Outbreak countries

The meeting came at a time of contrasts for polio eradication efforts. On the one hand, the Region’s most recent case of wild poliovirus was reported almost 5 months ago, in Pakistan, and the footprint of the virus is the smallest it has ever been. Additionally, efforts to search for polioviruses have never been stronger and the polio programme has made significant progress in accessing under-immunized children across a number of high-risk countries in the last year. On the other hand, the Region hosts 4 of the world’s 7 ‘consequential geographies’ – low-resource, high-risk areas in Afghanistan, Pakistan, Somalia and Yemen that the programme has identified as carrying a significant risk of spread of polio.

WHO’s Regional Director for the Eastern Mediterranean Dr Ahmed Al-Mandhari, who convened this virtual meeting, set the tone for the event by coining 2023 as a “defining year” for polio eradication.

He urged all Member States and partners to leverage the opportunity and momentum of the current moment and scale up collective efforts to wipe out polio. “Going forward, our regional solidarity and concerted action will be even more important, as we move closer to making history and ending polio,” said Dr Al-Mandhari.

Leading the demonstration of regional support to polio were the Co-chairs, Minister of Public Health of Qatar, HE Dr Hanan Al Kuwari, and Minister of Health and Prevention United Arab Emirates, HE Mr Abdul Rahman Mohammed Al Owais. They urged participating Member States to strengthen routine immunization and consider polio as “all of our problem” until transmission ends everywhere. They also called on Member States to offer all they can – funding, advocacy or technical expertise – to reach every child with vaccines.

Participants at the meeting also included ministers of health and senior delegates from countries in the Region, in addition to representatives from the Bill & Melinda Gates Foundation (BMGF), the Centers for Disease Prevention and Control (CDC), Gavi, Rotary and UNICEF.

In his address, the Minister of National Health Services Regulations and Coordination of Pakistan updated the audience of the timely and robust programmatic actions the country has been taking to end polio. In the face of catastrophic floods, the country turned response efforts into an opportunity to offer polio vaccines to children wherever possible. Additionally, Pakistan is using creative ways, such as truck art, to reach out to vulnerable communities living in hard-to-reach areas.

During discussions, the delegate from Egypt and the Minister of Health of Yemen offered updates on their polio eradication efforts, while delegates from Iraq and Saudi Arabia proposed actions to prevent the spread of polio during mass religious gatherings in their countries.

Member States and partners acknowledged the immense efforts directed at ending polio in the 2 countries where it is still endemic – Afghanistan and Pakistan – particularly in the wake of the earthquake and catastrophic flooding that took place in 2022, and the extraordinary political will and engagement in both countries. They also noted the work ongoing in countries witnessing outbreaks of circulating vaccine-derived poliovirus type 2 (cVDPV2), and lauded health workers for their valour and dedication to their work.

Member States issued 2 statements following the meeting. One called for the international development and humanitarian communities and donors to scale up support to the National Emergency Action Plans for Afghanistan and Pakistan. A second statement called for international partners to provide essential services, including a robust vaccination response, to polio outbreaks in Somalia and Yemen. In Yemen’s northern governorates, amidst a surge of anti-vaccine propaganda, a long-overdue outbreak response has still not been launched, and Somalia is experiencing the longest ever cVDPV2 outbreak.

Member States also reiterated the importance of focusing on zero-dose children, and strengthening routine immunization and surveillance in countries that are polio-free and those that currently have polioviruses. They also commended Regional Director Dr Al-Mandhari for his leadership and requested him to continue to support Member States in the Region to push towards ending polio and attaining Health for All by All.

While updating participants on a recent visit made by a high-level mission to Pakistan last year, a representative from the BMGF, on behalf of Dr Chris Elias, the Chair of the Polio Oversight Board, acknowledged the extraordinary and unmatched efforts made in Pakistan by the political and health leadership, law enforcement and security agencies, to prevent any further spread of polio. Despite the flooding and political changes the country has faced, the polio programme continued to “shift gears” and mount a swift and robust response to polio. This was one of several visits that high-level missions have been making to Pakistan in support of eradication efforts.

In closing remarks, WHO representatives recognized Iraq and Syria for the strides both countries have taken to maintain essential polio functions, including in polio surveillance, while concurrently transitioning away from funding from the Global Polio Eradication Initiative.

The seventh meeting of the Regional Subcommittee for Polio Eradication and Outbreaks demonstrated the high level of confidence that Member States and partners have in the 2 remaining polio-endemic countries, Afghanistan and Pakistan. As polio remains a Public Health Emergency of International Concern under the International Health Regulations (2005), the intensified regional- and international-level collaboration of Member States and partners at events like this will serve as a springboard for focused action in 2023.

Note for editors

The Polio Oversight Board is the highest decision-making body in the Global Polio Eradication Initiative (GPEI). It brings together senior leadership of the 6 GPEI partner agencies—the Bill & Melinda Gates Foundation (BMGF), U.S. Centers for Disease Control and Prevention (CDC), Gavi, Rotary International, UNICEF, and the World Health Organization (WHO)—along with a representative of the GPEI’s donor community.

Dr Tedros Adhanom Ghebreyesus, Director-General of WHO, visited Pakistan in his role as Chair of the Polio Oversight Board at the time. Following this, since mid-2021, the Polio Oversight Board* made 3 visits, and Mr Bill Gates of the BMGF visited in February 2022.

Acknowledging that our common goal is to attain ‘Health for All by All’, which is a call for solidarity and action among all stakeholders;

Noting the progress achieved globally in eradicating poliovirus transmission since 1988;

Noting with deep concern the challenges involved in stopping ongoing outbreaks of circulating vaccine-derived poliovirus type 2 (cVDPV2) in the Region, without full access to vaccinate all vulnerable children in the affected populations;

Observing with alarm the prolonged outbreak in Yemen and the persistent restrictions on implementing outbreak response vaccination in the country’s northern governorates, and further observing that the cVDPV2 outbreak which has been continuing since 2017 is the world’s longest ongoing such outbreak;

Recognizing the Global Polio Eradication Initiative’s efforts to target its resources in the most impactful way by identifying particular areas affected by polio, including Yemen’s northern governorates and south-central Somalia, as “consequential geographies” – two of seven subnational geographies globally which together accounted for 90% of all polio cases in 2022 and which are all affected by broader humanitarian emergencies;

Recognizing the high risk of expansion of the polio outbreaks within and from the two Regional consequential geographies due to their complex emergency settings, limited access to high-risk populations, weak immunization services, gaps in coverage of supplementary vaccination campaigns, and unmitigated spread of misinformation and disinformation in northern governorates of Yemen;

Recalling that the international spread of polio is a Public Health Emergency of International Concern under the International Health Regulations (2005);

Observing with alarm that 197 children have been paralyzed by cVDPV2 in Yemen’s northern governorates, representing almost one-third of all global cases of this strain in 2022, and that the international spread of poliovirus from Yemen to Djibouti, Egypt and Somalia has been confirmed;

Recognizing the best operational approach and experience to vaccinate all children, especially infants and young children, against polio, and achieve more than 90% coverage to stop an outbreak is through house-to-house delivery of vaccination; and if that is not possible, to implement an intensified fixed site vaccination with effective mobilization of families and young children to fixed sites near their homes;

Recognizing the continued threat to all children posed by vaccine-derived poliovirus and the importance of regional solidarity and support to deliver on the goals of the 2022-2026 Polio Eradication Strategy, which have been endorsed and supported by a wide range of committed donors, such as Rotary International and Member States of the Region, in particular the UAE through the sustained commitment of His Highness Sheikh Mohamed bin Zayed Al Nahyan, President of the UAE;

We, the Member States of the Regional Subcommittee on Polio Eradication and Outbreaks for the Eastern Mediterranean:

DECLARE THAT:

The ongoing circulation of any strain of poliovirus in the Region is a Regional Public Health Emergency;

COMMIT TO:

