A total of nine wild poliovirus cases have been reported so far, with one in Malawi and eight in neighbouring Mozambique since the declaration of an outbreak on 17 February 2022 in Malawi. The last confirmed case to date was in August 2022 in Mozambique. The wild poliovirus in Malawi and Mozambique originated from Pakistan, one of the two last endemic countries.
Concerted emergency response launched following the outbreak in 2022 has helped increase protection among children through vaccines in Malawi, Mozambique, Zambia, Tanzania and Zimbabwe. The countries have also ramped up disease surveillance and community mobilization to help find cases and halt the virus.
“Southern Africa countries have made huge efforts to bolster polio detection, curb the spread of the virus and ensure that children live without the risk of infection and lifelong paralysis,” said Dr Matshidiso Moeti, World Health Organization (WHO) Regional Director for Africa. “We continue to support the polio control efforts across the region so that every child receives the protection they need.”
To date, 19 vaccination rounds have been concluded in the most at-risk areas and at least five more are planned for 2023 in the five countries.
Additionally, more than 10 new environmental surveillance sites have been set up over the past year in the affected countries with support from WHO. The fully operational sites are playing a critical role in the efforts to detect silent circulating poliovirus in wastewater.
“Response teams have worked intensely in the fight against polio not only in Malawi but in the rest of the neighbouring countries in a coordinated manner. We will not rest until we reach and vaccinate every child to stop polio transmission,” said Dr Emeka Agbo, acting Country Coordinator for the Global Polio Eradication Initiative in Malawi.
Reaching all households where eligible children live is critical to protect them against the risk of paralysis. The national health authorities, with support from the Global Polio Eradication Initiative, efforts are ongoing to map cross-border communities, migratory routes, border crossings and transit routes.
“Community health workers have been pivotal in the vaccination campaigns and will continue going door-to-door, bringing polio vaccines to children who might otherwise be missed,” said Dr Jamal Ahmed, WHO Polio Eradication Programme Manager.
Polio is highly infectious and affects unimmunized or under immunized children. In Malawi and Mozambique, it has paralysed children younger than 15 years. There is no cure for polio, and it can only be prevented by immunization. Children across the world remain at risk of wild polio type 1 as long as the virus is not eradicated in the last remaining areas in which it is still circulating.
Despite the circulation of wild poliovirus type 1 and the variant polioviruses, incredible progress has been made. Since 1988, when the Global Polio Eradication Initiative was set up, polio cases have plummeted by 99% from an estimated annual total of 350 000.
Importation of any case must be treated as a serious concern and high-quality response efforts to reach every child with polio vaccine are critical to prevent further spread.
On 25 January 2023, the WHO Emergency Committee under the International Health Regulations concluded that the risk of international spread of poliovirus remains a public health emergency of international concern.
Two technical assessment missions worked on scrutinizing available evidence and analyzing the absence of polioviruses across Sudan. The first mission, conducted virtually in October 2021, shared their recommendations with Sudan’s polio eradication team to ramp up their efforts across the country.
A second official outbreak response assessment team undertook the next phase of this detailed task. They visited Khartoum and six of Sudan’s 18 states as part of their work from 24 July to 1 August 2022.
Both review teams comprised experts from the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF). Their skills and experience ranged from global public health, epidemiology and biostatistics to surveillance, vaccine management and communication.
They worked hand in hand with the Federal Ministry of Health of Sudan, with state-level ministry staff and with health workers at ground level.
After a close review of the functionality and sensitivity of the country’s surveillance system, the assessment team noted that Sudan’s acute flaccid paralysis (AFP) surveillance indicators are indeed meeting the necessary standards. The gold standard for polio surveillance is through searching for AFP in children, and testing stool samples to confirm the presence of the virus.
All poliovirus samples collected since 18 December 2020, the date of onset of paralysis of the last child affected in the outbreak, were processed like clockwork in Sudan’s laboratory. They were reported as poliovirus negative and recorded.
The missions noted Sudan’s 14 environmental surveillance sites are also collecting and testing waste water samples regularly, in line with international protocol.
During the polio outbreak, 14 sewage samples in the country’s bustling capital, Khartoum, tested positive for cVDPV2, indicating circulation there.
As part of their work, the technical mission also reviewed the core functions of Sudan’s laboratories and the country’s preparation mechanisms for poliovirus events or outbreaks. This also included data on population immunity, childhood immunization and vaccine management protocol.
A large part of Sudan’s success can be attributed to its swift response to the outbreak as soon as it was confirmed.
The country conducted two high-quality nationwide campaigns in all 18 states to curb virus spread in November 2020 and January 2021. Each campaign delivered monovalent oral polio vaccine type 2 (mOPV2) to over 8 million under-fives.
Weighing in on this milestone, senior experts in WHO’s polio eradication programme, including
Dr Hamid Jafari, WHO Director for Polio Eradication in the Eastern Mediterranean Region, and Dr Ni’ma Saeed Abid, WHO Representative to Sudan, lauded public health officials and immunization health workers on the ground for their swift response to the outbreak.
They reiterated the importance of maintaining sensitive AFP surveillance, ensuring better outbreak preparedness and response, enhancing coverage of essential immunization, and strengthening cross-border coordination. This is crucial given Sudan remains at high risk of importation of polioviruses.
Following this extensive work, the outbreak response assessment team concluded that the spread of cVDPV2 has indeed stopped, and that the outbreak is over.
May 2022, Geneva, Switzerland– Global public health leaders convening last week at the World Health Assembly called for urgent action to end polio once and for all before a unique window of opportunity closes for good.
Recent efforts have had a clear impact on the global epidemiology of poliovirus, with endemic wild poliovirus transmission at extremely low levels, with just Pakistan and Afghanistan remaining endemic, and efforts to curb circulating vaccine-derived polioviruses (cVDPVs) showing fruit. Steps have been taken towards securing the legacy of polio eradication systems and know-how, under the Strategic Action Plan for Polio Transition. But delegates cautioned that this ‘window of opportunity’ will not remain open indefinitely, as experts pointed to recent concerning developments such as new wild poliovirus cases confirmed in Pakistan (the first cases reported in 15 months), wild poliovirus detected in south-east Africa (the first on the African continent since 2016), and polio re-emergence in Ukraine and Israel.
“Worrying developments in recent months highlight how fragile this progress is,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General, addressing the Assembly. “These developments are tragic for the children affected and their families. But the reality is that in the final stages of an eradication effort, this is expected. This year, we have the real opportunity to halt wild poliovirus transmission. At the same time, we must respond faster and better to cVDPV outbreaks, to interrupt all transmission by end-2023.”
Success, however, depends on reaching remaining children who have not been immunized – the ‘zero-dose’ children at the heart of the Immunization Agenda 2030 (IA2030).
Such a need was identified at this month’s G7 joint Development and Health Ministers meeting in Berlin, Germany, where discussions focused on “supporting vaccine equity and pandemic preparedness in developing countries”. The meeting cautioned against letting global crises interfere with other development and public health priorities and urged continued support for existing efforts, including global polio eradication. Polio eradication is a clear and concrete example of the value of working in close integration with other public health and development efforts. Polio staff continue to contribute to the COVID-19 pandemic response and immunization recovery efforts, together with supporting the introduction and roll-out of COVID-19 vaccines.
Ministers and high-level delegations from 20 countries of regions affected by both WPV1 and cVDPV met with senior GPEI leaders for focused discussions on concrete ways to close the final chains of virus transmission. The meetings were chaired by Polio Oversight Board chair Dr Chris Elias from the Bill & Melinda Gates Foundation and respective WHO AFRO and EMRO Regional Directors, Dr Matshidiso Rebecca Moeti and Dr Ahmed Al-Mandhari. Key priorities were the importance of reaching zero-dose children, the challenges of complex emergencies and weak health systems, as well as the importance of inter-country coordination and collaboration.
Underscoring the urgency in giving the world one less infectious disease to worry about once and for all, WHO Director-General Dr Tedros issued a clear challenge to the Assembly: “For countries affected by polio, it is imperative that you reach every last child, and that you respond to vaccine-derived strains with the same urgency as you would to a wild strain. For countries that are now polio-free, it is crucial to accelerate efforts to use your polio assets and infrastructure to build stronger, more resilient health systems. And for all partners and donors, please help us seize the moment to raise predicable funding, for eradication and transition. I urge you to join us in Berlin this October at the pledging event* generously co-hosted by the Government of Germany. Your decision this week to support a stronger, sustainably financed WHO will enable us to sustain capacity in countries that are now polio-free and on the pathway to transition. Thank you all once again for your commitment to consigning polio to the history books.”
This call to action was echoed by Rotary International, the civil society partner of the global eradication effort. Addressing the Assembly on behalf of its 1.2 million members worldwide, Rotarian and Rotary Representative to the UN in Geneva, Professor Dr Pierre Hoffmeyer, concluded: “We call on all countries to address gaps in routine immunization levels and ensure robust surveillance to prevent further virus spread and avert future outbreaks.”
*In April 2022, GPEI partners, led by WHO Director-General, launched the ‘Investment Case for Polio Eradication’, the sister document to the Polio Eradication Strategy 2022-2026, which lays out the economic and humanitarian rationale for investing in a polio-free world, as well as the broader benefits of polio eradication. In October 2022, Germany will generously co-host a global pledging moment, giving the international development community the opportunity to publicly re-commit to this effort, including to support a stronger and sustainably-funded WHO, so that the organization can maintain its capacity to support countries in achieving and sustaining polio eradication, and continue to benefit broader public health efforts, including support for pandemic preparedness and response.
It is a hot afternoon in Chagai, a small community on the south bank of the River Gambia when the polio vaccination team arrives to a rapturous welcome. Children and women jump to their feet, some waving and swinging their hands as they pound their feet on the ground in near perfect sync with the beat of the drum.
This excitement is caused by one certain member of the vaccination team wearing a bush hat and playing the drums. Lamin Keita, 60, is a cultural musician supporting the vaccination team in raising awareness about polio and encouraging parents to vaccinate their children. Lamin, popularly called Takatiti, because of one of his songs, is immediately surrounded by excited children, as he adjusts his beats to respond to the ecstasy and rigor of the dancers.
