sanofi Pasteur Canada Archives

Farrell is one of thousands of women past and present at the forefront of the GPEI. The role of women in polio eradication is supported by Polio Gender Champions, who work to raise the voices of women engaged in the programme, and keep gender equality high on the global public health agenda.

And today, Monaco’s proud tradition of support for gender equality and polio eradication continues, with the announcement that H.E. Ms. Carole Lanteri, Ambassador and Permanent Representative of Monaco to the United Nations Office at Geneva will become the newest Gender Champion for Polio Eradication. The Ambassador, formerly co-chair of the GPEI’s Polio Partners Group, explains the significance of this new role:

“As the Covid-19 pandemic continues to affect our lives, women pay a higher price with regressive effects on gender equality. If gender dynamics are not taken into consideration, polio interventions will not be as effective, with the potential risk of exacerbating existing inequalities. More than ever before we must advocate for a meaningful inclusion of women in decision making processes and adopt policies in health programming to reflect this. Today my commitment to these causes is even stronger thanks to my new role as Gender Champion. Following in the footsteps of Princess Grace and taking forward Monaco’s longstanding commitment to gender equality and polio eradication, I am determined to use my voice to advocate for gender mainstreaming in polio eradication to reach every last child.”

Ambassador Lanteri joins the ranks of other gender champions striving to raise awareness of the role of women in polio eradication and on the importance of addressing gender related barriers to immunization. Their work will be instrumental not only in eradicating polio, but also in creating a legacy for recognizing and empowering the role of women in major public health initiatives.

A WHO team trains community volunteers and health workers on the user of AVADAR in Gurai, South Sudan. ©WHO/AFRO
A WHO team trains community volunteers and health workers on the user of AVADAR in Gurai, South Sudan. ©WHO/AFRO

Health workers and community volunteers in remote and security-compromised areas across ten African countries now rely on an SMS-based application to ferret out any possible poliovirus hiding in their midst.

The application is called AVADAR, short for “auto-visual AFP detection and reporting”, with AFP referring to acute flaccid paralysis, which is the main visible clinical symptom of poliomyelitis. AVADAR is an SMS-based mobile application used for reporting, monitoring and surveillance of poliovirus. It was developed in 2016 by the World Health Organization (WHO), in collaboration with the Bill & Melinda Gates Foundation and the Swiss software company Novel-T, to ensure that every case of wild poliovirus is detected.

On a weekly basis, the health workers and volunteers in selected hard-to-reach districts use the AVADAR application to report whether they have noticed any child with paralysis of a limb. The districts are selected based on being deemed high risk yet having the sufficient telecommunications infrastructure that allows the health workers and community volunteers to communicate with the investigations team.

“In the last mile of polio eradication, we are not sparing any resources to reach a polio-free world. That is why we developed the AVADAR app,” says Dr Pascal Mkanda, WHO Regional Coordinator of the Polio Eradication Programme for Africa.

In the WHO African Region, no outbreaks of wild poliovirus have been detected since 2016, when the last case was found in Nigeria’s Borno State. This brings the region closer towards being certified free of wild poliovirus in 2020.

Health workers and community volunteers use AVADAR to recognize and report cases of acute flaccid paralysis, which is the sudden onset of paralysis or weakness in any part of the body that can be caused by polio, among children younger than 15 years. Acute flaccid paralysis could be caused by other diseases than poliomyelitis.

“Polio eradication requires that the surveillance system is sensitive enough to detect all acute flaccid paralysis cases -regardless of the disease behind it- and that such cases are promptly reported and investigated by disease surveillance personnel. This system starts at the community level,” Dr Mkanda adds.

WHO team training community volunteers and health workers on the use of AVADAR in Cameroon. ©WHO/AFRO
WHO team training community volunteers and health workers on the use of AVADAR in Cameroon. ©WHO/AFRO

Health workers and community volunteers first received training in workshops on how to use AVADAR and then they were each handed a smartphone with the application installed. On a weekly basis, the app sends them video reminders illustrating acute flaccid paralysis cases. The app then asks: “Have you seen a child with weakness of the legs or arms that you have not previously reported?” They then select between yes or no. If yes, the health workers and community volunteers input extra information about the case, such as the child’s name, date of onset of symptoms and geographic information.

Once the health worker presses the “send” button, a text message is sent to a system that triggers the sending of an SMS to the government and a WHO team that will investigate the case.

“In the AVADAR training workshops, we realized that some health workers and the majority of volunteers do not know the implications of acute flaccid paralysis and are unable to accurately identify such cases within their communities. The weekly AVADAR reminder videos helped improve that significantly,” says Dr Godwin Akpan, WHO Regional Polio Data Manager for Africa.

Dr Godwin is part of the team behind the innovation of the AVADAR application and trains health workers and community members on its use.

AVADAR was first piloted in Nigeria in 2016 and has been rolled out since 2017 in 99 districts of ten African countries: Burkina Faso, Cameroon, Chad, Democratic Republic of the Congo, Liberia, Mali, Niger, Nigeria, Sierra Leone and South Sudan.

As of October 2019, AVADAR has detected 1019 confirmed acute flaccid paralysis cases after health workers and community volunteers sent out 25,747 alerts through the application. None of those cases were polio cases. This marks a significant enhancement to the existing surveillance system that faces difficulties in remote and high-risk areas.

“Innovation and new technologies are our hope to finally make the feat of eradicating polio a reality. Thanks to the Global Polio Eradication Initiative, today, we are closer than ever to eradicating polio,” concludes Dr Mkanda.

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(L-R): Jan Sayyed, Ali Raza and Muhammad Bilal Wasi Jan sifting through thousands of forms from across the country. © Mobeen Ansari
(L-R): Jan Sayyed, Ali Raza and Muhammad Bilal Wasi Jan sifting through thousands of forms from across the country. © Mobeen Ansari

As the sun sets across Sindh province, exhausted polio eradication volunteers head home after a busy vaccination campaign. Each has personally vaccinated hundreds of children. In total, it has taken just a week for 9 million children under the age of five to receive two drops of oral polio vaccine, boosting their immunity against the virus.

In the crowded office of Jan Sayyed, Ali Raza and Muhammad Bilal Wasi Jan however, work is only just beginning. They work in the Polio Eradication Data Support Centre, located in Pakistan’s biggest city Karachi. During the campaign, vaccinators fill in paperwork every time they distribute vaccine drops. They record the number of children reached with vaccines, their existing vaccination status, any vaccine refusals and whether the children are local to the area, or visiting.

Across a typical vaccination campaign, this generates data referring to over two million children, recorded on thousands of forms. It is the challenging job of Jan, Ali, and Bilal to label and classify all this data so that it can be uploaded to an online system and analyzed to improve the next campaign.

Data is the lifeblood of the polio programme

Waqar Ahmad, Technical Officer for Data at WHO Pakistan, analyzing data © Sadaf Kashif
Waqar Ahmad, Technical Officer for Data at WHO Pakistan, analyzing data © Sadaf Kashif

Waqar Ahmad, Technical Officer for Data at WHO Pakistan, believes that if immunization and disease surveillance represent the heart of the programme, then data is the lifeblood that helps the programme inch closer to vaccination.

Different kinds of reliable data help the programme make decisions based on evidence. For instance, data that shows a high rate of vaccine refusals in one area allows the programme to investigate the cause further and act to persuade parents of the importance of vaccination.

But creating effective systems for gathering, sorting, and analyzing high-quality data hasn’t been easy. It has required rethinking approaches, overcoming bumps in the road, and thinking beyond the usual parameters of data management.

Pakistan’s polio data journey

Data collection and record keeping in Pakistan’s polio eradication programme began in 1997. Originally, data was collected only in very specific circumstances, such as when cases of Acute Flaccid Paralysis were detected. Such limited data collection meant that broader programme activities could not be analyzed, which increased the chances that vaccination campaigns could be ineffective. Data on other aspects could ensure that logistics were right-sized, and that human resources were deployed where they were most needed.

