To strengthen the fight against polio, health ministers from across the WHO Eastern Mediterranean Region gathered virtually for the 10th meeting of the Regional Subcommittee on Polio Eradication and Outbreaks. It was the first meeting of the Subcommittee convened by the new WHO Regional Director for the Eastern Mediterranean, Dr Hanan Balhky.
Her Excellency Dr Hanan Al-Kuwari, Minister of Public Health, Qatar, and Subcommittee Co-chair, welcomed Dr Balhky’s determination to end polio during her tenure. His Excellency Mr Abdul Rahman Mohammed Al Oweis, Minister of Health and Prevention of the United Arab Emirates, and Subcommittee Co-chair, represented by His Excellency Dr Hussain Al Rand, also expressed enthusiasm that Dr Balkhy’s vision and expertise promise to propel regional efforts, bringing the world closer to eradication.
Port Sudan, Sudan – Sudan’s Federal Ministry of Health (FMOH) will launch a polio vaccination campaign in April 2024 in response to a new emergence of variant poliovirus type 2 reported in January 2024. It was detected in six wastewater samples collected from September 2023 to January 2024 in the Port Sudan locality, Red Sea State.
The FMOH, with support from the World Health Organization (WHO), has completed field investigations and a risk assessment to determine the extent of the virus circulation. Preparations for a polio vaccination campaign in April 2024 in Red Sea, Kassala, Gedaref, River Nile, Northern, White Nile, Blue Nile and Sennar states are under way, with a differentiated approach for the rest of the states as conditions allow.
It’s midmorning in Lashkar Gah, the capital of Helmand Province in south Afghanistan. The sun, climbing rapidly, has already burned through the wintry dawn. Inside the maternity ward of the Bost Provincial Hospital – the second biggest health care facility in the Southern Region – seven women nurse their newborn babies. The mother of the youngest bathes her just-born son’s face with a warm cloth. The eldest, at two hours’ old, is getting her first childhood vaccinations – BCG, hepatitis B and polio.
Here in Bost hospital, like every maternity facility in Afghanistan, babies are vaccinated in their first few hours of life. In any 24-hour period, the UNICEF-backed female vaccinators will vaccinate dozens of babies in this hospital alone. Some are medically trained to administer intravenous vaccinations, and others – known as female mobilizer vaccinators, or FMVs – are women from the local community, who administer polio drops and run health education sessions. FMVs are not just vaccinators: they are the first line advocates for polio eradication. They are a familiar face to the local community who provides sound advice and information for good health of their children and family members.
Introduced in 2020 as a pilot in three provinces, the FMV programme has since then expanded to 20 out of the country’s 34 provinces. Today, there are over 650 FMVs reaching thousands of women and children every day in hundreds of locations countrywide. The FMV programme also helps alleviate some of the burden on the national health system: the pastoral care service the FMVs provide frees up doctors, nurses and midwives to concentrate on their life-saving work. Some of the FMVs are trained nurses or midwives, and pitch in to help when an extra pair of hands are needed.
The FMVs are a unique group when it comes to reaching women. In the eastern part of the country where the polio virus persists, communities are also historically culturally conservative: here it really is a woman’s work to inform other women. Women are usually the primary caregivers, reaching more women means reaching more children, reducing missed vaccinations and broadening the cohort of fully immunized children. Moreover, they can reach all women, even getting the message to those who are unable to leave the house because they do not have a mahram– a male family member who acts as a chaperone, usually a husband, father, or brother.
Health education sessions run by FMVs include all important components for mothers and children’s health -– from nutrition to childhood diseases, breastfeeding, general hygiene and the importance of vaccination to protect children deadly diseases like measles and polio. Four times a day in hospitals and clinics from Kandahar to Mazar, women crowd into spaces transformed into temporary classrooms, presided over by an FMV with a handheld flipchart. Every session is packed.
One such session, on the importance of sanitation to prevent the spread of polio, is going on in a sunny courtyard of a health facility in Jalalabad, in eastern Afghanistan. Rows of women listen attentively to Lailuma, an FMV who lives in the locality, while children play at their feet. The occasional burst of children’s laughter break the rapt silence.
This is a unique programme, tailored for the complex realities of Afghanistan. Attitudes toward vaccination and healthcare differ between regions, provinces, and even between families. There is no single approach that would suit a country as culturally complex as Afghanistan. The FMVs are deeply embedded in the community that they serve, and their patients are family members, friends and neighbours. They have their trust, which is half the battle won.
