From the gold standard of detecting and investigating cases of acute flaccid paralysis (AFP) to testing environmental samples from sewage collection sites, timelyand sensitive surveillance is key to locating and eradicating polio. And in the endgame to finish the job, closing all remaining gaps in detection and investigation capacity is critical.
Global Polio Eradication Initiative has developed Global Polio Surveillance Action Plan, 2018 – 2020 to help endemic, outbreak and high-risk countries measure and enhance the sensitivity of their surveillance systems. It provides new strategies that may be useful in improving detection of polioviruses, and is designed to increase coordination across field team, laboratory and information management staff.
The Action Plan outlines activities and indicators at the global, regional and country levels for all priority countries, centred around six core objectives to strengthen surveillance systems, and is anchored within the broader strategic framework of the GPEI.
WHO Director-General Dr Tedros Adhanom Ghebreyesus opened the Organization’s Executive Board (EB) on 24 January with a report from his first visit of the year, to the polio endemic countries of Afghanistan and Pakistan: “This year I have taken over as chair of the Polio Oversight Board. That’s why my first trip of the new year was to Afghanistan and Pakistan. These are the two countries that are the last frontiers of wild poliovirus. We are so close to ridding humanity of this disease, and I am personally committed to ensuring that we do. I was really impressed by the commitment of the governments of Afghanistan and Pakistan.”
The Executive Board, comprised of 34 Member States’ designated experts in the field of health, convened in Geneva in late January to discuss a wide-ranging agenda on the most pressing and urgent health concerns of our times, including the urgency to rev up efforts in this last mile of polio eradication efforts.
The EB was encouraged by the progress achieved through the Endgame Strategic Plan 2013-2018, which has led the world to the brink of polio eradication and laid the groundwork for the new strategy – the Global Polio Eradication Initiative Strategic Plan 2019-2023. The new strategy will aim to sharpen the tools and tactics that led to the global progress in bringing down the case load from 350 000 annual wild polio virus cases in 1988 to only 33 cases in 2018. Success in the coming years will hinge on harnessing renewed financial and political support to fully implement the plan at all levels, with our one clear goal in sight: reach every last child with the polio vaccine to end this disease once and for all.
In a time of many global challenges and priorities, the coming year will require more than ever a singular commitment from the governments and partners as we near zero. On the sidelines of the EB, the DG held a stakeholder consultation to ensure that the 2019-2023 Strategic Plan reflects a transparent and inclusive stakeholder participation. The DG stressed the need for strengthened and systematic collaboration between partners, health, and non-health actors across cross-cutting areas of management, research and financing activities for polio eradication. Given that polio eradication effort continues to be a global priority, one of the salient features of the consultation was a renewed commitment to transparent long-term budgets for eradication efforts, including key post-certification costs such as stockpiles and inactivated polio vaccine to help protect more than 430 million children from polio each year.
“In a time of many global challenges and priorities, the coming year will require more than ever a singular commitment from the governments and partners as we near zero.”
Voicing similar sentiments earlier, Chairs of the effort’s main advisory bodies issued an extraordinary joint statement, urging all stakeholders, partners, countries, and individuals to strengthen their collective resolve to seeing polio fully eradicated for good. Polio continues to be a global health risk as confirmed at the end of last year, the Emergency Committee reiterated its advice that polio remains a public health emergency of international concern.
Polio resources for over three decades have helped reduce the number of endemic countries from 135 down to only 3 (Pakistan, Afghanistan, and Nigeria), eradicate polio from some of the most challenging areas in the world, and continue to enable countries around the world in advancing other national health goals.
With the continued commitment of all donors and partners, 2019 may very well become the decisive year when we finally stop wild polio virus transmission in Afghanistan and Pakistan.
The Endgame Plan through 2018 brought the world another year closer to being polio-free. While we had hoped to be finished by now, 2018 set the tone for the new strategic plan, building on the lessons learned and mapping out a certification strategy by 2023. 2018 was also marked by expanded efforts to reach children with vaccines, the launch of innovative tools and strategies, critical policy decisions and renewed donor commitment to the fight.
Circulation of wild poliovirus (WPV) continues in the common epidemiological block in Afghanistan and Pakistan. However, both countries steadily worked to improve the quality of their vaccination campaigns in 2018 through National Emergency Action Plans, with a particular focus on closing any immunity gaps to put the countries on track to successfully stop WPV in the near future. Given the priority on polio eradication, WHO Director General, WHO Regional Director for the Eastern Mediterranean and President, Global Development at Bill & Melinda Gates Foundation started off the new year with a four-day visit to meet the heads of state and have a first-hand experience of the on-the-ground eradication efforts in both the countries.
In August, Nigeria marked two years since detecting any WPV. With continuing improvements in access to the country’s northeast, as well as efforts to strengthen surveillance and routine immunization, the entire African region may be eligible for being certified WPV-free as early as late this year or early 2020. What’s more, the world has not detected type 3 WPV since 2012 and the strain could be certified eradicated sometime this year.
Program innovation
The programme is constantly developing new ways to more effectively track the virus, vaccinate more children and harness new tools to help end the disease for good.
In Nigeria and the surrounding region, health workers launched new tools to enable faster, more comprehensive disease surveillance. e-Surve, a smartphone app, guides officers through conversations with local health officials, offering prompts on how to identify and report suspected cases of disease. Then, with the touch of a button, responses are submitted to a central database where health officials can analyze and track outbreaks across multiple districts in real-time.
Beyond surveillance, health workers worked tirelessly to bring the polio vaccine to the remote communities of Lake Chad. Dotted with hundreds of small islands, the lake is one of the most challenging places on earth to deliver health services. Vaccinators must travel by boat on multi-day trips to deliver polio vaccines to isolated island villages, using solar-powered refrigerators to keep their precious cargo cool. In 2018, vaccination campaigns on the lake reached thousands of children for the first time – children who would otherwise have gone unprotected.
The programme also took important steps in developing new tools including, novel oral polio vaccine (nOPV), if studies show to be successful, could provide a safer form of OPV that provides the same level of protection without the small risk of vaccine-derived polio in under-immunized populations.
Battling circulating vaccine-derived poliovirus
In 2018, the Democratic Republic of the Congo, Niger, Nigeria, Papua New Guinea, Kenya, Somalia and Mozambique experienced outbreaks of circulating vaccine-derived polio (cVDPV). Although these cases are still rare – and only happen in places where immunity is low. The polio eradication initiative has two urgent tasks: eradicate WPV quickly as possible and stop the use of OPV globally, which in tandem will prevent new cVDPV strains from cropping up.
The program uses the same proven strategies for stopping wild polio in responding to cVDPV cases. These strategies, coupled with the rapid mobilization of resources on the ground, can bring outbreaks under control.
In December, an international group of public health experts determined that the 2017 cVDPV2 outbreak in Syria has been successfully stopped. This news follows 18 months of intensive vaccination and surveillance efforts led by the GPEI and local partners in conflict-affected, previously inaccessible areas. In Papua New Guinea, the programme carried out 100 days of emergency response this past summer and is continuing to vaccinate and expand surveillance across the country.