Data experts poring over the latest numbers on the Integrated Disease Information Management System (IDIMS). © Sadaf Kashif
Data experts poring over the latest numbers on the Integrated Disease Information Management System (IDIMS). © Sadaf Kashif

In November 2015, the programme introduced an online database designed to provide real-time data, named the Integrated Disease Information Management System (IDIMS).

The IDIMS database is used to store pre-, intra- and post-campaign data relating to multiple areas, including vaccination, disease surveillance, human resource planning, logistics planning, and mobile data collection. Data inputted into IDIMS is directly available for viewing and analysis at the provincial, national, and regional level. It can be cross-referenced with other polio eradication databases.

Young Pakistanis like Jan, Ali and Bilal are part of the workforce that keeps the whole system online. Once they have labelled and classified the paper forms, they pass the data onto their colleagues to be digitized and analyzed.

What’s next for polio eradication data management?

Open Data Kit software

In the Data Support Centres, employees are constantly thinking about how to further improve the IDIMS system. Jan, Ali and Bilal note that digitizing the whole data collection and management process would make the system more efficient, as well as environmentally friendly.

Data collection using Open Data Kit (ODK) software offers a way to do this. The data collection process is the same as with paper forms, except information is recorded in a mobile based application. Once vaccinators are in an area with internet, the data is directly uploaded to the ODK server and the IDIMS server. The ODK system has been rolled out in some areas of Pakistan.

Using data to inform decisions— polio eradication is an organized fight against the disease. © Sadaf Kashif.
Using data to inform decisions— polio eradication is an organized fight against the disease. © Sadaf Kashif.

Gender innovations

Gender-disaggregated data represents a new area of work for the data management teams. Data included in the IDIMS database assists with gender-conscious campaign planning at the provincial level, while a separate system analyses gender-disaggregated information at the country level. Ensuring female vaccinators are recruited for campaigns is crucial, as women can often vaccinate children in places where for cultural reasons, men cannot.

Increasing user-friendly interfaces  

As part of efforts to make systems user friendly, one year ago the polio programme launched online data profiles for Union Councils (UCs), the smallest administrative units in Pakistan. These profiles are available on the National Emergency Operation Centre data dashboard and allow polio programme staff to easily extract sizeable amounts of data about the local epidemiological situation within 30 seconds, as well as compare and analyze data for the past six years.

One of the most useful, innovative aspects of the UC profiles is that they collate information on children who were persistently missed during the last six campaign rounds, with information like contact details and the immunization history of the child. Such information assists the programme in follow-up engagement with the child’s parent or caregiver to encourage vaccination.

This requires speedy information sorting and uploading. Jan notes that his team is filing information more efficiently than they used to. This helps to ensure that details are up to date for nearly every town and village.

Over the coming months and years, further innovations will be introduced to improve data efficiency, range and quality.

Campaign by campaign, form by form, data handlers like Jan, Ali, and Bilal are helping to end polio.

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Environmental surveillance teams in Mogadishu access the underground closed drainage system to collect sewage waste water samples, which they package and send to the laboratory for testing. If poliovirus is identified in a sample, epidemiologists know that the disease is likely to be circulating amongst the community whose sewage drains into that part of the system. This process is called environmental surveillance and is one of the most important tools for the polio programme to help detect poliovirus.

Vaccinating every child and conducting disease surveillance to know where the poliovirus is circulating are key strategies to end the outbreak. Low immunization coverage has led to an outbreak of vaccine-derived poliovirus in Somalia. This can occur in places where not enough children have received their full vaccine doses.

The teams must follow best practice to collect samples, to ensure that any poliovirus present can be detected.

Click through this photo gallery to learn more about the sample collection process.

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The Emirates Polio Campaign works with communities at risk for polio. Through coordinated efforts, the Campaign provides vaccines along with food aid, sanitation and infrastructure projects. © WHO
The Emirates Polio Campaign works with communities at risk for polio. Through coordinated efforts, the Campaign provides vaccines along with food aid, sanitation and infrastructure projects. © WHO

On 9 September 2019, the Global Polio Eradication Initiative (GPEI) partners and the United Arab Emirates co-hosted an informal reception as a pre-event ahead of the Polio Pledging Moment in the United Arab Emirates’-hosted Reaching the Last Mile Forum in Abu Dhabi, in November 2019. The GPEI also presented the 2019-2023 GPEI Investment Case.

The reception brought together GPEI stakeholders including, Rotary International, His Excellency Obaid Saleem Saeed Al Zaabi, UAE Permanent Representative to the United Nations (UN), representatives from the UAE; WHO Director-General and Chair of the GPEI Polio Oversight Board, Dr Tedros Adhanom Ghebreyesus; partners, and representatives from donor countries.

Following the GPEI Endgame Strategy 2019-2023, which spells-out a comprehensive five-year plan to ‘finish the job,’ the 2019-2023 Investment Case presents an economic case for investing in polio eradication as an important public health cause. Committing to eradication and achieving the goal of reaching every last child with the polio vaccine, an estimated US$ 14 billion are expected in cumulative cost savings by 2050, with efforts to eradicate polio having already saved more than US$27 billion since 1988. The need of the hour now is a bold financial and political commitment from leaders, donors, and governments around the world to rally behind a polio-free future.

As the GPEI launches its new investment case for 2019-2023, it recognizes important stakeholders who have gotten the programme to where it is today. One of the most notable donors is His Highness Sheikh Mohamed bin Zayed Al Nahyan, Crown Prince of Abu Dhabi.

His Highness Sheikh Mohamed bin Zayed has been a critical partner and champion of the GPEI. His support has helped spur significant progress toward stopping polio in the remaining endemic countries, with a specific focus on strengthening immunization efforts in Pakistan and Afghanistan. In 2018, the GPEI was proud to announce that His Highness’ support for polio eradication activities through the GPEI and the UAE Pakistan Assistance Programme and helped deliver 417 million vaccines to protect some of the most vulnerable and hard-to-reach children in the highest risk districts across the country.

WHO-DG and Chair of the GPEI Polio Oversight Board, Dr Tedros Adhanom Ghebreyesus, sharing a candid moment with His Excellency Obaid Saleem Saeed Al Zaabi, UAE Permanent Representative to the United Nations (UN). ©WHO
WHO-DG and Chair of the GPEI Polio Oversight Board, Dr Tedros Adhanom Ghebreyesus, sharing a candid moment with His Excellency Obaid Saleem Saeed Al Zaabi, UAE Permanent Representative to the United Nations (UN). ©WHO

 

Starting off the reception, His Excellency Obaid Saleem Saeed Al Zaabi, UAE Permanent Representative to the United Nations (UN), gave insight into the UAE’s long-standing commitment to polio eradication efforts: “UAE, together with its partners, has played a leading role in polio eradication, has supported the delivery of vaccines to protect over 16 million children…and supported polio outbreak efforts in Afghanistan, Pakistan, Somalia, Ethiopia, Kenya and Sudan. For the implementation of the GPEI Endgame Strategy 2019-2023, which aims for a world free of wild poliovirus, the UAE in cooperation with the WHO will host a pledging event in Abu Dhabi in November 2019.”

WHO Director-General and Chair of the GPEI Polio Oversight Board, Dr Tedros Adhanom Ghebreyesus, also recognized the strong political and financial will of the donors —spanning over decades— which have helped the GPEI mark important milestones on the road to global polio eradication. “We have made good progress in accessing hard-to-reach communities…increasing cross-border efforts, enhancing surveillance, improving Supplementary Immunization Activities (SIAs), and focusing on social and behavioural change.”

“Unfortunately, we have seen an increase in the number of cases this year. This is a reminder that polio eradication is not a forgone conclusion…the last mile is the hardest. This will take a determined and unrelenting effort from all of us. Global progress to end polio would not be possible without partners like the UAE. On behalf of our partners at the GPEI, I would like to thank His Highness, Sheikh Mohammed bin Zayed Al Nahyan, Crown Prince of the Emirate of Abu Dhabi, and the UAE – a long-time supporter of the polio programme – for agreeing to host the GPEI pledging event on 19 November.”

