GPEI-Republic of Korea becomes first donor to support polio outbreak response in Horn of Africa

A girl receives two drops of the oral polio vaccine during an immunization campaign in Somalia. © UNICEF

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.

Dr Ranieri Guerra, Assistant Director-General for Strategic Initiatives at WHO, thanks Mr Lee Jang-Keun, Deputy Permanent Representative of the Republic of Korea, for his country’s generous contribution at a grant signing ceremony in Geneva. © WHO/S. Ramo

A female vaccinator administers polio vaccine during a campaign in Kabul, Afghanistan. © WHO/J Swan

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.

Minister Marie-Claude Bibeau announced Canada’s generous commitment at the 2017 Rotary International Convention in Atlanta. This latest funding comes on top of significant and long term support from the Canadian people. © Global Polio Eradication Initiative

A child is vaccinated in Raqqa. The recent polio vaccination activity was the first to go ahead in the city since it became accessible again. © WHO Syria

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.

About GPEI

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/

Bella smiles as she vaccinates a small baby against polio – one of hundreds of children she will protect over the course of a campaign. © WHO Somalia

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.”

“I am the mother of all Somali children. I am just doing my job”. © WHO Somalia

Ongoing determination

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”.

Mama Ayesha, a leader of eradication efforts in her district, considers what drives her work. © WHO Somalia

For more stories about women on the frontlines of polio eradication

Roqia holds her young son, who was reported through the local surveillance network in Bamyan, Afghanistan, as having acute flaccid paralysis. ©WHO Afghanistan

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.

Vaccination volunteers go tent to tent in a Syrian camp for internally displaced families, immunizing each child against polio. Some of these volunteers are also trained in surveillance, able to identify and report any child suffering from paralysis. ©WHO Syria

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.”

A doctor and surveillance volunteer checks a child for signs of paralysis in a clinic in Shawalikot district, Afghanistan. ©WHO / Jawad Jalali

Read more in the Reaching the Hard-to-Reach series

In Somalia, a Member State of the Organization of Islamic Cooperation, Minister of Health Dr Fawziya Abikar Nor (right), and Dr Ghulam Popal, WHO Representative for Somalia, vaccinate a child against polio. ©WHO / A.Wolasmal

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.

Crowds gather as Minister of Health Dr Fawziya Abikar Nor, and Dr Ghulam Popal, WHO Representative for Somalia attend a polio vaccination campaign following the declaration. ©WHO / A. Wolasmal

A WHO worker oversees vaccination campaigns in Raqqa, Syria, following the polio outbreak. © WHO Syria

Amidst conflict and humanitarian crisis in Syria, health workers are battling to end the current polio outbreak. Since the World Health Organization announced the outbreak on 8 June 2017, 70 cases have been confirmed, with 67 in Deir Ez-Zor governorate, two in Raqqa and one in Homs.

Vaccinating children

WHO and UNICEF are supporting the Government of Syria and local authorities to end the outbreak. Two mass vaccination campaigns have taken place, thanks to dedicated health care workers on the ground, striving to reach resident, refugee and internally displaced children. Despite the challenges of holding vaccination campaigns in a conflict zone and effectively reaching displaced populations from infected areas, more than 255,000 have been vaccinated in Deir Ez-Zor, and more than 140,000 in Raqqa.

Contingency plans for an additional vaccination campaign are being put in place to reach children under the age of five with monovalent oral polio vaccine type 2 in the infected zones and areas hosting high risk populations, particularly recently displaced families from Deir Ez-Zor.

Two different vaccines are being used to ensure that population immunity against polio is rapidly increased. The monovalent oral polio vaccine type 2 is being used to rapidly increase immunity against type 2 polio. To boost immunity against type 2 and also provide protection against types 1 and 3, the inactivated poliovirus vaccine is also being provided to children aged between 2 and 23 months in high risk areas.

Preventing spread of polio

While all hands are on deck to stop polio, outbreak response teams are also working hard and adapting complementary strategies such as vaccination at transit points and registration centres for internally displaced persons from infected zones, to prevent spread of the virus to other parts of the country. The inactivated poliovirus vaccine is being used strategically in high risk areas, especially where there are high numbers of internally displaced families.

In order to reduce the threat of polio spreading to the countries surrounding Syria, vaccination activities have been carried out in Iraq, Lebanon and Turkey. These activities are aiming to reach both Syrian children and those from local communities to limit the possibility for the virus to spread across international borders.

Searching for the virus

Knowing where the virus is at all times is crucial to stop the outbreak. Surveillance is ongoing across the country, with doctors, community members and vaccinators on the alert for any child with potential symptoms of polio. The surveillance system is operating well, despite the challenges of transporting stool samples from children with symptoms to laboratories for testing.