Bringing an end to ongoing cVDPV outbreaks remains an urgent priority for the program in 2019.
New policy decisions
At the World Health Assembly in May, Member States adopted a landmark resolution on poliovirus containment to help accelerate progress in this field and ensure that poliovirus materials are appropriately contained under strict biosafety and biosecurity handling and storage conditions. The programme also finalized a comprehensive Post-Certification Strategy that specifies the global, technical standards for containment, vaccination and surveillance activities that will be essential to maintaining a polio-free world in the decade following certification.
Recognizing the ongoing challenge posed by cVDPVs, the Global Commission for the Certification of Poliomyelitis Eradication (GCC) met in November and recommended an updated process for declaring the world polio-free. This plan will start with the certification of WPV3 eradication, followed by WPV1, and include a separate independent process to validate the absence of vaccine-derived polio.
Comprised of members, advisers, and invited Member States, the 19th IHR Emergency Committee met in November. The Committee unanimously agreed that poliovirus continues to be a global emergency and complacency at this stage could become the biggest hindrance. “We have the tools, we need to focus on what works, we need to get to every child,” commented Prof. Helen Rees, Chairperson of the Committee. “The reality is that there is no reason why we should not be able to finish this job, but we have to keep at it.” “We have achieved eradication of a disease once before, with smallpox,” Rees concluded. “The world is a much better place without smallpox. It’s now more urgent than ever that we redouble our efforts and finish this job once and for all as well.”
In 2018, the GPEI took major steps in adopting a more gender-responsive approach and strengthening gender mainstreaming across its interventions. The GPEI Gender Technical Brief highlighted the programme’s commitment to gender equality and included a thorough analysis of various gender-related barriers to immunization, surveillance and communication.
The programme introduced new gender-sensitive indicators to ensure that girls and boys are equally reached with polio vaccines, to track the timeliness of disease surveillance for girls and boys, and to monitor the rate of women’s participation as frontline workers in the endemic countries. The GPEI continues to regularly collect and analyze sex-disaggregated data and conduct gender analysis to further strengthen the reach and effectiveness of vaccination campaigns.
Donor countries made new financial contributions to the programme in 2018. Polio-affected countries also demonstrated continued political commitment to eradication efforts. The Democratic Republic of the Congo signed the Kinshasa Declaration committing to improve vaccination coverage rates in sixteen provinces throughout the country, and Nigeria approved a $150 million loan from the World Bank to scale up immunization services and end polio.
Looking ahead: 2019 and beyond
Over the last five years, the programme has been guided by the 2013-2018 Polio Eradication & Endgame Strategic Plan, helping to bring the world to the brink of polio eradication. This spring, the programme will finalize a new strategy –GPEI Strategic Plan 2019-2023– which will aim to sharpen the tools and tactics that led to this incredible progress. In 2019, the GPEI will also launch its first-ever Gender Strategy to further guide its gender-responsive programming and to increase women’s meaningful and equal participation at all levels of the programme.
Success in the coming years will hinge on harnessing renewed financial and political support to fully implement the plan at all levels, with our one clear goal in sight: reach every last child with the polio vaccine to end this disease once and for all. Echoing similar sentiments, Chairs of the effort’s main advisory bodies issued an extraordinary joint statement, urging all to step up their performance to end polio. 2019 may very well be the watershed year that the world will finally eradicate polio, thanks to the global expertise and experience over 3 decades.
A new circulating vaccine-derived poliovirus type 2 (cVDPV2) outbreak has been confirmed in Mozambique. Two genetically-linked circulating vaccine-derived poliovirus type 2 (cVDPV2) isolates were detected from an acute flaccid paralysis (AFP) case (with an onset of paralysis on 21 October 2018, in a six-year old girl with no history of vaccination, from Molumbo district, Zambézia province), and a community contact of the case.
As polio is a highly infectious disease which transmits rapidly, there is potential for the outbreak to spread to other children across the country, or even into neighbouring countries, unless swift action is taken. Global Polio Eradication Initiative and partners are working with country counterparts to support the local public health authorities in conducting a field investigation (clinical, epidemiological and immunological) and thorough risk assessment to discuss planning and implementation of immunization and outbreak response.
In January 2017, a single VDPV2 virus had been isolated from a 5-year old boy with AFP, also from Zambézia province. Outbreak response was conducted in the first half of 2017 with monovalent oral polio vaccine type 2 (mOPV2).
Read our Mozambique country page to see information on cases, surveillance and response to the developing outbreak.
In an extraordinary joint statement by the Chairs of the main independent, advisory and oversight committees of the GPEI, the Chairs urge everyone involved in polio eradication to ensure polio will finally be assigned to the history books by 2023. The authors are the chairs of the Strategic Advisory Group of Experts on immunization (SAGE), the Independent Monitoring Board, the Emergency Committee of the International Health Regulations (IHR) Regarding International Spread of Poliovirus and the Global Commission for the Certification of the Eradication of Poliomyelitis (GCC).
The Endgame Plan through 2018 has brought the world to the brink of being polio-free. A new Strategic Plan 2019-2023 aims to build on the lessons learned since 2013.
The joint statement urges everyone involved in the effort to find ways to excel in their roles. If this happens, the statement continues, success will follow. But otherwise, come 2023, the world will find itself exactly where it is today: tantalizingly close. But in an eradication effort, tantalizingly close is not good enough.
The statement therefore issues an impassioned plea to everyone to dedicate themselves to one clear objective: to reach that very last child with polio vaccine. By excelling in our roles. It means stepping up the level of performance even further. It means using the proven tools of eradication and building blocks that have been established in parts of the world that have been free of polio for years.
The Chairs remind us that as a global community, we have stood where we stand today once before, with smallpox. And we achieved the eradication of smallpox. And the world is a much better place without smallpox.
So, let us make the world again a better place. Together. Let us eradicate polio.
Jean-Marc Olivé, Chairman of the Technical Advisory Group (TAG), addressing the participants. WHO/L.Dore
From the 27 – 29 November, the Technical Advisory Group (TAG) met in Nairobi to review the outbreak response in Somalia, Ethiopia and Kenya, and preparedness measures in Yemen, Uganda, Tanzania, Sudan, South Sudan and Djibouti in case of international spread.
Jean-Marc Olivé, Chairman of the TAG, spoke to WHO about the recommendations made to address the challenges faced by countries, his hopes for eradication and his life in the programme.
What are the main challenges faced by the countries of the Horn of Africa in the drive to stop the outbreaks?
The major challenges have been the same for a long time – like, the issue of inaccessibility due to conflict and humanitarian crises. If we cannot access populations then it is very difficult to cover them properly during vaccination campaigns and so it is hard to stop poliovirus transmission. This is not a programme-related issue, it is a political one. Until we have access, it will be very difficult to make it.
