Following identification last month of an acute flaccid paralysis (AFP) case from which vaccine-derived poliovirus type 1 (VDPV1) had been isolated, genetic sequencing of two VDPV1s from two non-household contacts of the AFP case has now confirmed that VDPV1 is circulating and is being officially classified as a ‘circulating’ VDPV type 1 (cVDPV1).
The National Department of Health (NDOH) of Papua New Guinea is closely working with the GPEI partners in launching a comprehensive response. Some of the immediate steps include conducting large-scale immunization campaigns and strengthening surveillance systems that help detect the virus early. These activities are also being strengthened in neighboring provinces.
The GPEI and its partners are continuing to work with regional and country counterparts and partners in supporting the Government of Papua New Guinea and local public health authorities in conducting a full field investigation, risk assessment and to support the planning, implementation and monitoring of the outbreak response.
For more information:
Contact Oliver Rosenbauer, Communications Officer, Global Polio Eradication Initiative, tel: +41 79 500 6536
21 June 2018 – The Ministry of Foreign Affairs of the Republic of Korea announced today an additional US$ 2 million to fund polio outbreak response and surveillance activities in the Horn of Africa. This commitment makes Korea the first country to support outbreak response efforts in the region, critical to protecting global progress toward ending polio.
The Global Polio Eradication Initiative (GPEI) welcomed the contribution, with $1.5 million for UNICEF and $0.5 million for WHO.
This funding was raised through an innovative financing mechanism called the Global Disease Eradication Fund, through which KRW₩1,000 was collected from each international passenger flying out of Korean airports by the Government of Korea. Thanks to this Fund, every passenger flying from Korea directly supports global efforts to stop polio, an infectious disease that can lead to paralysis or even death, and can travel long distances undetected.
When the GPEI first began in 1988, polio paralysed more than 350,000 children each year in over 125 countries in the world. Today, there have only been eight cases to date in 2018, and polio is closer than ever to becoming the second human disease to ever be eradicated.
This progress is made possible through the ongoing support of donors, partners, and countless health workers around the world. Contributions from donors like Korea allow the GPEI to vaccinate and protect more than 450 million children against polio each year.
This additional funding follows a US$ 4 million commitment from the Republic of Korea announced at the Global Polio Pledging Event around the Rotary International Convention in June 2017. This contribution was matched by the Bill & Melinda Gates Foundation, doubling its impact to US$ 8 million.
“The Global Disease Eradication Fund is an incredibly innovative financing mechanism, and the funds raised will support UNICEF’s efforts to protect every last child from polio,” said Akhil Iyer, UNICEF Director of Polio Eradication. “We remain grateful to the Republic of Korea for their continued commitment to halting polio outbreaks and driving progress to eradicating polio once and for all.”
“The unique support of the Republic of Korea has been crucial for the remarkable progress we have made in polio eradication, especially in responding to outbreaks,” said Dr Michel Zaffran, Director of the Polio Eradication Programme at the World Health Organization. “These additional funds come at a critical time as we support the outbreak response in the Horn of Africa region by scaling up surveillance to ensure no virus goes undetected.”
The Republic of Korea has been a longtime supporter of the GPEI, contributing to outbreak response efforts in Syria, the Democratic Republic of Congo and the Lake Chad region, with a broad range of activities including delivering polio vaccines, intensifying surveillance, and convincing caregivers to vaccinate their children through community engagement.
Generous support from donors like the Republic of Korea remains essential to stopping outbreaks, ending this paralysing disease and ultimately achieving a polio-free world.
Efforts to protect children from polio take place all over the world, in cities, in villages, at border checkpoints, and amongst some of the most difficult-to-access communities on earth. Vaccinators make it their job to immunize every child, everywhere.