“Women in our culture are more responsive to a certain approach,” Hadiya, the FMV supervisor in Lashkar Gah, explains. “They need privacy, politeness, a relaxed atmosphere, before they can settle down to listen.”
Since the FMV programme began, vaccination rates, community awareness levels and, by extension, general trust in the healthcare system, have increased across Afghanistan.[1] The FMVs are the community’s first and trusted source of health information, who also play a pivotal role in identifying children missing vaccinations. Health seeking behaviour and visit to health facilities have also risen as a direct result of women’s increased levels of knowledge.
Despite challenges, the FMVs are driving the polio eradication programme forward, one family at a time. In Jalalabad, Lailuma remains positive: “Inshallah polio will be eradicated. Achievements feel small, but if we keep going we will succeed, and it will be gone from Afghanistan forever.”
(All names have been changed.)
By Kate Pond, UNICEF Afghanistan
[1] UNICEF, Formative Assessment on the Effectiveness of the Deployment of Female Mobiliser Vaccinators (FMV) in Polio High-Risk Locations, May 2023.
KARACHI – The only life Huma Ashraf has known outside her home is of a health worker. That’s what made her step out on September 11, 2023, when she was verifiying microplans in a slum behind a railway track.
Hours later, in a moment that would redefine her life, she was rushing to Karachi’s Jinnah Hospital in an ambulance all by herself, following a train accident.
“It all happened so fast. I had to verify the homes behind the tracks and the only way to get there is crossing the railway track,” she says, recalling that day of the accident with exceptional calm. “The train seemed far away, and I thought I could cross over, but there was a gush of wind and my dupatta was caught in the train.”
In a mere matter of minutes, her life changed as she lost both feet.
The people who witnessed the accident called for an ambulance. With startling presence of mind, she collected the feet in the hope of a surgical reattachment and specified which hospital she wanted to go to.
Hina, her younger sister, is amazed by Huma’s courage that day. Showing the text message she received, she shares how Huma wrote to her with striking clarity. “Pair kat gaye hain, hospital ja rahi hun. Ammi abbu ko mat batana” (Have lost my feet, going to the hospital, don’t tell mom and dad.)
By the time Huma was taken into surgery, nearly five hours later, the damage was irreversible.
Hina worked up the courage to tell their parents about the accident after the surgery. Her mother initially thought Huma’s toes were affected. “I couldn’t fathom the extent of it,” says her mother Rukhsana.
A Legacy of Healing
Since Huma was 14, she has known what an aspirin could do, the contraceptives women would seek and that two drops of the oral polio vaccine could protect a child from lifelong, paralytic polio. These were her mother’s teachings. As she grew older, she also learnt how to administer injections. Rukhsana would ask Huma to try injections on her, consistently training her on how to provide basic health services to the community.
Rukhsana, a lady health worker, started working in 1995. As the eldest child, Huma would go along, and the mother-daughter duo would navigate the streets of Karachi, bringing essential healthcare within reach to women and children, and making friends along the way.
All of Rukhsana’s five children have worked for the Polio Eradication Initiative at some point, but it was Huma who stayed on as a frontline health worker, working in the Polio Programme as a team member and eventually rising in the ranks to become an area in-charge.
As vaccinators, there was a time when Huma and Rukhsana were one team, a team that they were very proud of. “When important people came in big cars, we were the team that would be introduced to them because everyone knew we did our job well,” Rukhsana says. “Everyone who saw Huma was amazed at how much she could walk in a day and now…I would have never imagined that one day Huma won’t be able to walk.”
“Both of us still forget what happened. Last night, someone came knocking on the door with some tea and I couldn’t find my slippers, so I asked Huma where hers were, but then I remembered that they would be somewhere on the railway tracks that day,” she adds.
Much of Huma’s nights are spent in pain, especially in the feet that are no longer there. “I think it’s the nerves, my nerves still feel the pain. I can feel my toes hurting, and then realize that they aren’t there anymore.”
Despite a life-changing loss, this is the work Huma still wants to do. “I want to return to work in polio,” she says with a belief that better days are yet to come. The accident has offererd a new level of acceptance and grace. “If God has put me through this difficult time, then I will also be given the strength to bear it.”