Judith Diment, Chair of Rotary International Polio Eradication Advocacy Task Force, presenting the GPEI 2019-2023 Investment Case. © WHO
Judith Diment, Chair of Rotary International Polio Eradication Advocacy Task Force, presenting the GPEI 2019-2023 Investment Case. © WHO

Rounding off the event, Chair of Rotary International Polio Eradication Advocacy Task Force, Judith Diment, officially presented the GPEI 2019-2023 Investment Case and called for concerted global efforts —both political and financial­— to ensure that the hard-won gains in the fight against polio see us through the finish line. “Building on past progress and overcoming remaining hurdles requires continued support and (polio eradication) is a sound value-added investment. Today, we are proud to present the new 2019-2023 GPEI Investment Case…and thank all our partners for their input. This support and engagement are invaluable, given that this is a document that argues that polio can be eradicated but only with sufficient financial and political support. To ensure success, the Initiative needs US$ 3.27 billion through 2023… any investor is looking for measurable progress, tangible dividends, and return on investment— the GPEI has all of these. Rotary looks forward to joining all partners to make a funding pledge in Abu Dhabi, and to continued collaboration towards the fulfilment of a polio-free world from which we will all reap the dividends in perpetuity.”

The informal reception serves as a pre-event to the Reaching the Last Mile (RLM) Forum in November 2019, which will convene global health leaders to find solutions, best practices and eradication strategies to the most pressing health concerns of our times, including the global eradication of poliovirus. On the sidelines, the GPEI will also be hosting the Polio Pledging Moment to secure funding for the implementation of the Polio Endgame Strategy 2019-2023.

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Exciting research is underway on a novel oral polio vaccine for type 2 polio (nOPV2), which – if further trials are successful – could be a potential new tool to provide the same level of protection against poliovirus as the current oral polio vaccine (OPV), but without the same risk of mutating into vaccine-derived poliovirus in under-immunised populations.

Results from a phase I study to test two nOPV2 candidates were published in The Lancet in early June 2019. The study, led by the University of Antwerp in partnership with a global consortium of researchers and funded by the Bill & Melinda Gates Foundation, was conducted in 2017 at a unique container park named “Poliopolis” at the University of Antwerp. To test the vaccine, 30 individuals volunteered to spend a month living in the container park – complete with private, air-conditioned rooms, a lounge area and foosball table, fitness room, dining area, daily schedules of entertainment, exercise and health check-ups.

Construction of the Poliopolis “container park” in Antwerp. © University of Antwerp
Construction of the Poliopolis “container park” in Antwerp. © University of Antwerp

The initial findings from this study are promising, showing that the two vaccines tested at Poliopolis are safe and produce the immune response needed to protect individuals against polio. Results from phase II trials are expected in the coming months, which is when the program will learn whether nOPV2 is a tool that can ultimately be deployed for children at risk of poliovirus transmission.

About nOPV

The nOPV2 vaccine candidates were designed by a consortium of scientists from the UK National Institute for Biological Standards and Control (NIBSC), the US Centers for Disease Control and Prevention (CDC) and the University of California, San Francisco (UCSF), and manufactured by Bio Farma – with several other institutions playing key roles in the development process. Current clinical trials testing the vaccine candidates are taking place in Belgium and Panama. If ongoing and future trials are successful, nOPV2 could be kept in stockpiles and used in case of a VDPV2 outbreak in the near future or after eradication. This would make it a potentially vital tool for keeping the world free of all forms of the poliovirus.

The interior of a study participant's room in Poliopolis. © University of Antwerp
The interior of a study participant’s room in Poliopolis. © University of Antwerp

OPV, which has been responsible for reducing the number of global polio cases by over 99% since the launch of the Global Polio Eradication Initiative (GPEI) in 1988, remains the best available tool to eradicate wild poliovirus. It is a safe and effective vaccine that will continue being used widely.

This exciting research on nOPV, however, is just one more way in which the GPEI has continued to innovate to overcome hurdles over the past three decades. We look forward to seeing the results of further research that will tell us if we can add this vaccine to our “toolbox” to protect all children from polio.

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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

“We had not seen vaccination teams in our community for a very long time. Sometimes we go for months without vaccinating our children, if we don’t take our children to the mainland to get them vaccinated”, says Mr. Atebakuro Oton George, a fisherman and father of five, residing in Minibie ward of Nigeria’s Bayelsa State.

A largely riverine state, Bayelsa accounts for over 60% of the delta mangrove of the Niger Delta. Many children here continue to miss their chances at life-saving vaccination, as transport is precarious in the tangle of creeks and rivers that crisscross the state. In 2018 a number of innovative strategies such as, immunization boats at sea and community engagement through the traditional hierarchy and sensitization activities, supported by World Health Organization (WHO) through the Government of Bayelsa were introduced to reach a wider net of children.

“Now on weekly basis, health workers brave the seas and visit our communities to vaccinate our children”, an elated Mr. George continues.

Subsistence farming and fishing are the mainstay of the local population’s economy and diet. Health services are provided by primary health care centers located within the island communities.

“The difficulty of accessing healthcare services is due to suboptimal and expensive coastal and waterway transportation from the distant communities to healthcare centers, hence, innovative strategies are being employed to reach the underserved and vulnerable population with vaccination and other health interventions especially during Supplemental Immunization Activities (SIAs)”, says Dr Edmund Egbe, WHO State Coordinator in Bayelsa.

To reach ‘missed’ children, community engagement activities to increase demand for immunization have been initiated to bolster willingness of caregivers to readily access the interventions even when in the middle of the river or the ocean. The successful implementation of the community engagement framework has resulted in high-level acceptance of immunization services in the State. From April 2018 to April 2019, over 169 836 children received vaccination.

A young child receiving polio vaccination. ©WHO/Nigeria
A young child receiving polio vaccination. ©WHO/Nigeria

Routine immunization coverage has improved remarkably: the first quarter RI Lot Quality Assurance Survey (LQAS)— a quarterly activity organized by the National Emergency Routine Immunization Coordinator Centre (NERICC) to assess routine immunization performance, reasons for non-immunization as well as efforts to improve uptake and utilization of RI in Nigeria—conducted in April 2019 indicate that the State is second best in the country. Previously, the State was ranked amongst others in the country as poor-performing from the last National Immunization Coverage Survey (NICS) conducted in 2016; this led to the inauguration of an emergency response committee in March 2018.

King Diete-Spiff, the Chairman and the ‘Amanayanbo’ of Town-Brass, in his meeting with the State Traditional Rulers Council said, “Sustaining the innovative strategies of vaccinating vulnerable populations will undoubtedly increase immunity against vaccine preventable diseases and reduce the mortality and morbidity rate in difficult to access communities”. He described the polio infrastructure in Bayelsa, supported by WHO and partners, as the bedrock of driving successful healthcare intervention at the grassroots.

Support for polio eradication and routine immunization to Nigeria through WHO is made possible by funding from the Bill & Melinda Gates Foundation, the Department for International Development (DFID – UK), the European Union, Gavi, the Vaccine Alliance, the Government of Germany through KfW Bank, Global Affairs Canada, the United States Agency for International Development (USAID), Rotary International and the World Bank.

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Reposted with permission from Rotary.org

Ready for a long day—vaccines are put in cold boxes as a part of the cold chain to reach as many children as possible in the door-to-door vaccination campaigns. © Rotary International.
Ready for a long day—vaccines are put in cold boxes as a part of the cold chain to reach as many children as possible in the door-to-door vaccination campaigns. © Rotary International.

From the epidemics in the 1950s to the 1000 cases per day in the 1980s, polio’s devastation has seeped across generations. That is, until Global Polio Eradication Initiative and anchoring partners, Rotary International, WHO, UNICEF, CDC, and most recently, the Bill & Melinda Gates Foundation, united efforts and resources to develop a comprehensive polio eradication infrastructure.