“When I arrive on the back of a pick-up truck with my megaphone and drums, children from the communities run after us in full excitement and jump up and down and ask me to play my drums,” Takatiti explains.
This is what Takatiti is popular for – pulling crowds with his drums to communicate important messages like polio vaccination. For almost four decades, he has toured communities in the region, accompanying health workers as they seek to persuade parents and caregivers to vaccinate their children during mass vaccination campaigns like the polio campaign.
Local voices are the most powerful voices
Building trust in vaccines among parents and caregivers is the first critical step towards achieving high immunization coverage to stop the spread of polio. UNICEF, as a leading partner of the Global Polio Eradication Initiative (GPEI) for social and behaviour change, supports the government in strengthening engagements with communities, as the voices of local leaders and influencers like Takatiti play a powerful role in helping allay fears and concerns of parents and caregivers about vaccines.
“I have been making town announcements since the mid-1980s. I am aware of polio and its terrible consequences. Families hear myths and rumours and get concerned about vaccines. As they already know and trust me, I try my best to give them accurate information and clear their doubts, so that they can vaccinate their children against polio and other dangerous diseases,” Takatiti says.
“It’s important to deliver messages that are supported by facts in an effective way”
Days before the start of a polio vaccination campaign and during the campaign itself, Takatiti walks up and down the streets of villages, playing his drums and using his megaphone to talk to communities about the dangers of polio, how vaccination is the only way to protect children, and that polio vaccines are safe and free.
“I always try to promote peace and healthy life for all. It’s important to deliver messages that are supported by facts in an effective way. The Government and UNICEF provided me correct information and facts about polio and vaccines, so I am happy to volunteer for the campaign.”
A country mobilizes to stop polio
“If people trust health workers to cure other diseases, then it makes sense to trust the same health workers to protect our children from polio. Health workers even give the polio vaccine to their own children – so we should not doubt their good intentions. It is my job to let people know this truth, without offending them, and encourage them to vaccinate their kids,” Takatiti said.
In August 2021, The Gambia declared a national public health emergency in response to outbreaks of non-wild variants of polio in the country.
The Gambian government, with support from WHO, UNICEF, US Centres for Disease Control and Prevention (CDC)and GPEI partners, quickly responded and started preparing for nationwide immunization campaigns – managing supply and safe storage of vaccines, strengthening surveillance and monitoring, training health workers and vaccinators, and engaging with local leaders and influencers to build trust in vaccines.
The country undertook its first national polio vaccination campaign in November 2021 and followed up with a second round in March 2022.
Thanks to thousands of health workers, vaccinators, and community influencers like Takatiti, the vaccination campaigns have reached over 380,000 children aged five years and below in The Gambia.
April 2022 – Convening this month in Geneva, Switzerland, the Strategic Advisory Group of Experts on immunization (SAGE), the global advisory body to the World Health Organization (WHO) on all things immunization, urged concerted action to finish wild polioviruses once and for all.
The group, reviewing the global wild poliovirus epidemiology, highlighted the unique opportunity, given current record low levels of this strain. At the same time, it noted the continuing risks, highlighted in particular by detection of wild poliovirus in Malawi in February, linked to wild poliovirus originating in Pakistan.
On circulating vaccine-derived poliovirus (cVDPV) outbreaks, SAGE expressed concern at continuing transmission, in particular in Nigeria which now accounts for close to 90% of all global cVDPV type 2 cases, as well as the situation in Ukraine, and its disruption to health services, urging for strengthening of immunization and surveillance across Europe. It also noted the recent detection of cVDPV type 3 in Israel in children, and in environmental samples in occupied Palestinian territories, and urged high-quality vaccination activities and strengthened surveillance.
Preparing for the post-certification era, the group underscored the importance of global cessation of all live, attenuated oral polio vaccine (OPV) use from routine immunization, planned one year after global certification of wild poliovirus eradication. To ensure appropriate planning, coordination and implementation, the group endorsed the establishment of an ‘OPV Cessation Team’, to consist of wider-than-GPEI stakeholder participation and ensure leadership on all aspects of OPV cessation.
SAGE will continue to review available evidence and best practices on a broad range of GPEI-related programmatic interventions, including as relevant the increasing role of inactivated polio vaccine (IPV), including in outbreak response and effects of novel oral polio vaccine type 2 (nOPV2), as part of global efforts to secure a lasting world free of all forms of poliovirus.
Yemen is currently experiencing twin outbreaks of circulating vaccine-derived poliovirus type 1 and type 2 (cVDPV1 and cVDPV2). Both strains of poliovirus emerge in populations with low immunity and both can result in lifelong paralysis and even death.
Since 2019, 35 and 14 children have been paralysed by cVDPV1 and cVDPV2 respectively, three of the cVDPV2 cases confirmed in the past 10 days alone. The cVDPV2 outbreak, in particular, is ongoing and expanding and has already spread to other countries in WHO’s Eastern Mediterranean Region and UNICEF’s Middle East and North Africa Region. At its fourth meeting on 9 February 2022, the Eastern Mediterranean Ministerial Regional Subcommittee on Polio Eradication and Outbreaks issued a statement, expressing deep concern around these expanding outbreaks and requesting all authorities in Yemen to facilitate resumption of house-to-house vaccination campaigns in all areas.
The Global Polio Eradication Initiative (GPEI) partners strongly recommend high-coverage mass vaccination campaigns to stop a cVDPV outbreak. The vaccination response must achieve at least 90% of children vaccinated repeatedly with polio vaccine to protect them from polio and prevent seeding new vaccine-derived emergences. Therefore, the guidelines in the Polio Outbreak Response Standard Operating Procedures recommend that the vaccination response to polio outbreaks should be conducted using the house-to-house vaccine delivery strategy to maximize coverage of vulnerable children.
The GPEI urges the health authorities in Sana’a to conduct high quality house-to-house vaccination campaigns to stop the two concurrent outbreaks as soon as possible. If the current conditions in parts of Yemen do not permit house-to-house vaccination, then an intensified fixed-site vaccination campaign with appropriate social mobilization by the community and religious leaders trusted by the local communities should be implemented to maximize coverage among all vulnerable children.
Yemeni children face no shortage of threats: prolonged conflict, a devastated healthcare system, hunger and disease. But polio is one disease that can easily be prevented. Its circulation can be stopped in Yemen or anywhere else by vaccinating all children with oral polio vaccine.
The GPEI partners – WHO, Rotary International, the U.S. Centers for Disease Control and Prevention, UNICEF, the Bill & Melinda Gates Foundation and Gavi – are committed to providing support to all stakeholders in Yemen for responding to the polio outbreaks including in conducting polio vaccination campaigns that can reach all vulnerable children.
A poliomyelitis (polio) vaccination campaign for children aged 6 months to 6 years who missed routine polio doses in the past will begin in Ukraine on 1 February 2022. This catch-up campaign is part of a comprehensive response to stop an outbreak of poliovirus first detected in Ukraine in October 2021. This first stage will last 3 weeks and is expected to reach nearly 140 000 children throughout the country.
Years of low immunization coverage in Ukraine have created a large pool of unvaccinated or under-vaccinated children who are vulnerable to polio. While routine immunization coverage has gradually increased over the past 6 years, in 2020, only 84% of 1-year-olds received the required 3 scheduled doses of polio vaccines by 12 months of age.
The immediate goal of the campaign is to reach the WHO-recommended level of 95% vaccination coverage of eligible children.
Background
The polio outbreak in Ukraine was confirmed on 6 October 2021. Poliovirus (circulating vaccine-derived poliovirus type 2) was first isolated in a 17-month-old girl in the province of Rivne who developed acute flaccid paralysis. Analysis of all her contacts found that 7 household contacts (siblings) and 8 community contacts in Rivne as well as 4 cousins in the province of Zakarpattya (who had had contact with the girl’s siblings) also tested positive, but did not develop paralytic symptoms.
A second case with acute flaccid paralysis (a 2-year-old boy in the region of Zakarpattya) also tested positive for poliovirus, with onset of paralysis in December 2021.
The isolated strain of the virus found in both paralytic cases and their contacts is linked to a poliovirus in Pakistan, which was also the cause of several cases in Tajikistan in 2020–2021.
Comprehensive plan to stop the spread of poliovirus
Following an initial local vaccination campaign, conducted where the first case was detected, a comprehensive polio outbreak response plan was approved by the Ministry of Health in December 2021.
The first stage of the plan will provide inactivated polio vaccine (IPV) to children aged 6 months to 6 years who have not received the required number of doses. In the second stage, all children under the age of 6 will be vaccinated with oral polio vaccine (OPV), even if they have received all their scheduled vaccination doses. This is necessary to protect children from infection and to stop the circulation of the virus. Dates for the second stage are pending.
January 2022, Geneva, Switzerland– As the world enters 2022, and with it the year when the new GPEI Strategy 2022-2026 – Delivering on a Promise – takes effect, global public health leaders at this week’s WHO Executive Board urged for intensified eradication efforts to capitalize on a unique epidemiological window of opportunity. 2021 saw the lowest ever levels of wild poliovirus cases in history, with five cases reported from the remaining two endemic countries, Pakistan and Afghanistan. Cases of circulating vaccine-derived poliovirus have also declined compared to 2020.
Delegates attributed this favourable situation to sustained commitment from the highest levels in polio-affected areas, but issued severe warnings against complacency. “2021 set the stage for success,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “We must now not lower our guard.”
“What is clear is that in 2022, we have a very real and realistically achievable opportunity to finish wild poliovirus from the world once and for all,” said Aidan O’Leary, Director of the Global Polio Eradication Initiative, WHO. “But what is equally clear from the discussions at the Executive Board is that there is virtually no room for error now. If we take our foot off the accelerator even by a little bit, this virus will come roaring back, and we will perhaps have lost the best chance yet for success. The resounding message from this week’s meeting is this: we cannot allow this to happen. Success is the only acceptable outcome.”
Time and again, delegates, experts and partners such as Rotary International underscored the need to fully implement and finance the GPEI Strategy 2022-2026, highlighting that it clearly laid out the roadmap to achieving a lasting world free of all forms of polioviruses, through stronger community engagement, a renewed focus on gender equity and the rollout of new tools and technologies, including the novel oral polio vaccine type 2.