Plans are also in place to begin environmental surveillance in Syria by the end of the year. This will enable laboratories to identify the presence of polio in sewerage to provide early warning.

The information from disease surveillance being used to inform where and when vaccination campaigns need to take place.

Vaccine derived polio

The current outbreak in Syria is caused by circulating vaccine derived poliovirus type 2, a very rare virus that can occur when population immunity against polio is very low. In Syria, conflict and insecurity have compromised community access to immunization services, which has allowed the weakened virus in the oral polio vaccine to spread between under-immunized individuals and, over a long period of time, mutate into a virulent form that can cause paralysis. The only way to stop transmission of vaccine-derived poliovirus is with an immunization response, the same as with any outbreak of wild polio. With high levels of population immunity, the virus will no longer be able to survive and the outbreak will come to a close.

Abdullah Khalid marks a child’s finger with indelible ink at the Torkham border between Afghanistan and Pakistan in September 2017. © WHO/S.Ramo

Malik is one of the hardworking vaccinators making sure that even children on the move are protected against polio.

The poliovirus knows no borders, making children on both sides of the border between Afghanistan and Pakistan vulnerable to contracting the debilitating disease. This is why, placed strategically along the border, 19 WHO-supported vaccination posts reach children on the move as they cross between countries, ensuring that all children under the age of 10 receive two drops of the oral polio vaccine to protect them from polio.

One of these teams is led by Malik, who has worked for the polio eradication programme for 14 years.

“I wanted to join the eradication programme when I heard that polio is a contagious disease that affects children. I wanted to serve children and our community. I learned about polio on the TV and radio and the health workers who came to our home to share information about the virus.”

Protecting children on the move

Malik started working as a vaccinator and has now worked as a team supervisor for the past 10 years.

“I am proud when we can reach every child and when I see my team vaccinating children, making sure that no child is missed. This makes me very happy,” he says.

Cross-border vaccination teams are crucial in the fight against polio. The Torkham border between Afghanistan and Pakistan, in eastern Nangarhar province, is one of the busiest border crossings in Afghanistan. Currently 38 WHO-supported vaccinators work in three shifts, operating 24 hours a day, 7 days a week.

“Today I started my work at 5.30 am. When we arrive at work in the morning, I gather the team together and we go through any issues that arose in the previous shift. We revise the schedule of the day and I assign teams to their specific locations. We have three locations at this border where we vaccinate all children coming to Afghanistan and those who are leaving.”

Abdullah Khalid and his team approach a truck at the Torkham border vaccinate all children arriving to Afghanistan. © WHO/S.Ramo

Checking for signs of polio

Since January 2017, WHO and partners have vaccinated over 44 000 Afghan children under the age of 10 crossing the border to Afghanistan from Iran and Pakistan. Over 25 000 of these have been vaccinated at the Torkham border’s so called “zero point” – the first point where Afghan refugees and returnees returning from Pakistan arrive.

“We focus a lot of finding cases of acute flaccid paralysis, sudden onset of floppiness in the limbs that is a sign of polio. We check children in all the vehicles that arrive at the border and work hard not to miss any potential polio cases,” Malik says. “When the trucks park here, we talk to the parents and ask about any possible cases of paralysis in the family. We also educate them about the importance of vaccines and tell them about the routine immunization services that are available free-of-charge in Afghanistan’s health facilities.”

Building trust

Most caregivers crossing the border to Afghanistan accept the polio vaccine but challenges remain.

“Sometimes we see parents who refuse to vaccinate children. We try our best to convince them to vaccinate by telling them more about the benefits of the polio vaccine and how polio cannot be cured. Those who refuse to vaccinate their children often don’t understand what the vaccine is or how it is essential for protecting their children,” Malik says.

Despite difficulties and his demanding work in a challenging environment where the security situation can shift quickly, Malik and his team are determined to continue the fight against polio.

“Afghanistan is still polio-endemic and the virus is deadly,” he says as he leads his team to approach another truck that crossed the border into Afghanistan. “I want to deliver these crucial services, serve my community and protect vulnerable children.

Read the original interview here.

For World Polio Day on 24 October, the world celebrated the unsung heroes of the eradication effort. How important have volunteers been in eradicating polio so far?

In India, a volunteer vaccinates a child against polio. © Gavi/Manpreet Romana

Volunteers have been and continue to be the backbone of the eradication effort. Local Rotarians are raising critically-needed funds, and members of the community conduct the actual administration of the vaccines on the ground and report cases of paralysis. Without this vast network of volunteers – approximately 20 million strong worldwide – polio cannot be eradicated. They are the true unsung heroes of this effort.