Ranging from cutting edge research to dedicated laboratories to community engagement to sewage sampling, the polio infrastructure is as widespread as it is comprehensive. With presence in over 200 countries, the polio programme is second to none, making it one of the largest public-private health partnerships in history.

While the polio eradication infrastructure helps get us closer to a polio-free world, did you know that it is also used to fight and protect against other diseases, too? Here are five examples of the polio infrastructure at work:

The cold chain 

The Oral Polio Vaccine (OPV) requires constant refrigeration and vaccine must be kept cool between 2-8 degrees, or it risks losing its effectiveness. This is no easy task in countries and areas where electricity is either unavailable or unreliable.

So, the programme developed what is known as a cold chain system — made up of freezers, refrigerators, and cold boxes — to allow polio workers to store the vaccine and transport it over long distances in extremely hot weather. In Pakistan, a measles immunization program now relies on the same system. With the help of the cold chain, Sindh province recently reached its goal of immunizing more than 7.3 million children against measles.

One of the biggest successes of the polio programme has been the ability to reach every last child, in part due to microplanning. ©WHO
One of the biggest successes of the polio programme has been the ability to reach every last child, in part due to microplanning. ©WHO

Microplanning

A critical component in immunizing more children against polio, especially in remote regions, is microplanning. A microplan allows health workers to identify priority communities, address potential barriers, and develop a plan for a successful immunization campaigns.

The workers collect as many details as possible to help them reach and vaccinate all the children. This strategy has helped keep India polio-free for five years. Now the Mewat district of India is using microplanning to increase its rates of vaccination against measles and rubella.

Surveillance

The polio surveillance system helps detect new cases of polio and determines where and how these cases originated. Environmental surveillance, which involves testing sewage or other environmental samples for the presence of poliovirus, helps workers confirm polio cases in the absence of symptoms like acute flaccid paralysis (AFP).

In Borno state in Nigeria, the AFP surveillance system is now being used to find people with symptoms of yellow fever and was one of many tactics used during a 2018 yellow fever outbreak that resulted in the vaccination of 8 million people.

Contact tracing

Since polio is a transmittable disease, health workers use contact tracing to learn who has come in contact with people who might be infected. Contact tracing was also critical to containing an Ebola outbreak in Nigeria in 2014. When a traveller from Liberia was diagnosed with Ebola, Nigerian officials were able to quickly trace and isolate the traveller’s contacts, helping prevent the disease from spreading further.

The polio programme is meticulous in making sure we reach every child in every corner of the world. ©WHO/Chad
The polio programme is meticulous in making sure we reach every child in every corner of the world. ©WHO/Chad

Emergency operations centres

An important part of the polio infrastructure that Rotary and its partners have built is the emergency operations centres network. These centres provide a centralized location where health workers and government officials can work collaboratively and generate a faster, more effective emergency response. The emergency operations centre in Lagos, Nigeria, which was originally set up to address polio, was adapted to handle Ebola, and it ultimately helped the country respond quickly to an Ebola outbreak. Only 19 Ebola cases were reported, and the country was declared Ebola-free within three months.

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Sample stool and sewage collection in environmental surveillance has improved polio surveillance sensitivity by allowing early virus detection. © WHO
Sample stool and sewage collection in environmental surveillance has improved polio surveillance sensitivity by allowing early virus detection. © WHO

From the gold standard of detecting and investigating cases of acute flaccid paralysis (AFP) to testing environmental samples from sewage collection sites, timelyand sensitive surveillance is key to locating and eradicating polio. And in the endgame to finish the job, closing all remaining gaps in detection and investigation capacity is critical.

Global Polio Eradication Initiative has developed Global Polio Surveillance Action Plan, 2018 – 2020 to help endemic, outbreak and high-risk countries measure and enhance the sensitivity of their surveillance systems. It provides new strategies that may be useful in improving detection of polioviruses, and is designed to increase coordination across field team, laboratory and information management staff.

Knowledgeable and skilled workforce is a priority for the success of AFP surveillance. © WHO
Knowledgeable and skilled workforce is a priority for the success of AFP surveillance. © WHO

The Action Plan outlines activities and indicators at the global, regional and country levels for all priority countries, centred around six core objectives to strengthen surveillance systems, and is anchored within the broader strategic framework of the GPEI.

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The Endgame Plan through 2018 brought the world another year closer to being polio-free. While we had hoped to be finished by now, 2018 set the tone for the new strategic plan, building on the lessons learned and mapping out a certification strategy by 2023. 2018 was also marked by expanded efforts to reach children with vaccines, the launch of innovative tools and strategies, critical policy decisions and renewed donor commitment to the fight.

Dr Tedros Adhanom Ghebreysus, WHO Director General and Chair Polio Oversight Board, administering polio drops to a young child in Pakistan. WHO/Jinni
Dr Tedros Adhanom Ghebreysus, WHO Director General and Chair Polio Oversight Board, administering polio drops to a young child in Pakistan. © WHO/Jinni

Cornering wild poliovirus

Circulation of wild poliovirus (WPV) continues in the common epidemiological block in Afghanistan and Pakistan. However, both countries steadily worked to improve the quality of their vaccination campaigns in 2018 through National Emergency Action Plans, with a particular focus on closing any immunity gaps to put the countries on track to successfully stop WPV in the near future. Given the priority on polio eradication, WHO Director General, WHO Regional Director for the Eastern Mediterranean and President, Global Development at Bill & Melinda Gates Foundation started off the new year with a four-day visit to meet the heads of state and have a first-hand experience of the on-the-ground eradication efforts in both the countries.

In August, Nigeria marked two years since detecting any WPV. With continuing improvements in access to the country’s northeast, as well as efforts to strengthen surveillance and routine immunization, the entire African region may be eligible for being certified WPV-free as early as late this year or early 2020. What’s more, the world has not detected type 3 WPV since 2012 and the strain could be certified eradicated sometime this year.

Program innovation

The programme is constantly developing new ways to more effectively track the virus, vaccinate more children and harness new tools to help end the disease for good.
In Nigeria and the surrounding region, health workers launched new tools to enable faster, more comprehensive disease surveillance. e-Surve, a smartphone app, guides officers through conversations with local health officials, offering prompts on how to identify and report suspected cases of disease. Then, with the touch of a button, responses are submitted to a central database where health officials can analyze and track outbreaks across multiple districts in real-time.

Beyond surveillance, health workers worked tirelessly to bring the polio vaccine to the remote communities of Lake Chad. Dotted with hundreds of small islands, the lake is one of the most challenging places on earth to deliver health services. Vaccinators must travel by boat on multi-day trips to deliver polio vaccines to isolated island villages, using solar-powered refrigerators to keep their precious cargo cool. In 2018, vaccination campaigns on the lake reached thousands of children for the first time – children who would otherwise have gone unprotected.

Lake Chad Polio Task Team wave to polio vaccinators and community members on Ngorerom island, Lake Chad. © Christine McNab/UN Foundation
Lake Chad Polio Task Team wave to polio vaccinators and community members on Ngorerom island, Lake Chad. © Christine McNab/UN Foundation

The programme also took important steps in developing new tools including, novel oral polio vaccine (nOPV), if studies show to be successful, could provide a safer form of OPV that provides the same level of protection without the small risk of vaccine-derived polio in under-immunized populations.

Battling circulating vaccine-derived poliovirus

In 2018, the Democratic Republic of the Congo, Niger, Nigeria, Papua New Guinea, Kenya, Somalia and Mozambique experienced outbreaks of circulating vaccine-derived polio (cVDPV). Although these cases are still rare – and only happen in places where immunity is low. The polio eradication initiative has two urgent tasks: eradicate WPV quickly as possible and stop the use of OPV globally, which in tandem will prevent new cVDPV strains from cropping up.

The program uses the same proven strategies for stopping wild polio in responding to cVDPV cases. These strategies, coupled with the rapid mobilization of resources on the ground, can bring outbreaks under control.

