GPEI-Women Leaders in Polio Eradication: Dr. Alda Morais Pedro De Sousa

Dr. De Sousa has dedicated her career to ending polio in Angola. ©Alda De Sousa

From her first polio vaccination campaign in 1997 to the present day, Dr. De Sousa has never lost her passion for increasing access to immunization. The National Expanded Program on Immunization (EPI) Manager for Angola, she remembers her first impressions of the country, “At the time, I could see that most children in the country were not vaccinated and I was excited to help them.”

From the outset, she knew that taking on polio eradication would be challenging. “Angola had just emerged from an armed conflict and there were areas that were very difficult to access, due to dilapidated roads, broken bridges and mining activity, and for that reason there was low routine vaccination coverage. Nevertheless, I felt that I had a duty to fulfill for our children, so I accepted the challenge.”

In 1998, Dr. De Sousa was appointed by the National Directorate of Public Health to help implement the Epidemiological Surveillance System for Acute Flaccid Paralysis (AFP) – one of the primary symptoms of polio. It was a position that required grit and resilience.

She explains, “This was a big responsibility because highly sensitive surveillance for AFP, including immediate case investigation and specimen collection, are critical for the detection of wild poliovirus. AFP surveillance is also critical for documenting the absence of poliovirus circulation for polio-free certification.”

Dr. De Sousa speaks to a community member in Angola. ©Alda De Sousa

“One of my most vivid memories of the programme is from 1999 when I was trying to reach conflict-affected areas after a polio epidemic had registered more than 1190 cases and 113 deaths. I was early in my career with only two years of service and the sheer number of cases and deaths led me to be proactive and persistent in my day-to-day activities toward the eradication of the disease.”

“Another standout moment occurred on the second time that I went to coordinate a vaccination campaign in the province of Moxico; one of the vehicles in our convoy triggered a mine, so we were forced to stop the vaccination campaign as our colleagues were stranded in conflict zones for a few days. This incident captures the difficult circumstances we were operating in as health workers.”

Eradicating wild virus in Angola

For years the polio team worked to improve operations to detect polio and deliver vaccines, but the virus fought back. After registering a last case of indigenous wild poliovirus in September 2001, Angola recorded four successive outbreaks imported from India and Congo. Dr. De Sousa remembers that this caused many people to doubt that the eradication of polio would ever be possible.

“But I refused to be discouraged. I’ve never backed down from a challenge and I don’t plan to soon.”

After years of work, Angola finally received wild polio-free status in November 2015. Dr. De Sousa describes it as her proudest moment.

“I felt that I made a great contribution to my country and our children as the person managing the Extended Program on Immunization in Angola.”

A new challenge

In 2019, Angola’s immunization team faced a new challenge when the polio programme detected an outbreak of circulating vaccine-derived polio type 2, a type of polio that emerges in places with low immunity. Dr. De Sousa again found herself at the forefront of the action, starting by supporting the Government to respond with vaccination campaigns.

One of her key tasks since has been recruiting new immunization health professionals, who can help reach the children missed by routine immunization and polio campaigns. She explains, “my goal is to train my colleagues so that we can work together to reach the vast number of Angolan children missing out on lifesaving vaccines.”

In July 2020, Angola held its first polio campaign after a pause on vaccination activities in the early months of the COVID-19 pandemic. More than 1.2 million children were reached by over 4000 vaccinators.

Gender and leadership

Dr. De Sousa explains that being a woman leader in Angola isn’t easy. “It requires a lot of time, dedication and a balance with domestic, family, and social life, which has not been easy to manage. However, with the help of God and my family – especially my husband – I am managing to carry out my work.”

“It has all been worth it for the results I’ve helped to achieve, and even though we have some way to go in relation to vaccination coverage, I’m grateful for the opportunity to ensure the health of our children and serve my country.”

In Angola, at the provincial and municipal level, there are very few women compared to men. However, in public health programmes at the national level, women outnumber men. Dr. De Sousa says that, “In general, I think there should be more women leading and administering vaccination programmes”.

In 2021, the polio programme is aiming to implement more outbreak response vaccination rounds to reach children with low immunity to the poliovirus. Driven by her passion and sense of duty, Dr. De Sousa will continue to be on the frontlines of this effort.

In November:

1 case of Wild Polio Virus (WPV1) was confirmed
39,406,287 children were vaccinated during the November NIDs
One million children were vaccinated at 121 critical PTPs

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Health worker Saira Faisal vaccinates a child against polio in Saddar town, Karachi, in August 2020. ©UNICEF/Pakistan

With masks on their faces and sanitizers in their pockets, an immunization team makes their way through the narrow lanes of Lahore’s historic old city.

“Our children are like flowers and these anti-polio drives help them grow up healthy and strong,” says Zubair, who along with his colleague Afzal is part of Pakistan’s 260,000-strong frontline vaccinator workforce.

It is the second day of the National Immunization Days (NID) campaign, which launched on 21 September, and the third immunization drive after a four-month suspension of door-to door campaigns due to the risks associated with COVID-19.

After polio campaigns were stopped in March 2020, the number of polio cases in Pakistan continued to increase. An initial small-scale round of vaccinations resumed in July, when over 700,000 children were reached. A second round went ahead in August, where 32 million children were vaccinated across the country. In both campaigns, vaccinators took precautions to prevent the spread of COVID-19, including wearing masks and regularly washing hands.