What are the main hurdles to eradicating polio? Are there difficulties getting vaccines to remote communities and areas in conflict?

Those are precisely the main hurdles: reaching children who remain unreached by health systems, because of difficult terrain, conflict, security compromised access, urban sprawl, or large-scale population movements. These are all reasons some children are not vaccinated. The poliovirus is very effective at finding vulnerable children, so we have to be better than the poliovirus at finding that last unvaccinated child. And that is what we are doing with local authorities and partners. Identifying – area by area – the real reasons why children in that area are missed, and then putting in place operational action plans, at the community level, to overcome those reasons. We’re making strong progress: never before has polio been as geographically restricted as it is today. But we are not there yet, and we need to pursue our efforts.

How do you address the challenges of reliable data and identify areas with the lowest immunization coverage?

This is a key issue, particularly at this late stage of the effort, where we really have to focus on reaching the last one or two percent of children who we have so far missed. It is not good enough to achieve 95% coverage nationally, if sub-nationally we are still missing 5%-10% of children somewhere. So we need to be extremely rigorous in the monitoring of our activities, in particular when we assess population immunity levels. We have introduced a number of innovative approaches to address this challenge, such as Lot Quality Assessment sampling, to identify areas which fail to achieve campaign coverage targets; third party monitoring, to get an external view on data quality; and seroprevalence surveys, which show actual immunity levels of children in key areas or high-risk population groups. These tools provide the clearest and most reliable picture of immunity levels.

How can other disease programmes benefit from polio eradication?

Polio eradication has always been about more than polio. Rotary International calls this effort ‘PolioPlus’, with the ‘plus’ standing for more than polio. Polio-funded staff on the ground have been busy helping address other public health emergencies, from the Ebola outbreak in West Africa, the recent drought in the Horn of Africa, to the devastating earthquake in Nepal a few years ago.

Polio-funded staff have also supported Gavi’s immunization efforts, including assisting countries in their implementation of Gavi-funded vaccine and health system strengthening activities. As a concrete example, the proportion of children who have been fully immunized against all vaccine-preventable diseases in some of the most marginalised areas of India increased from less than 20% ten years ago, to more than 80% today.

These broader benefits of the polio eradication effort, however, require that countries and the international

Michel Zaffran, Director of Polio Eradication at the World Health Organization. © WHO

community make sure that the momentum is maintained when polio is eradicated. Indeed, unless this is well planned, the loss of funding coming through the Global Polio Eradication Initiative could negatively impact immunization programmes and other health interventions which have benefited from the large network of staff deployed to eradicate polio. Discussions with partners and countries are underway to map out this process for the post-polio world.

Polio eradication has indeed shown that all children – no matter where they live – can be reached with health interventions. The premise of this programme has been that every child has a right to be protected from lifelong polio paralysis, whether they live in Switzerland, or whether they live in conflict-affected areas of Somalia or areas with limited healthcare infrastructure of Afghanistan. And the lessons and experiences can be – and are being – applied to other disease control programmes.

During polio vaccination campaigns in big cities such as Cairo, Egypt, vaccinators go above and beyond to find millions of doors to knock upon to find children who need to be vaccinated. © GPEI

Rising up into the sky, a tower block’s outline trembles in the heat haze, even in the early morning. It’s hard to count the number of floors from the ground as the concrete block stretches up so high. Inside the door, you look around for an elevator – but there is none. Taking a deep breath and hoisting the vaccine carrier higher onto your shoulder, you begin the long climb up the stairs through the heat. At the top, many pauses for breath later, you knock on the first door. As a mother holding her baby opens it, your work for the day really begins – but there is a long way to go. To vaccinate every child in the city against polio, you and your fellow vaccinators must knock on every door in this building; on this street; in this neighbourhood; and across the entire city. It is a monumental task – and one you take on several times a year.

Cities: Uniquely challenging environments

Often it is the ability of polio vaccinators to reach the most remote and inaccessible villages, hampered by challenging weather or conflict, that is the biggest challenge to eradication. But big cities, while more easily accessible, can pose an equal challenge.

Dr Mohammed Sibak Abouzeid, has been working to stop polio in Egypt since 1999, planning and organising polio eradication campaigns and evaluating whether enough children were reached in each campaign so that the next one can be better. Over 40% of Egypt’s population lives in urban environments.