In December, an international group of public health experts determined that the 2017 cVDPV2 outbreak in Syria has been successfully stopped. This news follows 18 months of intensive vaccination and surveillance efforts led by the GPEI and local partners in conflict-affected, previously inaccessible areas. In Papua New Guinea, the programme carried out 100 days of emergency response this past summer and is continuing to vaccinate and expand surveillance across the country.

Bringing an end to ongoing cVDPV outbreaks remains an urgent priority for the program in 2019.

New policy decisions

At the World Health Assembly in May, Member States adopted a landmark resolution on poliovirus containment to help accelerate progress in this field and ensure that poliovirus materials are appropriately contained under strict biosafety and biosecurity handling and storage conditions. The programme also finalized a comprehensive Post-Certification Strategy that specifies the global, technical standards for containment, vaccination and surveillance activities that will be essential to maintaining a polio-free world in the decade following certification.

Recognizing the ongoing challenge posed by cVDPVs, the Global Commission for the Certification of Poliomyelitis Eradication (GCC) met in November and recommended an updated process for declaring the world polio-free. This plan will start with the certification of WPV3 eradication, followed by WPV1, and include a separate independent process to validate the absence of vaccine-derived polio.

Comprised of members, advisers, and invited Member States, the 19th IHR Emergency Committee met in November. The Committee unanimously agreed that poliovirus continues to be a global emergency and complacency at this stage could become the biggest hindrance. “We have the tools, we need to focus on what works, we need to get to every child,” commented Prof. Helen Rees, Chairperson of the Committee.  “The reality is that there is no reason why we should not be able to finish this job, but we have to keep at it.”  “We have achieved eradication of a disease once before, with smallpox,” Rees concluded.  “The world is a much better place without smallpox.  It’s now more urgent than ever that we redouble our efforts and finish this job once and for all as well.”

Six-year old Gafo was the first polio case in Papua New Guinea in decades, which prompted a national emergency and an outbreak response. © WHO/PNG
Six-year old Gafo was the first polio case in Papua New Guinea in decades, which prompted a national emergency and an outbreak response. © WHO/PNG

Spotlight on gender

In 2018, the GPEI took major steps in adopting a more gender-responsive approach and strengthening gender mainstreaming across its interventions. The GPEI Gender Technical Brief highlighted the programme’s commitment to gender equality and included a thorough analysis of various gender-related barriers to immunization, surveillance and communication.

The programme introduced new gender-sensitive indicators to ensure that girls and boys are equally reached with polio vaccines, to track the timeliness of disease surveillance for girls and boys, and to monitor the rate of women’s participation as frontline workers in the endemic countries. The GPEI continues to regularly collect and analyze sex-disaggregated data and conduct gender analysis to further strengthen the reach and effectiveness of vaccination campaigns.

Donor and country commitments

Throughout 2018, political leaders around the world voiced their support for the programme’s efforts, including Prime Minister Trudeau, WHO Director General Dr Tedros, Prime Minister Theresa May, His Highness Sheikh Mohamed bin Zayed Al Nahyan and His Royal Highness Prince Charles. Leaders demonstrated commitment by advocating for a polio-free world at various global events, including the G7, G20, CHOGM, and the annual Rotary Convention.

Donor countries made new financial contributions to the programme in 2018. Polio-affected countries also demonstrated continued political commitment to eradication efforts. The Democratic Republic of the Congo signed the Kinshasa Declaration committing to improve vaccination coverage rates in sixteen provinces throughout the country, and Nigeria approved a $150 million loan from the World Bank to scale up immunization services and end polio.

Looking ahead: 2019 and beyond

Over the last five years, the programme has been guided by the 2013-2018 Polio Eradication & Endgame Strategic Plan, helping to bring the world to the brink of polio eradication. This spring, the programme will finalize a new strategy –GPEI Strategic Plan 2019-2023– which will aim to sharpen the tools and tactics that led to this incredible progress. In 2019, the GPEI will also launch its first-ever Gender Strategy to further guide its gender-responsive programming and to increase women’s meaningful and equal participation at all levels of the programme.

Success in the coming years will hinge on harnessing renewed financial and political support to fully implement the plan at all levels, with our one clear goal in sight: reach every last child with the polio vaccine to end this disease once and for all. Echoing similar sentiments, Chairs of the effort’s main advisory bodies issued an extraordinary joint statement, urging all to step up their performance to end polio. 2019 may very well be the watershed year that the world will finally eradicate polio, thanks to the global expertise and experience over 3 decades.

Related resources

© GPEI

In an extraordinary joint statement by the Chairs of the main independent, advisory and oversight committees of the GPEI, the Chairs urge everyone involved in polio eradication to ensure polio will finally be assigned to the history books by 2023. The authors are the chairs of the Strategic Advisory Group of Experts on immunization (SAGE), the Independent Monitoring Board, the Emergency Committee of the International Health Regulations (IHR) Regarding International Spread of Poliovirus and the Global Commission for the Certification of the Eradication of Poliomyelitis (GCC).

The Endgame Plan through 2018 has brought the world to the brink of being polio-free.  A new Strategic Plan 2019-2023 aims to build on the lessons learned since 2013.

The joint statement urges everyone involved in the effort to find ways to excel in their roles.  If this happens, the statement continues, success will follow.  But otherwise, come 2023, the world will find itself exactly where it is today:  tantalizingly close.  But in an eradication effort, tantalizingly close is not good enough.

The statement therefore issues an impassioned plea to everyone to dedicate themselves to one clear objective:  to reach that very last child with polio vaccine.  By excelling in our roles.  It means stepping up the level of performance even further. It means using the proven tools of eradication and building blocks that have been established in parts of the world that have been free of polio for years.

The Chairs remind us that as a global community, we have stood where we stand today once before, with smallpox.  And we achieved the eradication of smallpox.  And the world is a much better place without smallpox.

So, let us make the world again a better place. Together. Let us eradicate polio.

A nomad child is vaccinated against polio in Lower Juba, Somalia.
A nomad child is vaccinated against polio in Lower Juba, Somalia. © WHO/EMRO

Since polio was confirmed in Somalia in late 2017, health authorities have led a complex response to twin outbreaks of circulating vaccine-derived poliovirus type 2 and type 3 (cVDPV2 and cVDPV3), paying special attention to high-risk populations: nomads, internally displaced people (IDPs), and people living in peri-urban slums and rural areas.

So far, five of Somalia’s 12 infected children are from nomadic communities, and another four are from internally displaced families living in urban areas. To boost immunization among eligible children in these populations, vaccination activities have placed a special focus on reaching these communities.

Somalia has a rich culture of people leading pastoral lifestyles, raising livestock and moving with them as the seasons and the weather change. Nomadism has a long history in Somalia and nomads have a special place in Somali society: almost a third of Somalia’s people are nomads. However, they do not observe formal international borders – just like the poliovirus.  For health workers, this context poses a significant challenge: How can you be sure you have vaccinated every last child when so many children are on the move?

For health workers, this means searching for polio symptoms in more than 900 health facilities across the country, as well as nutritional centres, camps for  IDPs, and key sites along Somalia’s borders. At transit points, along borders and at water collection points, polio teams work to vaccinate children moving in and out of areas experiencing conflict or with limited access to health services. In high-risk areas, the Somali Government, WHO and UNICEF hire local vaccinators – people known and trusted by their communities – and when additional security is necessary, polio partners provide it.

Gaining high-level political goodwill

Even in an emergency, cross-border collaboration is not always easy to come by. In the Horn of Africa outbreak, regional collaboration moved into high gear in September, when health ministers from across the region and representatives from the Intergovernmental Authority on Development (IGAD) countries came together in the Kenyan town of Garissa to reiterate their commitment to ending polio.

One of the event’s key messages was around the risks posed by the easy and frequent mobility of communities across borders. Kenya’s national polio immunization ambassador, former UN Person of the Year and polio survivor, Harold Kipchumba, spoke directly to the pastoral communities in the region.