Delegates expressed appreciation at the polio programme’s ability to adapt to programmatic, epidemilogical and political developments, as demonstrated in Afghanistan last year, where – for the first time in more than three years – nationwide immunization campaigns resumed. At the same time, 2021 again saw the broader benefits of polio eradication, with health workers at the forefront supporting global COVID-19 response, vaccination and immunization recovery efforts, and the polio infrastructure now increasingly being integrated into broader public health systems in polio-free countries across the world.
With over 50 countries transitioning out of GPEI support in 2022, Member States also supported efforts to sustain the gains in polio-free countries, calling on WHO to continue its technical support in polio-free countries, and to ensure that polio assets, tools and expertise are effectively integrated into broader immunization, disease surveillance, primary health care, and outbreak preparedness and response efforts.
“Together with our partners at Rotary International, CDC, UNICEF the Bill & Melinda Gates Foundation and Gavi, the Vaccine Alliance, we will continue to support Member States in their eradication efforts,” concluded O’Leary. “But much is on the line. We have everything in place – we need to focus now fully on optimizing our tools and tactics, and ensuring the resources to do so are available. If those two things come together, we will be able to give the world one less infectious disease to worry about once and for all.”
Watch this animation to learn how the Global Polio Eradication Initiative (GPEI) intends to reinvigorate polio prevention and outbreak response with the bold new GPEI Strategy for 2022-2026.
For many of the women and men who spent their careers fighting polio, retirement offers not rest and relaxation, but a continuation of their life’s work towards eradication. Across the Eastern Mediterranean Region, once and forever polio fighters are inspiring the next generation of eradicators with their commitment to the cause, and belief in the benefits of a polio-free future.
Meet some of the Region’s most beloved polio fighters as they look back on their careers and try to capture their unusual motivation to continue their quest, as long as it takes.
Back in 1997, during the devastating civil war, Dr Ali Farah started a pilot project to conduct Somalia’s first-ever national immunization days. Today, that pilot project is one of the reasons Somalia hasn’t seen a case of wild poliovirus in more than seven years.
Dr Farah retired in 2015 after years of hard work in a highly complex, volatile, and risky context. Yet he continues to fight polio by providing technical support to the polio programme team, participating in social mobilization activities and training district-level polio officers and vaccinators.
“I always feel that we must keep working to fight polio. It’s a humanitarian action,” he said. “Technical staff still call me occasionally to receive guidance about AFP cases and other technical areas. I feel so happy to provide advice and support when needed.”
Dr Farah has also utilized his long experience with the polio programme to support COVID-19 immunization in Somalia.
“This COVID-19 campaign wouldn’t succeed if there was no polio infrastructure. We used the polio system and network to make it happen,” he said.
After completing his bachelor’s degree in 1969, Professor Elsadig Mahgoub trained as a physician and epidemiologist. He devoted his career to infectious diseases, largely focusing on disease surveillance. In February 2000, he focused his efforts on polio, particularly surveillance for acute flaccid paralysis (APF), the primary symptom of paralytic polio.
Although he retired four years later, Prof Elsadig hasn’t stopped working or providing his technical support to polio programmes in Sudan and across the Region.
“I’m obliged to continue working. My enjoyment is when I see progress towards polio eradication,” he said. “The service we’re providing is critical. We always need to be vigilant to avoid any setback to our achievements towards polio eradication. When we end polio for good, then I will truly resign.”
Yemen’s Dr Mohammad Hajar is one of the oldest, most veteran health professionals in Yemen, having served the health sector and combated infectious diseases, including polio, for around 50 years.
In 1977, Dr Hajar was one of the founders of Yemen’s expanded programme on immunization. He played a major role in planning and conducting the first-ever polio campaigns in the country, and he contributed substantially to setting up the epidemiological surveillance system for polio and other diseases.
“Even after reaching retirement age in 2009, I continued to work for the polio programme, which I consider as one of my sons. Until now, I follow up and evaluate the activities of the immunization programme and polio campaigns,” said Dr Hajar.
“I had the privilege of working with nine WHO representatives and more than ten ministers of health in Yemen to help Yemen reach a polio-free status.”
When Dr Ibrahim Barakat was appointed as a manager of Egypt’s expanded programme on immunization in 2000, he was determined to achieve something remarkable – a polio-free Egypt.
“It was a hard journey, but we did it. Egypt was declared polio-free in 2006,” he said.
In 2009, Dr Barakat retired, but he hardly rested. “I cannot stop working when it comes to polio eradication. I take great comfort in working hard to combat this disease whether in Egypt or any place in the world.”
After 12 years of retirement, Dr Barakat still considers his office in the Ministry of Health as “a second home.”
“I continue going to the office every working day to plan, supervise and evaluate different polio activities, including polio vaccination campaigns, risk assessment and AFP surveillance. I can never be complacent,” he said.
“This is my life. My real retirement starts when I see this disease completely wiped out from all parts of the world.”
Mr. Alam and Mrs. Fatima, Pakistan
Khursheed Alam, 68, and Kaneez Fatima, 56, are a married couple who have spent 25 years working in the polio eradication programme in Batagram district of Khyber Pakhtunkhwa province, Pakistan.
Rain or shine, Mr. Alam and Mrs. Fatima have taken part in countless door-to-door vaccination campaigns, helping to vaccinate thousands of children.
“Now those little children have grown up, some have gotten married and had children who we have also vaccinated. This is fascinating and rewarding for us,” said Mr. Alam. “Wherever we go, people welcome us and don’t let us go without offering food.”
Mrs. Fatima personally knows every child in her neighborhood, including the newborns. She maintains close relationships with the mothers in her community and gives them health and hygiene advice.
Despite their age and medical complications such as asthma, their commitment to the polio programme remains strong.
“We take our work as a divine duty to serve our community for the sake of God. To see healthy children with smiles on their faces is our reward. This has kept us going for so long,” said Mrs. Fatima.
Dr Faten Kamel, Egypt
Dr Faten Kamel took a leading role in polio eradication efforts in the 1990s and early 2000s – years where the Global Polio Eradication Initiative made considerable gains against polio.
Growing up in Alexandria, Egypt, Dr Faten was exposed to the life-altering effects of polio on the people around her. She saw the human toll of the disease, and was inspired by the work of her father, a surgeon and Rotarian.
“We pushed the boundaries to make the programme more effective, shifting to house-to-house vaccination, detailed microplanning and mapping, retrieval of missed children and independent monitoring,” she said.
For Dr Faten, every child can, and must, be reached.
“If someone comes and says this area is inaccessible, this is not an answer for me. I ask: What should we do to reach? I like to make use of the ideas and experience that come from local people,” she said.
Dr Faten is proud to continue to be part of the polio eradication programme and looks forward to the day when polio eradication is achieved. After that, she plans to spend more time with her family in Australia.
“As a grandmother, I am especially determined to finish the job. I want my grandkids to grow up in a world free of polio. This will be my contribution to their futures.”
Following careful review of safety and genetic stability data from mass immunization campaigns conducted with the novel oral polio vaccine type 2 (nOPV2), the Strategic Advisory Group of Experts on immunization (SAGE) today endorsed the transition to the next use phase for the vaccine. WHO’s independent Global Advisory Committee on Vaccine Safety (GACVS) and SAGE confirmed that there were no major safety concerns associated with nOPV2 after reviewing data from campaigns that used more than 65 million doses in Nigeria, Liberia, Congo and Benin earlier this year. Rollout of nOPV2 began in March and to date approximately 100 million doses have been administered to children across seven countries.
“The move is a positive and welcome advancement as GPEI and countries strive to bring cVDPV2 outbreaks to an end, and sees the achievement of a milestone outlined in goal 2 of our strategic plan: the goal to stop cVDPV2,” commented Aidan O’Leary, WHO’s director of polio eradication. “Not only does the decision inspire further confidence in nOPV2 as a safe and effective tool, it will facilitate a smoother preparedness process for countries looking to use the vaccine in the future,” he added.
“We are very pleased with the SAGE’s endorsement of transitioning nOPV2 to the next rollout phase. Progress like this is a result of strong partnerships at every level and we must continue forging forward together, using innovative tools like nOPV2, to reach every last child and end all forms of polio for good,” said Akhil Iyer, the UNICEF Director of Polio Eradication.
Ananda Bandyopadhyay, deputy director from the Bill & Melinda Gates Foundation and co-lead of GPEI’s nOPV2 Working Group stated, “Today is an important milestone in the road to polio eradication. Innovation has always been key to progress, and this tool – the first vaccine ever to be approved under WHO’s EUL pathway – is a shining example of how the GPEI responds to challenges, but the work is far from over.” BMGF is a core partner in GPEI and has funded the development of nOPV2 from its inception.
Requirements for rollout
Prior to this transition, countries were required to meet an additional set of strict criteria to use nOPV2 during its initial use period. These were developed by GPEI and endorsed by SAGE to allow for even closer monitoring of nOPV2’s performance during its introductory phase and early large-scale uses. While countries no longer need to meet these initial use protocols, use of nOPV2 remains subject to specific post-deployment requirements under EUL, such as monitoring for safety and effectiveness.
“As we move forward into the next phase of the vaccine’s rollout, countries will still need to meet special use requirements, but they will be less onerous,” said Simona Zipursky, WHO co-lead of the GPEI’s nOPV2 Working Group. “GPEI will continue to work with all countries who wish to roll out nOPV2 to help them meet these remaining criteria,” she added.
Optimal response with available vaccine
In addition to those who have already rolled out the new tool, 16 other countries are also verified as ready to use nOPV2 by GPEI and a further 17 are in the midst of preparations. More nOPV2 campaigns are due to launch later this year, however, supply of the vaccine is limited.
Active cVDPV2 outbreaks are ongoing in more than 20 countries across Africa and Asia and there have been recent detections of the virus in Europe. COVID-19 has impacted production of the vaccine, including by limiting supplies, available personnel and manufacturer capacity. GPEI is working with nOPV2’s manufacturer, Bio Farma, to increase supply as soon as possible and is accelerating efforts to bring a second manufacturer online. A GPEI prioritization framework will guide distribution of nOPV2 for the immediate term, until supply is increased.