I have said it before and I will say it again: access is success.
I think the second challenge is – and this is one of the reasons why we still have the transmission of circulating vaccine-derived poliovirus in the Horn of Africa – is persistently low vaccination coverage. There are still remote areas, rural areas, heavily populated urban areas where routine immunization has really never been able to offer the same services and coverage as in more accessible areas with fewer challenges.
Since last TAG meeting in the Horn of Africa, what progress have you seen?
I have seen the capacity really building up in the Horn of Africa. The biggest shift is that we now have collected a lot of data about surveillance, about immunization coverage, vaccination campaigns, communications, and also data by the type of population we are reaching and not reaching. What is missing now, and what was the focus of this TAG, is to use this data to monitor progress and orient the programme toward those difficult areas. We have to use the data to tell us a story about what is happening and what to do next.
What were the most important recommendations made by the TAG this time around?
I think the most important is to follow the plan that has been set up for the three outbreak countries to interrupt transmission. Secondly, the countries that have not been yet infected by the virus should have a preparedness plan to ensure that if there are any problems they can move swiftly into action.
The Horn of Africa has seen several outbreaks in the past. What must be done to break the pattern and keep the region polio-free once and for all?
They have identified the problems. They just have to implement the solutions! We need to be sharing and analysing knowledge, information, and building capacity at the local level to ensure that we are on the right track to success.
I say to all the countries, go to the areas where you know you have problems and engage local communities and health authorities. Most of the issues can only be addressed at local levels by local people who understand the situation. Help them to do that, and monitor progress.
This is your thirteenth TAG; what have you learned about the process of international review?
First, you have to work as one team in support of National Teams, all agencies together. There cannot be any agency that claims, “This is us, we are doing that, this is WHO, this is UNICEF…”; this is the Global Polio Eradication Initiative, working together with all committed partners, using the competencies that each of them has. If you don’t address issues comprehensively as one, effective interventions are much more difficult to implement.
How long have you worked on polio eradication? What lessons have you learnt from this experience?
I was involved in the eradication of polio in the Americas. We started in 1985. We did it from A to Z in 9 years. We had very good leadership, commitment from the Government and partners, clear guidelines, very strong monitoring, and solid and reactive support to the field. Then we moved on into measles elimination with the same engagement – and the same results.
Because I have seen it happen, I know it is feasible. I think this is what keeps me so motivated. Polio eradication is a fantastic initiative. If we focus on weak and problematic areas within countries, if Governments and Partners continue to be engaged, we will make it. It’s going to be tough, mainly because of inaccessibility.
Is there anything else you want to add?
The people working in this programme, particularly local people working in the countries are amazing. They are the basis of any future public health intervention. In Pakistan and Afghanistan, woman are more and more playing an important role. This is an incredible advancement and an incredible contribution that was previously thought to be impossible.
But nothing is impossible – you just push, go slowly and constructively you will manage to gain ground over the virus.
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.
Left: Shire gives child two drops of the oral polio vaccine to protect them against lifelong paralysis Right: Shire works with vaccination teams to prepare cold boxes to carry polio vaccines
I have spent nearly my whole career working on eradication programmes – first smallpox, then polio. Eradication has been a rewarding career for me because I am so curious to know what is happening in the world. Every time I see a disease that we have worked so long to stop returning, I become so unhappy and know I need to work to stop it.
I worked for the smallpox eradication programme back in the 1970s. I was an epidemiologist – this means that my job was to track the disease and plan how we could stop it.
We used to hold vaccination campaigns at night because then we knew everyone would be at home, and we wouldn’t risk missing a single person. As our cars pulled up out of the dark, people would peer out of their houses to see what was happening. Somalis are very curious! As we brought them the vaccine, occasionally someone would make trouble, but mostly people were pleased to see us.
Somalia was the last country where smallpox was found in the whole world. When I knew we had really ended it in 1977, I was so happy. My name was printed there on the certification document – it was something to be proud of. We had freed the world from smallpox!
I remember one of my friends calling me in 1997 to tell me we were going to eradicate another disease, and that we had to look out for something called ‘AFP’. I thought to myself, what is this ‘AFP’? I hadn’t heard of it. They explained to me that it means acute flaccid paralysis – and that it was the symptom of a disease called polio.
Then one day in 1999, I received a call asking if I would come and work for the second eradication programme in my single lifetime. They said, “If you are ready, we will make you a coordinator. We don’t know if there is polio in Somalia or not, but we want you to come and see.” I jumped at the chance.
We started to search, looking for AFP cases, to collect stool samples and then to send them to the laboratory for testing. And soon, we had confirmation that polio was in Somalia. As soon as we found cases, lots of people came from inside and outside Somalia to help.
By 2002, we found the last case of indigenous polio, and thought the game was won. I even joked to my friends saying, what will we do now that polio is eradicated? They said to me, no – we still have polio in Nigeria, Egypt, Pakistan, many other countries – another case will come. We have to be prepared to stop it if it comes.
And true enough, we had an outbreak in 2005, and again in 2013. Each time we stopped it. Last year, we found circulating vaccine-derived poliovirus type 2. Vaccine-derived polio causes paralysis just like wild polio, and we must eradicate it too.
We started to organize ourselves and held two vaccination campaigns. But then we found another virus – circulating vaccine-derived poliovirus type 3. So now, we are responding to two outbreaks that need different vaccines at the same time. If we miss cases and miss getting vaccines to all children, we can’t stop polio. It is hard, but we will end these outbreaks just as we ended wild polio before.
Eradicating polio has been very difficult – more difficult than it was to end smallpox. I suffered – me and my wife were even kidnapped once. But I am always motivated to keep going. My motivation was never my salary – to stay alive, I need to work. I must know what is going on in my country, if my people are safe. From morning until night, my job is to make sure activities can go on peacefully. My family are my true reason for committing my life to eradication. I have seven children, and 30 grandchildren; I never once missed getting any of them vaccinated. Never.
I am sure that we will finish this job. When we eradicate polio, I will be so happy – I will have been involved in the certification of the second human disease ever to be eradicated. I feel so lucky to have spent my life working for these two eradication programmes; I am proud to tell stories to my grandchildren of my life’s work.
Eradicating polio won’t take a miracle. It is a job. It needs a lot of hard work to end an outbreak. There is no other way – the only way is to work hard, to find cases, and to respond. We hope that in the coming months we will make it. I do believe we will make it. Inshallah.
Participants of the Africa Regional Commission for the Certification of poliomyelitis eradication (ARCC) in Nairobi, Kenya, from 12-16 November 2018. WHO AFRO/2018
Efforts to end polio across the WHO African Region came under the microscope at a meeting of the Africa Regional Commission for the Certification of poliomyelitis eradication (ARCC) held in Nairobi, Kenya, from 12 – 16 November 2018.