Mobilizing all needed engagement and support by all political, community and civil society leaders and sectors at all levels to successfully end polio as a Regional Public Health Emergency;
Advocating with relevant community and subnational leaders to increase access and ensure full implementation of polio outbreak response in the most programmatically and epidemiologically impactful operational manner, ideally through house-to-house vaccination campaigns in all areas;
Focusing efforts on reaching remaining zero-dose children in the consequential geographies of the northern governorates of Yemen and south-central Somalia, working in the broader humanitarian emergency response context;
Helping to mobilize needed resources and highest-level international commitment to finalize and fully implement the Somalia Polio Eradication Action Plan 2023, in the context of competing health response priorities such as ongoing drought and the effects of the COVID-19 pandemic;
Helping to mobilize resources for the Global Polio Eradication Initiative partners to support the outbreak response in Yemen; and
Helping to strengthen coordination with other public health and humanitarian efforts in Somalia and Yemen, to ensure closer integration in particular with routine immunization and the delivery of essential health and nutrition services to children;

REQUEST THAT:

The international humanitarian and development communities scale up their support for providing essential services, including a robust vaccination response to the polio outbreaks in Somalia and Yemen using modalities that will deliver an acceptable level of coverage;
The authorities and polio eradication partners in Somalia accelerate high-quality and rigorous implementation of the Somalia Polio Eradication Action Plan 2023 to stop the longest-running outbreak in the country and prevent the further spread of cVDPV2 by the end of 2023;

10. The national authorities and the Regional Polio Eradication programme strengthen cross-border coordination across Somalia, Kenya, Ethiopia, Yemen and Djibouti, considering the documented importation of cVDPV2 from Somalia into Kenya and Ethiopia, and from Yemen into Djibouti, Egypt and Somalia, and the high risk of further instances of cVDPV2 crossing international borders;

11. Authorities in northern governorates of Yemen, all immunization partners and the humanitarian development community respond urgently to the unmitigated vaccine-related misinformation and disinformation that is being disseminated, which is risking the lives of thousands of children in Yemen and across the Region;

12. All authorities in northern governorates in Yemen facilitate the resumption of house-to-house vaccination campaigns in all areas to ensure the delivery of vaccines to the youngest and most vulnerable children, and in areas where house-to-house vaccination is not feasible, make all efforts to implement intensified fixed-site vaccination through a modality that also includes robust social mobilization and outreach to ensure high coverage; and

13. The Regional Director continue his strong leadership and efforts to support the cessation of polio outbreaks in Somalia and Yemen, including by advocating for all necessary financial and technical support, reviewing progress, implementing corrective actions as necessary, and regularly informing Member States of the aforementioned and of any eventual further action required, through the World Health Organization’s Executive Board, the World Health Assembly and the Regional Committee for the Eastern Mediterranean.

Under the leadership of the Ministry of Health, with support from Rotary and other GPEI partners, a multi-round polio vaccination campaign is being implemented in Mozambique. Six rounds of vaccination were completed in 2022, covering all provinces of the country and reaching 8.7 million children.

A further four rounds of vaccination are planned for 2023. Rotary and GPEI partners are jointly working together to support health authorities to deliver training on community-based surveillance, procuring and distributing 30 million vaccine doses and 8000 vaccine carriers, expanding field surveillance efforts, supporting vaccine management and social behaviour change activities. The GPEI are also supporting the deployment of vaccination teams, under the overall coordination of the Ministry of Health.

During a visit to Mozambique from 21 to 23 February 2023, representatives of the United Nations Children’s Fund (UNICEF), World Health Organization (WHO), Bill & Melinda Gates Foundation, Rotary Foundation and the United States Centers for Disease Control and Prevention, emphasized the importance of building on lessons learnt and successful approaches used in polio eradication to strengthen the country’s response to other health emergencies, including the ongoing cholera outbreak.

The polio outbreak response in Mozambique comes as the country is also addressing other emergencies, including the COVID-19 pandemic, cholera, floods and insecurity in the northern Cabo Delgado region.

The senior leaders included UNICEF Regional Director for Eastern and Southern Africa, Mr Mohamed Fall, WHO Regional Director for Arica, Dr Matshidiso Moeti, Mr Chris Elias, the Chair of the Polio Oversight Board of the Global Polio Eradication Initiative (GPEI), Mr Mike McGovern, Chair of the Rotary International PolioPlus Committee, Dr Omotayo Bolu, Polio Eradication Branch Chief for the United States Centers for Disease Control and Prevention, and other partners.

They met with Mozambican Prime Minister Adriano Afonso Maleiane and visited Mozambique’s northern Tete province, where eight wild poliovirus cases were detected last year.

During their visit to Tete province, the delegation witnessed polio response efforts in the field, engaged with health workers and support staff, supervisors, religious and community leaders. They also visited an Emergency Operations Centre and a Cholera Treatment Centre to better understand challenges and progress in the polio and cholera responses.

“The Government of Mozambique has shown strong leadership in the response to polio, ensuring that all eligible children are reached and protected with the vaccine through effective immunization campaigns,” said Dr Moeti. “We must not relent nor spare efforts to finish the job of ending polio once and for all.”

Polio, a debilitating viral disease that was once the leading cause of paralysis among children worldwide, is very close to being eradicated. Since 1988, the number of children affected by polio has reduced by 99 per cent. But outbreaks continue to occur, including in Mozambique, and ensuring every last child is immunised against the virus is a global priority.

Originally published here.

A child in Malawi getting the Oral Polio Vaccine drops. ©Moving Minds Multimedia/Malawi

A total of nine wild poliovirus cases have been reported so far, with one in Malawi and eight in neighbouring Mozambique since the declaration of an outbreak on 17 February 2022 in Malawi. The last confirmed case to date was in August 2022 in Mozambique. The wild poliovirus in Malawi and Mozambique originated from Pakistan, one of the two last endemic countries.

Concerted emergency response launched following the outbreak in 2022 has helped increase protection among children through vaccines in Malawi, Mozambique, Zambia, Tanzania and Zimbabwe. The countries have also ramped up disease surveillance and community mobilization to help find cases and halt the virus.

“Southern Africa countries have made huge efforts to bolster polio detection, curb the spread of the virus and ensure that children live without the risk of infection and lifelong paralysis,” said Dr Matshidiso Moeti, World Health Organization (WHO) Regional Director for Africa. “We continue to support the polio control efforts across the region so that every child receives the protection they need.”

To date, 19 vaccination rounds have been concluded in the most at-risk areas and at least five more are planned for 2023 in the five countries.

Additionally, more than 10 new environmental surveillance sites have been set up over the past year in the affected countries with support from WHO. The fully operational sites are playing a critical role in the efforts to detect silent circulating poliovirus in wastewater.

“Response teams have worked intensely in the fight against polio not only in Malawi but in the rest of the neighbouring countries in a coordinated manner. We will not rest until we reach and vaccinate every child to stop polio transmission,” said Dr Emeka Agbo, acting Country Coordinator for the Global Polio Eradication Initiative in Malawi.

Reaching all households where eligible children live is critical to protect them against the risk of paralysis. The national health authorities, with support from the Global Polio Eradication Initiative, efforts are ongoing to map cross-border communities, migratory routes, border crossings and transit routes.

“Community health workers have been pivotal in the vaccination campaigns and will continue going door-to-door, bringing polio vaccines to children who might otherwise be missed,” said Dr Jamal Ahmed, WHO Polio Eradication Programme Manager.

Polio is highly infectious and affects unimmunized or under immunized children. In Malawi and Mozambique, it has paralysed children younger than 15 years. There is no cure for polio, and it can only be prevented by immunization. Children across the world remain at risk of wild polio type 1 as long as the virus is not eradicated in the last remaining areas in which it is still circulating.

Despite the circulation of wild poliovirus type 1 and the variant polioviruses, incredible progress has been made. Since 1988, when the Global Polio Eradication Initiative was set up, polio cases have plummeted by 99% from an estimated annual total of 350 000.

Importation of any case must be treated as a serious concern and high-quality response efforts to reach every child with polio vaccine are critical to prevent further spread.

On 25 January 2023, the WHO Emergency Committee under the International Health Regulations concluded that the risk of international spread of poliovirus remains a public health emergency of international concern.

Originally published here.

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

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

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

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

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

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

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

Polio still exists

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

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

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

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

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

Management during COVID-19 was a challenge

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

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

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

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

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

More mentors needed for girls to join and grow in science

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

On 19 January 2023, representatives from the World Health Organization (WHO), United Nations Children’s Fund (UNICEF), and the Ministry of Health of Syria concluded a three day joint mission on polio transition planning.