“We are seeing sharp rises in demand for nOPV2, which is testament to the vaccine’s field performance, and we are working to increase supply as quickly as feasible,” said O’Leary. “We must be very clear though, that outside of nOPV2, there is no shortage of effective type-2 containing oral polio vaccines, and countries should not delay in responding to an outbreak. In line with SAGE’s guidance they should respond rapidly with whichever of the vaccines (mOPV2/nOPV2) is available to them,” he said.
With nOPV2 not yet WHO-prequalified, monovalent oral polio vaccine type 2 (mOPV2) ̶ nOPV2’s counterpart and close relative ̶ remains available to countries for outbreak response. The vaccine has a track record of successfully stopping cVDPV2 transmission and from 2019 to 2020, nearly 80% of outbreaks were closed following just two rounds of immunization. Trivalent oral polio vaccine (tOPV), containing all three vaccine serotypes, may be a more appropriate tool in situations where there is co-circulation of wild polio virus type 1 (WPV1) and cVDPV2.
“All OPVs can stop outbreaks,” said O’Leary. “Regardless of which vaccine is used, the key for any successful [outbreak] response is achieving high levels of vaccination coverage and quickly. That is what we need to remain mindful of and achieve. nOPV2 is only one of the effective vaccines in our toolkit and GPEI will continue to support countries to respond as rapidly as possible to outbreaks, as per the SAGE guidance.”
Next steps for nOPV2 development
Polio remains a Public Health Emergency of International Concern (PHEIC) under International Health Regulations, enabling nOPV2’s continued use through EUL. Field data collection and analyses will be ongoing to support the vaccine’s prequalification and full licensing, expected in 2023. Among other studies, a phase III clinical trial is currently underway in the Gambia.
As COVID-19 reached Somalia, Mohamed readied himself to respond. For years, he had been building strong relationships with local health officers and communities to deliver polio vaccines to every child. Now, he would use those relationships to try to track the spread of the pandemic.
In Nigeria, Dr Rosemary Onyibe, a Polio Eradication Zonal Coordinator for WHO, felt her duty was calling. “My expertise is needed to serve my community,” she remembers thinking. Within days, she was working on Nigeria’s COVID-19 response.
These two individuals are part of a team of 5923 polio eradication personnel, who pivoted in a matter of weeks to fight COVID-19 in some of the most vulnerable settings in the world. A recent report published by WHO comprehensively documents the significant role played by polio eradication personnel during the pandemic, and urges strong action to sustain this network to deliver essential public health services after polio is eradicated. By doing so, we can ensure we are ready to respond to established and emergent diseases in future.
The polio programme has a long history of stepping up during health emergencies to fill the gaps that no one else can. As COVID-19 changed lives around the globe, polio staff led outbreak response teams and trained laboratory staff to detect the virus. Polio disease surveillance officers searched for COVID-19 cases and thousands of frontline polio workers shared information on the disease with their communities. In some countries, polio emergency operations centres were converted for the pandemic response. As the situation has evolved, so have polio programme contributions – in coming months, the programme plans to use its expertise in immunization to help to deliver COVID-19 vaccines, as well as urgently reach at least 80 million childrenwho have missed out on vital vaccines during the pandemic.
As one of WHO’s largest operational workforces, comprising nearly 18% of the organization’s programme budget in 2020-21, the widespread utilisation of polio-funded infrastructure and human resources for COVID-19 has brought into focus why we must retain this network for the future. When polio is eradicated, funding for the programme’s vast infrastructure will end. Through the “polio transition” process, WHO is working to transfer the polio network to serve other public health goals, including the broader immunization, health emergencies and health systems strengthening agenda. This is no easy task – detailed planning and dedicated funding is needed to permanently integrate assets and functions into national health systems.
The report finds that COVID-19, whilst presenting challenges, provides an opportunity to accelerate this “transition” process. In the coming months, WHO regional offices will begin to launch ‘integrated public health teams’, which will bring together individuals with expertise in polio eradication, emergency response and immunization to work collaboratively on the next stages of COVID-19 response and recovery. Showing “transition in action”, these teams will exemplify one way via which health systems could be supported in future. Simultaneously, WHO is continuing work to support countries to develop detailed plans modelling how polio capabilities can be sustained.
The critical role that polio assets have played in tackling multiple health emergencies, in supporting immunization activities and in COVID-19 response, demonstrate that these assets have a clear role to advance future national and global health security. This will also help to sustain a polio-free world. In the South East Asia Region, which was certified free of wild polio in 2014, almost 2600 polio and immunization staff used their experience of managing immunization programmes in emergency settings to respond to COVID-19. Their work included undertaking training of health staff and village governors in Indonesia, acting as a focal point for the COVID-19 response in Cox’s Bazar, Bangladesh, and drafting vaccination plans for Rohingya refugees. In Nepal, the network supported COVID-19 field investigations and case clusters, whilst in Myanmar, personnel formed part of the pandemic incident management team, and supported disease surveillance. These contributions underline that sustaining polio and immunization capacity puts us in a better position to respond when health crises arise.
The report also details how polio assets were able to reach nomadic communities in Kenya to warn them about virus spread, deliver an integrated digital platform for tracking case investigations across the African region, and answer 70 000 calls a day through a polio call centre adapted for COVID-19 in Pakistan. In Uttar Pradesh, India, polio micro-plans were adapted to survey 208 million people twice in three months for COVID-19, resulting in the identification of over 200 000 individuals with symptoms of the virus. Such diversity of operations plays a key role in protecting our collective health.
In a time when sturdy public health systems are particularly vital, we must ensure that polio infrastructure is transitioned to tackle pressing health issues long into the future.
For a detailed costing of polio contributions to COVID-19 response and a country-level breakdown of how the polio network stepped up, please see the report annexes.
From her first polio vaccination campaign in 1997 to the present day, Dr. De Sousa has never lost her passion for increasing access to immunization. The National Expanded Program on Immunization (EPI) Manager for Angola, she remembers her first impressions of the country, “At the time, I could see that most children in the country were not vaccinated and I was excited to help them.”
From the outset, she knew that taking on polio eradication would be challenging. “Angola had just emerged from an armed conflict and there were areas that were very difficult to access, due to dilapidated roads, broken bridges and mining activity, and for that reason there was low routine vaccination coverage. Nevertheless, I felt that I had a duty to fulfill for our children, so I accepted the challenge.”
In 1998, Dr. De Sousa was appointed by the National Directorate of Public Health to help implement the Epidemiological Surveillance System for Acute Flaccid Paralysis (AFP) – one of the primary symptoms of polio. It was a position that required grit and resilience.
She explains, “This was a big responsibility because highly sensitive surveillance for AFP, including immediate case investigation and specimen collection, are critical for the detection of wild poliovirus. AFP surveillance is also critical for documenting the absence of poliovirus circulation for polio-free certification.”
“One of my most vivid memories of the programme is from 1999 when I was trying to reach conflict-affected areas after a polio epidemic had registered more than 1190 cases and 113 deaths. I was early in my career with only two years of service and the sheer number of cases and deaths led me to be proactive and persistent in my day-to-day activities toward the eradication of the disease.”
“Another standout moment occurred on the second time that I went to coordinate a vaccination campaign in the province of Moxico; one of the vehicles in our convoy triggered a mine, so we were forced to stop the vaccination campaign as our colleagues were stranded in conflict zones for a few days. This incident captures the difficult circumstances we were operating in as health workers.”
Eradicating wild virus in Angola
For years the polio team worked to improve operations to detect polio and deliver vaccines, but the virus fought back. After registering a last case of indigenous wild poliovirus in September 2001, Angola recorded four successive outbreaks imported from India and Congo. Dr. De Sousa remembers that this caused many people to doubt that the eradication of polio would ever be possible.
“But I refused to be discouraged. I’ve never backed down from a challenge and I don’t plan to soon.”
After years of work, Angola finally received wild polio-free status in November 2015. Dr. De Sousa describes it as her proudest moment.
“I felt that I made a great contribution to my country and our children as the person managing the Extended Program on Immunization in Angola.”
A new challenge
In 2019, Angola’s immunization team faced a new challenge when the polio programme detected an outbreak of circulating vaccine-derived polio type 2, a type of polio that emerges in places with low immunity. Dr. De Sousa again found herself at the forefront of the action, starting by supporting the Government to respond with vaccination campaigns.
One of her key tasks since has been recruiting new immunization health professionals, who can help reach the children missed by routine immunization and polio campaigns. She explains, “my goal is to train my colleagues so that we can work together to reach the vast number of Angolan children missing out on lifesaving vaccines.”
In July 2020, Angola held its first polio campaign after a pause on vaccination activities in the early months of the COVID-19 pandemic. More than 1.2 million children were reached by over 4000 vaccinators.
Gender and leadership
Dr. De Sousa explains that being a woman leader in Angola isn’t easy. “It requires a lot of time, dedication and a balance with domestic, family, and social life, which has not been easy to manage. However, with the help of God and my family – especially my husband – I am managing to carry out my work.”
“It has all been worth it for the results I’ve helped to achieve, and even though we have some way to go in relation to vaccination coverage, I’m grateful for the opportunity to ensure the health of our children and serve my country.”
In Angola, at the provincial and municipal level, there are very few women compared to men. However, in public health programmes at the national level, women outnumber men. Dr. De Sousa says that, “In general, I think there should be more women leading and administering vaccination programmes”.
In 2021, the polio programme is aiming to implement more outbreak response vaccination rounds to reach children with low immunity to the poliovirus. Driven by her passion and sense of duty, Dr. De Sousa will continue to be on the frontlines of this effort.
13 Novembre 2020 – Aujourd’hui, le programme de préqualification de l’Organisation mondiale de la Santé (OMS) a émis une recommandation d’autorisation d’utilisation d’urgence au titre du protocole EUL pour un nouveau vaccin antipoliomyélitique oral de type 2 (nVPO2). Le déploiement du vaccin sera ainsi autorisé pour une utilisation initiale limitée dans les pays touchés par des flambées de poliovirus circulant dérivé d’une souche vaccinale de type 2 (PVDVc2).
L’émission de cette recommandation au titre du protocole EUL pour le nVPO2 vient au terme de plusieurs mois d’analyse rigoureuse des données issues d’essais cliniques qui ont démontré l’innocuité du vaccin et une protection contre la poliomyélite comparable à celle fournie par le VPO monovalent de type 2 (VPOm2) actuellement utilisé.