“While my colleagues in the countryside are battling challenging terrain, weather and long journeys, we have a different set of barriers: slums, high rise buildings, marginalised communities and big populations that can change overnight,” says Dr Mohammed. “But our goal is the same: to reach every single child, no matter where they live.”

One critical tactical shift to ensure all floors of a tower block were covered was to ensure vaccinators first walked to the top floor, and then knocked on every door coming down, rather than the other way around, which meant the very top floors were missed.

A playground for polio

Cities provide an easy environment in which for polio to spread. The poliovirus spreads between humans through faeces, so wherever sanitation systems or hygiene practices are poor, or many people live in close quarters, the virus is able to spread rapidly.

Vaccination teams go door to door in urban slums such as this. This location is also used to collect sewage water which is tested for poliovirus as part of the country’s environmental surveillance network. UNICEF/S. Biswas

The city of Karachi is one of the remaining strongholds of the virus. People move in and out of Pakistan’s biggest city constantly: these ever changing populations make it difficult to know how many children need to be vaccinated and where they live. Many children are born every day, giving the virus many opportunities to hide in the unvaccinated guts of infants who have not received at least three doses of polio vaccine. Given the informal nature of many of the slums within this city, the lack of infrastructure such as health care centres can make it especially difficult to get vaccines to every child.

Slums have another consequence for polio eradication; with high levels of poverty, malnutrition and diarrhoea are regular threats. Malnutrition can damage the immune systems of children, meaning that even if they receive the vaccine, it might not be able to kick start the process of generating protection against the virus. Diarrhoea can lead to the vaccine leaving the body too quickly for it to begin creating antibodies; but it also can act as a vehicle to cause the poliovirus to spread further and faster.

Stopping polio in cities

Stopping polio even in these challenging environments takes ingenuity and creativity. Luckily, people like Dr Mohammed have the experience necessary to make a difference.

The city of Dhaka, Bangladesh, stretches off as far as the eye can see, hiding from view the millions of children who need to be vaccinated against polio. © Gavi

“To stop polio in urban environments, you need to train all vaccinators incredibly well, and give them the motivation they need to work in difficult environments. But the most important thing is to come to understand the networks that city inhabitants are a part of so that you can engage them, involve them in vaccination campaigns and find the right influencers from local communities to encourage parents to vaccinate their children.”

In cities like Cairo in Egypt and Mumbai in India, once thought to be the hardest places in the world to stop polio, such tactics were instrumental in stopping poliovirus. Indeed, they continue to be used even now in order to ensure high vaccination coverage and keep their populations protected. It may be a matter of getting the right neighbourhood religious leader to announce vaccination campaigns during a sermon, or the right midwife to tell new mothers about vaccination, but one thing is for sure: success against polio is ensured one person at a time, even in a city of millions.

Anytime a child is paralyzed by polio in any country, the World Health Organization and its partners move fast to stop the outbreak.

Watch more in the polio eradication animation series

Vaccinators visiting an IDP camp in Raqqa. Photo: WHO Syria

Three mass immunization rounds have been carried out in Deir Ez-Zor and Raqqa governorates, Syria, in response to an outbreak of circulating vaccine-derived poliovirus type-2 (cVDPV2). The latest round, targeting resident, refugee and internally displaced children less than five years in Deir Ez-Zor concluded 28 August.

“The detection of circulating vaccine-derived poliovirus indicates that there has been low population immunity in affected areas for a considerable period of time,” said Chris Maher, manager of WHO’s regional polio eradication programme based in Amman, Jordan. “WHO is working with all parties on the ground to ensure access to and vaccination of all children under five in these areas, to put an end to this outbreak as quickly as possible,” he said.

As of the end of August, 39 cases of cVDPV2 have been confirmed in Syria ‒ 37 cases from Deir Ez-Zor governorate, and 1 case each from Raqqa and Homs governorates. All three governorates are affected by active conflict.

“Conflict and inaccessibility continue to hamper efforts to raise population immunity levels in areas across the country. These same factors that paved the way for the outbreak of wild poliovirus in Syria in 2013,” said Maher. “We are using the same approaches to achieving access that were successfully used in responding to the 2013 outbreak, and working together with all partners to make sure that children can be reached with vaccine,” he added.

In addition to ensuring access for vaccination teams, innovative methods have been used to increase response reach and effectiveness. The advertising of campaigns through bakeries, and engagement of a local ice cream factory to assist with the daily freezing and refreezing of ice packs for vaccinator cold boxes, are examples.

“Vaccinators on the ground in Deir Ez-Zor and Raqqa continue to face difficult circumstances, but their efforts show clear dedication to protect children against this preventable disease,” said Maher. “We must maintain this high level of commitment and drive,” he said.