“My father cries a lot about this. I told him we have to accept things as they are. This has happened, Allah has put us through a difficult time. If one door closes, another one opens.”
The Bonds That Strengthen
The accident has redefined the meaning of family for Huma. The outpouring of support from colleagues and leaders in the Polio Programme has been overwhelming. For Irshad Sodhar, Coordinator for Sindh’s Emergency Operations Centre, ensuring Huma’s recovery is a mission.
“Looking after the wellbeing of frontline workers is most important. While they do this arduous job selflessly, it is the programme’s duty to support them when they face any adverse situation, especially in the course of their work,” he says.
He is a frequent visitor to the family, and Huma and Rukhsana both look forward to seeing him.
“It is my mission to ensure that Huma gets back on her feet. After the accident, I mobilized everyone we could, from the National EOC Coordinator to the Sindh Health Minister and Deputy Commissioner. We have worked to ensure the family has enough funds and the house is made disability friendly with toilets remade and all parts of it accessible for her. I am amazed by her resilience. After all this, she still wants to work to end polio,” he says, adding “Global polio eradication depends on the motivation of frontline workers. We can’t finish the job without the utmost support of frontline teams on ground.”
When Dr Shahzad Baig, the National EOC Coordinator, talks about Huma, the word that is oft repeated is of family. “Huma is one of the most remarkable people I have ever met,” he says. “We met soon after the accident and I was amazed to see how unbroken her spirit was. She only had gratitude and determination to be better. This feeling of awe stayed with me for days after I met her,” he says.
“She is the true spirit of our polio family. We will make sure she recovers completely and is able to walk on prosthetic feet. Our polio partner, Rotary, has already provided the support for the prosthesis.”
For Dr Zainul Abedin, the WHO National Polio Team Lead, Huma’s unbreakable spirit exemplifies the strength within the polio family. “Huma’s journey, marked by both loss and unyielding hope, mirrors the dedication of health workers across the country. There are many brave souls like Huma who are part of this noble mission to end polio from Pakistan,” he said.
Dr Abedin added: “We salute Huma and every frontline worker, acknowledging their sacrifices and commitment, and will continue to ensure a highly supportive environment for them.”
Huma’s journey and resilience caught the nation’s attention on October 24, 2023, World Polio Day.
In a ceremony that highlighted the relentless efforts of health workers in the fight against polio, Prime Minister Anwaarul Haq Kakar honoured Huma with a shield appreciating her services. This recognition was not just for her contributions to public health but also for her unyielding spirit in the face of adversity. Huma was unable to travel to Islamabad. Dr Baig accepted the award on her behalf and the PM vowed to bring it to her himself.
As Huma prepares for a new chapter in her life, her story is not just one of loss and hardship, but of immense strength, community support, and unwavering hope. “Things have changed, but life goes on,” Huma says with a smile. “We have to embrace it, whatever it brings.”
Huma is eager to start working for polio eradication again.
Sindh EOC Coordinator Irshad Sodhar got frontline workers from across Pakistan to send her messages, all of them expressing their belief in her and wishing for her strength. Huma had a message for them too: “You are not alone. There is a huge programme behind you, which is there for your support. Your work is greater than you think.”
Rukhsana says she has never felt as supported since she started working in 1995. “In this time, I have really felt what it means to be part of a family.”
By Zehra Abid, Communications Officer, WHO Pakistan (Video by NEOC)
The sound of drums is enough to rouse even the sun, prompting it to wrestle the early morning smog for a front-row seat in a local Pashtun community in Rawalpindi, Pakistan. As tea stall owners set up shop for the day, curious women peek out of their windows, and excited children rush out of their houses to flock around the mysterious drummer. And as he moves from street to street, they run alongside him. Flushed with excitement, they start dancing to the familiar local tunes, some of them falling over each other. All smiling. It is a welcome distraction on a cold January morning.
This lively scene, however, is no accident. A banner draped around the drummer carries a powerful message: “Let’s vaccinate our children regularly to eradicate polio. The upcoming vaccination campaign begins on 8th January. Help us vaccinate your children whenever a health team visits your house.” This ‘attention-grabbing’ approach, blending cultural traditions with polio awareness campaigns, is the brainchild of UNICEF’s Social Behavior Change team working with the government’s Provincial Polio Emergency Operations Centre in Punjab.
Leading this creative team is Sajida Mansoor, who understands that information overload on polio vaccination can overwhelm parents, at times to the point of inaction.