Making their way from the crowded streets of Taxila Gate, the polio team reaches a historic cultural hub of Lahore city called Heera Mandi.

In this neighbourhood, the team knocks on one door after another. “Sister, do you have children under five at home?”, they say.

When the answer is yes, one of the vaccinators stands to the side while Zubair hands them a hand sanitizer. They all stand at a safe distance from each other, to remain compliant with COVID-19 safety measures, and to make sure the dual message of the necessary fight against both polio and COVID-19 reaches home.

Polio Worker Aliza Mukhtiyar Using Hand Sanitizer ©WHO/EMRO

Zubair says that since the resumption of immunization campaigns in Pakistan, parents have been more enthusiastic to ensure their children are vaccinated.

Next door, a Maulana (a religious cleric) answers. When he sees the polio team, he immediately goes back inside. Team members worry that he may reject the vaccine, but soon enough, he returns with his two children.

“Did you ever believe that the polio vaccination was a conspiracy?,” the Maulana is asked. In some parts of Pakistan, false rumours about the vaccine have damaged confidence in immunization, with sometimes devastating results for children subsequently infected with polio.

“No Sir, only a fool can think like that,” he replies.

Afzal, another member of the immunization team, says that he finds his work fulfilling because it allows him to directly speak to parents about polio and explain that they can give their children a healthy future by vaccinating them.

With a physical disability, Afzal often faces discrimination based on his health condition. He explains that this hasn’t prevent him from pursuing his ambitions.

“I never allowed my disability to become an obstacle. I completed my master’s degree while attending regular classes at college, and now I have been working with the polio programme for nine years.”

“If a family is hesitant during a polio campaign, I approach the parents,” he says. “I show the parents my polio-affected leg and ask them if they really want their child to have one too. This changes hesitation to acceptance.”

Health workers like Zubair and Azfal are working every day to achieve the dream of ending polio in Pakistan. With their effort and the efforts of thousands like them, the September campaign successfully reached over 39 million children across the country. These promising results, achieved during a pandemic, are a testament to an ongoing commitment to overcome challenges and move Pakistan closer to a polio-free future.

In August:

6 cases of Wild Polio Virus (WPV1) were confirmed – 2 from Kandahar, 2 from Hilmand, 1 from Uruzgan, and 1 from Khost
221 children with Acute Flaccid Paralysis (AFP) -96 girls and 125 boys – were reported.

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Dr Elaha prepares to head out for the day to educate communities on polio and COVID-19. ©WHO/Afghanistan

Dr Elaha, at 22 years old, is a medical graduate and a District Polio Officer. She’s also helping fight the COVID-19 pandemic in Afghanistan.

“COVID-19 has affected both our work life and personal life. When I joined the polio team, I had plans to take initiative and look for innovative ways to fight polio, however, with the COVID-19 pandemic all my plans were challenged,” she says. “Campaigns were postponed and the number of cases were on the rise.”

The temporary pause in polio vaccination campaigns, necessary to keep health workers and communities safe during the early months of the pandemic, led to a widened immunity gap in both Afghanistan and Pakistan, the only two countries that still harbour wild poliovirus. Now, polio teams are urgently working to close the gap while continuing their support to Afghanistan’s COVID-19 response. To ensure their safety, all polio personnel have been trained to take precautionary measures against COVID-19, including wearing masks correctly and regular handwashing.

Dr Elaha doesn’t underestimate the danger of her work to fight COVID-19. She explains, “I start my day at 8am by visiting private and public clinics, pharmacies, traditional healers at their homes. Of course, I am worried about myself and my family getting COVID-19. My mother is elderly, and COVID-19 can be dangerous for her.”

“However, I am committed to serve my people and go out in the field to help save others’ lives. It is not easy. My family understand that I am a medical doctor, so no matter what virus is there, I have to do my job as a doctor.”

Dr Elaha heads out for the day to educate communities on polio and COVID-19. ©WHO/Afghanistan

Through her work, Dr Elaha has come up against rumours and misinformation. A major part of both ending polio and fighting COVID-19 is working to inform and build trust with communities about diseases and how they can be prevented.

Elaha says, “A lot of people thought that COVID-19 was a disease of nonbelievers. At first, when I used to go to clinics, because of my medical degree, they respectfully listened to me. However, when I talked about COVID-19 and washing hands and other preventative methods, they would tell me that this disease was for nonbelievers.”

“Unfortunately, a lot of people got sick and many also lost their lives. People have started to believe the pandemic. They know that people can get sick and die of the disease.”

Although public awareness about the dangers of COVID-19 has improved, Dr Elaha believes there is still plenty to do to encourage communities to adopt disease prevention measures such as widespread mask wearing.

Until the pandemic is over, she is determined to work long hours to fight both polio and COVID-19. The polio workforce currently contributing to COVID-19 response includes almost 36,000 members of the Polio Surveillance Network, and over 47,000 polio frontline workers.

In August

32.1 million children were vaccinated during the SNID campaign.
24,747 children were vaccinated at Permanent Transit Points.

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Community Health Workers deliver polio vaccine in Pehlwan Goth in Karachi. ©PEI/2020

Welcome to Pehlwan Goth, Pakistan. A low-income neighbourhood on the edge of Karachi city, it is home to many families from Khyber Pakhtunkhwa province who have moved here for work.