The team conducted various meetings with national counterparts, United Nations agencies and other stakeholders to assess the current situation, and identify the needs and resources required to maintain polio-essential functions and strengthen routine immunization to maintain Syria’s polio-free status. As part of the mission, the team agreed on the way forward to design a roadmap to support and sustain the ongoing integration of polio assets to ensure long-term benefits for immunization and emergency response.

While Syria is a polio-free country, it is at very high risk of imported polio outbreaks. In the last decade, the country experienced two polio outbreaks, including an outbreak of wild poliovirus following an importation from Pakistan in 2013, that paralyzed 36 children. In addition, a 2017 outbreak of circulating vaccine-derived poliovirus type 2 (cVDPV2) left 74 children paralyzed. In both cases, the country managed to contain the poliovirus and stopped the outbreak in less than a year using intensive polio vaccination campaigns and surveillance.

WHO is working closely with the Government and other stakeholders to maintain highly sensitive surveillance for polio and capacities to detect and respond to polio outbreaks swiftly. Furthermore, WHO and UNICEF are supporting the country to leverage the capacity and rich legacy built from years of polio operations to strengthen the essential immunization programme and capacities to detect and respond to other disease outbreaks.

“The main goal of this mission is to ensure that the polio essential functions are well preserved,” said Dr Rana Hajjeh, Director of Programme Management at WHO’s Regional Office for the Eastern Mediterranean. “We at WHO emphasize the importance of strengthening essential programmes like the national routine immunization and also strengthening the emergency response to take advantage of all the polio assets and building health systems. Overall, Syria has integrated polio functions very well in their national immunization programme and we will do our best to continue supporting them as needed,” she added.

Polio essential functions are managed by the Ministry of Health, with the technical and logistical support of WHO. Given the importance of ensuring the sustainability of functions, with support from Gavi, the Vaccine Alliance, both partners have been able to cover critical programme needs pertaining to routine immunization, including polio.

“While protecting the success achieved in containing the poliovirus outbreaks in record time, we should combine our efforts at all levels to maintain the high levels of immunity of the Syrian people against this life-threatening disease,” said Dr Iman Shankiti, WHO Representative a.i. for Syria. “WHO is working closely with the Ministry of Health and all other partners to resume the robust immunization programme in Syria,” she added.

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The programme is focusing on reaching zero-dose children (children who are either un- or under-immunized), in identified ‘consequential geographies’.

But what exactly are consequential geographies, and why are they so vital to the global effort to eradicate polio?

In this explanatory video, long-time polio eradicator and Director for polio eradication at WHO’s Eastern Mediterranean Region, Dr Hamid Jafari, explains more.

Children show their inked fingers - a sign they have been vaccinated against polio. © WHO/Afghanistan — Children show their inked fingers – a sign they have been vaccinated against polio. © WHO/Afghanistan

2022 may well go down in history as the year of contrasts in the global effort to eradicate polio. At first glance, with polio detections in places such as New York and London and an increase in cases in Pakistan, it may seem that the effort is backsliding. And while any detection of any poliovirus is a setback—particularly in areas where the disease had been long gone, like southeast Africa—a deeper analysis reveals a more encouraging story: 2022 saw perhaps some of the most significant progress in the programme’s history, and has set up the global polio effort for a unique opportunity to achieve success in 2023.

Endemic wild poliovirus transmission in both Pakistan and Afghanistan is becoming increasingly geographically restricted, with fewer virus lineages remaining active. The bulk of variant type 2 polio (cVDPV2) cases are also becoming more restricted, with 90% of all global cases restricted to three ‘consequential geographies’ (eastern Democratic Republic of Congo, northern Yemen and northern Nigeria). And emergency outbreak response efforts to wild poliovirus type 1 in southeast Africa continue to gain momentum.

To evaluate this progress as 2022 draws to a close, independent technical expert and advisory groups are taking an in-depth look at the prevailing epidemiology, assessing impact of eradication efforts and putting forth key strategic approaches to enable an all-out effort against the virus in the first half of 2023.

The first of these groups met in early October, when the Technical Advisory Group (TAG) for Pakistan reviewed vaccination coverage and disease surveillance across the country. Despite the increase in new cases, the TAG found the outbreak to be extremely geographically confined, thanks to concerted emergency efforts led by the government and supported by partners. Today, polio transmission is restricted to the six districts of southern Khyber Pakhtunkhwa province—a fraction of the country’s 180 districts. Encouragingly, the virus has not re-established a foothold outside the core outbreak zone, meaning the traditional reservoirs of Karachi, Peshawar and Quetta are no longer endemic to the virus, a historical first.

More good news came out of the TAG’s analysis of the genetic biodiversity of virus transmission. In 2020, Pakistan had 11 separate chains of virus transmission. This was reduced to four in 2021, and today, just one family of the virus remains in the country. The approaches being implemented in Pakistan are working—despite some serious challenges.

Pakistan’s polio team supporting flood relief efforts © NEOC

In September, Pakistan experienced catastrophic flooding that impacted more than 33 million people and submerged one third of the country under water. In the face of this tragedy, and despite being affected themselves, polio staff supported the broader relief efforts while adapting polio operations to ensure that the eradication effort could continue unabated. Long-time polio eradicator and Director for Polio Eradication in WHO’s Eastern Mediterranean Region, Dr Hamid Jafari, said: “Rarely have I seen such commitment and dedication than I have seen in Pakistan – from national leaders, to health workers, right to the mother and father on the ground.

They are making a huge difference to people’s lives, which goes far beyond the effort to eradicate polio.”

In December, a high-level delegation led by GPEI Polio Oversight Board (POB) Chair Dr Chris Elias, WHO Regional Director Dr Ahmed Al-Mandhari and UNICEF Regional Director George Laryea-Adjei visited Pakistan during a nationwide vaccination campaign. After meeting with women health workers, provincial and national polio coordinators and even the Prime Minister, the group concluded that there is unprecedented support and commitment to ending polio in the country in 2023.

In Afghanistan too, an epidemiological deep dive reveals a promising picture: just over twelve months on from the political developments in the country in 2021, access to all children in the country continues to improve, albeit against a tragic backdrop of a severe and acute humanitarian crisis. More than 3.5 million children in Afghanistan who had been out-of-reach for almost five years can now be reached with polio vaccines, and thanks to strong vaccination and disease surveillance efforts, polio transmission has been restricted to just two chains in two provinces. And following the country’s devastating earthquake in June, polio teams sprang into immediate action to both support the broader emergency relief effort and adapt polio operations.

This progress in Pakistan and Afghanistan is identical to what epidemiologists observed during the ‘end game’ efforts in global polio reservoirs in the past, notably Nigeria, India and Egypt, giving rise to optimism that these remaining two endemic countries are on the right track.

Expert groups focus on outbreaks…

2022 saw a number of high-profile polio events, like the detections in New York City and London, but it is important to recognize the distinction between these and the outbreaks that have the capacity to endanger, or at least significantly delay, the global eradication goal.

Aidan O’Leary, Director of the Global Polio Eradication Initiative (GPEI) at the World Health Organization (WHO), contextualized the situation: “90 percent of global media attention has been on the polio emergence in New York, London and Israel. However, 90 percent of actual cases are in eastern Democratic Republic of Congo, northern Yemen and northern Nigeria.” It is in those areas, commonly referred to as consequential geographies, that programmatic efforts must maintain their focus. Notably, these areas also overlap with some of the highest proportions of ‘zero-dose’ children—those who are either un- or under-vaccinated.

WHO medical officer Dr Audu Idowu conducts an acute flaccid paralysis examination in Jere Local Government Area, Borno State. ©WHO/Nigeria

While the outbreaks in northern Yemen and eastern DR Congo continue to expand at an alarming rate in 2022, the situation in northern Nigeria is far more encouraging. Nigeria accounted for two-thirds of all global cases in 2021, seeding outbreaks in 19 countries. In the second half of 2022, however, there has been a dramatic decrease in new detections, with just nine cases reported during that time.