Le nVPO2 est une version modifiée du VPOm2, mis au point depuis près de dix ans grâce à la collaboration d’un vaste réseau d’experts mondiaux.[1] Outre son innocuité et son efficacité, les essais cliniques montrent que ce vaccin est génétiquement plus stable que le VPOm2, ce qui réduit nettement la probabilité qu’il retrouve une forme pouvant entraîner une paralysie dans les milieux présentant un faible niveau d’immunité. Par conséquent, le nVPO2 réduit le risque de voir apparaître de nouvelles flambées de PVDVc2, même si le VPOm2 demeure un vaccin sûr et efficace qui protège contre la poliomyélite et qui a permis d’empêcher des flambées de PVDVc2 par le passé.
La procédure EUL de l’OMS, anciennement connue sous le nom de procédure d’évaluation et d’homologation en situation d’urgence de l’OMS (Emergency Use Listing, EUL), a été créée pour évaluer et répertorier les nouveaux vaccins, traitements et produits diagnostiques qui ne sont pas encore homologués afin qu’ils puissent être utilisés de façon précoce et ciblée en réponse à une urgence de santé publique de portée internationale (USPPI).
Ce mécanisme a déjà été utilisé avec succès pour accélérer la mise à disposition de produits diagnostiques pour les virus Ebola et Zika et, fin septembre, une autorisation d’utilisation d’urgence au titre du protocole EUL a été émise pour un test de diagnostic rapide de l’antigène de la COVID-19 qui donne des résultats en 30 minutes.
Pour qu’un produit reçoive une recommandation d’utilisation au titre du protocole EUL, l’OMS et des experts indépendants examinent les données cliniques existantes afin de déterminer son innocuité, sa qualité et son efficacité, et la décision d’émettre une recommandation est fondée sur une évaluation approfondie des avantages et des risques au vu de l’urgence de santé publique.
Pendant toute la durée d’utilisation d’un produit au titre du protocole EUL, on continue à recueillir des données et à les suivre de près afin de déterminer si ce produit peut recevoir une autorisation d’utilisation d’urgence au titre du protocole EUL.
Pourquoi le protocole EUL est-il utilisé pour lenVPO2 ?
Compte tenu des situations d’urgence actuelles concernant le PVDVc2 en Afrique et en Asie et du fait que la poliomyélite est considérée depuis 2014 comme une urgence de santé publique de portée internationale (USPPI), au mois de février, le Conseil exécutif de l’OMS a prié instamment les États Membres d’accélérer les procédures d’autorisation de l’importation et de l’utilisation du nVPO2 au titre du protocole EUL au vu des résultats prometteurs de ce vaccin dans la lutte contre le PVDVc2.
Les flambées de PVDVc2 se produisent lorsque la souche affaiblie du poliovirus contenue dans le vaccin antipoliomyélitique oral (VPO) peut se propager au sein de populations sous-vaccinées pendant une période prolongée et retrouver une forme pouvant entraîner une paralysie. L’année dernière, il y a eu 366 cas de PVDVc2 dans le monde. Au cours des dix premiers mois de 2020, on a recensé 588 cas (données au 28 octobre 2020).
Outre la décision du Conseil exécutif, le Groupe stratégique consultatif d’experts (SAGE) sur la vaccination a approuvé dans son principe un cadre définissant les critères d’une utilisation initiale pour permettre le déploiement rapide et ciblé du nVPO2. À la suite de sa réunion du 5 au 7 octobre, le SAGE a également approuvé, sur le principe, que le nVPO2 devienne le vaccin de choix pour lutter contre les flambées de PVDVc2, une fois que l’examen de la période initiale d’utilisation sera terminé et que toutes les conditions d’utilisation de ce nouveau vaccin seront remplies.
Des études cliniques sur le nVPO2, menées en Belgique et au Panama, ont montré que le vaccin était sûr et efficace pour protéger contre la poliomyélite, et qu’il présentait moins de risque de retrouver une forme pouvant entraîner une paralysie dans des populations sous-vaccinées.
Au cours des six derniers mois, le programme de préqualification de l’OMS a minutieusement analysé les données émanant de ces études afin de déterminer si le nVPO2 répondait aux exigences du protocole EUL. Grâce à la recommandation au titre de ce protocole, le nVPO2 constitue désormais un moyen supplémentaire de la Stratégie de lutte contre le PVDVc2 de l’IMEP.
Quelle est la période d’utilisation initiale du nVPO2 ?
Comme le précise le cadre approuvé par le SAGE, la période d’utilisation initiale durera environ trois mois après la première utilisation du nVPO2 au titre du protocole EUL, et ce vaccin sera déployé de manière mesurée dans la lutte contre les flambées de PVDVc2.
L’IMEP travaille étroitement avec les pays touchés par des flambées de PVDVc2 afin de déterminer où le nVPO2 peut être utilisé pendant la période initiale. Cette décision s’appuiera notamment sur la situation épidémiologique actuelle et sur la capacité du pays à mener la surveillance renforcée requise en termes d’innocuité et d’efficacité du nVPO2 pendant son déploiement.
Il est important de noter que toute décision d’utiliser le nVPO2 sera prise par le pays et soumise à l’accord des responsables concernés dans le pays et des autorités de réglementation nationales. Le VPOm2 restera disponible pour faire face aux flambées dans les pays qui ne répondent pas aux critères d’une utilisation initiale ou qui décident de ne pas utiliser le nVPO2 initialement.
L’utilisation initiale du nVPO2 devrait avoir lieu environ cinq à huit semaines après la publication de la recommandation d’utilisation au titre du protocole EUL, en tenant compte des processus réglementaires et des approbations définitifs, de l’achat des vaccins, de l’expédition et de l’état de préparation du pays. L’IMEP continue de travailler en étroite collaboration avec les pays à haut risque, en les aidant à se préparer à utiliser le nVPO2.
Perspectives d’avenir
On continuera à recueillir des données sur le nVPO2 pendant la période d’utilisation initiale, en plus des études en cours et de celles qui seront menées prochainement.
Parallèlement à l’utilisation initiale du nVPO2, l’IMEP poursuivra la mise en œuvre des autres volets de sa stratégie globale de lutte contre les flambées de PVDVc2. Cette stratégie consiste notamment à optimiser la riposte aux flambées en utilisant le VPOm2, à renforcer la vaccination systématique avec le vaccin antipoliomyélitique inactivé dans les zones à haut risque et à veiller à ce que les stocks de VPO soient suffisants pour que chaque enfant puisse en bénéficier.
[1] Le nVPO2 a été mis au point grâce à un partenariat mondial réunissant de multiples agences et experts internes et externes à l’Initiative mondiale pour l’éradication de la poliomyélite (IMEP). Il s’agit notamment de Bio Farma, de l’Université d’Anvers, de la FIDEC (Fighting Infectious Diseases in Emerging Countries), du NIBSC (National Institute for Biological Standards and Control), de l’UCSF (University of California San Francisco), des CDC (Centers for Disease Control and Prevention des États-Unis), de PATH et de la Fondation Bill et Melinda Gates.
13 November 2020 – Today, the World Health Organization’s (WHO) Prequalification (PQ) program issued an Emergency Use Listing (EUL) recommendation for the type 2 novel oral polio vaccine (nOPV2). This will allow rollout of the vaccine for limited initial use in countries affected by circulating vaccine-derived poliovirus type 2 (cVDPV2) outbreaks.
The PQ program’s issuance of an EUL recommendation for nOPV2 follows months of rigorous analysis of existing data from clinical trials of the vaccine, that have shown it to be safe and provide comparable protection against polio as the currently used type 2 monovalent OPV (mOPV2).
nOPV2 is a modified version of mOPV2 and has been in development for close to a decade thanks to the collaboration of an extensive network of global experts.[1] In addition to nOPV2’s safety and efficacy, clinical trials show the vaccine to be more genetically stable than mOPV2, making it significantly less likely to revert into a form which can cause paralysis in low immunity settings. This means a reduced risk of seeding new cVDPV2 outbreakscompared to mOPV2, which remains a safe and effective vaccine that protects against polio and has successfully stopped cVDPV2 outbreaks in the past.
What is an Emergency Use Listing?
The WHO’s EUL procedure, previously known as the Emergency Use Assessment and Listing (EUAL) procedure, was created to assess and list new and yet-to-be licensed vaccines, therapeutics and diagnostics to enable their early, targeted use in response to a Public Health Emergency of International Concern (PHEIC).
This mechanism has previously been used to successfully accelerate the availability of diagnostic products for Ebola and Zika virus, and in late September, EUL was issued for an antigen rapid diagnostic test for COVID-19 that provides results within 30 minutes.
For a product to receive an EUL recommendation, existing clinical data is scrutinized by WHO and independent experts to determine its safety, quality and efficacy, and a decision to list is based on a thorough benefit-risk assessment considering the public health emergency.
Throughout a product’s use under EUL, data continues to be collected and closely monitored to help inform decisions about whether the emergency listing can be maintained.
Why is EUL being used for nOPV2?
In light of ongoing cVDPV2 emergencies across countries in Africa and Asia, coupled with polio’s status as a Public Health Emergency of International Concern (PHEIC) since 2014, the WHO Executive Board urged Member States in February to expedite the processes for authorizing the importation and use of nOPV2 under the EUL given data showing the vaccine’s promise against cVDPV2s.
cVDPV2 outbreaks occur when the weakened poliovirus strain contained in the oral polio vaccine (OPV) is able to spread among under-immunized populations for a prolonged period and reverts to a form that can cause paralysis. Last year, there were 366 cases of cVDPV2 globally, while in the first 10 months of 2020 alone there have been 588 cases (data as of 28 October 2020).
In addition to the Executive Board decision, the Strategic Advisory Group of Experts (SAGE) on Immunizationendorsed in principle an initial use criteria framework to support early, targeted nOPV2 rollout. Following its 5-7 October meeting, SAGE also endorsed, in principle, that nOPV2 become the vaccine of choice in response to cVDPV2 outbreaks after review of the initial use period is completed and all requirements for nOPV2’s use are met.
Clinical studies on nOPV2, conducted in Belgium and Panama, have shown the vaccine to be safe and efficacious in protecting against polio, while carrying less risk of reverting into a form that can cause paralysis in under-immunized populations.