An open sewage drain lined with litter runs the length of the settlement. Cattle are often seen grazing near the heaps of garbage. It is a high-risk area for polio, and virus is regularly detected in the environment.

Samreen, a 25-year-old Polio Area Supervisor, leads a team of four community health workers in the area.

“I started working with the Polio Eradication Programme four years ago and I am happy to say that we have made a lot of progress here. This is my neighbourhood; this is where I grew up and this helps me immensely. People here listen to me, especially the women, and I know most of the children by name,” says Samreen.

Converting refusals

There are around 32,000 children under five years of age in Pehlwan Goth. In April 2019, parents of around 3,000 children refused the polio vaccine. Through the hard work of supervisors like Samreen however, now over 80% of these children have received vaccines.

“I am in charge of an area that has 210 households with 196 children. In 2019, families of more than 50 children refused vaccines. That’s almost one fourth of all the children in my area,” said Samreen.

Samreen delivers polio drops to children whose parents initially rejected vaccination. ©PEI/2020

“Building trust takes time, and we continued engaging with community members, visiting families, listening to their concerns, and explaining the benefits of vaccination. Today, we have only eight refusal cases out of the previous 50. I will try my level best to bring this number down to zero during the polio campaign next month.”

“But for me, it is not just about just converting refusals during every campaign, I want all families to understand the benefits of vaccines in the long run and ensure the immunization of their children against polio and other diseases.”

Her rapport with families is apparent during house visits. A family with three children, who had refused vaccination in previous months, agreed that their children could this time receive the life-saving polio drops.

Confronting misconception

Building trust with the community has not been an easy task. Samreen is supported by a social mobilizer as well as a local religious support person. The team members work together to address misconceptions and raise awareness of good health practices among caregivers in Pehlwan Goth.

Samreen and Maulana Mohammad Hanif vaccinate the children of local resident Tayyab Khan. ©PEI/2020

“We speak the same language and our homes are in the same area where we work. It is easier to communicate with people when you are part of the same community,” said Maulana Mohammad Hanif, the religious support person in Samreen’s team.

Sometimes, however, it can take only one negative social media video or news item to reignite refusals and overturn all their efforts.

“The process takes time. The work is tough but I am grateful to Allah for this job, which allows me to feed my family, and contribute to a noble cause, which will save future generations of Pakistanis,” added Maulana Mohammad Hanif.

It’s clear that Samreen and her team will do whatever it takes to deliver a polio-free future to all 196 children in their care. Pakistan and Afghanistan are the final two polio endemic countries in the world and there are still many challenges that remain.

It is the local efforts of teams like Samreen’s that will make all the difference – by listening to communities, building trust and ensuring rapport, they are playing a crucial role to bring their country closer to ending polio.

During March, polio social mobilisers provided routine immunization referral services to over 37,000 children. ©UNICEF Afghanistan

In March 2020, polio social mobilisers from the UNICEF-run Immunization Communication Network (ICN) provided routine immunization referral services to over 37,000 children in southern and eastern Afghanistan.

The polio programme’s routine immunization efforts in Afghanistan have made important gains, especially in the country’s east, in the areas bordering Pakistan. Polio social mobilisers support mother and child health referral services, and help families keep track of their children’s health records. As the mobilisers are recruited from their community, they know the families in their neighborhood and can trace each child’s planned immunization schedule from birth.

It is critical that routine immunization continues throughout the pandemic to protect children from life-threatening diseases including polio. Polio mobilisers have found their work is even more valued during the COVID-19 response.

Masoud, a polio mobiliser, says ‘’I used to announce the immunization sessions through the Mosque but not all the targeted children were brought to the health facility. Now through the ICN support to routine immunization, the number of missed children has reduced due to tracking of every child in the community and coordinating with the health facility.”

“This is critical during the ongoing pandemic, as families are not sure if they can leave their homes to take their children to the health facility for immunization. The polio mobilisers are their guide in the community.’’

Part of Joana’s role as a nurse involves vaccinating children in Barangay 105 Happyland, Tondo, in the city of Manila. A vaccine-derived poliovirus outbreak was detected in the Philippines in 2019, and health workers are working to close a polio immunity gap present amongst some of the nation’s children. To successfully vaccinate children in Barangay 105 Happyland, the teams speak to community leaders, dodge traffic, and answer the questions of parents about the vaccine.

*This footage was recorded before the introduction of measures to reduce the spread of COVID-19 in the Philippines.

To find out more about the response, please visit WHO’s Polio Outbreak in the Philippines webpage

In March

17.2 million children were vaccinated during the SNID campaign.
0.9 million children were vaccinated at 371 Permanent Transit Points.

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Melissa Corkum with women polio workers of the Immunization Communication Network in Afghanistan. ©Melissa Corkum

In 2003, Melissa Corkum received a call that would change her life. The World Health Organization wanted to interview her for a position in their polio eradication team. Like most people who are hearing about polio eradication for the first time, the story compelled her, and she packed her bags to embark on a new adventure. Seventeen years later, she remains a dedicated champion of polio eradication.

A self-proclaimed ‘virus chaser’, Melissa has worked in all three polio endemic countries – Afghanistan, Pakistan and Nigeria. She found inspiration in her first field job in Nigeria, where she realized the scale of the polio eradication programme and that she was a part of something tremendous in public health history.