In November, the Nigerian Government, with GPEI partners in attendance, hosted the Global Roundtable Discussion on variant type 2 polio outbreaks, reviewing progress in outbreak response following the upsurge in cases in 2021. The Roundtable recognized efforts to reach zero-dose children in consequential geographies throughout the country, in particular with the novel oral polio vaccine type 2 (nOPV2), as well as Nigeria’s focus on strengthening routine immunization with bivalent OPV and inactivated polio vaccine (IPV). Whichever strategy is used, however, the group cautioned: “coverage is king!” Any vaccine is only as good as the proportion of children it reaches.

The group’s conclusions and recommendations will be further evaluated by Nigeria’s Expert Review Committee on Polio Eradication and Routine Immunization (ERC).

Meanwhile, in southeast Africa, a comprehensive Outbreak Response Assessment reviewed the regional response to wild poliovirus type 1 (WPV1), linked to virus originating from Pakistan, with cases confirmed in Malawi and Mozambique. Experts noted the high-level, comprehensive support for the outbreak response across the region, and that vaccination campaigns have been consistently improving with time.

At the same time, the group concluded that the outbreaks are not over. With simultaneous outbreaks of WPV1, cVDPV1 and cVDPV2 affecting in particular Mozambique, the group put forward key recommendations and strategies, building on the momentum and knowledge gained over the past six months. These conclusions were further endorsed by the Africa Regional Certification Commission for Eradication (ARCC), which met in South Africa.

Challenges remain ahead. Zero-dose children must be reached, particularly in consequential geographies. Remaining financial resources to achieve success must be mobilized. Campaigns must be strengthened in southeast Africa. But despite initial appearances, 2022 put the world on an extremely strong footing to interrupt all remaining chains of poliovirus transmission by end 2023—the goal of the GPEI Strategy 2022-2026.

There is a clear momentum as the year draws to a close. We must carry it into 2023 for a final, concerted push. Success is in our hands.

Pledging table

2022 pledges from various donors

Dr Hamid Jafari, EMRO Director for Polio Eradication. © WHO/EMRO

Members of the Regional Subcommittee for Polio Eradication and Outbreaks in the Eastern Mediterranean reviewed recent progress during the 69th session of the Regional Committee. It was the sixth meeting of the subcommittee since it was formed during the 67th Regional Committee.

During the meeting Member States and partners reiterated their commitment to freeing current and future generations of children from polio and called for sustained efforts to end polio once and for all, including the pockets of wild poliovirus that linger in Afghanistan and Pakistan.

Visit the EMRO website for the full story.

This two-year old outbreak of circulating vaccine-derived poliovirus (cVDPV) type 2 began after the virus was imported from neighbouring Chad.

Click on the photo gallery to see what it took to close the outbreak.

The Global Polio Eradication Initiative (GPEI) has been informed of a case of paralytic polio in an unvaccinated individual in Rockland County, New York, United States.

The US Centers for Disease Control and Prevention (CDC) are coordinating with New York State health authorities on their investigation. Initial sequencing confirmed by CDC indicates that the case is type 2 VDPV.

Following the detection, the Global Polio Laboratory Network (GPLN) has confirmed that the VDPV2 isolated from the case is genetically linked to two Sabin-like type 2 (SL2) isolates, collected from environmental samples in early June in both New York and greater Jerusalem, Israel, as well as to the recently-detected VDPV2 from environmental samples in London, UK. Further investigations – both genetic and epidemiological – are ongoing to determine possible spread of the virus and potential risk associated with these various isolates detected from different locations around the world.

It is vital that all countries, in particular those with a high volume of travel and contact with polio-affected countries and areas, strengthen surveillance in order to rapidly detect any new virus importation and to facilitate a rapid response. Countries, territories, and areas should also maintain uniformly high routine immunization coverage at the district level and at the lowest administrative level to protect children from polio and to minimize the consequences of any new virus being introduced.

Any form of poliovirus anywhere is a threat to children everywhere. It is critical that the GPEI Polio Eradication Strategy 2022-2026 is fully resourced and fully implemented everywhere, to ensure a world free of all forms of poliovirus can be achieved.

Dashboard showing real-time data on active case finding and routine immunization from integrated supportive supervisory visits to priority sites in Senegal. © WHO

While the WHO Africa Region (AFRO) has been facing its last hurdle in eradicating polio of all types since being certified indigenous wild polio free in 2020, a circulating variant of polio virus type two has been present in 26 countries with more than 1,000 cases between them, coupled with the recent importation of two wild polio type 1 cases. To help reverse this trend, the WHO/AFRO Geographic Information Systems (GIS) Center is equipping over 200 key country office focal points and Ministry of Health personnel across 47 countries with essential innovative technologies to better address outbreaks with necessary speed and quality.

Concluding a series of one-week capacity-building workshops over the past six months and targeting of the WHO regions of Central, East & Southern, and West Africa – – the AFRO GIS Center, with the support of the Bill & Melinda Gates Foundation (BMGF), WHO HQ Polio Unit and GIS Centre for Health, the United States Centers for Disease Control and Prevention (CDC), and Novel-t on-boarded digital GIS and Mobile Health (mHealth) technologies to support regional and national agendas particularly on planning and analysis for improvement of surveillance, campaigns and outbreak response for polio and all other routine immunization and outbreaks. While the initial investment was made by polio these tools are being leveraged for all health interventions.

A group of participants from the AFRO Geographic Information System (GIS) and Information Visualization Capacity Building Training session, in Dakar, Senegal. © WHO

“These are solutions to advance national and regional agendas even beyond polio” stated Kebba Touray, Technical Manager – AFRO GIS Centre, “the COVID-19 pandemic response was able to advance using the AFRO polio GIS Centre’s technical support with the development of real-time data collection, analysis and monitoring tools and generated several products including dashboards (providing easy availability and visualization of information), which facilitated rapid decision making for response activities across the region.”

The GIS Capacity Building training transferred knowledge to key country office focal points and Ministry of Health personnel across Africa on innovations to better enable countries to:

Design country-level specific static and dynamic maps – using platforms such as Microsoft Power BI, and ArcGIS – for the outbreak response and provide real time analysis through the dashboards.
Provide country specific information visualization (using Dashboards) to publish in the existing AFR-mHealth workspace at AFRO and in their respective public health systems.
Develop data collection, data validation and monitoring mechanisms that provides increased accuracy on immunization information and populations through the Open Data Kit (ODK) platform to enhance mobile data collection.
Use AFRO GIS and information visualization innovative solutions at country level to receive real-time information on active surveillance visits conducted at health facility level, environmental surveillance site performance, rapid population estimates data, vaccination team movement during polio campaigns, among others.

“I am particularly eager to take back the new capacity I have on ODK and PowerBI when monitoring our entire Expanded Programme on Immunization (‎EPI)‎ interventions” stated participant Dexter Merchant, Assistant Director for Monitoring and Evaluation at the Ministry of Health in Liberia, “using ODK as the process to collect data on where we have essential services and where we don’t is going to make things move a lot faster and more efficiently in identifying gap, I am confident these tools will now be integrated in Liberia”.

John Kipterer and Frank Salet moderating a PowerBI training session at the GIS capacity building workshop in the Dakar. © WHO

To ensure sustainability, country accountability and ownership, in-country GIS working groups which will constitute personnel from WHO and Ministries of Health will be established to continue efforts of knowledge transfer and capacity building principally amongst data managers, GIS analysts, and surveillance officers.

In closing, the WHO Representative in Senegal, Dr. Lucile Imboua and host of the last training series emphasized the “need to ensure harmonization of all the GIS tools and to be flexible to accommodate the use of other tools across different programs.”

The underlining consensus from all WHO, government and partner participants is that in order to end polio and strengthen health systems, the region heavily relies on the innovative technologies of GIS in executing health responses. The use of GIS innovations with precision in accuracy, transparency, accountability and ease of application and sustainability provides a huge opportunity to reach every last child across the 47 countries, eradicate polio from the region, and serve public health for all.

Dr Mutahar Ahmed, R, reviewing the location of AFP cases with Dr Khaled Al-Moayad, Director of Disease Control and Surveillance in Sanaa, Yemen © Omar Nasr / WHO Yemen

At his office in Sana’a, Yemen, Dr Mutahar Ahmed stands before a wall-sized map of his country and feels the weight of the world on his shoulders.