Seven countries (Cameroon, Nigeria, Guinea-Bissau, the Central African Republic, South Sudan Equatorial Guinea and South Africa) made presentations to the ARCC on their efforts to eradicate polio, presenting evidence on their level of confidence that there is no wild polio in their borders, the strength of their surveillance systems, vaccination coverage, containment measures and outbreak preparedness. Kenya, the host country, alongside the Democratic Republic of the Congo and Namibia, presented updated reports on their efforts to maintain their wild poliovirus- free status.
Professor Rose Leke, Chair of the ARCC, speaking to the participants. WHO AFRO/2018
A total of 109 participants including partners of the Global Polio Eradication Initiative, non-governmental organisations and Health Ministries were in attendance to hear the reports.
The ARCC is an independent body appointed in 1998 by the WHO Regional Director for Africa to oversee the certification and containment processes in the region. It is the only body with the power to certify the Africa region free from wild polio. The African Regional Office and the Eastern Mediterranean Regional Office are the two WHO regions globally that remain to be certified free from wild poliovirus.
Professor Rose Leke, Chair of the ARCC, reflected on the importance of this meeting: “The rich, open and in-depth discussions held this week with each of the ten countries will allow these countries to strengthen ongoing efforts to further improve the quality of surveillance and routine immunization including in security compromised and hard to reach areas as well as in special populations such as nomads, refugees and internally displaced persons.”
Recommendations made
The ARCC, made up of 16 health experts, made recommendations to the ten countries. They noted with concern that outbreaks of circulating vaccine-derived poliovirus in the Democratic Republic of Congo, Kenya, Niger, Nigeria and Somalia were symptoms of low population immunity and varied quality vaccination campaigns. These countries were encouraged to conduct a high-quality outbreak response. Neighbouring countries were advised that they should assess the risk of spread or outbreaks within their borders. Low population immunity was identified as a significant concern, given the risk further emergences of vaccine-derived poliovirus strains.
Inaccessibility and insecurity were also flagged as a significant concern, with limits to the number of children who were being reached with polio vaccines and the coverage of surveillance efforts in affected areas. Countries were advised to scale up strategies that have proved in the past to be effective in the face of these challenges and to build relationships with civil society and humanitarian organisations who could provide immunization services.
Recommendations were made across the board to address chronic surveillance gaps, especially related to factors affecting the quality and transportation of stool samples reaching the laboratory for testing. The introduction of innovative technologies was commended, and a call was made for countries to expand their use, especially in inaccessible and hard-to-reach areas. Countries were also encouraged to accelerate their progress towards poliovirus containment.
In addition, all of the presenting countries received specific recommendations to support their efforts towards improving surveillance, immunization and containment in order to achieve a level that would give the ARCC the confidence needed to declare the region to have eradicated polio.
Dr Rudi Eggers, WHO Kenya Country Representative, said: “I commend all the countries on the efforts that have gone into achieving the results presented in their reports. It gives us hope that eradication is achievable in the midst of the unique challenges faced by all countries. We appeal to all the countries to fully implement all ARCC recommendations.”
Polio eradication efforts in Kenya
Dr Jackson Kioko, Director of Medical Services, the Kenyan Ministry of Health, said: “Kenya has worked hard to rid the country of wild poliovirus, and we will continue to do so until Africa and the world are certified polio-free.”
While Nigeria remains the only country in Africa to be endemic for wild poliovirus, responses are underway to stop outbreaks of circulating vaccine-derived poliovirus in the Democratic Republic of the Congo, Kenya, Niger and Somalia.
The circulating vaccine-derived poliovirus in Kenya was found in a sewage sample in Eastleigh, Nairobi, in March 2018, closely related to viruses found in Somalia. The Ministry Health, with the support of WHO, UNICEF and partners, has done several polio vaccination campaigns since then to ensure that every child’s immunity is fully built and no virus can infect them.
In June 2017, some of the first circulating vaccine-derived poliovirus type 2 (VDPV2) cases were reported in Deir Ez-Zor governorate, in eastern Syria, confirming an outbreak of polio. Since then, 74 cases were reported, with the most recent case reported on 21 September 2017.
Despite being a high-risk country with large scale population movements, inadequate health infrastructure, and accessibility issues, the outbreak response was successfully carried out. Health workers reached out to children to raise immunity levels, vaccinate children, and stop the outbreak, regardless of the location or socio-political climate.
An official outbreak response assessment was carried out by experts on global health, virology, and epidemiology, which concluded that the outbreak could now be closed.
“(Disease) Surveillance is stronger today than it was 18 months ago, when the initial cases were detected…so, as we celebrate what is a remarkable achievement in stopping this outbreak, amid very challenging circumstances, we must not lose sight of the risks posed by continued circulation of virus in other parts of our Region,” said Chris Maher, Manager for Polio Eradication in the WHO Eastern Mediterranean Region.
One of the most challenging aspects of polio eradication is timely disease surveillance: knowing where the poliovirus is lurking, so we can roll out targeted immunization activities quickly and effectively. With new tools, eradicators are getting the information they need in real time.
For the past three decades, there have been two approaches to find polio: passive and active surveillance. Passive surveillance involves health workers routinely reporting cases of acute flaccid paralysis (AFP) as they find them in health facilities. Active surveillance takes place where there is a higher level of concern that polio might be present. Experts go to hospitals, clinics and even community healers to search out cases of AFP. This approach, often called active case searching, reduces the risk that cases are missed due to human error – people forgetting to report AFP or health care workers or community healers not knowing that they need to report the case.
However, in active case search the key steps of detecting, reporting and investigating the case might not always be happening consistently in all health facilities. There can be a delay of two months or more between a child being paralyzed, experts finding out and alerting the polio surveillance system. In an outbreak setting, this can be long enough for the virus to infect and paralyze more children, moving from one area to another. There was an obvious need to make the surveillance system even more reliable and time-sensitive to ensure the polio surveillance framework is as robust as ever.
In order to ensure that active search is conducted timely with real time evidence the polio surveillance systems in Kenya, Ethiopia, Uganda, Eritrea, South Sudan, and Tanzania have adopted an easy-to-use, portable disease surveillance monitoring tool. It delivers unprecedented accuracy across huge areas. The best bit? Most people already have the basic component in their pockets: their mobile phones.
The tool is known as Integrated Surveillance and Routine Immunization Supervision. The idea is simple: surveillance officers use an app on their mobile phones to document active case searching as it happens, by tagging the location of every healthcare facility they visit and check.
“This provides real-time monitoring in the field. Previously, officers would report having done active case searching after the fact – like, ‘I was here and I did x, y, z’. But this is vulnerable to human error in remembering accurately. Sometimes, before we introduced it, someone would go to a distant, rural area and not be able to pinpoint their location on a map for others to follow up. Now, we are sure we are not missing things.” said Christopher Kamugisha, WHO’s Horn of Africa Outbreak Coordinator.
The app guides surveillance officers through a checklist (questions cover resources available at the facility, polio, measles and routine immunization) that they fill out and send then and there, using their mobile phones, even without an internet connection. It can also provide on-the-spot data analysis so that the surveillance officer can take immediate, evidence-based action.