Data from these studies has been subject to WHO PQ program’s rigorous analysis for the past six months to determine if nOPV2 meets requirements for EUL. The EUL recommendation means nOPV2 is now an additional tool in the GPEI’s Strategy for Control of cVDPV2.
What is the initial use period for nOPV2?
The initial use period, as detailed in the SAGE-endorsed framework, will last for approximately three months following the first use of nOPV2 under EUL and will see nOPV2 deployed in a measured way to tackle ongoing outbreaks of cVDPV2.
The GPEI is working closely with countries affected by cVDPV2 outbreaks to determine where nOPV2 can be used during the initial period. Factors that will inform this decision include the current epidemiology and the country’s ability to conduct the required enhanced monitoring of nOPV2’s safety and effectiveness during rollout.
Importantly, any decision to use nOPV2 will be country-led and subject to agreement from relevant in-country officials and national regulatory authorities. mOPV2 will remain available for outbreak response in countries that do not meet initial use criteria or choose not to use nOPV2 initially.
It is anticipated that the initial use of nOPV2 will take place approximately five to eight weeks after the EUL recommendation issues, factoring in final regulatory processes and approvals, vaccine procurement, shipping and country readiness. GPEI continues to work closely with high-risk countries, supporting with preparations to use nOPV2.
Looking ahead
Data on nOPV2 will continue to be collected during the initial use period, in addition to further nOPV2 studies that are underway and will be conducted in the near future.
Alongside nOPV2’s initial use, the GPEI will continue to implement the other strands of its comprehensive strategy to control cVDPV2 outbreaks. This includes optimizing outbreak response using mOPV2, strengthening routine immunization with inactivated polio vaccine in high-risk areas, and ensuring adequate supplies of OPV are available to reach every child.
[1] A global partnership across multiple agencies and experts from within and outside of GPEI have supported nOPV2’s development. This includes Bio Farma, University of Antwerp, Fighting Infectious Diseases in Emerging Countries (FIDEC), National Institute for Biological Standards and Control (NIBSC), University of California San Francisco (UCSF), US Centers for Disease Control and Prevention (CDC), PATH, the Bill & Melinda Gates Foundation, and several others.
Ismail Taxta/Ildoog/WHO Somalia
From 30 August to 3 September, Somalia conducted an integrated measles and polio campaign in the Banadir region – the first immunization campaign held since the COVID-19 pandemic reached Somalia. Over the last seven months, health workers have been fully engaged in fighting the pandemic. This campaign, conducted whilst observing safety measures to prevent spread of COVID-19, was a chance to get back on track to protect children who have missed out on vital immunizations.
Ismail Taxta/Ildoog/WHO Somalia
The campaign was conducted by Somalia’s Federal Ministry of Health, with technical support from WHO and UNICEF, and financial support from the Global Polio Eradication Initiative and Gavi, the Vaccine Alliance. The campaign had initially been scheduled to take place in 2019 as part of a nationwide effort, but was postponed due to technical challenges.
Ahead of the campaign, vaccines were procured and stored in optimum cool conditions. Microplans and maps were updated to help vaccinators reach all children at health facilities and fixed outreach sites. Building population immunity to polio and measles is extremely important in Somalia: Since the start of the year, 744 children in Banadir have contracted measles, accounting for half of the cases nationwide. Two forms of polioviruses, in circulation in Somalia since the end of 2017, have caused paralysis in 19 children across the country.
As part of the planning, 602 teams of health workers were given protective face masks and gloves, and were trained rigorously to keep themselves and their families safe from COVID-19. Every morning, they were checked to see if they had COVID-19 symptoms. Precautionary measures taken during the campaign included washing hands regularly, wearing face masks and ensuring physical distancing.
On the first day of the campaign, health teams set up fixed outreach vaccination sites and health facilities in different locations in Banadir. The aim was to reach as many children as possible: those living in urban and rural locations, those with nomadic lifestyles, and those living in camps for internally displaced persons.
All children under five who visited facilities during the campaign received deworming tablets and vitamin A, in addition to measles and polio vaccines. The inclusion of other health interventions in polio campaigns is a safe and effective way to help parents give their children the best possible protection against childhood diseases. This is particularly crucial in the Somali context, where children have limited access to health facilities, and population immunity is chronically low.
Two hundred and twenty-four district field assistants supervised more than 3000 vaccinators to ensure vaccinations were administered correctly and COVID-19 safety measures were observed. The campaign was also monitored by staff from the Ministry of Health, UNICEF and WHO.
Women and men played an important role in the campaign as social mobilizers, sharing messages on the benefits of vaccinations and COVID-19 prevention measures. Additionally, community volunteers helped to manage crowds of caregivers who visited health facilities and vaccination sites, ensuring that physical distancing was observed.
At the end of the day, all waste products from the campaign, including syringes, sharps and empty vials, were disposed of safely. By delivering multiple health interventions at once, cost savings can be achieved, and environmental impact is reduced when compared to delivering interventions separately.
Vaccination teams provided caregivers with vaccination cards for children, so that monitors could keep track of children who did not receive measles and polio vaccines.
Around 408 000 children aged between six months and five years (92% of those targeted by the campaign) received vaccinations against measles and 459 000 children aged under five (93% of the target) were vaccinated against polio. Ninety-two percent of children also received vitamin A and deworming tablets. This campaign proved that delivering health interventions amid COVID-19 in Somalia is achievable – and paved the way for subsequent campaigns to fill immunity gaps.
In 2003, Melissa Corkum received a call that would change her life. The World Health Organization wanted to interview her for a position in their polio eradication team. Like most people who are hearing about polio eradication for the first time, the story compelled her, and she packed her bags to embark on a new adventure. Seventeen years later, she remains a dedicated champion of polio eradication.
A self-proclaimed ‘virus chaser’, Melissa has worked in all three polio endemic countries – Afghanistan, Pakistan and Nigeria. She found inspiration in her first field job in Nigeria, where she realized the scale of the polio eradication programme and that she was a part of something tremendous in public health history.
“I was amazed and inspired when I first saw the efforts of the front-line workers delivering vaccines to the doorstep. It may seem simple to deliver a couple drops into a child’s mouth, but when you see it in motion for the first time, it is truly remarkable,” Melissa said.
To this day, Melissa remains in awe of the work required to make ‘reaching every child’ possible. From mobilizing financial resources, to getting vaccines where they need to be while keeping them cool. From the microplanning to ensure all children and their houses are on a map, to the mobilization of champions in support of polio and immunization. Along the way, the stewards of these processes play an essential role to deliver the polio vaccine.
Melissa has worn many hats during her time in polio eradication, but her current role may be the most challenging yet. As the Polio Outbreak Response Senior Manager with UNICEF, she must answer the formidable challenge of containing outbreaks, using her expertise to inform global policy, strategy and operations.
To do this Melissa spent 80% of her time in the field prior to the outbreak of COVID-19, working with partners of the Global Polio Eradication Initiative (GPEI), Ministries of Health and local health workers.
Her work is a mix of challenge and excitement – the challenges of containing outbreaks, including those affected by the COVID-19 emergency – and excitement in developing new tools and methods to overcome the evolving challenges that present barriers to eradicating polio.
“There is never a dull day no matter what hat you may be wearing within this programme. If we are going to put an end to polio for good, we are going to have to fight the fight on a number of fronts – endemics and now the emerging issue of outbreaks in a post-COVID world,” said Melissa.
“The key is a willingness to do whatever it takes to get the job done.”
At times, Melissa felt the weight of the enormous challenges to eradicate polio, especially during her time in Afghanistan, where protracted conflict has complicated efforts to deliver basic services to the most vulnerable. Melissa often reflects on her time as Polio Team Lead there and the emotional rollercoaster she faced trying to stay ahead of the virus, while watching the tragedy of war unfold in the country.
“But when I felt down, I would pick myself up and get ready to face the next challenge. I found hope and inspiration in the resilience of the Afghan people, especially the women who worked in the polio programme, risking their lives and demonstrating a courage that stood out amidst all the difficulties.”
Melissa sees gender as one of the keys to polio eradication. She firmly believes that the only way to tighten the gaps in the system is by involving and empowering women equally in all roles across the programme, and that the only way to reach every child is to ensure their caregivers are equally informed and engaged in the decision making process.
“Unless we involve more women in the programme in certain corners of the world, we will continue to reach the same children and miss the same children, making polio eradication ever more difficult,” Melissa said.
“Change won’t happen if we don’t change the way we think about involving women. We need to listen to their views and open the doors for more women to join and participate equally from the community level and all the way to the leadership, decision-making level.”
Melissa was born in a small town in Nova Scotia, Canada. Her views on the critical involvement of women and gender equality in the polio programme very much align with her government’s Feminist Aid Policy. The Government of Canada has been a long-time champion of polio eradication and recently generously pledged C$ 190 million to assist the GPEI achieve its objectives of polio eradication.
Greater gender equity is one of the legacies that the polio programme is working to leave behind after eradication. Reflecting on her career, Melissa explains what keeps her working to defeat polio after all these years.
“It is so inspiring to be part of something tangible and something that is completely possible if we commit ourselves to doing everything possible to find every last child”.
“The road to the mountain village was rough. It’s only 50 kilometres, but it took more than 3 hours,” says Dr Fatima Ismail, a disease surveillance officer working in Somaliland. “We were bouncing in the car.”
In early 2020, Dr Fatima’s team headed to a remote village near Djibouti to check on a small boy. The boy’s right arm and leg showed a kind of paralysis that sometimes indicates polio. “The village polio volunteer in this mountainous area, geographically inaccessible, found an acute flaccid paralysis (AFP) case,” Dr Fatima remembers.
When children show signs of this paralysis, it is critical to get stool samples to a laboratory to determine whether they have polio. Polio teams ride camels in the desert or donkeys in the mountains when they have to. They brave conflict to get samples to laboratories. In brutally hot climates, they plug mini-freezers into car dashboards to keep samples cool.
All over the world, polio surveillance systems that have been built up over decades track infection sources, evaluate symptoms and transport samples to the laboratory — despite distance, natural disasters, and sometimes war. Now, disease surveillance network — reaching into the most far-flung corners of the globe — is being tapped to address the COVID-19 pandemic.