In places where families are displaced and on the move due to conflict, it is especially important to ensure high population immunity, to protect all children and to prevent virus spread. In Iraq last month, vaccinators undertook a five-day campaign in five camps for internally displaced people around Erbil, in the north of the country, as part of the first spring Subnational Polio campaign targeting 1.6 million children in the high risk areas of Iraq (mainly in internally displaced person camps, and newly accessible areas).
Iraq has not had a case of indigenous wild poliovirus since 2000. However, due to the drastic drop in immunity in the country after years of conflict, two children were paralyzed when wild poliovirus was imported in 2014.
Poliovirus spreads from person to person, transmitted through populations. Last year, there were 74 cases of polio in Raqqa and Deir ez-Zor governorates in Syria. Over the border in Iraq, children in Mosul and Anbar are deemed to be at high risk of being infected because of the history of regular movement of armed groups between the two countries. Violence has caused many families to leave their homes – potentially carrying the virus with them as they travel to internally displaced persons camps and other destinations.
Baharka camp, one of the five internally displaced persons camps near Erbil, is where many families from Mosul, Anbar, and other areas currently reside. During the polio vaccination campaign, male and female vaccinators walked tent-to-tent to deliver vaccine to all children under the age of five. Their aim was to ensure whole-camp immunity by finding and protecting every child.
After visiting a household, the vaccinators marked on wood, stone and canvas how many children had received vaccine, along with information about any vaccine refusals. Over the course of the campaign, vaccinators aimed to reach 4203 children.
As well as twice-yearly vaccination campaigns, health workers in the Erbil camps look for signs of Acute Flaccid Paralysis (AFP) amongst children living there, which is one of the most common indicators of polio. Any suspected cases are recorded, and investigated through the poliovirus surveillance network. Since surveillance began in the camps, thirty AFP cases have been discovered and investigated for signs of the virus.
“We conduct continuous monitoring,” said WHO Polio Eradication Officer Dr Rebaz Lak. “If any child displays weakness of the limbs, the doctor must notify health authorities.”
Since 2014, more than five million civilians have fled their homes inside Iraq. At the same time, families are returning to places where instability has lessened. As many as two million displaced Iraqis are likely to return home this year, which means children will be on the move once more. This makes the vaccination of every child even more important – allowing them to travel safely, and be protected from virus when they reach their destination.
Some families choose to go home, but keep a safe place to flee to should violence return. Since Baharka camp opened, a number of families have travelled back to Mosul, but have maintained their displaced person status and a caravan in the camp. The World Health Organization carefully monitors the names and caravan numbers of the children in these groups, to ensure that vaccinators visit them whenever there is a campaign. Once vaccinated, each child has their little finger stained purple – an easy way to prevent children being missed.
Alongside the children protected in Baharka camp, the Global Polio Eradication Initiative partners vaccinate over 400 million children every year. Efforts to eradicate polio also help to fight other diseases at the same time, whilst the valuable polio eradication infrastructure, data and tools can help to strengthen the health systems of conflict-affected countries.
Thanks to the devotion of vaccinators and health workers, the displaced children of Mosul and Anbar are protected together from the virus. When they return home, they won’t have missed out on a valuable health intervention – allowing them to lead healthier, polio-free lives in the future.
From the front passenger seat of a small utility truck, Mahmoud Al-Sabr hangs out the window, looking for families and any child under five years old to be vaccinated against polio. As the car he travels in dodges rubble and remnants of buildings that once stood tall in Raqqa city, he flicks the ‘on’ switch for his megaphone.
“From today up to January 20, free and safe vaccine, all children must be vaccinated to be protected from the poliovirus that hit Syria for the second time,” he calls, beckoning families with young children who have recently returned to Raqqa city to come outside of their makeshift homes amongst destroyed buildings, to have their children vaccinated.
In 2017, amidst the protracted conflict and humanitarian crisis in Syria, an outbreak of circulating vaccine-derived poliovirus type 2 (cVDPV2) was detected, threatening an already vulnerable population.