Kipchumba highlighted their focus on vaccinating animals, and urged parents in these communities to use the same vigour to vaccinate their children against polio, so they are able to serve as future herders for their families.

A regional response to support high-risk populations

The Technical Advisory Group, an independent body of experts that monitors outbreaks and offers guidance, recommended that countries in the region strengthen their coordination. In response, the Horn of Africa Coordination Unit coordinates joint responses among HoA countries – work that includes monitoring current outbreaks, and collaboratively planning, mapping, conducting immunization campaigns and communicating with various audiences. This ensures that countries work together in partnership rather than in silos, viewing the outbreak as one epidemiological block.

At regional and district levels, teams have spent the last few months building records of every settlement in their area, by lifestyle (nomad, IDP, peri-urban slums, rural). The highest priority: locating special populations – internally displaced persons, refugees, nomadic families, people living in informal settlements in urban areas and communities living in access-compromised areas – in order to reach them with vital polio vaccine.

Vaccinators at work in a camp for internally displaced people (IDPs). © UNICEF/Somalia
Vaccinators at work in a camp for internally displaced people (IDPs). © UNICEF/Somalia

Using technology to reach more children

A vital step in reaching more children, particularly those on the move, has been to move away from paper records and use electronic tools to collect data on children reached and missed during campaigns. This gives data specialists and decision-makers timely, accurate information, allowing them to analyze data in real time and flag areas with where high numbers of children are missed, so teams can revisit these households the following day.

Getting vaccines to the doorstep is not the only challenge for polio eradication teams in Somalia. Parents and caregivers also need information to ensure their children are vaccinated – something Kipchumba spoke to. On rare occasions, vaccinators meet families unconvinced of the need for vaccinations, particularly when the family has a newborn child or a sick child. In the lead up to every campaign, teams of social mobilizers, sometimes joined by influential Islamic leaders or scholars, visit communities to alert them of dates of polio immunization campaigns and the benefits of vaccination. Here, too, special attention is paid to nomadic communities, as polio teams liaise with elders from these communities in order to learn more about these communities and their needs, and to inform community members in appropriate ways about immunization dates and benefits of vaccination.

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What is polio surveillance?

One of the most challenging aspects of polio eradication is timely disease surveillance: knowing where the poliovirus is lurking, so we can roll out targeted immunization activities quickly and effectively. With new tools, eradicators are getting the information they need in real time.

For the past three decades, there have been two approaches to find polio: passive and active surveillance. Passive surveillance involves health workers routinely reporting cases of acute flaccid paralysis (AFP) as they find them in health facilities. Active surveillance takes place where there is a higher level of concern that polio might be present. Experts go to hospitals, clinics and even community healers to search out cases of AFP. This approach, often called active case searching, reduces the risk that cases are missed due to human error – people forgetting to report AFP or health care workers or community healers not knowing that they need to report the case.

However, in active case search the key steps of detecting, reporting and investigating the case might not always be happening consistently in all health facilities. There can be a delay of two months or more between a child being paralyzed, experts finding out and alerting the polio surveillance system. In an outbreak setting, this can be long enough for the virus to infect and paralyze more children, moving from one area to another. There was an obvious need to make the surveillance system even more reliable and time-sensitive to ensure the polio surveillance framework is as robust as ever.

Never missing a beat again

©WHO EMRO/Sara Williams
With the Integrated Surveillance and Routine Immunization Supervision system, surveillance officers use an app on their mobile phones to document active case searching as it happens, by tagging the location of every healthcare facility they visit and check.

In order to ensure that active search is conducted timely  with real time evidence the polio surveillance systems in Kenya, Ethiopia, Uganda, Eritrea, South Sudan, and Tanzania have adopted an easy-to-use, portable disease surveillance monitoring tool. It delivers unprecedented accuracy across huge areas. The best bit? Most people already have the basic component in their pockets: their mobile phones.

The tool is known as Integrated Surveillance and Routine Immunization Supervision. The idea is simple: surveillance officers use an app on their mobile phones to document active case searching as it happens, by tagging the location of every healthcare facility they visit and check.

“This provides real-time monitoring in the field. Previously, officers would report having done active case searching after the fact – like, ‘I was here and I did x, y, z’. But this is vulnerable to human error in remembering accurately. Sometimes, before we introduced it, someone would go to a distant, rural area and not be able to pinpoint their location on a map for others to follow up. Now, we are sure we are not missing things.” said Christopher Kamugisha, WHO’s Horn of Africa Outbreak Coordinator.

©WHO EMRO/Sara Williams
The map that is generated at the national level allows public health experts responding to the polio outbreak the opportunity to see where the gaps in surveillance for polio are in real time.

The app guides surveillance officers through a checklist (questions cover resources available at the facility, polio, measles and routine immunization) that they fill out and send then and there, using their mobile phones, even without an internet connection. It can also provide on-the-spot data analysis so that the surveillance officer can take immediate, evidence-based action.

With a swipe of the screen, users marry surveillance findings to the facility’s location and send the information to a centrally generated map. This gives staff at the national level a clearer picture of where surveillance is working and where it is not, including data on where possible polio cases are, so they know where to direct extra resources.

It also means health workers actively searching for AFP do not have to spend extra time ensuring the information gathered in the field is being shared with the right people for them to take action. For the ongoing outbreak of circulating vaccine-derived poliovirus in the Horn of Africa, this means better disease surveillance – and a better chance to protect children against polio.

Dr Adele Daleke Lisi Aluma speaks to Robert about the symptoms of measles, polio, and other vaccine-preventable diseases. His answers are recorded using a smartphone app, and transmitted to a central database. © WHO/ Darcy Levison

Nine hours away from the nearest large town, Dr Adele Daleke Lisi Aluma speaks to Robert, who manages a small health clinic on an island in the Lake Chad Basin. With paperwork spread around them, she listens carefully he responds to each question: Can you tell me how to recognise the symptoms of a potential polio case? Can you show me the records of any measles cases since I last visited?

In the past, she would be writing down details of the disease surveillance system in this village in a notebook, spending time later typing up her notes, and emailing them to a central database. Today, thanks to the introduction of an electronic surveillance approach for active surveillance and monitoring of disease outbreaks, she inputs Robert’s answers directly into an app, allowing for quick, accurate, and up-to-date data collection.

Hundreds of kilometres away in Nigeria, on the other side of the basin, surveillance officer Dr Namadi Lawal also feels the difference that innovative application-based technology has made to operations. For years, his employer, the National Primary Health Care Development Agency, depended on paper-based recording methods.

When the World Health Organization introduced the electronic surveillance (e-Surve) approach, Dr Namadi discovered he was receiving far more accurate information in real time, making his work to defeat the poliovirus more efficient.

“e-Surve is such a wonderful innovation. I can only imagine how much more accurate data I would have collected in a fast and effective manner if I had adopted this approach long time ago,” he says.

© WHO/ Darcy Levison
Using application-based technology, conversations with health workers in the field are guided by a simple questionnaire, which improves the quality and consistency of data collection. © WHO/ Darcy Levison

The e-Surve approach involves the use of a smartphone application to ensure that health workers know what symptoms they should be looking for and how to report suspected cases of vaccine-preventable disease.

After using the application to guide their conversations with health workers, disease surveillance and notification officers send the results of the questionnaire to a central database, where the data can be analysed and sorted by health district.

This is one way to keep track of an outbreak response that covers areas of five different countries, all with their own unique health challenges.

“This is remarkable progress as it shows where we can actually reach for surveillance”, said Dr Isaac Adewole, Nigeria’s Minister of Health, as he was presented with a dashboard of e-Surve during the recent opening ceremony of the African Regional Certification Commission in Nigeria.

New technology helps to reduce outbreak risk

This innovation is particularly important as when cases of disease are not properly reported, an outbreak can be in full swing before a country even realises that there is a problem.