Deir Ez-Zor has carried out two mass immunization rounds in July and August while Raqqa has carried out one. The second round for Raqqa is planned for after the Eid holiday.

Inactivated polio vaccine (IPV) is being given to targeted children in each of the second rounds along with the oral vaccine to maximize individual and community protection.

“These local polio vaccination campaigns represent a significant step that has culminated in the close cooperation between WHO, UNICEF and local health partners to reach all targeted children under five in Ar-Raqqa and Deir Ez-Zor governorates,” said Elizabeth Hoff, WHO Representative in Syria.

“Despite security challenges, WHO is committed to ensure the distribution of polio vaccines and the implementation of the local campaigns as planned with a view to achieving sound wellbeing and growth for children with a special attention given to the affected governorates,” Hoff added.

In addition to supporting the response, WHO and partners are also working with neighboring countries to enhance immunization and disease surveillance activities in high-risk areas.

Circulating vaccine-derived poliovirus can occur in rare instances when population immunity against polio is very low. In these settings, the weakened virus found in the oral polio vaccine can spread between under-immunized individuals and over time, mutate into a virulent form that can cause paralysis. The only way to stop transmission of vaccine-derived poliovirus is with an immunization response, the same as with any outbreak of wild polio. With high levels of population immunity, the virus will no longer be able to survive and the outbreak will come to a close.

Late August marks the beginning of the Hajj season – the annual pilgrimage of Muslims to Mecca – bringing together people from all over the world. While a holy time of pilgrimage, this also presents health risks as people are coming together from many countries where they may have been exposed to different infectious diseases.

The Ministry of Health of Saudi Arabia has issued health requirements and recommendations for entry into Saudi Arabia during the Hajj season, including requirements relating to polio vaccination. Regardless of age, all travellers from certain, specified countries must show proof of vaccination against polio within the last twelve months, and at least four weeks before departure. All travellers from these countries will also receive one dose of oral polio vaccine on arrival in Saudi Arabia.

These requirements apply to travellers from the following countries:

WHO African Region	Cameroon, Central African Republic, Chad, Democratic Republic of the Congo, Equatorial Guinea, Ethiopia, Guinea, Kenya, Liberia, Madagascar, Nigeria, Niger, Sierra Leone, South Sudan
WHO Eastern Mediterranean Region	Afghanistan, Iraq, Pakistan, Somalia, Syrian Arab Republic, Yemen
WHO South-East Asian Region	Myanmar
WHO Western Pacific Region	Lao People’s Democratic Republic
WHO European Region	Ukraine

A doctor greets a Syrian child in a refugee camp, where children are vaccinated against polio and other diseases. Photo: WHO

In recent years, the global drive to eradicate polio has seen the virus cornered in fewer places than ever before. Yet polio’s final strongholds are some of the most complicated places in the world to deliver vaccination campaigns. Insecurity and conflict are some of the challenges to delivering vaccines, as well as populations on the move, testing terrain and weather, and weak health systems.

In 2013, polio outbreaks in Central Africa, the Horn of Africa and the Middle East paralysed hundreds of children. The Global Polio Eradication Initiative (GPEI) developed strategies to deliver vaccines and stop the virus, even when access seemed impossible. All three of these outbreaks were put to an end just a year later, by not letting the complexity of the situation undermine the quality of vaccination campaigns.

The valuable lessons learned by the GPEI in tackling these outbreaks are now being used to end polio in the final polio endemic countries – Afghanistan, Nigeria and Pakistan – as well as to stop a newly-detected circulating vaccine-derived polio outbreak in Syria.

Challenges to immunization in emergencies

Disruptions to routine immunization systems and mass displacement caused by conflict can rapidly reduce population immunity, making individuals much more vulnerable to polio outbreaks. Polio eradication relies on being able to repeatedly access over 95% of children with vaccines. Yet emergency settings can interrupt systems that gather data about a population, functioning health facilities, health care personnel, vaccine supplies, cold chains to keep vaccines safe, power supply, financial resources, population demand for vaccines, and disease surveillance. When these factors are at play, the GPEI calls on past experience and adopts new approaches to reach every last child.

Lessons learned in conflict zones

Community acceptance and trust

When there are barriers to access, the first step is to have community trust and acceptance of vaccination. Every community and context is different and calls for a targeted approach to communicate exactly why immunization campaigns need to take place. The polio eradication programme identifies and trains vaccinators from local communities, engages religious figures to support the campaign and gets local leaders on board to advocate for, plan and implement vaccination efforts. The polio programme has seen time and time again that when securing access is a challenge, the answer often lies in the very communities we are trying to reach.