With a swipe of the screen, users marry surveillance findings to the facility’s location and send the information to a centrally generated map. This gives staff at the national level a clearer picture of where surveillance is working and where it is not, including data on where possible polio cases are, so they know where to direct extra resources.
It also means health workers actively searching for AFP do not have to spend extra time ensuring the information gathered in the field is being shared with the right people for them to take action. For the ongoing outbreak of circulating vaccine-derived poliovirus in the Horn of Africa, this means better disease surveillance – and a better chance to protect children against polio.
At Malahang health clinic near Lae in Morobe Province, a health worker administers the oral polio vaccine (OPV) at a supplementary vaccination activity targeting children under five years. As part of the health ministry’s response to Papua New Guinea’s recent polio outbreak, four additional rounds of OPV vaccination are planned in Morobe, Madang and Eastern Highlands provinces.
An aerial view near Lae, Morobe Province. Papua New Guinea’s first polio outbreak since 1996 was first identified at Lae. Low immunization coverage rates, poor water sanitation and hygiene all contributed to cases of circulating vaccine-derived poliovirus (cVDPV).
Officer-in-charge Daisy Basa (centre) checks a child’s vaccination card at the Malahang Health Clinic. More than 2900 health workers, vaccinators and volunteers have been mobilized to vaccinate almost 300,000 children under five years old in Morobe, Madang and Eastern Highlands provinces.
Locals in traditional dress provide entertainment for families attending the supplementary vaccination sessions at Malahang health clinic. A national public awareness campaign has played a key part in the Government’s comprehensive response to the polio outbreak, helping to maximise vaccine coverage of children under five years old.
The National Department of Health (NDOH) is leading efforts to limit the spread of the disease, in collaboration with WHO, GPEI and other partners. As well as the supplementary vaccination sessions, the National Public Health Emergency plan includes strengthening surveillance systems for early virus detection. WHO is supporting this work, ensuring swift investigation of every case of suspected polio paralysis.
Vaccine supplies are loaded into the cold room at the Morobe Province supply store in Lae. Thanks to the quick response of the National Department of Health (NDOH), along with WHO and other partners, thousands of children have already been vaccinated. Efforts continue to detect and protect against the virus.
The first of four large-scale immunization campaigns is set to kick off in Papua New Guinea next week, following last month’s confirmation of a circulating vaccine-derived poliovirus type 1 (cVDPV1). More than 2900 health workers, vaccinators and volunteers have been mobilized to vaccinate almost 300 000 children under 5 years of age in Morobe, Madang and Eastern Highlands provinces. The campaign from 16-29 July is the first in a series of vital immunization campaigns planned every month for the next four months.
“Polio is back in Papua New Guinea and all un-immunized children are at risk,” said Pascoe Kase, Secretary of the National Department of Health (NDOH). “It is critical that every child under five years of age in Morobe, Madang and Eastern Highlands receives the polio vaccine during this and other immunization campaigns, until the country is polio-free again.”
As polio is a highly infectious disease which transmits rapidly, there is potential for the outbreak to spread to other children across the country, or even into neighbouring countries, unless swift action is taken. With no cure for polio, organisers of the immunization drive are calling for the full support of all sectors of society to ensure every child is protected. Parents living in the three provinces are encouraged to bring their children to local health centres or vaccination posts to receive the vaccine, free of charge, during the campaign.
“Everyone has a role to play in stopping this terrible disease,” commented Dr Luo Dapeng, WHO Representative in Papua New Guinea. “We call on parents to bring your children under five years of age for vaccination, irrespective of previous immunization status. Together, we can help ensure that this outbreak is rapidly stopped and that no further children are paralysed by polio.”
The Officer In Charge for UNICEF Representative, Ms. Judith Bruno, stressed, “As long as the polio virus persists anywhere, all un-immunized children remain at risk, and since polio carries enormous social costs, we must make it a key priority to stop its transmission so that children, families and communities are protected against this terrible disease.”
The immunization campaign is organized by the National Department of Health and the Provincial Health Authorities, with support from the World Health Organization (WHO), UNICEF, Rotary International and other partners.
Campaign dates are:
• First Round: 16-29 July 2018
• Second Round: 13-26 August 2018
• Third Round: 10-23 September 2018
• Fourth Round: 8-21 October 2018
Following confirmation of the cVDPV1, on 22 June the National Department of Health of Papua New Guinea immediately declared the outbreak a ‘national public health emergency’, requiring emergency measures to urgently stop it and prevent further children from lifelong polio paralysis. The measures implemented by the government intend to comply fully with the temporary recommendations issued under the International Health Regulations ‘Public Health Emergency of International Concern (PHEIC)’.
Papua New Guinea has not had a case of wild poliovirus since 1996, and the country was certified as polio-free in 2000 along with the rest of the WHO Western Pacific Region. In Morobe Province, polio vaccine coverage is suboptimal, with only 61% of children having received the recommended three doses of polio vaccine. Water, sanitation and hygiene are also challenges in the area, which could contribute to further spread of the virus.
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
21 June 2018 – The Ministry of Foreign Affairs of the Republic of Korea announced today an additional US$ 2 million to fund polio outbreak response and surveillance activities in the Horn of Africa. This commitment makes Korea the first country to support outbreak response efforts in the region, critical to protecting global progress toward ending polio.
The Global Polio Eradication Initiative (GPEI) welcomed the contribution, with $1.5 million for UNICEF and $0.5 million for WHO.
This funding was raised through an innovative financing mechanism called the Global Disease Eradication Fund, through which KRW₩1,000 was collected from each international passenger flying out of Korean airports by the Government of Korea. Thanks to this Fund, every passenger flying from Korea directly supports global efforts to stop polio, an infectious disease that can lead to paralysis or even death, and can travel long distances undetected.
When the GPEI first began in 1988, polio paralysed more than 350,000 children each year in over 125 countries in the world. Today, there have only been eight cases to date in 2018, and polio is closer than ever to becoming the second human disease to ever be eradicated.
This progress is made possible through the ongoing support of donors, partners, and countless health workers around the world. Contributions from donors like Korea allow the GPEI to vaccinate and protect more than 450 million children against polio each year.
This additional funding follows a US$ 4 million commitment from the Republic of Korea announced at the Global Polio Pledging Event around the Rotary International Convention in June 2017. This contribution was matched by the Bill & Melinda Gates Foundation, doubling its impact to US$ 8 million.
“The Global Disease Eradication Fund is an incredibly innovative financing mechanism, and the funds raised will support UNICEF’s efforts to protect every last child from polio,” said Akhil Iyer, UNICEF Director of Polio Eradication. “We remain grateful to the Republic of Korea for their continued commitment to halting polio outbreaks and driving progress to eradicating polio once and for all.”