“I was amazed and inspired when I first saw the efforts of the front-line workers delivering vaccines to the doorstep. It may seem simple to deliver a couple drops into a child’s mouth, but when you see it in motion for the first time, it is truly remarkable,” Melissa said.

To this day, Melissa remains in awe of the work required to make ‘reaching every child’ possible. From mobilizing financial resources, to getting vaccines where they need to be while keeping them cool. From the microplanning to ensure all children and their houses are on a map, to the mobilization of champions in support of polio and immunization. Along the way, the stewards of these processes play an essential role to deliver the polio vaccine.

Melissa has worn many hats during her time in polio eradication, but her current role may be the most challenging yet. As the Polio Outbreak Response Senior Manager with UNICEF, she must answer the formidable challenge of containing outbreaks, using her expertise to inform global policy, strategy and operations.

To do this Melissa spent 80% of her time in the field prior to the outbreak of COVID-19, working with partners of the Global Polio Eradication Initiative (GPEI), Ministries of Health and local health workers.

Her work is a mix of challenge and excitement – the challenges of containing outbreaks, including those affected by the COVID-19 emergency – and excitement in developing new tools and methods to overcome the evolving challenges that present barriers to eradicating polio.

“There is never a dull day no matter what hat you may be wearing within this programme. If we are going to put an end to polio for good, we are going to have to fight the fight on a number of fronts – endemics and now the emerging issue of outbreaks in a post-COVID world,” said Melissa.

“The key is a willingness to do whatever it takes to get the job done.”

At times, Melissa felt the weight of the enormous challenges to eradicate polio, especially during her time in Afghanistan, where protracted conflict has complicated efforts to deliver basic services to the most vulnerable. Melissa often reflects on her time as Polio Team Lead there and the emotional rollercoaster she faced trying to stay ahead of the virus, while watching the tragedy of war unfold in the country.

“But when I felt down, I would pick myself up and get ready to face the next challenge. I found hope and inspiration in the resilience of the Afghan people, especially the women who worked in the polio programme, risking their lives and demonstrating a courage that stood out amidst all the difficulties.”

“It is so inspiring to be part of something tangible and something that is completely possible if we commit ourselves to doing everything possible to find every last child”. ©Melissa Corkum

Melissa sees gender as one of the keys to polio eradication. She firmly believes that the only way to tighten the gaps in the system is by involving and empowering women equally in all roles across the programme, and that the only way to reach every child is to ensure their caregivers are equally informed and engaged in the decision making process.

“Unless we involve more women in the programme in certain corners of the world, we will continue to reach the same children and miss the same children, making polio eradication ever more difficult,” Melissa said.

“Change won’t happen if we don’t change the way we think about involving women. We need to listen to their views and open the doors for more women to join and participate equally from the community level and all the way to the leadership, decision-making level.”

Melissa was born in a small town in Nova Scotia, Canada. Her views on the critical involvement of women and gender equality in the polio programme very much align with her government’s Feminist Aid Policy. The Government of Canada has been a long-time champion of polio eradication and recently generously pledged C$ 190 million to assist the GPEI achieve its objectives of polio eradication.

Greater gender equity is one of the legacies that the polio programme is working to leave behind after eradication. Reflecting on her career, Melissa explains what keeps her working to defeat polio after all these years.

“It is so inspiring to be part of something tangible and something that is completely possible if we commit ourselves to doing everything possible to find every last child”.

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A polio worker administering the life-saving polio drops to children in Pakistan © WHO/EMRO

In the midst of the COVID-19 pandemic, it is more critical than ever to recognize the power and importance of vaccines, which save millions of lives each year. Canada, the first government to contribute to the global effort to eradicate polio in 1986, has announced new investments to support immunization. Alongside renewed funding for Gavi, the Vaccine Alliance, the Honourable Karina Gould, Canada’s Minister of International Development, committed C$ 47.5 million annually over four years to support the Global Polio Eradication Initiative’s Endgame Strategy.

Due to widespread polio vaccination efforts over the past 30 years, more than 18 million people are walking today who would otherwise have been paralyzed, and cases have dropped by 99.9% thanks to the tireless efforts of health workers, local governments and global partners. The GPEI is proud to count on generous donors, including Canada, who have helped make this progress possible. This new investment will help the programme ensure gains made to date are not lost, resume activities as soon as it is feasible, implement strategies to overcome the remaining barriers to eradication, and further the dream of a polio-free world.

Minister Gould stated: “As a global community, we must work to ensure that those most vulnerable, including women and children, have access to vaccinations to keep them healthy wherever they live. COVID-19 has demonstrated that viruses do not know borders. Our health here in Canada depends on the health of everyone, everywhere. Together, we must build a more resilient planet.” The Minister added “The world has never been closer to eradicating polio, but the job is not done. With continued transmission in Afghanistan and Pakistan, we cannot afford to be complacent.”

Frontline polio workers in countries around the world are currently supporting the COVID-19 response, using networks established by the GPEI to focus on case detection, tracing, testing and data management. The G7 and the G20, including the Canadian Government, have recognized the important role GPEI assets play in strengthening health systems and advancing global health security, especially among the most vulnerable populations of the world.

In line with its feminist international assistance policy, Canada has encouraged the GPEI to build on the important role played by women in the programme, from the front lines to programme management and political leadership.