“The situation here in Yemen is very complex, and the problems we face are quite immense,” said Dr Ahmed.

As Yemen’s national surveillance coordinator, Dr Ahmed leads the country’s acute flaccid paralysis (AFP) surveillance efforts, the primary means of tracking poliovirus transmission. With an explosive outbreak of circulating vaccine-derived poliovirus type 2 having paralysed 115 children and counting, and with swathes of the country’s infrastructure – from roads to hospitals – decimated by conflict, you’d be forgiven for thinking that his and his team’s efforts to surveil for poliovirus were falling short or otherwise compromised. But you’d be wrong.

In Yemen, despite a long-running conflict and complex humanitarian disaster that has significantly impacted health care, AFP surveillance indicators tell a promising story of a functioning system where case detection, sample collection and laboratory analysis – the steps that enable us to detect poliovirus so we can respond to it – are, in fact, on track.

Surveillance data allows the polio programme to identify new AFP cases and to test those cases to determine whether polio infection is the cause. In this way, a robust and wide-reaching AFP surveillance system enables health workers to detect the presence and circulation of poliovirus.

Dr Mutahar Ahmed, national surveillance coordinator, at a health facility in Sanaa, Yemen. © Omar Nasr / WHO Yemen

“In addition to our work building the engagement and knowledge of pediatricians and clinicians, we are reaching the community and community-based health care providers including traditional healers. We also appeal to families for their support in reporting cases. The more aware they are of the symptoms of paralysis in a child, the quicker our surveillance coordinators can collect the stool sample for analysis,” said Dr Ahmed.

Early detection of symptoms such as AFP is a crucial step in the chain of polio surveillance. If a case of paralysis is not reported within the first 14 days of the onset of symptoms, the reliability of testing the sample in the lab reduces significantly. In Yemen, the AFP surveillance system in high-risk districts is supported by volunteers trained in community-based surveillance. In 2021, 82% of AFP cases were detected early, within the first seven days of the onset of paralysis, which is above the global target of 80%.

Once a case is detected and stool samples are collected, it’s vital to make sure the samples reach the laboratory in good condition.

“Two stool samples are required from each child showing symptoms of paralysis. Both samples need to be collected within the first 14 days, 24 hours apart. They need to be correctly labelled, and their temperature needs to be maintained at between 2 and 8 degrees. Otherwise, they are not adequate samples,” said Dr Ahmed.

In 2021, 921 AFP cases were detected. Of these cases, 87.84% had adequate specimens collected, which is above the global target of 80%.

Along with stool adequacy, another key performance indicator for surveillance is the non-polio AFP rate. This refers to the detection of diseases, other than polio, that can cause AFP. Yemen’s non-polio AFP rate is 5.96 per 100,000 children aged below 15 years in 2021, significantly higher than the global standard of three per 100,000 for polio outbreak countries like Yemen. This accomplishment points to the sensitivity of Yemen’s surveillance system due to the relentless efforts and commitment of the surveillance personnel working with Dr Ahmed.

Dr Mutahar Ahmed, L, inspecting samples with Dr Abdullah Yahya, assistant national coordinator for AFP surveillance © Omar Nasr / WHO Yemen

Due to electricity shortages, maintaining the cold chain (keeping vaccines cold) and reverse cold chain (keeping stool samples cold) poses a significant challenge for the programme. To overcome this and further increase the efficiency and sensitivity of the surveillance system to detect polioviruses as quickly as possible, solar power panels have been installed in health facilities at the central and governorate levels to support the storage and transfer of stool samples. One indicator of the impact of this change is Yemen’s non-polio enterovirus rate, which tells us what percent of stool samples tested negative for poliovirus, but were in such condition that they could still test positive for enteroviruses. In 2021, that rate was 20 percent above the global target of 10 percent.

Because Yemen does not have a poliovirus laboratory in-country for testing, samples are first collected at the central level in Sana’a and then sent by road to Muscat, Oman. The journey can take up to seven days, barring any obstacles or emergencies.

“Working in this role is a challenge, but what I particularly enjoy is how we are able to turn these challenges into opportunities for the AFP surveillance programme. The AFP indicators for the last year show us how far we have come in our journey,” said Dr Ahmed.

He explained why these indicators are so critical to the polio programme.

“The fact that our indicators are above the minimum global standards shows that the surveillance system is functioning, sensitive and responsive, despite the critical humanitarian situation. The data from our surveillance work has helped us identify the outbreak of circulating vaccine-derived polioviruses type-1 and type-2. The situation is quite fragile, but we are committed to addressing these challenges, and we will continue to do so.”

WHO has supported Yemen to establish an environmental surveillance system to supplement its AFP surveillance system and support early detection of polioviruses and more timely responses.

Following wide engagement of stakeholders – from lab workers to engineers to certification bodies responsible for signing off on the lockdown of poliovirus strains after certification of eradication – WHO’s chief guidance document for poliovirus containment has been given an overhaul. The update to the WHO Global Action Plan for Poliovirus Containment (GAP-IV, previously GAP-III) comes at the request of the WHO Containment Advisory Group (CAG) and streamlines the tool with other relevant WHO guidance and technical recommendations made by CAG. Its availability is expected to help accelerate containment implementation worldwide.

Containment involves biosafety and biosecurity requirements for laboratories and vaccine production sites, or any other place handling and storing eradicated polioviruses, to minimize the risk of these pathogens being released into communities. It also concerns risk mitigation measures associated with field use of some live oral polio vaccines. WHO urges facilities holding virus to move through its Containment Certification Scheme, and follow guidance contained in GAP-IV.

“Retention of poliovirus materials for what their governments deem to be critical functions is a risk and responsibility for all countries that choose to do so,” said Prof David Heymann, Chair of the CAG and professor of infectious disease epidemiology at the London School of Hygiene and Tropical Medicine. “GAP provides guidance that aims to minimize the risk of escape of the poliovirus from a retention facility, and we hope that the revised publication ̶ which stakeholders in polio eradication helped shape ̶ will ensure faster action by countries that decide to retain poliovirus materials,” he said.

“The revision of the guidance has been a long time in the making and comes with a lot of anticipation,” stated Dr Harpal Singh, WHO polio technical officer and CAG secretariat. “WHO and CAG have taken on board the numerous concerns and feedback from Member States with regards to carrying out the guidance, and a certain degree of flexibility based on local risk mitigation measures has been applied in some areas, whilst maintaining the rigor of evidence-based best practice,” he added. “We anticipate that this will result in a better implementation of the requirements for Member States opting to retain [poliovirus] materials, and having their facilities certified,” he added.

To date, two of three strains of wild poliovirus have been declared globally eradicated – type 2 and type 3. Countries around the world, however, continue to handle and store these viruses for functions including polio vaccine manufacture, diagnostics and research, among others. It is essential that any facility holding poliovirus types 2 and/or wild or VDPV type 3 stocks, regardless of purpose, either put in place the necessary biorisk management measures outlined in GAP or destroy their virus stocks.

“The world is on the precipice of eradication of wild poliovirus type 1 with the lowest ever case count recorded in 2021, and we got rid of WPV2 and WPV3 in 2015 and 2019, respectively. While some progress has been made, we’re actually quite behind schedule in ensuring those two eradicated serotypes are properly contained, and more needs to be done in this regard,” said Aidan O’Leary, head of WHO’s polio eradication programme.

“Importantly, Member States all committed to accelerating poliovirus containment action in 2018 through a World Health Assembly Resolution,” he reminded. “WHO will continue to work with and encourage Member States to move on their targets, and reprioritize these actions. Failure to do so not only heightens but prolongs the risk of the reintroduction of virus, the effects of which could be devastating,” he added.

There are currently 25 countries hosting 65 facilities officially designated by their respective governments to retain poliovirus materials. The majority of countries have established a National Authority for Containment for domestic oversight over containment action, in line with commitments from the 2018 resolution, and work is underway to progress their facilities through the Containment Certification Scheme.

For now, containment measures apply to all type 2 and wild and vaccine-derived type 3 materials.

More on Containment.