“The unique support of the Republic of Korea has been crucial for the remarkable progress we have made in polio eradication, especially in responding to outbreaks,” said Dr Michel Zaffran, Director of the Polio Eradication Programme at the World Health Organization. “These additional funds come at a critical time as we support the outbreak response in the Horn of Africa region by scaling up surveillance to ensure no virus goes undetected.”
The Republic of Korea has been a longtime supporter of the GPEI, contributing to outbreak response efforts in Syria, the Democratic Republic of Congo and the Lake Chad region, with a broad range of activities including delivering polio vaccines, intensifying surveillance, and convincing caregivers to vaccinate their children through community engagement.
Generous support from donors like the Republic of Korea remains essential to stopping outbreaks, ending this paralysing disease and ultimately achieving a polio-free world.
Last month, Canada signed a generous pledge of Can$ 100 million to help eradicate polio in Afghanistan as well as in the two other endemic countries, Nigeria and Pakistan, and to continue to protect many polio-free countries. The pledge was announced by the Honourable Marie-Claude Bibeau, Minister of International Development and La Francophonie, at the 2017 Rotary International Convention in Atlanta.
In addition to previous donations of approximately Can$ 650 million, this most recent funding consists of Can$ 30 million to WHO and UNICEF to support programme activities in Afghanistan, and Can$ 70 million of flexible funding that can be used to support vaccination campaigns, rapid outbreak response, poliovirus surveillance and other critical eradication strategies and activities to reach every last child worldwide with a safe vaccine.
This latter funding is especially valuable to the programme, as it will help sustain the priority areas of work that make global polio eradication possible. In 2017, there were 22 cases of wild poliovirus reported worldwide, from only two countries, Afghanistan and Pakistan. In Nigeria, wild poliovirus was last detected in 2016. However, since 2001, there have been wild polio outbreaks in 41 countries that were previously polio-free.
Flexible funding, such as that provided by Canada, is critical to allow the programme to react quickly to the most urgent needs, successfully stopping each outbreak, and ensuring that every child is protected from polio worldwide.
Minister Marie-Claude Bibeau used the signing as an opportunity to underline Canada’s ongoing commitment. “Canada has been a supporter in the fight against polio from the very beginning and we are committed to seeing it through to the end,” she said. “Keeping the momentum is key, particularly in Afghanistan, Pakistan and Nigeria, where polio still exists. Canada remains committed to ensuring every child is immunized, particularly girls, who continue to face barriers.”
As a champion of feminist development, Canada has particularly emphasized the role played by women in the programme, from the front lines, to programme management and political leadership. Polio eradication moreover forms a crucial part of Canada’s “Right to Health” commitment, and has the potential to become one of the first tangible outcomes of the UN Sustainable Development Goals.
Akhil Iyer, Director of the Polio Eradication Programme at UNICEF said, “Whilst polio exists in the smallest geographic area in history, this includes some of the most dangerous and difficult-to-reach parts of the world. Canada’s long-standing political and financial commitment helps our dedicated health workers, mostly women, go the extra mile and vaccinate every child to build a polio-free world.”
With this funding and ongoing support, Canada is striving to protect every girl and boy child. In doing so, Canada is making history.
The funding is also a testament to the major role played by the Canadian people at every level of the polio eradication programme. To date, Canadian Rotarians have raised and contributed more than US$ 52 million to eradication efforts, whilst Canada’s citizens have played an important role in tracking progress and publically voicing their support to end polio through the Scientific Declaration on Polio Eradication, and the One Last Push Campaign.
Michel Zaffran, Director of the Polio Eradication Programme at the World Health Organization said, “The ongoing support of Canada is fundamental to the programme’s success. With their global advocacy in international forums such as the G20 and G7 and their strategic and high quality support in Afghanistan and across the world, we can ensure that polio is eradicated forever.”
Canada’s contribution comes at an important time for the programme, in the run up to the 2018 G7 Summit. Previous summits have recognized polio eradication efforts, noting that programme assets also help to strengthen other aspects of health and development. This year, the Presidency is held by Canada, the first country to place polio eradication on the G7 agenda.
The Global Polio Eradication Initiative partners extend their profound gratitude to the Government and to the citizens of Canada for their tremendous support and engagement to end polio globally.
From the front passenger seat of a small utility truck, Mahmoud Al-Sabr hangs out the window, looking for families and any child under five years old to be vaccinated against polio. As the car he travels in dodges rubble and remnants of buildings that once stood tall in Raqqa city, he flicks the ‘on’ switch for his megaphone.
“From today up to January 20, free and safe vaccine, all children must be vaccinated to be protected from the poliovirus that hit Syria for the second time,” he calls, beckoning families with young children who have recently returned to Raqqa city to come outside of their makeshift homes amongst destroyed buildings, to have their children vaccinated.
In 2017, amidst the protracted conflict and humanitarian crisis in Syria, an outbreak of circulating vaccine-derived poliovirus type 2 (cVDPV2) was detected, threatening an already vulnerable population.
Due to ongoing conflict, Raqqa city, which was once host to half of the governorates population, had been unreached by any vaccination activity or health service since April 2016. During the first phase of the outbreak response, more than 350,000 resident, refugee and displaced children were vaccinated against polio in Syria, but “Raqqa city remained inaccessible,” says Mahmoud.
In January 2018, polio vaccinators conducted the first vaccination activity in the city since it became accessible again, following the end of armed opposition group control.
There were no longer accurate maps or microplans that vaccinators could use to guide them in their work. Unrecognizable, the city was a picture of devastation with few dwellings untouched by the violence that once caused families to flee. The house-to-house vaccination campaign that usually helps the programme to reach every child under five wouldn’t work here. Teams knew they would have to innovate to seek out families wherever they were residing to vaccinate their children.
“All children must be vaccinated to protect against poliovirus,” Mahmoud echoes around shelled out buildings, and slowly mothers and fathers carrying their children start to appear in the street.
Mahmoud and Ahmed Al-Ibraim are one of 12 mobile teams that are going street by street, building by building, by car in search of children to vaccinate. Carrying megaphones to alert families of their presence and to tell them of the precious vaccines they carry that will protect their children from the paralysing but preventable poliovirus, they slowly cover areas of the city now unrecognizable.
“No one could enter Raqqa City now for two years,” says Abdul-Latif Al-Mousa, a lawyer from the city who joined the outbreak response as a Raqqa City supervisor for polio campaigns. “So children have not been vaccinated here since that time. Now that people have returned, we are learning where they have returned from and we vaccinate them regardless.”
“We must reach each child with the vaccine to protect them – polio is preventable, why should they suffer more?” Ahmed appeals.
Campaign brings vaccines and familiar faces
Vaccines were not the only thing to return to Raqqa City in January. It was the first time that WHO polio focal point Dr Almothanna could return to Raqqa City after being force to flee under the rule of the armed opposition group. Imprisoned for refusing the demands of the group, friends and neighbours of Dr Almothanna facilitated his escape from the city in 2016.