Active disease surveillance, where officers physically go out to communities to speak to health staff and parents, is proven to increase case detection rates. There are hundreds of these frontline workers spread out across the Lake Chad Basin, each conducting multiple visits every month. Before mobile technology, the outcomes of these visits were cumbersome to track, time consuming to catalogue, and difficult to analyse for a prompt response.

Real-time reporting stems the spread of diseases

With e-Surve, governments and partners in the polio programme and other health programmes can easily see trends, track data, and take action. This encourages a preventive approach to disease outbreaks rather than a reactive one.

Dr Isaac Adewole, Nigeria’s Minister of Health, views a dashboard of e-Surve during the recent opening ceremony of the African Regional Certification Commission in Nigeria. With government commitment, the polio eradication programme is getting closer to closing the outbreak. © WHO/ AFRO

In Nigeria, as of May 2018, about 18 840 active surveillance visits to health facilities had been made using e-Surve technology: as a result, over 3000 suspected cases of vaccine-preventable diseases – previously unreported from health facilities – were identified and investigated.

 

Strong support from government 

Behind the new technology stands commitment from governments, communities, and partners to close the polio outbreak response. Dr. Sume Gerald at the WHO Nigeria office, states that “e-Surveillance in Nigeria is government-led and driven, supported by WHO.”

Through innovation, determination, and commitment at all levels, those working to end polio are getting ever closer to their goal.

A child is vaccinated with fIPV during a campaign in Hyderabad, India. © WHO/Harish Verma
A child is vaccinated with fIPV during a campaign in Hyderabad, India. © WHO/Harish Verma

A new study published this month in the Journal of Infectious Diseases has shown that a single dose of fractional dose inactivated poliovirus vaccine (fIPV) boosts mucosal immunity to a similar degree as a full dose of IPV, in children previously immunized with oral polio vaccine (OPV). During the current IPV shortage, this vaccine is not recommended for outbreak response, however, if it is used, then this finding provides further evidence in support of fIPV rather than full dose IPV at a time of IPV global supply shortage.

The efficacy of fIPV in boosting humoral immunity (offering individual protection against paralytic disease) in comparison to full-dose IPV had already been established, and this dose-sparing approach for routine immunization programmes was subsequently recommended by the Strategic Advisory Group of Experts on immunization (SAGE). Thanks to an increasing number of countries adopting this approach, including Bangladesh, India, Nepal, Sri Lanka, Cuba and Ecuador, there have been significant improvements in the global supply of this vaccine.

These latest findings show that fIPV also has a significant role to play in outbreak response. Mucosal immunity is needed to interrupt person-to-person spread of the virus in a community, so is a critical factor in outbreak response. Used in conjunction with OPV, even a single dose of this formulation could now play a key role in such settings, by rapidly boosting mucosal immunity at a similar level to a full-dose IPV while using a fifth of the vaccine amount. This has clear benefits both on cost and supply.

“Globally, demand for IPV is high and the supply is constrained,” commented Dr Tahir Yousafzai from Aga Khan University in Karachi, Pakistan. “As polio eradication is gradually eliminating OPV, countries will eventually rely solely on IPV, further increasing demand. Fractional IPV can stretch the limited IPV supply and provide similar humoral and mucosal protection when compared to full-dose IPV in children vaccinated with OPV. In addition, it will play an important role in stopping poliovirus transmission, and hence help in the eradication of wild poliovirus and circulating vaccine-derived poliovirus.”

For the post-polio era, the Global Polio Eradication Initiative and its partners are continuing to explore new IPV approaches to ensure an affordable and sustainable supply following global polio eradication, including through the use of IPV vaccine manufactured from Sabin strains or non-infectious materials such as virus-like particles.

Additional information:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

By providing communities with clean water, Rotary International is helping to improve child health and reduce poliovirus spread. Those attending the opening of the sixth water filtration plant in Karachi included representatives from the World Health Organization, UNICEF, the Bill & Melinda Gates Foundation, Rotary International, Qatar Hospital, and community stakeholders. © WHO Pakistan
By providing communities with clean water, Rotary International is helping to improve child health and reduce poliovirus spread. Those attending the opening of the sixth water filtration plant in Karachi included representatives from the World Health Organization, UNICEF, the Bill & Melinda Gates Foundation, Rotary International, Qatar Hospital, and community stakeholders. © WHO Pakistan
Binta marks a girl’s finger with indelible ink after vaccinating her in Kano State, Nigeria. © WHO Nigeria
Binta marks a girl’s finger with indelible ink after vaccinating her in Kano State, Nigeria. © WHO Nigeria

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

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

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

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

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

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

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

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

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

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

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

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

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

Poliopolis is a 66-unit container village built by the University of Antwerp, Belgium, to house a polio vaccine clinical trial. © Ananda Bandyopadhyay / Bill and Melinda Gates Foundation
Poliopolis is a 66-unit container village built by the University of Antwerp, Belgium, to house a polio vaccine clinical trial. © Ananda Bandyopadhyay / Bill and Melinda Gates Foundation

Welcome to Poliopolis! You’ll spend the next 28 days in a container village to help us test a new polio vaccine. Poliopolis is equipped with all the amenities to make your stay comfortable: air-conditioned private rooms with workstations and sinks, a lounge area with a flat screen TV and foosball table, a fitness room with a variety of exercise equipment, and a bright, sunny dining area. Enjoy your stay!

Sounds like a scene from a science fiction story, right? But this is a real polio vaccine trial that took place in a parking lot at the University of Antwerp, Belgium in mid-2017. The study, funded by the Bill and Melinda Gates Foundation, evaluated two novel oral polio vaccine candidates. These vaccine candidates were developed by scientists from the US Centers for Disease Control and Prevention’s polio laboratory, the National Institute for Biological Standards and Control in the United Kingdom, and the University of California, in San Francisco, with support from the US Food and Drug Administration.

Once fully developed and tested, these new, more genetically-stable, live, attenuated vaccines will prove a critical resource to ensure global polio eradication.

Read more:

US Centers for Disease Control and Prevention – Welcome to Poliopolis

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

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

A bold sign in the camp for internally displaced persons makes it clear where people can come to be vaccinated against yellow fever. WHO/NIGERIA

As he climbs out of his car and walks across to the entrance of Bakassi camp for internally displaced persons in Borno, northern Nigeria, Dr Terna Nomwhange is met by a familiar sight. Standing at the gates, greeting a tired, dusty family laden with possessions, is a team of polio vaccinators. As families arrive at this sea of shelters following a long, hard journey, these people offering polio vaccines are the first sign that they have reached a place of protection.

Not only are families in northern Nigeria facing insecurity, a humanitarian crisis and the threat of polio, but since September they have also been at risk from an outbreak of yellow fever. By early January 2018, a total of 358 suspected cases had been reported in 16 states, with 45 deaths recorded for 2017. In Borno, the ongoing conflict means that the health infrastructure on the ground to respond to the outbreak is limited to local government and the polio eradication infrastructure.

At the camp gates, the polio vaccinators give two drops of vaccine into the mouth of every child; but they also tell the parents where to go to get their yellow fever vaccination. As Dr Terna, who works for the WHO Nigeria polio eradication programme, walks further into the camp, he catches sight of the distinctive blue that signifies the uniform of a polio volunteer community mobilizer. As she emerges from the door of a shelter, he hears her reminding the family within to get their children vaccinated against polio, but also for the whole family to be vaccinated against yellow fever.

With weakened health system in parts of north eastern northern Nigeria, the infrastructure that is already on the ground to stop polio is providing the volunteers needed to support the yellow fever vaccination campaign. More than eight million people are being targeted with yellow fever vaccines in the states of Borno, Zamfara Kwara and Kogi states in 2018.

Vaccinating adults

By providing both polio and yellow fever vaccinations, the polio infrastructure protects everyone – the young children vulnerable to polio, as well as the whole population at risk of yellow fever. WHO/NIGERIA

Regular polio vaccination campaigns reach children under five years of age with polio vaccines, as this age group is the most vulnerable to the virus. But reaching everyone between nine months and 45 years to protect them against yellow fever takes creative thinking. People who would not usually be vaccinated have to be mobilised to come to health clinics where they can receive that one shot of yellow fever vaccine that infers life-long protection.