Due to ongoing conflict, Raqqa city, which was once host to half of the governorates population, had been unreached by any vaccination activity or health service since April 2016. During the first phase of the outbreak response, more than 350,000 resident, refugee and displaced children were vaccinated against polio in Syria, but “Raqqa city remained inaccessible,” says Mahmoud.
In January 2018, polio vaccinators conducted the first vaccination activity in the city since it became accessible again, following the end of armed opposition group control.
There were no longer accurate maps or microplans that vaccinators could use to guide them in their work. Unrecognizable, the city was a picture of devastation with few dwellings untouched by the violence that once caused families to flee. The house-to-house vaccination campaign that usually helps the programme to reach every child under five wouldn’t work here. Teams knew they would have to innovate to seek out families wherever they were residing to vaccinate their children.
“All children must be vaccinated to protect against poliovirus,” Mahmoud echoes around shelled out buildings, and slowly mothers and fathers carrying their children start to appear in the street.
Mahmoud and Ahmed Al-Ibraim are one of 12 mobile teams that are going street by street, building by building, by car in search of children to vaccinate. Carrying megaphones to alert families of their presence and to tell them of the precious vaccines they carry that will protect their children from the paralysing but preventable poliovirus, they slowly cover areas of the city now unrecognizable.
“No one could enter Raqqa City now for two years,” says Abdul-Latif Al-Mousa, a lawyer from the city who joined the outbreak response as a Raqqa City supervisor for polio campaigns. “So children have not been vaccinated here since that time. Now that people have returned, we are learning where they have returned from and we vaccinate them regardless.”
“We must reach each child with the vaccine to protect them – polio is preventable, why should they suffer more?” Ahmed appeals.
Campaign brings vaccines and familiar faces
Vaccines were not the only thing to return to Raqqa City in January. It was the first time that WHO polio focal point Dr Almothanna could return to Raqqa City after being force to flee under the rule of the armed opposition group. Imprisoned for refusing the demands of the group, friends and neighbours of Dr Almothanna facilitated his escape from the city in 2016.
Dissatisfied but not deterred, Dr Almothanna continued to work with the polio programme, serving the whole governorate except his own city. Over the course of the January 2018 campaign, he worked tirelessly with vaccination teams to ensure more than 20 000 children under the age of five in Raqqa City received a dose of mOPV2 to protect them against polio. For many, it was the first vaccination they had received. In the additional campaigns that followed in March 2018, even more children were reached.
The microplans developed by vaccinator teams in the first vaccination round have become a critical road map for reaching children and families with health services, accounting for the locations of returned families and information about neighbouring families that teams had not yet located. In the second round, the microplans were updated to include new families who had returned.
Syria reported 74 circulating vaccine-derived poliovirus cases between March and September 2017. It has been more than six months since the last case was reported (21 September 2017). Efforts are continuing to boost immunity in vulnerable populations, maintain sensitive surveillance for polioviruses and strengthen routine immunization to enhance the population immunity.
Ondrej Mach of the WHO polio research team discusses why new inactivated polio vaccine solutions are needed for the post-eradication era. Why are we developing entirely new vaccines for a disease which will no longer exist?
Le jour se lève dans le district sanitaire de Bol, au Tchad, et la Dre Adele commence sa journée. Elle monte dans son canoë et, après avoir jeté un coup d’œil à sa carte, commence un long voyage sur les eaux du lac Tchad. Dans quatre à six heures, se frayant un chemin parmi les roseaux, elle aura atteint une île isolée où les enfants n’ont encore jamais été vaccinés.
La Dre Adele Daleke Lisi Aluma vit dans l’une des régions du monde où la vaccination est la plus difficile. Dans le district de Bol, 45 pourcent des enfants vivent dans des îles isolées et difficiles d’accès où les obstacles géographiques, la violence, l’insécurité et la pauvreté empêchent le plus souvent de prodiguer à la population les services de santé et les autres services publics.