“Out-of-the-box thinking was required to respond to the challenge. That’s how we came up with this unconventional but fun idea of using drums to spread awareness and highlight key immunization dates to reach children, especially those who were consistently missing polio vaccination,” says Sajida, a long time UNICEF staffer supporting polio eradication efforts in the country.
Zafar Iqbal, the drummer, suddenly stops playing, to allow the call for prayers from the local mosque to be heard in the community. Zafar is a seasoned professional musician who sustains his livelihood by showcasing his talent at various cultural events when he is not engaged with the polio eradication programme.
But the polio percussion show isn’t over yet. Joining Zafar at center-stage is seven-year-old Gul Bahisht. She confidently delivers a brief speech she has composed: “Do you know Pakistan is very close to finishing off polio? But I learnt that the virus is still spreading in our area and can paralyze children. We must vaccinate all children and protect them from being hurt and disabled from polio. I have been vaccinated. Why not vaccinate your child too. It’s easy and simple. Just two drops for your child in every campaign and we will all be free from polio forever.”
Zafar picks up where he left off and the rhythmic beat of his drums resume, bringing immense laughter and joy to the delighted children and their families in the neighborhood.
This engaging strategy has struck a chord with local communities. In neighborhoods where the initiative was first introduced, parents became more receptive. Mother and fathers happily opened their doors to polio vaccination teams. It enabled them to vaccinate a large cohort of children who had consistently missed vaccination due to reasons cited as ‘not available,’ which often meant the parents did not open their doors to vaccinators. Children embraced the teams without distrust, resulting in more efficient vaccination coverage.
This achievement underscores the importance of extending the initiative to other neighborhoods in future campaigns, particularly in communities where some children consistently miss their vaccinations.
“This approach has helped us break down the barriers with caregivers and they are more receptive to communicating with us. We are dedicated to ensuring that our teams on the ground actively respect the religious and cultural norms of the local community. For instance, drummers like Zafar pause their beats during calls for prayer, demonstrating social and religious sensitivity. Additionally, the musical elements are in accordance with the cultural norms of the community,” adds Sajida.
In communities across Lahore and Rawalpindi where the ‘drummer’ strategy was introduced, polio teams managed to vaccinate every single available child. This was a significant contribution to the 96 per cent vaccination coverage achieved in the Punjab province during the recent campaign.
Meanwhile, back in Rawalpindi, Zafar’s percussion jam for polio eradication continues to reverberate in the neighborhood. A father himself, he made sure his youngest two-month-old daughter was vaccinated during the recent vaccination campaign.
“I feel very happy and blessed that the beats from my drums bring joy to people, and at the same time support an important cause that protects our children in Pakistan from deadly diseases like polio,” says Zafar with a smile.
By Wasif Mahmood, UNICEF Polio Communication Officer, Provincial Emergency Operations Center, Punjab
WHO/Europe has declared an outbreak of poliovirus in Ukraine, detected in October 2021, officially closed. The European Regional Commission for the Certification of Poliomyelitis Eradication endorsed the closure of the outbreak during its annual meeting on 8 September 2023. The country has achieved this milestone – stopping transmission of the virus that threatened the lives and futures of its children and preventing spread to other countries – in the face of the ongoing war.
The comprehensive outbreak response, initiated by the Ministry of Health of Ukraine in December 2021, faced multiple challenges since the end of February 2022, including massive population displacement, destruction of health-care infrastructure and disruption of logistical routes for medical product deliveries.
“Stopping the spread of poliovirus in the midst of a devastating war is a major achievement and a clear demonstration of the highest level of political commitment of the Government of Ukraine to the welfare of its population,” said Dr Hans Henri P. Kluge, WHO Regional Director for Europe.
“In the face of unprecedented challenges, the necessary steps taken by the Ministry of Health of Ukraine to prevent the spread of poliovirus within and beyond the borders of Ukraine are immensely commendable.”
The decision to close the outbreak was based on:
the recommendations of a poliovirus outbreak response assessment (OBRA) conducted by Global Polio Eradication Initiative (GPEI) partners, including WHO, in May 2023;
additional documentation provided by Ukraine in support of the ongoing surveillance, immunization and communication efforts since May; and
a comprehensive review of poliovirus surveillance and vaccination performance in the countries hosting the majority of the Ukrainian refugee population.