In Pakistan, a number of Religious Support Persons have been recruited based on the guidance of the Islamic Advisory Group for polio eradication, to address concerns of local communities about polio vaccinations in some challenging areas of the country. This has resulted in enhanced community acceptance of immunization, with refusal rates of less than 1.5%, as well as broader child welfare interventions.

Opportunistic vaccination campaigns

When different forces make populations periodically inaccessible, vaccination schedules can be interrupted and leave pockets of people unprotected against polio. In these situations, health authorities try to reach children in whatever ways are possible. Transit points can be set up around insecure areas, to vaccinate children as they enter or leave; vaccinators work with local leaders to track and reach populations on the move; communities within the inaccessible areas can store and deliver vaccines themselves; and brief periods of calm can be used to bring vaccines and other essential health services into villages through a health camp.

In Pakistan, over 350 transit points have been set up in recent years along borders and near areas with access challenges. This is one of the innovative approaches that have reduced the percentage of children missed on vaccination campaigns from 25% in 2014 to 5% in 2017.

Negotiated access

In the most challenging situations, when all other approaches are not able to overcome the severity of vaccination challenges, the programme has negotiated access by engaging non-state actors, governments, religious figures and local leaders. Reiterating the humanitarian principle of “neutrality,” the GPEI works with all parties to a conflict to highlight the importance of vaccination campaigns, and secure agreements to access targeted communities for specific periods of time.

In the past, negotiating access to conflict zones was comparatively simple to today. In the 1980s, days of tranquillity were first used in the Americas, through negotiation with two groups – often the government and the opposition group. In many areas where polio persists, there are many different actors and groups engaged in conflict, so negotiation is more complex. It includes identifying who is appropriate to negotiate with in any given district or area, and, importantly, finding appropriate negotiators. Often, third party partners such as the International Committee for the Red Cross are engaged to negotiate operations of vaccination campaigns in security-compromised areas, and in areas where vaccination bans have been imposed by local authorities.

Conflict and insecurity continue to pose significant challenges to eradication. Our best chance of ending polio for good in conflict zones lies in learning from these lessons and adhering to the principles of neutrality in health.

New funding and political commitment will enable the GPEI to protect 450 million children from polio every single year. WHO/L.Dore

Atlanta, USA, 12 June – Public health leaders gathered at the Rotary Convention in Atlanta to unite in their commitment to securing a polio-free world. Endemic countries and donors together pledged US$ 1.2 billion to finance the polio endgame.

The Global Polio Eradication Initiative was launched in 1988, spearheaded by Rotary International. For the past three decades, Rotary has brought political commitment, funding and energy to the fight against polio. At this pledging event, Rotary committed a further US$ 150 million to the cause.

At a time when polio eradication has never been closer, new funding and political commitment is more important than ever. The poliovirus has been cornered to just three remaining countries – Afghanistan, Nigeria and Pakistan – but this progress is fragile. While polio continues to exist anywhere in the world, children everywhere remain at risk. Each year, the GPEI reaches 450 million children to vaccinate them against the virus, in polio endemic countries and elsewhere, and maintains disease surveillance systems in more than 70 countries to find and stop every last virus.

Today, 16 million people are walking who would have been paralysed if they had not been protected against polio thanks to the extraordinary efforts of public health workers. This new injection of funding and commitment will ensure that in the future, no child will ever again suffer from the consequences of this incurable, but preventable, disease.

A circulating vaccine-derived poliovirus type 2 (cVDPV2) outbreak has been confirmed in the Deir-Ez-Zor Governorate of the Syrian Arab Republic. The virus strain was isolated from two cases of acute flaccid paralysis (AFP), with onset of paralysis on 5 March and 6 May, as well as from a healthy child in the same community.

Outbreak response plans are being finalized, in line with internationally-agreed outbreak response protocols, including plans for targeted vaccination campaigns to rapidly raise population immunity. An initial risk analysis has been conducted, finding low overall population immunity levels in the area but solid levels of disease surveillance. Active searches are being conducted for additional cases of acute flaccid paralysis. Surveillance and immunization activities are also being strengthened in neighbouring countries.

Although access to Deir-Ez-Zor is compromised due to insecurity, the Governorate has been partially reached by several vaccination campaigns against polio and other vaccine-preventable diseases since the beginning of 2016. Most recently, two campaigns have been conducted in March and April 2017 using bivalent oral polio vaccine (OPV). However, only limited coverage was possible through these campaigns. Syria also introduced two doses of inactivated polio vaccine in the infant routine immunization schedule in 2018.