Son travail consiste à surmonter ces obstacles en cherchant chaque enfant non encore vacciné, tout en mettant à profit son expérience pour que le programme fasse le meilleur usage des ressources en vue d’atteindre à chaque fois le plus d’enfants possible.
Un itinéraire à planifier
La première étape de chaque campagne consiste à planifier l’itinéraire. En étudiant les cartes, en en comparant les informations, la Dre Adele et son équipe s’efforcent de trouver la façon la plus efficace d’atteindre les nombreuses îles où les vaccinateurs doivent se rendre.
« L’équipe prévoit souvent ses campagnes lors du marché hebdomadaire, car on peut alors vacciner les enfants qui accompagnent leur mère pour l’achat et la vente des produits de base », explique-t-elle.
Afin que le vaccin soit mieux accepté, la Dre Adele et ses collègues téléphonent aux anciens et aux chefs de village quelques jours avant chaque campagne afin de leur expliquer pourquoi il est si important de se protéger contre la poliomyélite et les autres maladies évitables par la vaccination.
Cette approche permet d’accroître la portée du programme. Auparavant, les vaccinateurs parcouraient parfois de longues distances, pendant de nombreux jours, avant d’arriver sur des îles où se trouvaient en réalité très peu d’enfants. Cela entraînait des gaspillages, les vaccinateurs ne parvenant pas à maintenir, sur le trajet de retour, les vaccins à une température suffisamment froide pour qu’ils puissent profiter à d’autres enfants. Aujourd’hui, une meilleure planification et l’achat de réfrigérateurs solaires pour le stockage des vaccins contribuent à résoudre le problème.
« Pour tirer le maximum d’une session de vaccination, nous devons nous assurer que nos opérations sur le terrain soient efficientes et efficaces, en manquant le moins possible d’occasions », ajoute-t-elle.
Le lac Tchad n’est pas un plan d’eau dégagé : les voies navigables y sont entravées par des roseaux et des arbres et par la vie animale. Pour atteindre les îles, la Dre Adele utilise un canoë, naviguant adroitement dans ces eaux difficiles pendant plusieurs heures. Les équipes doivent faire preuve de la plus grande vigilance. Il leur faut avancer, maintenir les vaccins au froid et éviter les piqûres d’insectes, voire les rencontres avec les hippopotames.
Malgré ces difficultés, elle trouve son travail extrêmement gratifiant.
« À chaque fois que j’atteins un village isolé, je me sens plus motivée que jamais à poursuivre mon action. »
Opérationnelle dès son arrivée
Dès qu’elle est arrivée sur l’île, la Dre Adele commence à vacciner. La majorité des enfants qui vivent dans des villages insulaires isolés ont reçu moins de trois doses de vaccin antipoliomyélitique oral, et sont donc vulnérables face au virus. La Dre Adele s’efforce de protéger chacun d’eux.
Un membre de la famille proche de la Dre Adele a été touché par la poliomyélite et cette expérience est pour elle un véritable moteur. Auparavant, elle a participé à des campagnes de vaccination et à la surveillance épidémiologique de cette maladie en République démocratique du Congo et en Haïti, dans le cadre d’une carrière qui l’a menée partout dans le monde.
Des résultats tangibles
À chaque campagne, la Dre Adele vaccine des centaines d’enfants, mais recherche également des signes du virus.
Lors d’un récent déplacement dans les îles, elle et son équipe ont découvert un enfant atteint de paralysie flasque aiguë, un signe potentiel de poliomyélite, qui n’avait pas été signalé au réseau de surveillance de la maladie. Il s’est finalement avéré que l’enfant n’avait pas la poliomyélite, mais cet exemple montre que le programme doit absolument continuer d’intervenir dans ces zones difficiles d’accès, de vacciner les enfants et d’inciter les communautés à signaler tout cas présumé.
La Dre Adele contribue d’ores et déjà à renforcer la surveillance en formant les habitants de chaque village à reconnaître les signes d’un cas de poliomyélite potentiel.