The outbreak was first detected in a young child in Ukraine in October 2021, following the importation of a poliovirus that had emerged in Pakistan and was previously detected in Tajikistan in 2021. A second child became paralysed in December 2021, and an additional 19 close contacts tested positive without developing symptoms.
“The Ministry of Health of Ukraine declared importation of this poliovirus a local public health emergency, and acted swiftly since its detection in close coordination with the global public health community,” said Dr Viktor Liashko, Minister of Health of Ukraine.
Dr Liashko continued, “The outbreak is now closed, but our work to prevent polio and other vaccine-preventable diseases in Ukraine continues despite all obstacles. As long as polio remains a threat globally, Ukraine will remain vulnerable. The Ministry of Health is committed to strengthening vaccine-preventable disease surveillance and working to achieve and sustain high routine immunization coverage nationwide to protect every child.”
What does it take to stop a polio outbreak?
In October 2021 the detection of poliovirus in Ukraine triggered the declaration of a public health emergency in affected oblasts, the creation of a response working group with technical support from GPEI and WHO specialists, and an immediate epidemiological investigation including contact tracing and environmental sampling at a summer camp, school and residences where the virus had been initially detected.
On 30 December 2021 the Ministry of Health approved an action plan in response to the outbreak that included, among other initiatives, an accelerated immunization catch-up campaign for children aged 6 months to 6 years who had not received the required doses through routine immunization.
The campaign began in mid-February 2022, but its scale and pace were significantly affected by the war in Ukraine. GPEI partners including WHO provided technical and operational support tailored to the context to build capacity and strengthen routine immunization services, disease surveillance, communication and transportation of samples to reference laboratories abroad.
Dr Jarno Habicht, WHO Representative in Ukraine, coordinated the WHO response within the country. “WHO and GPEI partners have been on the ground from day one, supporting Ukraine’s health authorities, medical and public-health professionals, laboratory staff, and communities to keep this virus from spreading,” he explained. “The excellent collaboration and perseverance of the local and international teams to protect children in the most difficult of circumstances has been truly inspiring.”
Despite the many challenges in implementing the national action plan for the outbreak response, no new detections of poliovirus were identified after December 2021. The OBRA conducted in May 2023 assessed the critical components of the outbreak response, such as the quality of surveillance (and thereby the risk of undetected poliovirus transmission), planning and coordination, the vaccination campaign, routine immunization performance, communication, and vaccine management. Based on the field assessment and review of the documentation, the OBRA concluded that poliovirus was no longer circulating in Ukraine.
The OBRA in Ukraine was followed by a comprehensive review of actions taken by Bulgaria, Czechia, Hungary, Poland, the Republic of Moldova, Romania and Slovakia. This was coordinated by WHO/Europe with financial support from the United States Agency for International Development (USAID).
The review assessed the actions to expand capacities to detect the virus, identify gaps in vaccination coverage and increase coverage of the local populations hosting Ukrainian refugees, and offer vaccination to refugees entering from Ukraine. This review, along with the additional information provided by Ukraine on actions implemented during the months following the OBRA, enabled WHO/Europe to declare the outbreak officially closed.
Mr Robb Butler, Director of the Division of Communicable Diseases, Environment and Health at WHO/Europe, stated, “Ukraine has been steadfast in recent years in its efforts to achieve and sustain high routine vaccination coverage, and within the realm of the European Immunization Agenda 2030, WHO/Europe will continue to support health authorities to prevent further outbreaks of vaccine-preventable diseases including polio, measles, diphtheria and many more.”
Mr Butler concluded, “Tremendous credit goes to the health professionals and parents who continue to make every effort to vaccinate children on schedule to protect them from the threat of polio and other diseases, even while navigating the daily realities and dangers of war.”
With 117 confirmed cases of circulating variant polioviruses and 107 detections in sampled wastewater so far in the African Region in 2023, the Africa Regional Certification Commission (ARCC) has urged countries and health partners to urgently address gaps in polio immunity to avert outbreaks.
The ARCC, which held it 31st meeting in the Democratic Republic of the Congo from 3 to 7 July, also called for an accelerate implementation of supplementary immunization activities, while considering challenges in accessibility to services including gender-related issues. The commission stressed the importance of gender equality in the polio fight, noting the crucial role women play in management, supervision, decision-making, message development and monitoring for polio control. The ARCC also urged countries to conduct robust preparations and ensure the vaccination campaigns are of the highest quality.