“In Somalia, the polio programme pivoted its workforce of thousands of frontline staff to support the effort as the cases of COVID-19 spread. Rapid response teams — made up of disease surveillance officers, community health care workers and volunteers — were trained to educate people about the virus and to test suspected cases. By April 2020, the teams were deployed in the field,” said Dr Mamunur Malik, WHO Representative in Somalia.
“In Somalia’s remote villages, they know us as their polio teams, and once they see us, what comes to their minds is that we’re giving them information about polio,” says Mohamed*, a surveillance officer. “So we also give them information about COVID-19. Social mobilisers tell them about COVID-19 symptoms, how to prevent getting infected, physical distancing, cleaning their hands very well with running water and soap.”
The careful procedures that the teams learned for polio surveillance have been adapted for COVID-19, where the required sample is a naso-pharyngeal swab. “We’ve trained our surveillance people on the case definition and how to collect the samples correctly, from people that meet the definition of a suspected case of COVID-19,” says Dr Fatima. “It’s the same infrastructure. After, when we collect the samples from the patient, we send it to the laboratory in Hargeisa.” WHO has given the laboratory equipment and supplies to test samples for COVID-19.
“As with polio samples, the samples of COVID-19 have to be refrigerated, the ice packs should be VERY cold,” says Mohamed. Teams are used to monitoring the packs’ temperature, even in Somalia’s hot weather.
“The logistical challenges we face with AFP/polio surveillance are still the same. This is the rainy season and the roads tend to be terrible,” says Mohamed. “You can’t get to certain places you normally get to, because of the situation on the road. Most of our vehicles can’t make it through the mud.” In those situations, teams work with other United Nations agencies to arrange special humanitarian flights to ship samples.
Frontline staff put their own lives on the line. In April 2020, the polio team lost a colleague due to COVID-19-related infection. Ibrahim Elmi Mohamed, who joined WHO in 2001, was working as a district polio officer in Lower Shabelle. His tragic death, one of many frontline staff around the world due to COVID-19, reminds us of the risks they face every day they go to work.
“Despite overwhelming challenges, teams are committed to continuing their polio work in tandem with the COVID-19 response. It is critical that polio surveillance continues during the pandemic, as Somalia is also fighting outbreaks of vaccine-derived polio type 2 and 3. With polio vaccination campaigns temporarily paused, the teams must be able to track any resulting spread of poliovirus and get ready to respond as soon as it is safe to do so,” says Dr Malik.
“All of us are still doing polio surveillance at the same time as we do surveillance for COVID-19,” says Dr Fatima. “I used to hear from my colleagues that the polio surveillance system is the strongest disease surveillance system. Any polio surveillance team can work in the detection of COVID-19 cases because of the system’s structure, the capacity and experience of the teams.”
Mohamed agrees. “My surveillance coordinator said don’t leave the AFP surveillance behind, follow that normal routine, don’t forget it and leave it aside.’”
As Somalia grapples with the COVID-19 pandemic, its trained teams are working quickly to prevent the spread of both COVID-19 and polioviruses. “What gives me hope in the COVID-19 response is when I look behind and I see what we have done with the polio teams, the impact we’ve had on so many lives,” says Mohamed. “We face everything and we overcome it.”
From a small prefabricated container where the walls host detailed maps and desks prop up computer screens beaming data, tables and graphics, the Rapid Response Team at the World Health Organization’s (WHO) Regional Office for Africa coordinate polio outbreak response. The team work across the continent, where 12 countries are battling the vaccine-derived strain of the virus.
Dr Ndoutabe Modjirom, a former Chadian university professor-turned WHO medical officer, coordinates the multi-agency team, which was formed in September 2019. It is composed of twenty experts in operations and vaccination management, epidemiology, logistics, and communications. They are drawn from the core partners of the Global Polio Eradication Initiative (GPEI): WHO, the United Nations Children’s Fund (UNICEF), Rotary International, the US Centers for Disease Control and Prevention, the Bill & Melinda Gates Foundation, and Gavi, The Vaccine Alliance.
The team is mobilized whenever a new polio outbreak is confirmed in the African region.
The first 72 hours
“Our work starts once the lab confirms that a sample collected from either the environment or a paralysed child is caused by a poliovirus. Every minute that passes after the lab confirmation means that the poliovirus is circulating and risks infecting more children,” says Dr Modjirom.
Within the first 72 hours, the Rapid Response Team deploys Team A. This team includes the GPEI Coordinator alongside an epidemiologist, an operations officer, a vaccine manager and a communicator for development. The team works closely with the health authorities in the affected country along with the relevant WHO and UNICEF country offices to prepare a risk assessment and outbreak response plan. The emergency response vaccination campaign, called ‘Round Zero’, starts within 14 days.
Team B takes over from Team A after the first eight weeks and continues the outbreak response activities.
According to standard operating procedures for responding to outbreaks, the polio programme must implement three rounds of high-quality vaccination campaigns in response to every outbreak. Parallel to vaccination, countries must intensify disease surveillance activities to detect new cases of acute flaccid paralysis, a clinical symptom of poliomyelitis.
“Priorities are constantly shifting for the Rapid Response Team,” says Dr Christopher Kamugisha, who has been working with WHO since 1998. He has been a member of the Rapid Response Team since its inception and like the rest of the team has been chasing new polio outbreaks across the region.
“In August I was in Somali Region in Ethiopia supporting the outbreak response, conducting the first vaccination campaign round. On the second day of the campaign, Dr Ndoutabe informed me that a new case was detected in Cheporoni in Ghana and asked me to go and provide technical support,” Dr Kamugisha recalls.
Within 24 hours, he was on a plane to Accra through Addis.
“I arrived at noon the next day and went straight to support the national technical team in their preparations and risk assessment. I assisted with ensuring that their plans are in line with the international standard operating procedures set by the GPEI,” Dr Kamugisha says.
No cure for polio
Polio is a viral disease, multiplying in the intestines and transmitted from person to person mainly through a faecal-oral route or, less frequently, through contaminated water or food.
While there is no cure for polio, the disease can be prevented through administration of a simple and effective vaccine. That is why efforts are underway across the country to rapidly boost immunity levels in children and protect them from polio paralysis.
Thanks to the efforts of the GPEI and country governments, no wild poliovirus has been detected anywhere in Africa since 2016. This stands in stark contrast to 1996, a year when wild poliovirus paralysed more than 75,000 children across every country on the continent.
In 2020, the central challenge for the African Region is overcoming outbreaks of circulating vaccine derived poliovirus. Vaccine-derived polioviruses are rare, but can affect unimmunized and under-immunized populations living in areas with inadequate sanitation and low levels of polio immunization.
Countries experiencing outbreaks of vaccine-derived poliovirus in Africa are Angola, Benin, Cameroon, Central African Republic, Chad, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana, Nigeria, Togo and Zambia. Reasons these outbreaks have occurred include weak routine vaccination systems, vaccine hesitancy, difficulty accessing some locations and low-quality vaccination campaigns, which have made immunization of all children challenging.
In addition to the response activities, the Rapid Response Team work to build the capacity of health workers and decision makers in countries that are not experiencing polio outbreaks, training them to be ready to respond if virus is ever detected.
The team also aims to recruit more women with expertise in outbreak response. Achieving gender balance amongst personnel through a more equitable recruitment process forms part of the GPEI Gender Equality Strategy 2019 – 2023, which was launched in May 2019.
By supporting countries during outbreaks, and building health system resilience in vulnerable settings, the polio programme is working to establish a sustainable legacy that will improve health long after global eradication of the virus.
In Karachi’s Gadap Town, many families lack basic health and municipal services. To fill the gap, the Polio Emergency Operations Centre in Pakistan’s Sindh province has recently renovated an abandoned hospital to create an Emergency Response Unit (ERU). The unit provides polio vaccination to communities alongside PolioPlus activities to improve overall health. The unit was built with the support of Rotary International, WHO, UNICEF and the Bill & Melinda Gates Foundation.
Click through the gallery to see how the Gadap Emergency Response Unit has changed health delivery:
Gadap Town is home to many informal doctors who are not sufficiently trained to provide basic health services to the community. Often, they put their patients at risk. Before the creation of the Emergency Response Unit (ERU), most people had no choice but to rely on them for basic healthcare.
Now, the PolioPlus programme has helped turn the once abandoned Jannat Gul Hospital into a vibrant health centre. The hospital was renovated in record time and was inaugurated by the Minister of Health for Sindh Dr. Azra Fazal Pechuho, EOC Coordinator Mr. Umer Farooq Bullo and Rotary Pakistan PolioPlus Committee Chair Mr. Aziz Memon.
The new ERU hosts essential immunization services for children, including polio vaccination. The site also houses equipment to keep vaccines cold and ready for use.
Outside, a lawn with play equipment has been set up. Gadap is one of Pakistan’s largest slums, and the provision of a rare child-friendly environment as part of the health facility is helping to build community trust and acceptance of the polio eradication programme.
One room is for use by children suffering Acute Flaccid Paralysis and is also used to monitor any child having a reaction to immunization. The room is managed by a Government Medical Officer, supported by WHO provincial and federal monitors during polio vaccination campaigns.
A multipurpose room is used for trainings and planning before and during polio vaccination campaigns.
The ERU also hosts a data support centre that allows staff to relay live updates on polio campaign performance to the Sindh Emergency Operations Centre.
Five health dispensaries have been set up Gadap Town as part of the project, whilst a local Maternity Home is also being renovated.
These facilities will improve essential immunization and provide basic primary health services. They will also provide gynecological and maternal health services, which are in extremely high demand in Gadap.
The Government envisages that the ERU will continue to provide vital health services to families long after polio is eradicated. Rather than resorting to the care of informal doctors and nurses, the community can now access better quality healthcare, funded by the public sector.
From an abandoned hospital to a successful community health project: This is what the ‘plus’ in PolioPlus looks like.
Compared to the busy streets of Hargeisa, Somaliland, just 20 kilometres outside of the city are broad stretches of barren land—home to the nomads. Nomadism is part of Somalia’s culture, and there are thousands of families throughout the country who lead pastoral lifestyles, raising livestock and moving their animals and families as the seasons change. Their frequent movement means that children are not always nearby a health clinic to receive their scheduled vaccinations on time. Such disruption or delay in receiving vaccines can result in low or no protection against common childhood infections.