Elle prévoit également de futurs déplacements : « Nous pensons revenir bientôt encadrer et accompagner les équipes de vaccination dans les zones insulaires. »
Ces efforts sont indispensables pour atteindre les communautés les plus isolées du lac Tchad.
“When I received the confirmation of the first case of Lassa fever…nothing prepared me for the tasks ahead other than my work in polio eradication” – Mrs Faith Ireye, WHO State Coordinator in Edo state.
In the first two months of 2018, there were 110 deaths in Nigeria from suspected Lassa fever. Outbreak response, led by the Nigerian government and WHO, is focused on detecting every case, and tracing the virus wherever it is hiding.
Bolstering this effort are individuals with experience of guarding against a different disease – polio.
Ms Ireye, who has worked with the Global Polio Eradication Initiative for over ten years, is currently helping to coordinate the Lassa fever outbreak response in Edo State, one of the hardest hit by the outbreak.
“My experiences in polio eradication activities allowed me to immediately swing into action. So, when the [Lassa fever] outbreak was confirmed, I realized the need to use my expertise to serve communities at risk,” she says.
Part of her job is to help coordinate surveillance, specifically ensuring that everyone who has come into contact with someone with Lassa fever is found, and tested for the virus.
Her work is critical to help prevent further fever cases. Deputy Governor of Edo State, His Excellency Philip Shaibu said, “WHO…is one of the pillars that have helped lead surveillance in Edo state… In this particular outbreak, WHO was the first to draw attention to the fact that we need to galvanize resources from all partners, from other parts of the country, to ensure that things get done.”
The polio infrastructure
When outbreaks of other diseases happen, the knowledge and experience of polio personnel like Ms Ireye can make a significant difference to outbreak response. For example, polio workers were essential to containing the Ebola virus outbreak in 2014. For the Lassa fever response, 271 polio workers are involved in active case search, 235 in contact tracing, and 320 in community sensitization activities across the 18 at-risk states.
“The polio infrastructure was originally designed towards achieving the polio eradication goals,” said Dr Wondimagegnehu Alemu, WHO Country Representative to Nigeria. “Now polio infrastructure has expanded its support to broader disease surveillance strengthening, outbreak response and basic health care services including immunization.”
Other activities carried out by polio workers include data collation and analysis, and case reporting.
“The polio teams on ground in the states were crucial for mounting the initial response to the Lassa fever outbreak, and have continued to be WHO’s frontline technical support to the NCDC, States Ministry of Health and local government area teams,” Dr Emmanuel Musa, WHO Incident Manager for Lassa fever Management Team in Nigeria observed.
A legacy for posterity
Investments by donors and partners have gone far beyond polio eradication. Reflecting the positive impact that polio infrastructure and knowledge has had on other health priorities such as Lassa fever, WHO and other partners are currently supporting the development of a national transition plan. This will ensure that the investments that have brought the world to the brink of eradication are made available to support other national public health efforts, long after polio has been defeated.
“We must carefully consider how we transition many of the polio workers and the polio infrastructure to help with managing other health needs,” Dr Alemu said. “Future funding and partnerships will be a key part of this work.”
For now, experienced polio personnel continue their work to end the Lassa fever outbreak. Thanks to them, and the support of governments, partners and donors, we are ending polio, and are also helping to strengthen other health interventions.
Support for immunization to the Federal Government of Nigeria through the World Health Organization is made possible by funding from the Bill & Melinda Gates Foundation (BMGF), the United Kingdom, the European Union (EU), Gavi, Global Affairs Canada (GAC), the Government of Germany, the Japan International Cooperation Agency (JICA), the Korea Foundation for International Healthcare (KOFIH), the Measles and Rubella Initiative (M&RI) through the United Nations Foundation (UNF), Rotary International, the United States Agency for International Development (USAID), the United States Centers for Disease Control and Prevention (CDC) and the World Bank.