Leaders at this week’s G7 Head of State meeting in Germany and last week’s Commonwealth Heads of Government meeting in Rwanda renewed global commitment to polio eradication. In their official Communiqué, the Leaders of the Group of Seven (G7) vowed to ‘continue our support for polio eradication through the Global Polio Eradication Initiative’, while the Commonwealth Heads of Government, in their joint Communiqué on ‘Delivering a Common Future’, urged the continued intensified effort to eradicate polio, even amid other pressing health and development issues. These calls and commitments follow similar engagements made at previous global political fora this year, notably the recently-held G7 Development and Health Ministers meeting, and the World Health Assembly.

Global partners of the eradication effort, notably led by Rotary International and Rotarians around the world, are working with the public sector to ensure political commitments are fully operationalized.

In April 2022, GPEI partners, led by WHO Director-General, launched the ‘Investment Case for Polio Eradication’, the sister document to the Polio Eradication Strategy 2022-2026, which lays out the economic and humanitarian rationale for investing in a polio-free world, as well as the broader benefits of polio eradication.

In October 2022, Germany will generously co-host a global pledging moment, giving the international development community and polio-affected countries the opportunity to publicly re-commit to this effort, including to support a stronger and sustainably-funded WHO, so that the organization can maintain its capacity to support countries in achieving and sustaining polio eradication, and continue to benefit broader public health efforts, including support for pandemic preparedness and response.

The Global Polio Laboratory Network (GPLN) has confirmed the isolation of type 2 vaccine-derived poliovirus (VDPV2) from environmental samples in London, United Kingdom (UK), which were detected as part of ongoing disease surveillance. It is important to note that the virus has been isolated from environmental samples only – no associated cases of paralysis have been detected. Recent coverage for the primary course of DTaP/IPV/Hib/HepB vaccination, which protects against several diseases including polio, in London suggests immunization coverage of 86.6%.

Initially, vaccine-like type 2 poliovirus (SL2) had been isolated from samples taken from the same site between February and May 2022. Genetic analysis suggests that the new VDPV2 and previous SL2 isolates have a common origin, still to be identified, but the technical definition and criteria for ‘circulation’ of VDPV2 are not met at this time. Additional sewage samples collected upstream from the main waste-water treatment plant’s inlet are being analysed.

Investigations and response by the UK Health Security Agency are ongoing to:

assess both origin and risk of circulation associated with these isolates;
strengthen poliovirus surveillance including enterovirus and environmental;
explore routine immunization catch-up of children who are under-immunized, including of families that have recently arrived in the UK from countries with recent use of type 2-containing oral polio vaccine; and,
enhance communications about this incident to health professionals and caregivers.

It is important that all countries, in particular those with a high volume of travel and contact with polio-affected countries and areas, strengthen surveillance in order to rapidly detect any new virus importation and to facilitate a rapid response. Countries, territories, and areas should also maintain uniformly high routine immunization coverage at the district level and at the lowest administrative level to protect children from polio and to minimize the consequences of any new virus being introduced.

Dr. Nabil vaccinating administering polio drops to one of his grandsons in front of the community to convince people about the safety of the polio vaccine. © UNICEF Yemen — Dr. Nabil vaccinating administering polio drops to one of his grandsons in front of the community to convince people about the safety of the polio vaccine. ©UNICEF/Firdous

It’s been a long day for Dr. Nabeel Abdu Omar Ali. Since early morning, he has been going from one house to the next in a community in Aden, Yemen – listening to the concerns of parents and speaking to them about the importance of vaccination to save their children from polio. And he plans to continue till the sun goes down.

“The weather is pleasant now and I want to meet as many parents as possible, especially those who have concerns about vaccines. In a month’s time, the heat and humidity will be unbearable, making it difficult to walk from house to house,” says Dr. Nabeel.

Nicknamed “the mobile imam” by his peers, Dr. Nabeel is a pediatrician by profession, and a certified imam (Islamic teacher) from the Ministry of Endowment in Southern Yemen. He uses his religious knowledge and medical facts to educate the public about the importance of vaccination in protecting children from polio and other deadly diseases.

A few weeks back, he visited several families who were refusing vaccines in a nearby neighborhood. In addition to speaking to them about the safety and benefits of the polio vaccine, the ‘mobile Imam’ administered polio drops to his grandchildren in front of everyone at the community meeting.

“When the people saw a doctor and Imam like me vaccinating my own grandchildren, I think it was easier for them to believe that the vaccine was safe for their children too,” says Dr. Nabeel with a smile.

Reaching out to other Imams for support

Dr. Nabeel frequently reaches out to other Imams, training them about the benefits of vaccination and encourages them to share with the public during their Friday sermons.

Dr. Nabeel accompanying a polio vaccination team from one house to the next to speak with parents and caregivers. © UNICEF Yemen — Dr. Nabeel accompanying a polio vaccination team from one house to the next to speak with parents and caregivers. ©UNICEF/Firdous

“Imams are very influential in our communities – to raise awareness, shape social values, and promote positive attitudes, behaviours and practices. For example, a single sermon is powerful enough to change misconceptions about vaccines in some communities. If Imams are fully equipped with accurate information, it goes a long way in build trust and creating vaccine acceptance among the people – helping children in the community to stay health and free from polio and other vaccine-preventable diseases,” he adds.

The ongoing conflict in Yemen has severely damaged the health and basic infrastructure. There are frequent interruptions in power supply, and this often creates suspicion among community members as well as Imams whether vaccines are being stored safely.

“I was training a group of imams and they shared their doubts about the safety of the vaccine. They were skeptical about how refrigerators could store polio vaccines safely when there are so many power cuts in the area.”

In response, Dr. Nabeel organized a tour for the group to a vaccine storage facility where they were able to see and learn about special refrigerators that are powered by solar energy when there are power cuts.

Promoting the benefits of vaccination for over a decade

Dr. Nabeel has been working for the immunization programme in Yemen for over 12 years, partnering with UNICEF for numerous polio vaccination campaigns and routine immunization services.

When he first started out as pediatrician, he met many children who were paralyzed by polio. He felt frustrated that so many children would have to suffer for the rest of their lives by a disease that could have been easily prevented by a vaccine. That is when he decided to dedicate his time to educate caregivers and parents on the benefits of vaccination.

Dr. Nabeel (third from left) speaking with male members of a local community on the benefits of vaccination for children’s health and well-being. Photo: ©UNICEF Yemen — Dr. Nabeel (third from left) speaking with male members of a local community on the benefits of vaccination for children’s health and well-being. Photo: ©UNICEF/Firdous

“There are many misconceptions about vaccines. Throughout my career I have been confronted by people who were resistant to the idea of vaccination. Some people think that the vaccine will make them infertile, while others believe it’s some kind of a conspiracy. However, my many years of work in immunization and knowledge of religious scriptures has proven to be valuable so far in building trust in vaccine in communities,” says Dr. Nabeel.

The ‘mobile Imam’ is also quite adept in working with the media to promote vaccination. He is often seen and heard on TV and radio talk shows speaking about the benefits of vaccination and answering to questions from concerned parents and caregivers.

“I use a mixed approach to address vaccine hesitancy and dispel misinformation about vaccines. Sometimes it is helpful to talk about vaccines during Friday sermon, while other times, it is more effective to explain to a caller on a radio programme why vaccines are important,” he explains with a smile.

Three-year-old Yumna, niece of Samar al-Sheikh, receives her dose of OPV at Biddo UNRWA health facility on 18 May 2022. © WHO/occupied Palestinian territory

Over four days in the middle of May, parents in the governorates of Bethlehem and Jerusalem were urged to take their children under age five to health facilities for a supplementary dose of oral polio vaccine. The aim: boost immunity to poliovirus in the face of increased regional risk.

Unlike most polio campaigns in the Eastern Mediterranean Region, the mechanism for the campaign in occupied Palestinian territory (oPt) was via health facilities, rather than house to house. This can be a major ask for parents, who must organize time and transport to get children to health facilities during a relatively brief window.

Round 1, from Monday 16 May through Thursday 19 May, tested the resolve of a community that is famously pro-vaccine (routine immunization coverage across oPt is typically between 98% and 100%), but like parents everywhere, juggling work, childcare and other commitments.

While most often, mothers took their children for vaccination, in many of the health facilities where vaccination took place, grandmothers were seen supporting mothers or even stepping into their shoes.