The detection of the cases demonstrates that disease surveillance systems are functional in Syria. The polio programme is working with local authorities and organisations on the ground to respond immediately, using proven strategies. In 2013-2014, Deir-Ez-Zor was the epicentre of a wild poliovirus type 1 (WPV1) outbreak, resulting in 36 cases at the time. This outbreak was successfully stopped; the now-detected cVDPV2 strain is unrelated to the WPV1 outbreak.

Circulating VDPVs are extremely rare forms of poliovirus, mutated from strains in the oral polio vaccine (OPV) that can emerge in under-immunised populations. OPV has been a critical tool in eliminating 99.9% of polio cases worldwide, and while cVDPV is rare, the GPEI is actively working with countries to eradicate both vaccine-derived and wild polio. The same strategies that are eliminating wild poliovirus also stop cVDPV – it remains critical that all countries maintain strong disease surveillance and ensure all children are vaccinated.

More information on Syria

A child in west Africa receives polio vaccine. Photo: WHO.

More than 190 000 polio vaccinators in 13 countries across west and central Africa will immunize over 116 million children over the next week, to tackle the last remaining stronghold of polio on the continent.

The synchronized vaccination campaign, one of the largest of its kind ever implemented in Africa, is part of urgent measures to permanently stop polio on the continent. All children under five years of age in the 13 countries – Benin, Cameroon, Central African Republic, Chad, Côte d’Ivoire, Democratic Republic of Congo, Guinea, Liberia, Mali, Mauritania, Niger, Nigeria and Sierra Leone – will be simultaneously immunized in a coordinated effort to raise childhood immunity to polio across the continent. In August 2016, four children were paralysed by the disease in security-compromised areas in Borno state, north-eastern Nigeria, widely considered to be the only place on the continent where the virus maintains its grip.

“Twenty years ago, Nelson Mandela launched the pan-African ‘Kick Polio Out of Africa’ campaign,” said Dr Matshidiso Moeti, WHO Regional Director for Africa. “At that time, every single country on the continent was endemic to polio, and every year, more than 75 000 children were paralysed for life by this terrible disease. Thanks to the dedication of governments, communities, parents and health workers, this disease is now beaten back to this final reservoir.”

Dr Moeti cautioned, however, that progress was fragile, given the epidemic-prone nature of the virus. Although confined to a comparatively small region of the continent, experts warned that the virus could easily spread to under-protected areas of neighbouring countries. That is why regional public health ministers from five Lake Chad Basin countries – Cameroon, Central African Republic, Chad, Niger and Nigeria – declared the outbreak a regional public health emergency and have committed to multiple synchronized immunization campaigns.

UNICEF Regional Director for West and Central Africa, Ms Marie-Pierre Poirier, stated that with the strong commitment of Africa’s leaders, there was confidence that this last remaining polio reservoir could be wiped out, hereby protecting all future generations of African children from the crippling effects of this disease once and for all. “Polio eradication will be an unparalleled victory, which will not only save all future generations of children from the grip of a disease that is entirely preventable – but will show the world what Africa can do when it unites behind a common goal.”

To stop the potentially dangerous spread of the disease as soon as possible, volunteers will deliver bivalent oral polio vaccine (bOPV) to every house across all cities, towns and villages of the 13 countries. To succeed, this army of volunteers and health workers will work up to 12 hours per day, travelling on foot or bicycle, in often stifling humidity and temperatures in excess of 40°C. Each vaccination team will carry the vaccine in special carrier bags, filled with ice packs to ensure the vaccine remains below the required 8°C.

“This extraordinary coordinated response is precisely what is needed to stop this polio outbreak,” said Michael K McGovern, Chair of Rotary’s International PolioPlus Committee . “Every aspect of civil society in these African countries is coming together, every community, every parent and every community leader, to achieve one common goal: to protect their children from life-long paralysis caused by this deadly disease.”

The full engagement of political and community leaders at every level – right down to the district – is considered critical to the success of the campaign. It is only through the full participation of this leadership that all sectors of civil society are mobilized to ensure every child is reached.

More information

WHO_EB140_23JAN2017_0005 — 140th session of WHO Executive Board, Geneva, Switzerland. Photo: WHO/C.Black

27 January 2017, Geneva, Switzerland – Ministries of health gathering at this week’s Executive Board of the World Health Organization (WHO) reviewed the latest global poliovirus epidemiology and concluded that the world has never had a better chance to complete the job. Amid discussions on Ebola, Zika and pre-elections for the new WHO Director-General, delegates stressed the urgent need to secure a lasting polio-free world, by fully implementing the Global Polio Eradication Initiative (GPEI) Polio Eradication Endgame Strategic Plan.