Somalia, which stopped indigenous wild polio in 2002, is currently at risk of circulating vaccine-derived poliovirus type 2, after three viruses were confirmed in the sewage of Banadir province in January 2018. Although no children have been paralysed, WHO and other partners are supporting the local authorities to conduct investigations and risk assessments and to continue outbreak response and disease surveillance.
Underpinning these determined efforts to ensure that every child is vaccinated are local vaccinators and community leaders – nearly all of whom are women.
Bella Yusuf and Mama Ayesha are different personalities, in different stages of their lives, united by one goal – to keep every child in Somalia free from polio. Bella is 29, a mother of four, and a polio vaccinator for the last nine years, fitting her work around childcare and the usual hustle and bustle of family life. Mama Ayesha, whose real name is Asha Abdi Din, is a District Polio Officer. She is named Mama Ayesha for her maternal instincts, which have helped her to persevere and succeed in her pioneering work to improve maternal and child health, campaign for social and cultural change, and provide care for all.
Protecting all young children
Working as part of the December vaccination campaign, which aimed to protect over 700 000 children under five years of age, Bella explains her motivation to be a vaccinator. Taking a well-deserved break whilst supervisors from the Ministry of Health and the World Health Organization check the records of the children so far vaccinated, she looks around at the families waiting in line for drops of polio vaccine.
“I enjoy serving my people. And as a mother, it is my duty to help all children”, she says.
For Mama Ayesha too, the desire to protect Somalia’s young people is a driving force in her work. A real leader, she began her career helping to vaccinate children against smallpox, the last case of which was found in Somalia. Since then, she has personally taken up the fight against female genital mutilation, working to protect every girl-child.
She joined the polio programme in 1998, working to establish Somalia as wild poliovirus free, and ever since to oversee campaigns, and protect against virus re-introduction. In her words, “My office doesn’t close.”
Working in the midst of conflict
The work that Bella and Mama Ayesha carry out is especially critical because Somalia is at a high risk of polio infection. The country suffers from weak health infrastructure, as well as regular population displacement and conflict.
For Bella, that makes keeping children safe through vaccination even more meaningful.
“Through my job I can impact the well-being of my children,” she says. “For every child I vaccinate, I protect a lot more”.
Mama Ayesha echoes those words when she contemplates the difficulties of working in conflict. For most of her life, the historic district where she works, Hamar Weyne, has been affected by recurrent cycles of violence and shelling. With her grown children living abroad, she could easily move to a more peaceful life. But she chooses to stay.
“This is my home, and this is where I am needed. I am here for my team, and all the children.”
Looking up at a picture of her husband, who died many years ago, Mama Ayesha considers the determination and courage that drives her, Bella, and thousands of their fellow health workers to protect every since one of Somalia’s children. Behind her thick wooden desk, she is no less committed than when she began her career. “If I had to do it again it would be my pleasure.”
Bella has a similar professional attitude, combined with the care and technical skill that make her a talented vaccinator. Returning to her stand below a shady tree, she greets the mothers lined up with their children. As she carefully stains the finger of the first small child purple, showing that they have been vaccinated, she grins.
“I am the mother of all Somali children. I am just doing my job”.
When the sun rises in the health district of Bol, in Chad, Dr Adele’s day begins. Launching her canoe into the reed-filled waters of Lake Chad, and taking a look at the map, she readies herself for the long journey ahead. In four to six hours time she will arrive at a remote island, where there are children never before reached with vaccines.
Dr Adele Daleke Lisi Aluma works in one of the most challenging areas of the world in which to vaccinate. In Bol, 45% of children live on difficult-to-access, remote islands, where geographical barriers, violence, insecurity, and poverty mean people usually do not receive health or other government services.
Her job is to overcome these barriers, seeking out every last child for vaccination, whilst using her experience to ensure that the programme makes the best use of resources to reach the most children, every time.