If children are not immunized against polio, they risk contracting the virus and developing paralysis. They also risk passing polioviruses to other under-immunized children. But the polio eradication teams are committed to reach every last child with polio vaccine notwithstanding challenging terrains.
Look through the lives of polio vaccinators in Somaliland on the third day of the vaccination campaign activities as part of the larger efforts to reach over 1.1 million children with the oral polio vaccine.
It’s 7am, and a late August dawn is stretching across a broad, sparsely populated landscape. At the side of the dirt track road, a man herds a group of camels to their grazing land for the day.
Today, their focus is the children living among nomadic communities.
Parking up amongst stones and tree roots, with arid scrub-land stretching away behind the 4x4, the vaccination team pull on their Somalia Polio Programme vests, which identify them as health workers, and retrieve their vaccine cold box from the back of the car.
The team is tired from the early start, but excited to provide vaccine to these communities.
Tiny newborn fingers are too small to mark with indelible ink to show that the child has received a vaccine today, so instead, Suad stains Abdirisaq’s big toe before he is tucked back into his warm blankets.
Suad discusses with the family that there are other vaccines that are essential for Abdirisaq to receive to stay well. She encourages his parents to take him to the nearest health clinic when the time comes for his next scheduled doses.
When he is 14 weeks old, he should receive the injectable polio vaccine, which will ensure he is fully protected against all polio virus strains.
As they vaccinate, the health workers are also busy greeting the local community and strengthening awareness of the importance of vaccination.
Being willing to have a discussion about the vaccine helps to build trust with families and gives health workers an insight into the lives of the children they are vaccinating.
By 11am, the teams have vaccinated every child under age five in this nomadic community.
Along the way, they’ve attracted interest from excited children, encountered curious goats and camels, and increased awareness of the importance of polio vaccination for every child.
The next time polio vaccinators encounter this community, they might be residing in a completely different spot.
Close community relationships help the Somalia polio programme know where nomadic groups are moving to, meaning that they can be visited again when the next vaccination campaign happens.
This campaign was the third round to take place as part of the latest stage of polio outbreak response in reaction to virus detected in the north of Somalia. The next campaign, using a different vaccine, is scheduled for this coming autumn.
Back in the car, the vaccinators set off for their next destination, driving slowly on the bumpy roads.
They are dedicated to delivering vaccines to all children, no matter where they live.
Environmental surveillance teams in Mogadishu access the underground closed drainage system to collect sewage waste water samples, which they package and send to the laboratory for testing. If poliovirus is identified in a sample, epidemiologists know that the disease is likely to be circulating amongst the community whose sewage drains into that part of the system. This process is called environmental surveillance and is one of the most important tools for the polio programme to help detect poliovirus.
Vaccinating every child and conducting disease surveillance to know where the poliovirus is circulating are key strategies to end the outbreak. Low immunization coverage has led to an outbreak of vaccine-derived poliovirus in Somalia. This can occur in places where not enough children have received their full vaccine doses.
The teams must follow best practice to collect samples, to ensure that any poliovirus present can be detected.
Click through this photo gallery to learn more about the sample collection process.
Mohamed Sharif Mohamed, Regional Polio Eradication Officer for Banadir, is responsible for organizing the collection of waste water samples at two sites in Mogadishu.
He explains, “Environmental surveillance was established in September 2017, when the outbreak of vaccine-derived poliovirus occurred.”
So far in 2019, 36 samples have been collected from four sites in the city as part of this important initiative.
First, Mohamed Sharif’s team put on face masks, aprons, and gloves. They are collecting untreated sewage waste water, so it’s crucial that they wear protective clothing to protect themselves from bacteria and viruses that they may encounter during their work.
Their next task is to detect the atmospheric temperature of the site, and record this on the lab request form.
The officers try to collect a high-quality sample from a pipe with running waste water. The sample must be free of contaminants, such as detergent liquids or rubbish, which could kill the virus before it is detected.
Mohamed Sharif explains that collecting a high-quality sample can be a challenge in Mogadishu, “The sewage system is old and poorly maintained. Often, rubbish is visible. Despite this, we try our best.”
Once the sample is collected, it is drained into a secure screw-cap container, which is sealed, cleaned with liquid bleach, and labelled with a unique ID code.
The ID code references this specific environmental collection site.
“Mogadishu is the first region in the country to establish environmental surveillance for polio,” Mohamed Sharif says. “The community, Ministry of Health, and the Mogadishu Municipality are aware of the hard work we are doing.”
The sample is put into a cool box for transportation to the WHO office. From there, it will be immediately flown to Kenya Medical Research Institute (KEMRI) in Nairobi, where there is a specialized poliovirus laboratory. This lab tests samples from countries across the Horn of Africa.
The sample should be kept at 4°c throughout the four-hour journey to the laboratory. This is known as the ‘reverse cold chain’ and prevents the virus deteriorating during transportation.
Packing a sample from Waberi District Site ready for transportation to the lab
Back at the office, the sample container is sealed in a plastic zip lock bag, and paperwork is completed. Then the sample is transported, surrounded by fresh icepacks, to Nairobi.
At the laboratory, a highly trained technician will analyse the sample for viruses.
Staff in Somalia follow up the results with the laboratory two weeks after the sample arrives at the lab.
Carrying a sample collected from Egyptian Hospital site
Mohamed Sharif explains what motivates him to continue this challenging work: “It is our hope that in future, when polio eradication is achieved, our names will be written in the offices of the Eastern Mediterranean region of the World Health Organization.”
“We will be part of the legacy of polio-free Somalia.”
“Our area is a pretty difficult terrain because we live in the water and it is not easy for the teams coming from outside the community to gain access. So, the (hand-drawn) maps make it possible for us to identify areas we have yet to reach during the immunization exercise”, says Peter Idowu, a veteran community mobilizer and team supervisor in Makoko — a riverine shanty town located on the coast of mainland Lagos city, southwest Nigeria. Native to the village, Peter is the man to go to whenever the polio immunization teams face challenges navigating the waterways or the community.
The sprawling water city Makoko is a slum located across the Third Mainland Bridge on the lagoon. It is a largely low-income community with half the population on water and the other half on land. Informal, makeshift houses with corrugated iron roofs sit precariously atop stilts. Down below, narrow wooden boats act as a form of aquatic taxi ferrying goods and people around the bustling community. Nobody knows the exact population of this slum district of Lagos, but it is estimated to be as high as 100 000. It is mostly a fishing community inhabited by the Egun people.
“My goal is to see that all the kids in our community are immunized and live healthy lives. That is why I engage our teams in sensitizing parents all the time on the importance of routine immunization and the dangers of polio. As a member of the community and with a passion of becoming a health worker myself, I kept on mobilizing our people for easy accessibility, because our language is different from Yoruba and most of the Polio teams can’t speak the language. It is always easy with me being in the Polio team as our people will readily accept the vaccine without rejecting,” says Peter.
Nigeria is the only country in Africa and one of the only three in the world endemic to wild poliovirus, alongside Afghanistan and Pakistan. Nigeria is also affected by circulating vaccine-derived poliovirus type 2 (cVDPV2) outbreaks.
UNICEF works closely together with Global Polio Eradication Initiative (GPEI), key polio partners and the Nigerian government. There is a vast network of over 20 000 community mobilizers focusing on demand creation and improving health-seeking behaviors of caregivers.
Amidst a poliovirus outbreak in Papua New Guinea, legions of women health workers and leaders are playing a critical role in ensuring children are fully protected from lifelong paralysis. In the current emergency outbreak response, women have emerged as a strong, reliable, and a decisive group that continue to administer key services in the outbreak response implementation. From medical doctors to surveillance officers to community mobilizers to health workers, women are active and present on all fronts.
World Immunization Week—celebrated in the last week of April— aims to encourage the use of vaccines as one of the safest methods to protect against diseases, including poliovirus. This year’s theme – Protected Together: Vaccines Work! – highlights “heroes” who are ensuring that people of all ages, all across the world are protected through vaccines. Women on the frontlines of the outbreak response in Papua New Guinea are a fitting example who continue to inspire the public health community across the world.
Here is a roundup of some of the extraordinary vaccine “heroes”:
Dr Fiona Kupe is a Paediatric Medical Officer at the Gerehu General Hospital in the National Capital District, Papua New Guinea. She is, in effect, a one (wo)man army as she dons multiple hats in the polio eradication efforts in her home country by searching for children with acute-flaccid paralysis (AFP) at Port Moresby General Hospital and Gerehu General Hospital. She also leads the mapping of communities – or microplanning – for all Supplementary Immunization Activities (SIAs) across three districts.
Along with that, she finds time to train vaccinators and community volunteers, all the while carrying out her clinical duties as a child specialist.
“As a paediatric doctor and a mother…every day, I keep (my) passion alive to overcome challenges and basically to do everything I can to check on children’s vaccination status whenever they come to see me for check-up. As a mother, I know that vaccines save lives. I want my child to survive with good health and I would definitely want the same for all the mothers and children I see.”
Melanie Serei
Seen most days with her trusty pet dog by her side, Melanie works in one of the most challenging areas for immunization activities as a health worker in a remote village of Terapo in Kerema, Gulf province. Geographical inaccessibility aside, Melanie constantly juggles issues of insecurity, violence and community vaccine hesitancy. But, she tries every single day to overcome barriers in her mission to reach every last child with the life-saving polio vaccination.
Building community trust and demand for vaccination were considered key tenets in the risk communication for the polio outbreak response. Melanie successfully carried out door-to-door checks on all the children in the village. Thanks to her diligence, she was quickly able to notice polio symptoms in a child that allowed adequate and rapid actions.
Dr Winnie Sadua
Working as a paediatrician in Angau Memorial General Hospital in Morobe province, Dr Winnie treats one very special patient: six-year-old Gafo—the first reported case of polio in PNG in over 18 years, triggering a national outbreak emergency.
Since his diagnosis, Gafo has gone on to become somewhat of a celebrity, a symbol of hope, and a staunch advocate for polio eradication. Through timely treatment and physiotherapy by Dr Winnie, Gafo can now walk with his signature gait. He is now healthy and excited to start school next year.
With all the patients that come to her, Dr Winnie makes sure to remind all the parents to take heed from Gafo’s case and get their children vaccinated.