Akhil Iyer, Director of the Polio Eradication Programme at UNICEF said, “The new funding from the Canadian government is a testament to the major role played by the Canadian people in the historical fight against polio, and I am proud to be part of this endeavour as a Canadian citizen myself. Back in the 1950’s in Canada, poliovirus outbreaks could have paralysed or killed so many more children, and could have plagued the economy and pushed millions in vicious circles of poverty and ill health. But thanks to the scientific breakthrough of Dr. Leone Farrell who made mass production of polio vaccines possible, strong leadership and a learning health system, Canada was able to overcome the polio outbreaks and thrive during the following decades. It is more inspiring than ever, as we strive together to end polio from the world for good.”

Rotary clubs throughout Canada welcomed the new pledge as a continuation of the country’s leadership and partnership to end polio. Canada has worked closely with Rotary clubs in Canada since 1986 when Canada became a donor to GPEI. To date, Canadian Rotarians have raised and contributed more than US$ 41.3 million to eradication efforts.

Michel Zaffran, Director of the Polio Eradication Programme at the World Health Organization said, “I would like to express the profound gratitude of the GPEI partners to the Government and to the citizens of Canada for their tremendous support and engagement to end polio globally. The pandemic we are facing today is a stark reminder of the critical need for solidarity at all levels, international cooperation and of the power of vaccines and immunization. Canada is walking the talk: it is demonstrating once more its exemplary commitment to ensuring access to essential vaccinations, leading efforts to advance gender equality and reducing the burden of infectious diseases.”

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The Friendship Gate (R) and Torkham (L) are two of the Pakistan-Afghanistan border crossings where all-age polio vaccinations are carried out. ©WHO/Pakistan.

On both sides of the historical 2640-kilometre-long border between Pakistan and Afghanistan, communities maintain close familial ties with each other. The constant year-round cross border movement makes for easy wild poliovirus transmission in the common epidemiological block.

All ages and all genders: polio vaccines are for all travellers crossing the Pakistan-Afghanistan border. ©WHO/Pakistan

As a new tactic in their joint efforts to defeat poliovirus circulation, Afghanistan and Pakistan have introduced all-age polio vaccination for travellers crossing the international borders in efforts to increase general population immunity against polio and to help stop the cross-border transmission of poliovirus. The official inauguration of the all-age vaccination effort took place on 25 March 2019 at the border crossings in Friendship Gate (Chaman-Spin Boldak) in the south, and in Torkham in the north.

Although polio mainly affects children under the age of five, it can also paralyze older children and adults, especially in settings where most people are not well-immunized. Adults may play a role in poliovirus transmission, so ensuring that they have sufficient immunity is critical to simultaneously eliminating poliovirus from the highest risk areas on both sides of the Pakistan-Afghanistan border.

This is particularly important at the two main border crossing points – Friendship Gate and Torkham – given the extensive amount of daily movement. It is estimated that the Friendship Gate border alone receives a daily foot traffic of 30 000. Travellers include women and men of all ages, from children to the elderly.

Pakistan and Afghanistan first increased the age for polio vaccination at the border in January 2016, from children under five years to those up to 10 years old. The decision was in line with the recommendations of the Emergency Committee under the International Health Regulations (IHR) which declared the global spread of polio a “public health emergency of international concern”,

The all-age vaccination against polio at the border crossings serves a practical implementation of another recommendation of the IHR Committee: that Pakistan and Afghanistan should “further intensify crossborder efforts by significantly improving coordination at the national, regional and local levels to substantially increase vaccination coverage of travelers crossing the border and of high risk crossborder populations.”

As part of the newly introduced all-age vaccination, all people above 10 years of age who are given OPV at the border are issued a special card as proof of vaccination. The card remains valid for one year and exempts regular crossers from receiving the vaccination again. Children under 10 years of age will be vaccinated each time they cross the border.

Before all-age vaccination began at Friendship Gate and Torkham, public officials held extensive communication outreach both sides of the border to publicize the expansion of vaccination activities from children under 10 to all ages. Radio messages were played in regional languages, and community engagement sessions sensitized people who regularly travel across the border. Banners and posters were displayed at prominent locations.

Deputy Commissioner for Khyber District in Khyber Pakhtunkhwa province, Mr Mehmood Aslam Wazir, inaugurated the launch of All-Age Vaccination by vaccinating elderly persons at the Torkham border crossing. “Vaccination builds immunity and it is necessary for children to be vaccinated in every anti-polio campaign. The polio virus is in circulation and could be a threat to any child. The elders in our community could be carrier of the virus and take along the virus from one place to another, therefore, vaccination of every traveller, of all ages and genders, crossing Pakistan-Afghanistan border will be the key determinant to interrupt polio virus transmission in the region, and the world.”

The introduction of the all-age vaccination at border crossings is the latest example of cross-border cooperation between Pakistan and Afghanistan. The two countries continue to work closely together to ensure synchronization of strategies, tools and activities on both sides of the border.

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©Gavi/2018/Brendan Esposito.
A health worker administering polio vaccine to a young child.

In the wake of a polio outbreak confirmed on June 26 2018, the Government of Papua New Guinea declared polio a national health emergency. It was imperative that all children under the age of five be vaccinated, even those living in the most inaccessible regions of the country.