Dissatisfied but not deterred, Dr Almothanna continued to work with the polio programme, serving the whole governorate except his own city. Over the course of the January 2018 campaign, he worked tirelessly with vaccination teams to ensure more than 20 000 children under the age of five in Raqqa City received a dose of mOPV2 to protect them against polio. For many, it was the first vaccination they had received. In the additional campaigns that followed in March 2018, even more children were reached.
The microplans developed by vaccinator teams in the first vaccination round have become a critical road map for reaching children and families with health services, accounting for the locations of returned families and information about neighbouring families that teams had not yet located. In the second round, the microplans were updated to include new families who had returned.
Syria reported 74 circulating vaccine-derived poliovirus cases between March and September 2017. It has been more than six months since the last case was reported (21 September 2017). Efforts are continuing to boost immunity in vulnerable populations, maintain sensitive surveillance for polioviruses and strengthen routine immunization to enhance the population immunity.
On top of the US$ 120 million committed in 2013, last year, HH Sheikh Mohamed bin Zayed pledged an additional US$ 30 million towards polio eradication, and the UAE is active on the ground in Pakistan through the UAE-Pakistan Assistance Program
UAE support also funded more than 5000 committed full-time vaccinators in highest-risk districts of Pakistan
Last year saw the lowest number of wild poliovirus cases in history (22 worldwide); Pakistan reported a 97 percent decline in cases between 2014 and 2017
GENEVA (16 April 2018) – The Global Polio Eradication Initiative (GPEI) announced today that the UAE has completed the US$ 120 million commitment made by His Highness Sheikh Mohamed bin Zayed Al Nahyan at the 2013 Global Vaccine Summit in Abu Dhabi.
“We thank the UAE for their long-term generous support and unwavering dedication to polio eradication, and particularly the personal commitment of His Highness Sheikh Mohamed bin Zayed Al Nahyan, Crown Prince of Abu Dhabi,” WHO Director General Dr Tedros Adhanom Ghebreyesus said. “This is the kind of support that will ensure we reach every last child to complete the job and to show the way to delivering health to all.”
Polio is a highly infectious disease that can cause lifelong paralysis, but it is entirely preventable with vaccines. Only three countries remain which have never stopped polio: Afghanistan, Pakistan and Nigeria. When the polio eradication effort was launched in 1988, 350 000 children were paralyzed by polio every year across 125 countries.
Polio eradication efforts have since made remarkable progress and there were only 22 cases in 2017 – the lowest ever recorded number. However, a number of key challenges remain. Reaching the most vulnerable children with the polio vaccine is hampered by a range of hurdles including difficult terrain, insecurity, and large-scale population movements.
Following the Global Vaccine Summit, the UAE expanded its role through the UAE Pakistan Assistance Program (UAE-PAP) to ensure that further gains would be made where it was needed the most. Through the “Emirates Polio Campaign” initiative, the UAE has helped drive on-the-ground eradication efforts within the most vulnerable communities in Pakistan.
Speaking about the UAE’s work, His Excellency Mohamed Mazrouei, Undersecretary of the Crown Prince Court of Abu Dhabi said: “The UAE’s pivotal role in eradicating polio completely is not limited to being a donor only, but extends to include its capacity to convene key groups and provide on-ground support to deliver vaccines in the highest risk areas of Pakistan.
“The UAE’s support – both as a leading donor and passionate advocate – has been critical for getting as close as we’ve ever been to making history by eradicating polio,” UNICEF Director of Polio Eradication Akhil Iyer said. “This is a gift not only to the children of Pakistan but to all future generations of children, everywhere, who are so close to the goal of being able to be born and be raised in a polio-free world.”
Dr. Chris Elias, President of the Global Development Program, Bill & Melinda Gates Foundation, said: “The UAE and His Highness Sheikh Mohamed bin Zayed Al Nahyan have shown an unwavering commitment to end polio, and we are delighted to partner with them in this effort. Without their involvement, achieving a record low number of polio cases in 2017 would not have been possible.”
The UAE is a longtime supporter of the polio eradication program. In addition to the US$ 120 million that His Highness Sheikh Mohamed bin Zayed Al Nahyan pledged in 2013, he pledged a further US$ 30 million to polio eradication, announced by Bill Gates at the Rotary International Convention in Atlanta, USA in June 2017. With additional commitments in 2011 and 2014, in total, the UAE has contributed US$ 167.8 million since 2011 to help end polio, with direct support to Pakistan, Afghanistan, Somalia, Ethiopia, Kenya, and Sudan.
The Global Polio Eradication Initiative (GPEI) is led by national governments and spearheaded by the World Health Organization (WHO), Rotary International, the US Centers for Disease Control and Prevention (CDC), and the United Nations Children’s Fund (UNICEF), with the support of the Bill & Melinda Gates Foundation. Since its launch at the World Health Assembly in 1988, the GPEI has reduced the global incidence of polio by more than 99%.
The GPEI receives financial support from governments of countries affected by polio, private sector foundations, donor governments, multilateral organizations, private individuals, humanitarian and non-governmental organizations and corporate partners. A full list of all contributors is available on the GPEI website, http://polioeradication.org/financing/donors/
Somalia, which stopped indigenous wild polio in 2002, is currently at risk of circulating vaccine-derived poliovirus type 2, after three viruses were confirmed in the sewage of Banadir province in January 2018. Although no children have been paralysed, WHO and other partners are supporting the local authorities to conduct investigations and risk assessments and to continue outbreak response and disease surveillance.
Underpinning these determined efforts to ensure that every child is vaccinated are local vaccinators and community leaders – nearly all of whom are women.
Bella Yusuf and Mama Ayesha are different personalities, in different stages of their lives, united by one goal – to keep every child in Somalia free from polio. Bella is 29, a mother of four, and a polio vaccinator for the last nine years, fitting her work around childcare and the usual hustle and bustle of family life. Mama Ayesha, whose real name is Asha Abdi Din, is a District Polio Officer. She is named Mama Ayesha for her maternal instincts, which have helped her to persevere and succeed in her pioneering work to improve maternal and child health, campaign for social and cultural change, and provide care for all.
Protecting all young children
Working as part of the December vaccination campaign, which aimed to protect over 700 000 children under five years of age, Bella explains her motivation to be a vaccinator. Taking a well-deserved break whilst supervisors from the Ministry of Health and the World Health Organization check the records of the children so far vaccinated, she looks around at the families waiting in line for drops of polio vaccine.
“I enjoy serving my people. And as a mother, it is my duty to help all children”, she says.
For Mama Ayesha too, the desire to protect Somalia’s young people is a driving force in her work. A real leader, she began her career helping to vaccinate children against smallpox, the last case of which was found in Somalia. Since then, she has personally taken up the fight against female genital mutilation, working to protect every girl-child.
She joined the polio programme in 1998, working to establish Somalia as wild poliovirus free, and ever since to oversee campaigns, and protect against virus re-introduction. In her words, “My office doesn’t close.”