“I brought my granddaughters today to take the polio vaccine because their mother is studying in university and their father is working,” said Abeer Nasrallah, who brought Zeina (two) and Mariam (three) to El-Azariyeh, a Palestinian Ministry of Health clinic in Jerusalem governorate.

Tamam Taha, a nurse at the Biddo UNRWA health facility, greets a mother at the campaign registration desk. © WHO/occupied Palestinian territory

In Biddo, an area of Jerusalem governorate where the main UNRWA clinic serves both local families and those from more remote regions, a steady stream of clinic visitors climbed out of mini-buses and taxis after lengthy journeys.

“Many Bedouins come to us from remote areas like Bani Samuel and Beit Iksa, although the transportation from their areas is very hard for two reasons. First, the roads are very difficult, and second, there are a lot of checkpoints that could keep you waiting for hours,” said Tamam Taha, a nurse at the Biddo UNRWA health facility.

“We have good numbers of people coming to the clinic, both refugee and non-refugees, and we give the vaccine to all of them,” she said.

One of the groups she served was headed by Samar Al-Sheikh, a mother of one who arrived with three girls in tow.

“I brought my brother’s daughters because he can’t come. Usually, I would walk from my home, but I took public transportation today because I have three kids with me. It was hard to manage them, but it’s important to give them the vaccine,” she said.

In some cases, the hurdles parents faced to bring their children to health facilities were starkly visible.

Nidal Kandeel, father of Janette (three) and Jolan (21 months), arrived at Biddo UNRWA health facility on crutches.

“I got an injury in my work a year ago, and I’m now disabled for the rest of my life. It was hard for me to come to the clinic using public transportation, but I know how important it is for my children to take the polio vaccine, and this is why I am here,” he said.

While the results of this preventative campaign are still pending, clinics promoted the campaign heavily through their own social media groups, and health workers explained that logistics aside, it wasn’t difficult to convince Palestinian parents of the need to vaccinate under-fives.

“There is a lot of demand for this vaccine. Many people have been coming since this morning to get their children to take the vaccine. In the last hour, we have vaccinated more than 100 children,” said Khawla Abu Khdeir a nurse running the registration desk at El-Azariyeh.

Following the four-day vaccination blitz at health facilities, nursing teams will review registers of children vaccinated and cross-reference these with patient lists. Parents of children who weren’t vaccinated will be telephoned and efforts made to reach those children through in-clinic follow-up or outreach.

Round two of the bivalent oral polio vaccine (bOPV) campaign is expected in mid to late June, with the aim of raising immunity levels in these two governorates.

Palestine has been polio-free for more than 25 years, thanks to a robust routine immunization programme and a strong culture of vaccine acceptance.

Nurse Khawla Abu Khdeir (rear left) hands a mother a campaign information pamphlet at El-Azariyeh Ministry of Health clinic on 16 May 2022. © WHO/occupied Palestinian territory

But following the detection of circulating vaccine-derived poliovirus type 3 (cVDPV3) in sewage outflow in Wadi Alnar site, a junction between wastewater coming from inside the green line with wastewater coming from Bethlehem and Jerusalem, the Palestinian Ministry of Health launched efforts to boost immunity in the areas deemed most at risk.

The campaign was carried out with support from WHO, UNICEF and UNRWA’s Palestine country offices.

WHO’s Palestine office provided technical support to the Ministry in planning and executing this campaign, drawing on the extensive expertise of our regional polio eradication programme.

The vaccination campaign in Palestine is part of the global effort to eradicate poliovirus, spearheaded by the Global Polio Eradication Initiative.

In this two-part video series, we chat with Dr Ananda Bandyopadhyay, Deputy Director of Polio Technology, Research & Analytics, BMGF, about the new tool in GPEI’s kit to combat cVDPV2: novel oral polio vaccine type 2 (nOPV2).

As a result of ongoing disease surveillance, the Global Polio Laboratory Network (GPLN) has confirmed that a child in Changara district, Tête province, Mozambique, was paralyzed by type 1 wild poliovirus (WPV1).

The child experienced onset of paralysis on 25 March 2022, and sequencing of the virus confirms that it is linked to the imported WPV1 case confirmed in Malawi in February.

While this detection of another WPV1 in the southeast Africa region is a concern, it is not unexpected following the Malawi detection in February and further underscores the importance for all countries to prioritize immunization of children against polio.

Mozambique has participated in the multi-country coordinated vaccination campaigns in response to Malawi’s imported WPV1, with two vaccination rounds already conducted. The most recent took place at end of April, with 4.2 million children vaccinated across the country, and the Global Polio Eradication Initiative (GPEI) is supporting countries to strengthen disease surveillance and prepare for the remaining two campaign rounds. These will cover Malawi, Tanzania, Mozambique and Zambia, with Zimbabwe joining the later rounds to ultimately help reach over 23 million children under five years with polio vaccine by end of August 2022.

Mozambique last recorded a case of wild polio in 1992 though the country has more recently been affected by an outbreak of circulating vaccine-derived poliovirus type 2 (cVDPV2). Three cases have been detected since April 2021 and vaccination campaigns in response to the outbreak are continuing, which include use of the novel oral polio vaccine type 2 (nOPV2).

Wild polio remains endemic in just two countries – Pakistan and Afghanistan. The WPV1 detection in Mozambique does not affect the WHO African Region’s wild poliovirus-free certification status officially marked in August 2020, as the virus strain originated in Pakistan. However, any child paralysed by polio is one too many. The polio eradication programme has seen importations from endemic countries to regions that have been certified wild poliovirus-free in the past and has moved quickly to successfully stop transmission of the virus in these areas.

Polio anywhere is a threat to children everywhere. It is vital that all parties ensure that the GPEI has the support it needs to implement its five-year eradication Strategy in full and ensure no child is paralysed by polio ever again.

On Monday 16 May, the Palestinian Ministry of Health will launch round one of a polio vaccination campaign targeting all children under age five in Bethlehem and Jerusalem.

The vaccination campaign is scheduled to run over three days: Monday 16 May through Wednesday 18 May 2022. Vaccination, using bivalent oral polio vaccine (bOPV), is free and will be offered at maternal and child centres and UNRWA centres throughout Bethlehem and Jerusalem.

Palestine has been polio-free for more than 25 years, thanks to a robust routine immunization programme and a strong culture of vaccine acceptance. But following the detection of circulating vaccine-derived poliovirus type 3 (cVDPV3) in sewage outflow in Wadi Alnar site, where there is a junction between wastewater coming from inside the green line with wastewater coming from Bethlehem and Jerusalem, the Ministry of Health has taken the decision to launch a preventative vaccination campaign to boost children’s immunity in the two areas deemed most at risk: Bethlehem and Jerusalem.

“It is all of our duty to keep Palestine polio-free by making sure that our children under the age of five receive the polio vaccine every time it is offered. I encourage every parent to make it a priority to vaccinate their children – for their sake, and for Palestine,” said Dr Mai al-Kaila, Minister of Health, Palestine.

The vaccination campaign is being carried out with support from WHO, UNICEF and UNRWA’s Palestine country offices.

“WHO’s Palestine office has provided technical support to the Ministry in planning and executing this campaign, drawing on the extensive expertise of our regional polio eradication programme. Palestine is in a strong position thanks to its routine immunization programme and to the value Palestinian parents put on childhood immunizations, but the regional risk of polio is increasing and it is absolutely crucial that we reach and vaccinate every child under age five in the target areas,” said WHO occupied Palestinian territory Representative Dr Rik Peeperkorn.

“It is critical that every child can access their right to a life free from polio and other vaccine-preventable diseases. UNICEF and its partners in this campaign are making every effort to ensure no child in Palestine will be affected by this debilitating disease. It is a duty upon all of us to keep Palestine polio free,” said UNICEF’s Special Representative to the State of Palestine Lucia Elmi.

Round two of the campaign will take place in June and will offer all children under age five a second two drops of polio vaccine, further boosting their immunity. Children living outside of Jerusalem and Bethlehem do not currently require an additional dose of oral polio vaccine. If their routine immunizations are up to date, they are well protected from poliovirus and other vaccine-preventable diseases.