Endemic polio is now restricted to a handful of areas of Pakistan, Afghanistan and Nigeria, all of which are implementing regionally-coordinated emergency plans to reach and vaccinate the remaining pockets of under-immunized children.

Despite more children being reached in these traditional ‘reservoir’ areas for the virus, delegates cautioned that risks remained, as underscored by the detection of polio cases in Borno state of Nigeria, the first in two years anywhere in Africa. Countries are now focusing on making sure there are no surveillance gaps at a subnational level so that virus cannot circulate undetected, while working to increase population immunity levels.

Delegates commended the successful global switch from trivalent oral polio vaccine (OPV) to bivalent OPV in 2016, and emphasized that strong surveillance to detect any type 2 poliovirus from any source is now critical. A global stockpile of monovalent OPV type 2 (mOPV2) remains on hand for potential response as needed. A critical global supply shortage of inactivated polio vaccine (IPV) continues to pose a risk, but is being managed by prioritizing available supply to high-risk areas and implementing new measures to stretch available supply, notably use of fractional IPV, as recommended by the Strategic Advisory Group of Experts on immunization (SAGE).

At the same time, countries expressed appreciation at the ongoing efforts to fully implement global laboratory containment activities. They also encouraged plans to transition the infrastructure of the GPEI for the long-term, to ensure the assets and infrastructure established to eradicate polio will continue to benefit broader public health efforts even after the disease is gone. At the World Health Assembly in May, the GPEI will present a strategic roadmap towards polio transition and the development of a post-certification strategy.

With all technical and programmatic building blocks in place to achieve success, ministries urged all stakeholders to ensure that the necessary financial resources to fully implement the Endgame Plan are rapidly mobilized.

Closing the discussion, partners from civil society addressed the ministries through Rotary International with a clear call to action: “We must protect hard won gains by sustaining immunity levels and careful monitoring of virus transmission. An additional US$1.3 billion is needed through 2019 to reach more than 400 million children in up to 60 countries and to ensure high quality surveillance. The eradication of polio will be a monumental achievement by a global partnership. Such achievements exemplify what we can do when united for a common purpose. Together we can end polio and forever build a better future for all children.”

Vaccination_Nigeria — A health worker prepares to administer a vaccine in northern Nigeria. WHO/L.Dore

A mass vaccination campaign to protect more than 4 million children from a measles outbreak in conflict-affected states in north-eastern Nigeria started on 13 January. The polio eradication infrastructure has been on hand to help with this feat of logistics. GPEI partners WHO, UNICEF and US Centres for Disease Control have been working with nongovernmental organizations to support the campaign in a range of areas including data management, training, social mobilization, monitoring and evaluation, supportive supervision and waste management.

“Nigeria’s well-established polio vaccination programme provides a strong underpinning for the campaign,” says Dr Wondimagegnehu Alemu, WHO Representative in Nigeria. “Population data from the polio programme has been essential to guide planning for the measles campaign. We are also able to make use of staff that have vast experience in providing health services in very difficult and risky areas.”

One third of more than 700 health facilities in Borno State, north-eastern Nigeria, have been completely destroyed, according to a report released in December by WHO. Of those facilities remaining, one third are not functioning at all. This is leaving the health of communities vulnerable.

WHO has a strong presence in the community in these areas thanks to a well-established polio programme which includes teams of health workers trained to work in areas of high insecurity and reach communities that no other partner can reach.

With levels of malnutrition as high as 20% in some populations in Borno State, children are particularly vulnerable to diseases like measles, malaria, respiratory infections and diarrhoea.

Planning for the future

This measles campaign in northern Nigeria is by no means the only example of polio funded functions and infrastructure contributing to other critical functions. On average, polio-funded staff spend more than 50% of their time on non-polio activities, such as routine immunization, measles campaigns, maternal and child health initiatives, humanitarian emergencies and disease outbreak, sanitation and hygiene programmes and strengthening health systems. In Nigeria in 2015, the Emergency Operations Centres set up to tackle polio were repurposed instantly in response to the spread of Ebola to the country, which enabled the outbreak to be ended almost as soon as it began.

Polio is closer to eradication than it has ever been; and while we keep all efforts on rooting out the virus in its final hiding places, the Global Polio Eradication Initiative is also beginning to plan for the future. The 16 priority countries, including Nigeria, where 95% of the programmes assets are based are planning now so that some polio funded functions and infrastructure can continue to contribute to other critical health and development goals, as polio funding gradually decreases

Read more about the measles vaccination campaign in Nigeria.