This is where the polio infrastructure comes in. To prepare for the launch of the yellow fever vaccination campaign that took place at the beginning of February, polio experts supported the preparations by developing detailed microplans, mapping each community so that every individual can be vaccinated. Volunteer community mobilisers, well versed in educating communities about the risks of infection, used their skills to warn populations of the high mortality rates associated with yellow fever.

Surveillance

Volunteer community mobilizers for the polio programme spread awareness of the importance of polio and yellow fever vaccinations. WHO/NIGERIA

The polio surveillance system in Borno is already on high alert to identify any case of polio, even in conflict affected areas. “Surveillance remains everyone’s number one priority,” says Dr Terna. “While the polio infrastructure is doing everything it can to find any trace of polio, it is killing two birds with one stone by keeping an eye out for yellow fever as well. This is a win-win situation to stop both diseases.”

While surveillance focal persons move house to house, they are also raising awareness about the symptoms of yellow fever. When a potential case is found, the polio infrastructure is being used to collect blood samples and transport them to the national laboratory down the reverse cold chain, keeping samples at the correct temperature for testing.

Collaboration

Volunteer community mobilizers for the polio programme spread awareness of the importance of polio and yellow fever vaccinations. WHO/NIGERIA

“What makes this campaign special is not just the fact that the strong polio infrastructure is helping to control other diseases, but also that it underscores what can be achieved with intersectoral collaboration and partnership,” said Dr Wondimagegnehu Alemu, WHO Country Representative to Nigeria. “Without the polio eradication infrastructure, a campaign of this scale would not have been able to take place.”

“Everyone is pulling in one direction – the government, partners and volunteers within communities – to protect any and every vulnerable person against polio and yellow fever,” says Dr Aliyu Shettima, Polio Incident Manager at the Emergency Operations Centre (EOC) in Maiduguri.

 

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

Shokria, aged 4, displays her ink-stained finger to show that she has been vaccinated against polio. ©WHOEMRO 2016

In Afghanistan this year, staff from the non-governmental organization Care of Afghan Families collected 420 blood samples from children under 4 at the Mirwais Regional Hospital in Kandahar province. The aim? To find out whether polio vaccination campaigns have been reaching enough children, and whether the vaccines have been generating full protection against this paralysing disease. These ‘serosurveys’ showed that immunity in Afghanistan is high – and also identified where vaccination campaigns need to reach out further.

Whenever a polio vaccination campaign takes place, a purple dot of ink is painted onto the little finger nail of every immunised child to show that they have received the lifesaving vaccine. This data is collected and allows people to monitor the campaign and know exactly where children have been reached.

Now, with more children being vaccinated than ever before, the polio eradication programme needs to know more than how many children are being reached: we need specific data on where children are being missed.

Serosurveys testing for immunity

Serosurveys are simple tests of the serum in a child’s blood, which measures their immunity (or seroprevalence) to different diseases. The polio eradication programme uses this test to see what level of protection a child has against wild poliovirus types 1, 2 and 3, allowing them to assess whether the vaccination campaigns are reaching enough children, enough times, to give them immunity.

At the Mirwais Regional Hospital, the children tested were from a diverse range of provinces. Their results were sent to Aga Khan University for initial testing, and then sent for further analysis to one of the Global Polio Eradication Initiative partners, the US Centers for Disease Control and Prevention in Atlanta. Through mapping both where they live and their immunity results, scientists at both institutions helped polio eradicators to discover the areas where a child is at most risk of being missed by vaccination campaigns.

Serosurvey results can be crucial for planning campaign strategies – making sure that every last child is reached, no matter where they live.

Serosurveys help to map where at-risk children are living. ©WHOEMRO 2016

For Ondrej Mach, team lead for clinical trials and research in the WHO’s Polio Eradication Department, serosurveys “… are increasingly important for eradication efforts, allowing us to form an accurate picture of our progress so far, and the locations where we are being most effective.”

High immunity in Afghanistan

The Mirwais serosurvey proved that Afghanistan is closer than ever to eradicating polio, with more than 95% of children surveyed immune to wild poliovirus type 1, the virus type still circulating in some areas of Afghanistan, Pakistan and Nigeria, and more than 90% immune to type 3, which hasn’t been found anywhere in the world since November 2012. The tests also pointed to where gaps in immunity are, so that missed children can be found and protected.

These results are a strong reflection of the devoted work of polio vaccinators and community workers throughout the country, using their expertise to reach into every family, and spread awareness of the importance of polio vaccination.

Volunteer vaccinator Haji Mohammad inspects children from all over Kandahar, ensuring that no child is missed. ©WHOEMRO 2016

Using serosurveys in at-risk countries

As in Afghanistan, serosurveys are increasingly used in other countries where polio remains or poses a threat, to help identify the last remaining pockets of under-immunized children in high risk areas. This is especially important because with polio in fewer places than ever before, it is these unreached children that will take us over the finishing line.

By getting an increasingly accurate picture of where vaccination campaigns are operating successfully, as well as where the programme needs to renew efforts, we can move further towards the goal of reaching every child.

This helps us reach our ultimate goal – ensuring that every last child, everywhere, can be polio free.

Polio worker Imran Khan vaccinates a child at Karachi Cantonment Railway Station ©WHO/J. Muhammad
Polio worker Imran Khan vaccinates a child at Karachi Cantonment Railway Station ©WHO/J. Muhammad

Dressed in a blue uniform, carrying a vaccine carrier on his shoulder, Imran Khan is a polio vaccinator working at Karachi Cantonment Railway station. “I make sure no child under five travelling by train is missed during the immunization campaign,” he says. Apart from vaccinating children, Imran also sensitizes their parents on the importance of vaccination and threats posed by the crippling disease.

Vaccinating children inside trains is a unique initiative introduced in Pakistan’s Sindh province which is connected with the rest of country through a railway network that transports millions of people every day. Passengers include people travelling to visit family and communities living on the border between Pakistan and Afghanistan as well as seasonal migrants and displaced populations. With many of these people moving between areas where polio continues to circulate, the threat of the virus continuing to survive as it moves from place to place via this human network is one of the biggest challenges the programme is facing. Reaching children on the move with the polio vaccine is therefore critical for stopping the virus.

Currently there are more than 500 permanent transit points across the country, where vaccination teams work to vaccinate all children under the age of five as they cross district, provincial and national borders. The strategy to vaccinate children inside trains themselves was started in Pakistan’s Sindh province in January 2017. Since then, during each vaccination campaign, polio workers vaccinate children travelling on the popular rail route between Karachi and Hyderabad, Sindh’s two biggest cities, which was selected for the project implementation.

“During campaign days, I travel from Karachi to Hyderabad on a daily basis. Along with other team members, we visit all the train compartments to vaccinate each and every eligible child”, says Imran Khan with passion in his voice.

Team of vaccinators get on a train at Karachi Cantonment Railway station ©WHO/J. Muhammad

According to Dr Nawab Khan, High Risk Mobile Population coordinator with Pakistan’s Polio Eradication Initiative: “To maintain and increase population immunity against polio in Pakistan, reaching children through public transport routes is an effective outreach strategy. It plays an important role in interrupting the transmission of poliovirus and represents a great opportunity to vaccinate children missed during door-to-door immunization campaigns.”

More than 24 thousand children have been vaccinated inside trains running between Karachi and Hyderabad since the project started.

It is thanks to the use of innovative strategies such as this one that the Pakistan Eradication Polio Programme has come so close towards achieving a future in which polio no longer endangers children, families, and communities. The progress can be seen in the declining number of wild poliovirus (WPV) cases in Pakistan: from 306 cases in 2014, to 54 in 2015, and 20 in 2016. As of October 2017, the total number of WPV cases reported in Pakistan stands at five.