Poliovirus primarily affects children under age five and can lead to lifelong paralysis. It can easily be prevented through vaccination. Parents are urged to accept polio vaccines every time they are offered.

The vaccination campaign in Palestine is part of the global effort to eradicate poliovirus, spearheaded by the Global Polio Eradication Initiative.

It is a hot afternoon in Chagai, a small community on the south bank of the River Gambia when the polio vaccination team arrives to a rapturous welcome. Children and women jump to their feet, some waving and swinging their hands as they pound their feet on the ground in near perfect sync with the beat of the drum.

This excitement is caused by one certain member of the vaccination team wearing a bush hat and playing the drums. Lamin Keita, 60, is a cultural musician supporting the vaccination team in raising awareness about polio and encouraging parents to vaccinate their children. Lamin, popularly called Takatiti, because of one of his songs, is immediately surrounded by excited children, as he adjusts his beats to respond to the ecstasy and rigor of the dancers.

“When I arrive on the back of a pick-up truck with my megaphone and drums, children from the communities run after us in full excitement and jump up and down and ask me to play my drums,” Takatiti explains.

Whenever Takatiti enters a village with his drums, children and adults flock around him and jump and dance to his music, which gives him the opportunity to speak with community members about polio and the importance of vaccination in protecting children from the deadly disease. Photo: © UNICEF/UN0624019/ Lerneryd

This is what Takatiti is popular for – pulling crowds with his drums to communicate important messages like polio vaccination. For almost four decades, he has toured communities in the region, accompanying health workers as they seek to persuade parents and caregivers to vaccinate their children during mass vaccination campaigns like the polio campaign.

Local voices are the most powerful voices

Building trust in vaccines among parents and caregivers is the first critical step towards achieving high immunization coverage to stop the spread of polio. UNICEF, as a leading partner of the Global Polio Eradication Initiative (GPEI) for social and behaviour change, supports the government in strengthening engagements with communities, as the voices of local leaders and influencers like Takatiti play a powerful role in helping allay fears and concerns of parents and caregivers about vaccines.

“I have been making town announcements since the mid-1980s. I am aware of polio and its terrible consequences. Families hear myths and rumours and get concerned about vaccines. As they already know and trust me, I try my best to give them accurate information and clear their doubts, so that they can vaccinate their children against polio and other dangerous diseases,” Takatiti says.

“It’s important to deliver messages that are supported by facts in an effective way”

Days before the start of a polio vaccination campaign and during the campaign itself, Takatiti walks up and down the streets of villages, playing his drums and using his megaphone to talk to communities about the dangers of polio, how vaccination is the only way to protect children, and that polio vaccines are safe and free.

Awa plays with her baby, Abdoulay, after he was vaccinated during the a polio vaccination campaign in Jenoi, The Gambia, on 21 March 2022. Photo: © UNICEF/UN0623991/Lerneryd

“I always try to promote peace and healthy life for all. It’s important to deliver messages that are supported by facts in an effective way. The Government and UNICEF provided me correct information and facts about polio and vaccines, so I am happy to volunteer for the campaign.”

A country mobilizes to stop polio

“If people trust health workers to cure other diseases, then it makes sense to trust the same health workers to protect our children from polio. Health workers even give the polio vaccine to their own children – so we should not doubt their good intentions. It is my job to let people know this truth, without offending them, and encourage them to vaccinate their kids,” Takatiti said.

In August 2021, The Gambia declared a national public health emergency in response to outbreaks of non-wild variants of polio in the country.

Sainabou, a healthcare worker, administers the polio vaccine to school children at New Town School during a vaccination campaign in Bakau, The Gambia, on 19 March 2022. Photo: © UNICEF/UN0624057/Lerneryd

The Gambian government, with support from WHO, UNICEF, US Centres for Disease Control and Prevention (CDC)and GPEI partners, quickly responded and started preparing for nationwide immunization campaigns – managing supply and safe storage of vaccines, strengthening surveillance and monitoring, training health workers and vaccinators, and engaging with local leaders and influencers to build trust in vaccines.

The country undertook its first national polio vaccination campaign in November 2021 and followed up with a second round in March 2022.

Thanks to thousands of health workers, vaccinators, and community influencers like Takatiti, the vaccination campaigns have reached over 380,000 children aged five years and below in The Gambia.

Children in Vakhsh region in Tajikistan receiving their first dose of oral polio vaccine. © WHO / Mukhsindzhon Abidzhanov

Infectious diseases like poliomyelitis (polio) know no borders. Importation and subsequent spread of the virus led to the paralysis of 34 children, and 26 others tested positive without developing symptoms of paralysis. Extensive immunization efforts began in February 2021, and no child, adult or environmental sample in Tajikistan has tested positive since August 2021.

The outbreak in Tajikistan marked the first detection of circulating vaccine-derived poliovirus type 2 (cVDPV2) in the WHO European Region. It is now the first cVDPV2 outbreak in the world to be declared officially closed following supplemental immunization using the novel oral polio vaccine type 2 (nOPV2).

The Region has been free of endemic poliovirus since 2002. Detection of just 1 case of polio – whether from a wild or vaccine-derived poliovirus – is considered an outbreak, and requires an immediate and comprehensive response.

“Tajikistan’s success in stopping this outbreak is a major achievement and a clear demonstration of the highest level of political commitment of the Government of Tajikistan,” says Dr Hans Henri P. Kluge, WHO Regional Director for Europe.

“This outbreak and the subsequent response came at a time when the health system was already overstretched by the COVID-19 pandemic and the country was mounting a massive COVID-19 vaccination drive. Both outbreak responses had to be done without disrupting the vitally important provision of other routine vaccines to children. We acknowledge the efforts of the Ministry of Health over the past several years, which resulted in a resilient immunization system able to successfully manage all these competing immunization priorities.”

Actions taken to stop the outbreak

Following confirmation of the outbreak, the Ministry of Health and Social Protection of the Population took immediate steps, with support and guidance from WHO and other Global Polio Eradication Initiative partners. Actions included enhanced poliovirus surveillance, intensive contact tracing and a thorough review of immunization coverage at subnational levels. A rigorous risk assessment was conducted to determine the outbreak response scale and choice of vaccine, and the country rapidly completed a comprehensive verification process for readiness to use the nOPV2 vaccine.

In February 2021, a high-quality nationwide inactivated polio vaccine campaign was conducted to close the immunity gap against poliovirus type 2 among the more than half a million children born from 2016 to 2018 who had been left vulnerable as a result of global inactivated polio vaccine (IPV) supply constraints following cessation of trivalent oral polio vaccine use.
From June to September 2021, 2 nationwide and 1 subnational nOPV2 immunization rounds were implemented for all children under 6 years of age, with coverage confirmed (through external assessment) to be greater than 95%. Extensive social mobilization and communication strategies were deployed to reach groups who were at risk of being missed, including internal migrants in urban areas and unregistered children.

Assessment of the outbreak response

Several criteria must be met to officially close an outbreak, including at least 6 consecutive months in which no poliovirus is detected. The independent experts of the Global Polio Eradication Initiative who conducted the assessment in Tajikistan also looked at the performance of routine polio vaccination, the coverage achieved during the supplemental immunization rounds, and the capacity and sensitivity of the polio surveillance system to detect any poliovirus circulation.

Following the thorough assessment, which included briefings at the national level and field visits to national referral hospitals, public hospitals, polyclinics, regional and district immunization programme offices, and public health centres, the team recommended closure of the outbreak.

nOPV2 – a new chapter in global efforts to eradicate polio

Ending this outbreak using nOPV2 is an important milestone for the global polio programme. The innovative vaccine is a key part of the new strategy to stop cVDPV2s. Clinical trials show that nOPV2 is safe and effective, and more genetically stable than the traditional type 2 oral polio vaccine.

Since the rollout of nOPV2 began in March 2021, over 265 million doses have been administered across 14 countries. The majority of countries using the vaccine have also managed to stop transmission of cVDPV2; however, this is the first official closure of an outbreak to take place following nOPV2 use.

In addition to successfully halting transmission and lowering the risk of infection for millions of people, Tajikistan contributed to global research on nOPV2 with the support of WHO through an nOPV2 immunogenicity study. The country also participated in a global vaccine wastage study.