As part of the outbreak response, a team from Madang Provincial Health Authority, supported by WHO, travelled for over half a day by road and helicopter to reach the Hagahai people who live in the highlands of Madang province in Papua New Guinea, which is one of the most geographically isolated places in the world.

Ever wondered what it is like to be on the forefront of the fight against polio? Watch and learn how the team made their way to the remote mountain top to deliver vaccines.

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A frontline worker is vaccinating a child against polio. WHO Afghanistan/R Akbar

In November, polio vaccination teams across Afghanistan targeted 5.3 million children under the age of five in high-risk provinces. The vaccination campaign came on the heels of several newly reported cases. Afghanistan has 19 documented cases of wild poliovirus in 2018, as of November. Confirmation of even one polio case anywhere signals remaining vaccination coverage gaps which must be filled to achieve eradication.

The targeted vaccination campaign took place from 5-9 November, and with support across the board from healthcare workers, communities, religious clerics, and the government. “The Ministry of Public Health and health partners are committed to ending this disease,” said Dr. Ferozuddin Feroz, Minister of Public Health.

Afghanistan is one of the three remaining endemic countries in the world along with Pakistan and Nigeria. The endemic countries are intensifying their efforts by making sure they fully implement the strategies in their national polio emergency action plans.

Read more about the details of Afghanistan’s vaccination campaign here.

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The Mazar-e-Quaid is a prominent symbol of Pakistani independence. © WHO/Dawood Khan

Children clutch parents as the crowds gather. Overhead, clouds fill the sky, whilst below, noise rolls around the square where people stand. Shouts, music, and laughs all contribute to a growing sense of occasion.

The excitement lies at the heart of Karachi, Pakistan’s largest metropolis. Mazar-e-Quaid, the mausoleum of Pakistan’s founding father Muhammad Ali Jinnah, is a prominent symbol of Pakistani independence, and of the united people of Pakistan.

Each year, millions of people from across Pakistan and the world visit Mazar-e-Quaid. The number of visitors reaches its peak on 14 August, Pakistan’s Independence Day. As the sun rises, thousands arrive dressed in green, the national colour, carrying food and flags, ready to be first to enter once the site is opened up to the public.

A duty to the people of Pakistan

A child dressed in green, Pakistan’s national colour, is vaccinated against the poliovirus. © WHO/Dawood Khan

For the Pakistan polio eradication programme, Independence Day is an important opportunity. From morning to night, they will take part in a herculean effort to vaccinate all children visiting the mausoleum against the poliovirus. In doing so, they are setting world records for the number of children vaccinated in one location.

Permanent Transit Points (PTPs) are vaccination sites established at important transit points such as country and district borders, bus terminals and railway stations, to make sure that children on the move are vaccinated against polio. Currently, there are 390 PTPs across Pakistan.

On an ordinary day, eight vaccinators work at a PTP at Mazar-e-Quaid. After a quick brief, they are ready to protect all visiting children from the virus with just two drops of the safe, effective oral polio vaccine.

Independence Day requires a different kind of operation. The teams know that they have to take the opportunity to vaccine young children who otherwise might miss out.

Twenty vaccinators volunteer, enthusiastic to meet the influx of parents with young children entering the site.

As the crowds surge into the mausoleum, vaccinators immunize a new child every few seconds at fixed points at the entrance and exit, whilst others mingle with the crowds, searching for any young child without a purple stained finger – the sign used to indicate that they have been vaccinated.

This year, 11 409 children were vaccinated at Mazar-e-Quaid over the course of Independence Day. With such a small team, this is an impressive achievement.

The vaccinators

Mehwish Sheikh stands in front of the Mazar-e-Quaid, where she works as a polio vaccinator. © WHO/Dawood Khan

Mehwish Sheikh is a vaccination supervisor at Mazar-e-Quaid and is considered to be one of the most dynamic polio eradicators to have ever worked there.

Talking about her passion for polio eradication, and what drives her to protect Pakistan’s children, she says,

“Working against polio is in my blood. My mother started as polio worker in 1992 with the start of the polio eradication drive. Following her, I have worked for more than a decade now.”

“My mother vaccinated the current Chairman of Pakistan People’s Party Mr. Bilawal Bhutto Zardari, and she was featured on television and newspapers. My sister is also a vaccination worker so vaccination and work against polio is our passion.”

“Will you believe that I took only 3 days off on my wedding and then rejoined the team here?”, she laughs.

So what is it like vaccinating on Independence Day?

Mehwish isn’t afraid to acknowledge the challenges that the teams face on 14 August each year.

“This is really a tough day for all of us because the number of people is so overwhelming. Peoples’ connection with their leader is especially strong on Independence Day.”

With a wry smile, she continues, “Of course, our real independence will be our independence from polio virus.”

The parents

Whilst vaccination in this context might seem unexpected, parents visiting the Mausolem are enthusiastic. This is thanks to the efforts of the Pakistan polio programme and the government to educate the population about the vaccine.

One father notes, “As parents, it’s our duty to protect our children from going into harm’s way and administering all sorts of vaccines is one way of doing this.”

A nearby mother concurs, “The vaccinators are here to save the lives of our children and we must cooperate with them.”

The eradication of polio in Pakistan will be a success for thousands of people involved in the programme, and a source of national pride.

Speeding past to vaccinate more children, one vaccinator calls out, “We want to see our names among those who are fighting the final battle against polio in Pakistan”.