“The guidance will allow health authorities and partners to provide focused support to strengthen microplanning and social mobilization in areas with poor campaign performance, among other key areas of action“ said Professor Rose Leke, head of the Africa Regional Certification Commission.
The meeting gathered representatives of national and provincial health authorities from Chad, the Democratic Republic of the Congo, Ethiopia, Madagascar, Mali and Mozambique who committed to strengthen disease surveillance and consolidate the Expanded Programme on Immunization in hard-to-reach areas, with the support of the World Health Organization (WHO) and health partners.
Attendees took note of the increasing risk of poliovirus type 1 beyond Madagascar and the DRC, especially with the deterioration of routine immunization during the COVID-19 pandemic. Concerns were also raised regarding the persistently security-compromised areas, especially in Nigeria, that are impeding the elimination of circulating variant poliovirus type 2 (cVDPV2).
The commission, therefore, encouraged health authorities to also expand the use of Geospatial Information Systems to improve quality of surveillance and outbreak response.
“We are looking forward to implementing the additional ARCC recommendations to guide how we can deliver on the promise of polio-free Democratic Republic of the Congo and Africa,” said Dr Serge Emmanuel Holenn, Deputy Minister of Health of the Democratic Republic of the Congo, who applauded the commission, WHO and the Global Polio Eradication Initiative partners for the continued financial and technical support in the fight against polio in the country.
In addition to the DRC, Chad, Ethiopia, Madagascar, Mali and Mozambique also presented progress in polio control and lessons learned. Although certification of polio eradication occurs at the regional level, all countries with polio-free status are required to provide the certification commission with annual updates. These containment reports and outbreak preparedness plans allow for continuous monitoring.
The ARCC commended health authorities for their leadership in responding to ongoing polio outbreaks, as “this reflects the deep commitment and continued collective efforts by African countries and partner organizations to the fight against polio,” said Professor Leke.
The ARCC is an independent body established in 1998 to oversee the certification status of the African region as free from indigenous wild poliovirus. It continues to evaluate reliability of data in documentation submitted by National Certification Committees to ensure that countries are adhering to the criteria set for the global certification of wild polio virus. The ARCC meets twice a year to review progress made in the annual certification updates of selected countries on polio eradication activities of all the 47 member’s state of the WHO African region.
After completing her bachelor’s degree in medical laboratory science, she cut her teeth in a HIV drug resistance lab in Botswana, where she tested blood samples to determine whether a patient with HIV had a mutated form of the virus which did not respond to antiretroviral therapy.
“Once you are in the lab you realize it’s not just a job, it’s more like a calling,” she says. “Someone sends samples to you, and you are the first one to see results and ask, ‘how is this going to impact the patient, the community as a whole, and then the country as a whole?’”
In 2019, just before the onset of the COVID-19 pandemic, Mphoyakgosi was transferred to the National Health Laboratory and when the pandemic hit, she was one of the first national experts to be trained by World Health Organization on how to test for COVID-19.
This period was a career highlight for Mphoyakgosi. “COVID-19 taught us a lot. When we get outbreaks now, we have learnt from COVID what can be done better,” she says.
Currently, as part of polio prevention, she tests wastewater samples for the poliovirus. And believes firmly in homegrown excellence in her field.
“My dream for my country Botswana is to have a well-established, operationalized national public health laboratory,” she says. “I think we have capacity in terms of human resources, in terms of infrastructure. What we need now is the drive to move towards excellence. You know, embracing the science as it is and technology as it comes.”
Following the recent outbreak of Wild poliovirus type 1 in the country, she has been helping to prepare her community for a forthcoming vaccination drive, which aims to protect nearly 4 million children in the four most at-risk provinces.
Having been involved in the health sector for decades, Raquelina also spends her days encouraging other older people around her to stay active, eat healthily and to keep serving their community, just as she does.
According to the World Bank, people aged 65 and above represent only 3% of the total population in Mozambique. But Raquelina sees her age and many years of experience as an asset rather than a hindrance.
¨I am not afraid of getting old,” she says. “I feel proud because I am active, and my experience is key when it comes to contributing to the health of the people in my community. ¨
Raquelina doesn’t let her age restrict her ambitions either. “I want to go back to school and further my education,” she says. “I will keep moving forward. I will do whatever I am supposed to do. No one can take that away from me.”
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.