Working in the midst of conflict
The work that Bella and Mama Ayesha carry out is especially critical because Somalia is at a high risk of polio infection. The country suffers from weak health infrastructure, as well as regular population displacement and conflict.
For Bella, that makes keeping children safe through vaccination even more meaningful.
“Through my job I can impact the well-being of my children,” she says. “For every child I vaccinate, I protect a lot more”.
Mama Ayesha echoes those words when she contemplates the difficulties of working in conflict. For most of her life, the historic district where she works, Hamar Weyne, has been affected by recurrent cycles of violence and shelling. With her grown children living abroad, she could easily move to a more peaceful life. But she chooses to stay.
“This is my home, and this is where I am needed. I am here for my team, and all the children.”
Looking up at a picture of her husband, who died many years ago, Mama Ayesha considers the determination and courage that drives her, Bella, and thousands of their fellow health workers to protect every since one of Somalia’s children. Behind her thick wooden desk, she is no less committed than when she began her career. “If I had to do it again it would be my pleasure.”
Bella has a similar professional attitude, combined with the care and technical skill that make her a talented vaccinator. Returning to her stand below a shady tree, she greets the mothers lined up with their children. As she carefully stains the finger of the first small child purple, showing that they have been vaccinated, she grins.
“I am the mother of all Somali children. I am just doing my job”.
The poliovirus remains in just a few small pockets around the world. However, these final hiding places are some of the most challenging settings on earth in which to eradicate a disease. Finding and stopping a virus whose special power is staying hidden is no mean feat, especially in remote or inaccessible places.
Disease detectives around the world are working tirelessly to find every last virus in these hard to reach places. Some areas are vast and sparsely populated, such as the broad plains and river beds making up areas of the Lake Chad region. Others are densely packed residential areas of Afghanistan, where security issues can sometimes make immunization difficult. In areas of Syria, civil war continues to rage through towns, communities, and families. Yet these challenges are not enough to stop the surveillance system.
Community-based surveillance
In such difficult environments, the polio surveillance system must overcome numerous challenges to ensure that the poliovirus is tracked. Experts look for the virus in children with symptoms of acute flaccid paralysis and also in water samples from sewage systems in high risk areas.
For Dr Arshad Quddus, Coordinator for the detection and interruption of poliovirus at WHO headquarters, the key to overcoming the challenges facing polio surveillance is tapping into communities. Illustrating his point, he draws a circle on a piece of paper, placing a dot in the middle. In Afghanistan, he explains, that dot represents a surveillance focal point, based at a District Health Centre or hospital. The circle extending from them is their information network – a collection of mullahs, healers, health-care providers, teachers, parents and other surveillance recruits – who have been trained to spot cases of acute flaccid paralysis in their community that could turn out to be polio.
Each volunteer is given a book in which to write down the information they find, and a phone number to call. If they come across a case in their local community, they must ring their focal point, setting in action a series of events that will allow the child to be examined, stool samples to be taken from them to be tested in the laboratory for polio and their close contacts tested.
Overcoming challenges
The system may seem simple, but insecurity, weather and challenging landscapes can be obstacles. In Afghanistan, the programme has developed creative ways to ensure that nothing stands in the way of the surveillance system being able to work as it needs to. In most cases, following the reporting of a case of acute flaccid paralysis, health workers will visit the child’s home to inspect them, and collect stool samples from the child to send for lab testing for the poliovirus. However, if the area is inaccessible, the child and their caregivers are transported to the nearest hospital in a safe area for inspection.
For Dr Quddus, the success of this system in Afghanistan is clear: “We have regular reports of where the poliovirus is circulating in difficult and hard-to-reach communities and this shows us we are being successful, despite tremendous challenges.”
Surveillance in conflict zones
These diverse methods also strengthen surveillance in countries where the security situation is rapidly changing. In Syria, the health-care system has been weakened due to conflict, with many of those at the heart of the polio surveillance system displaced. By building new networks in camps for internally displaced families where communities are created by proximity, and recruiting surveillance volunteers at the key points of entry and exit into the worst of the conflict zones, the polio surveillance system ensured that an outbreak of circulating vaccine-derived poliovirus in 2017 was rapidly identified and an outbreak response launched. The programme also thought outside of the box in Borno, Nigeria, by training medical corps being deployed to reach conflict-affected populations to spot signs of the virus.
The polio surveillance system is strengthened by a mixture of community, adaptability, and fierce commitment to finding every last trace of virus. These are the lessons learned that help find the virus everywhere, from urban districts of Afghanistan, to hard-to-reach areas of Nigeria. For Dr Quddus, “It is the individuals on the ground willing to give their all that will enable us to achieve eradication. The surveillance system is the eyes and ears of polio eradication, showing us where to focus our best efforts to vaccinate every last child.”
The Organization of Islamic Cooperation has celebrated the efforts of its Member States to eradicate polio and is working to ensure that eradication remains at the top of national health agendas. In a resolution passed at the sixth session of the Islamic Conference of Health Ministers, held in Jeddah in early December, the Organization of Islamic Cooperation recognized the importance of ensuring that all children are consistently reached and vaccinated with the polio vaccine. It also highlighted the critical roles of Government leaders and the Islamic Advisory Group in the effort to put an end to the crippling disease.
The Jeddah Declaration
In the Jeddah Declaration, signed by representatives from all Member States, the Organization of Islamic Cooperation reiterated health as one of the basic rights of every human being and reaffirmed their belief that “… the right to health must be at the core of the global agenda.” They reiterated their support to polio eradication and to the full implementation of the Polio Eradication and Endgame Strategic Plan, and recognised the efforts of their Member States to stop transmission. In particular, members were called upon to support the work of the remaining polio endemic countries – Afghanistan, Nigeria and Pakistan – and for the Islamic Advisory Group to continue their work to support the Global Polio Eradication Initiative. The resolution issued at the end of the conference also called upon Member States and other donor entities to provide the necessary financial support that would allow the Islamic Advisory Group to continue its work.
High level support in action in Somalia
Just days after the commitment of member states was reemphasised, the Minister of Health of Somalia Dr Fawziya Abikar Nor showed her commitment to eradication by attending a polio vaccination campaign, alongside Dr Ghulam Popal, WHO Representative for Somalia. High level government commitment has been one of the most important components of eradication in some of the most challenging countries around the world.
The Islamic Advisory Group for Polio Eradication has launched a new training manual for students of religious studies in support of polio eradication efforts. The manual provides practical guidance on how to engage with local communities to advocate for vaccination as well as other maternal and child health issues.
The launch of the training manual follows Islamic Advisory Group’s efforts to prepare students of religious studies at key universities in predominantly Muslim countries to act as advocates for critical health initiatives particularly in high-risk areas where marginalized and underserved populations reside. As future religious leaders and scholars the students will be well placed within their local communities to promote healthy behaviour and dispel rumours and misinformation that hamper the work of vaccination teams and deprive their community members of protection against polio and other vaccine preventable diseases.