In April 2016, the polio programme embarked on a massive, coordinated effort to withdraw Sabin type-2 from routine use, through a synchronized switch from the trivalent formulation of the oral poliovirus vaccine (tOPV) to the bivalent form (bOPV). Over a two-week period, 155 countries and territories successfully made this change, marking the largest and fastest vaccine rollout in history.

Referred to as simply “the switch,” this global undertaking was a major programmatic achievement, but it was also a necessary step on the road to eradication. That’s because, in rare cases, the live, weakened virus contained in OPV can mutate and spread, resulting in cases of circulating vaccine-derived polioviruses (cVDPVs). The vast majority of these cases are caused by just one of the three components contained in tOPV (Sabin type-2 virus), so switching to a bivalent form that doesn’t contain this component was an attempt to significantly minimize the risk of further cVDPV2 cases – a decision that was endorsed by the global health community. Further, with Sabin type-2 responsible for 40% of vaccine-associated paralytic polio (VAPP) occurrences – a much rarer phenomenon at 2-4 cases per 1 million ‒ there was even stronger justification for the switch.

To assess whether the switch was successful, a group of researchers from Imperial College London, the World Health Organization and the Bill & Melinda Gates Foundation analysed stool and sewage samples from 112 countries collected in the first 15 months after the switch. The results, published in The New England Journal of Medicine, show that VDPVs and Sabin type-2 excreted into the environment after vaccination disappeared rapidly after the switch, shrinking to a much smaller geographic area.

These findings validate the GPEI decision to withdraw tOPV and demonstrate that the switch achieved its desired goal of reducing VDPVs and VAPP. This research also provides important evidence that the complete withdrawal of OPV after eradication of all wild polioviruses will eventually eliminate the risk of VDPVs, provided high immunity and effective surveillance are maintained. Eradication is simply not compatible with continued use of OPV.

The study also showed, however, that while some outbreaks of VDPV were expected post-switch, the number and magnitude of some of these outbreaks in different geographies has proven more difficult to control than expected. Type-2 VDPV outbreaks outside of Africa have been responded to with monovalent type-2 OPV (mOPV2) and controlled. However, outbreaks in the Horn of Africa, DR Congo and Nigeria have been very difficult to bring to a rapid close.

VDPV outbreaks emerge in areas with very low population immunity, due to low immunization coverage. Factors which enable them ‒ insecurity and resulting inaccessibility, weak health systems, and poor campaign performance – are the same that need to be addressed to stop their transmission. While the programme is aware of these risk factors and has proven experience and strategies to respond to them, the longer outbreaks persist, the harder they can be to stop.

The key to stopping these outbreaks will be to increase the focus on improving the quality of vaccination campaigns in accessible areas. In inaccessible areas, we need to use all available means to negotiate access and implement vaccination campaigns. Achieving high quality campaign activities will give us the best chance to stop all types of poliovirus for good and prevent any child from being paralysed by the virus ever again.

Reposted with permission from gavi.org.

Last month, Afia and her colleagues vaccinated 9.9 million children and educated millions of parents about vaccination across the country. © UNICEF Afghanistan

This is southern Afghanistan. A place characterized by a rich, diverse, but often complex history. Enveloped by mountains, this part of the country has seen years of conflict which have left hospitals under-resourced and health services shattered. Children face many challenges – as well as conflict and poverty, southern Afghanistan has the highest number of polio cases in the world.

In this difficult environment, the virus can only be defeated if every child is vaccinated.

Afia holds a young child who has just received a polio vaccination. The polio eradication programme is one of the biggest female work forces in Afghanistan. © UNICEF Afghanistan

Afia (not her real name), who is nineteen years old, is one of over 70 000 committed polio workers in Afghanistan, supported by WHO and UNICEF. Last month, she and her colleagues vaccinated 9.9 million children and educated thousands of parents about vaccination across the country.

The polio eradication programme comprises one of the biggest female workforces in Afghanistan: a national team, all fighting polio. Some women work as vaccinators, whilst others, like Afia, are mostly engaged in education and social mobilisation efforts. The polio programme gives women culturally-appropriate opportunities to work outside the house and engage in their community, speaking to parents about the safe, effective polio vaccine, and answering their questions. Often, women vaccinators offer other kinds of health advice, including recommendations for good child and maternal health.

To be a good vaccinator and educator, women must be committed to better health for all, with strong communication skills. They must also be organized to ensure that every child is reached during the campaign.

Afia says that if she wasn’t eradicating polio, her parents would expect her to give up her education and get married. Her younger sisters look up to her, excited to work in the polio eradication programme when they are old enough.

Her job is very important to protect all children. Afghanistan is just one of three countries – the others are Nigeria and Pakistan - that have never interrupted poliovirus transmission.

Women can vaccinate children who might otherwise miss out. Culturally, male vaccinators are unable to enter households to administer vaccine, causing difficulties if young children are asleep or playing inside. Their freedom to enter homes and give the vaccine to every child is one reason female polio workers are so critical.

Afia started work at 7 am, and is now walking home ten hours later with a young boy she has just vaccinated. Her purple burka stands out against the sand as she goes home to tell her parents and siblings about her day.

Afia feels positive about the future of polio eradication in Afghanistan: “We have a duty to protect our children, and I won’t stop working until every child is protected.”

Women have a right to participate in all aspects of polio eradication. Removing barriers to women’s full participation at all levels is a key goal for the Global Polio Eradication Initiative (GPEI). To learn more, see the gender section of our website, and read the GPEI ‘Why Women’ Infographic.

Afghanistan is just one of three countries —the others are Nigeria and Pakistan — that have never interrupted poliovirus transmission. © UNICEF Afghanistan

Member of Provincial Scholars Task Force Molvi Hameedullah Hameedi vaccinating a child whose parents used to refuse vaccination. Killa Abdullah, Balochistan, July 2018. © D. Khan

Molvi Hameedullah Hameedi is a prominent religious scholar in a mountainous rural area of Killa Abdullah district, one of the poorest districts in Balochistan province, Pakistan. With a close connection to his community, who are mostly Pashtuns, he delivers the sermon each week during Friday prayers, and runs a religious seminary.

He is also a determined supporter of routine vaccination for all children, and an advocate for better health.

This might come as a surprise if you met Molvi Hameedullah just a year or two ago. For most of his life, he did not believe in the safety and effectiveness of the oral polio vaccine, the key tool of polio eradication.

“I was a religious scholar who was very sceptical of non-governmental organizations and the polio vaccine,” he reflects.

“After reading anti-vaccine books and papers, I began following the work of anti-vaccine campaigners. Soon, I came to consider it my religious duty to spread awareness against the polio vaccine.”

“But it all changed when I was invited to a two-day International Ulema conference in Islamabad where religious scholars from all over Pakistan and other Islamic countries were invited to debate polio vaccination.”

The conference Molvi Hameedullah attended was hosted by the Islamic Advisory Group for Polio Eradication (IAG). The IAG was launched in 2014 by leading Islamic institutions including Al-Azhar University, the International Islamic Fiqh Academy (IIFA), the Islamic Development Bank (IsDB) and the Organization of Islamic Cooperation (OIC).

For Molvi Hameedullah, attending the conference marked the beginning of a change in perspective. “At the conference, I was given an opportunity to discuss my apprehensions towards polio vaccine. The talks I had motivated me to further research the pro-polio vaccine stance, and I started meeting with religious scholars in Karachi to debate polio vaccination.”

“Through talking to these people, I was getting a completely different picture to what I had believed earlier.”

By educating religious leaders and scholars about the poliovirus, and explaining religious justifications for vaccine acceptance, the IAG and its national equivalent equip people like Molvi Hameedullah with the tools to act as health advocates. The same skills that help scholars engage with parents about the polio vaccine are applicable for wider health, including improving routine immunization, hygiene practices, and maternal and child health.

After the conference Molvi Hameedullah was offered support by other vaccine-promoting scholars.

“I received a book from a religious support person working for polio vaccination in my area. Included were dozens of fatwas from highly esteemed madrassahs and religious teachers. I was initially sceptical, so I telephoned the madrassahs who had written them. To my surprise, all the fatwas were genuinely issued by them, and they also urged me to support vaccination wherever I called.”

Today, Molvi Hameedullah teaches similar fatwas as a member of the Provincial Scholar Task Force under the National Islamic Advisory Group. Most Task Force members have an honorary position, and are not paid a salary. Instead, the local government facilitates their transport and communication needs during immunization campaigns. Of his new role Molvi Hameedullah says, “I was faced with a different problem. I had been working against polio vaccination for many years, and now felt that I had done a great damage to the children and parents of my community. I felt it was now my absolute religious duty to negate all that I had taught before. I decided to step forth, and started working in the community voluntarily to promote vaccination.”

Religious refusals in Molvi Hameedullah’s area have declined. He has begun supporting other ways of ensuring that every child receives a vaccine, including by recruiting women vaccinators.

He acknowledges that the work he does now is not easy. He and his fellow scholars sometimes face challenges from those accusing them of having a political agenda, and changing beliefs informed by years of cultural and religious tradition takes time and patience. But he vows to continue his new mission until eradication.

There have been no cases of polio in the area of the district that Molvi Hameedullah covers since he joined the Provincial Scholars Task Force. Looking ahead, he is determined not to stop until all of Pakistan is polio-free.

Since he joined the Provincial Scholars Task Force, there have been no polio cases in Molvi Hameedullah Hameedi’s district. © D. Khan

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.

A child is protected from lifelong polio paralysis through OPV vaccination. © WHO

Following identification last month of an acute flaccid paralysis (AFP) case from which vaccine-derived poliovirus type 1 (VDPV1) had been isolated, genetic sequencing of two VDPV1s from two non-household contacts of the AFP case has now confirmed that VDPV1 is circulating and is being officially classified as a ‘circulating’ VDPV type 1 (cVDPV1).

The National Department of Health (NDOH) of Papua New Guinea is closely working with the GPEI partners in launching a comprehensive response. Some of the immediate steps include conducting large-scale immunization campaigns and strengthening surveillance systems that help detect the virus early. These activities are also being strengthened in neighboring provinces.

The GPEI and its partners are continuing to work with regional and country counterparts and partners in supporting the Government of Papua New Guinea and local public health authorities in conducting a full field investigation, risk assessment and to support the planning, implementation and monitoring of the outbreak response.

For more information:

Contact Oliver Rosenbauer, Communications Officer, Global Polio Eradication Initiative, tel: +41 79 500 6536