Planning the route
A first step for every campaign is to plan the route. Studying maps, and comparing information, Dr Adele and her team find the most efficient way to reach the multiple islands that must be visited by vaccinators.
“The team often plans campaigns to take place at the same time as the weekly market, to vaccinate children when they are with their mothers buying and selling necessities,” she says.
To increase acceptance of the vaccine, a few days before each campaign, Dr Adele and her colleagues telephone village elders and leaders, explaining why protection against polio and other vaccine-preventable diseases is so important.
This helps to improve the programme’s reach. In the past, vaccinators sometimes travelled long distances over many days to islands where there are very few children. This meant wasted vaccine, as vaccinators were not able to keep the spare vaccines cold enough on the return journey to be used for other children. Today, better planning, as well as the purchase of solar refrigerators for vaccine storage, helps to solve this issue.
“To maximise a vaccination session, we need to make sure our field operations are efficient and effective, minimizing missed opportunities” she says.
Lake Chad is made up of waterways filled with reeds, trees, and wildlife: not a flat stretch of water. To get to the islands, Dr Adele uses a paddle canoe, deftly navigating the difficult terrain for hours at a time. The teams need to be careful – while steering straight and keeping the vaccines cold, they must also watch out for insect bites – and even hippos.
Despite the challenges, she finds a huge sense of achievement in her work.
“Reaching a difficult to access village gives me every time a sense of motivation to continue.”
Arrival
Upon reaching an island, Dr Adele begins vaccination. The majority of children in remote island villages have received less than three doses of oral polio vaccine, leaving them vulnerable to the virus. One by one, Dr Adele works to protect them.
Dr Adele is driven in her work by her experience of a close family member with polio. Previously, she conducted immunization and epidemiological surveillance for polio in the Democratic Republic of the Congo and in Haiti, as part of a career that has taken her all over the world.
The results
With each campaign, Dr Adele vaccinates hundreds of children, but she also looks for signs of the virus.
On a recent trip to the islands, she and her team discovered a child with acute flaccid paralysis, a potential signal of polio, who had not been reported to the polio surveillance network. While the child didn’t have polio, this underlines the crucial need for the programme to continue to access these difficult to reach places, vaccinate children, and encourage communities to report any suspected polio cases.
Dr Adele is already helping to strengthen surveillance through training community members in each village to recognise the signs of a potential polio case.
She is also planning her next journeys: “We plan to return soon to supervise and accompany vaccination teams in the island areas.”
To reach the remotest communities in Lake Chad, this is what it takes.
The discovery of wild poliovirus in Borno and Sokoto states in Nigeria in 2016 after more than two years without any reported cases prompted a multi-country response in neighbouring countries of the Lake Chad basin, covering Cameroon, Central Africa Republic, Chad, Niger and Nigeria. Since the outbreak response started, coordinated vaccination campaigns have been taking place in all five countries, reaching tens of millions of children. This year, campaigns are planned for March, April and October – all of them synchronized between the neighbouring countries.
In Chad, vaccination activities for polio and other diseases are being carried out in priority districts, supplementing regional campaigns which aim to target the hardest-to-reach children.
A child is vaccinated in a nomadic camp in the village of Ngouboua, in Chad’s north-west region. Additional vaccination activities have taken place in priority districts in Chad between regular campaigns to help strengthen the immunity of children under five.
Teams make dedicated efforts to reach children from difficult-to-access populations: particularly nomadic and island-dwelling families who are often not reached by routine health services, as well as returnee, displaced and refugee populations with limited access to regular vaccination.
Health centers in Chad’s 11 priority districts are supplied with routine vaccines including tuberculosis vaccine, polio vaccine, pentavalent, and measles vaccines, so that trained health workers can vaccinate all children from 0 to 11 months against vaccine-preventable childhood diseases, using fixed, advanced and mobile vaccination strategies.
Vaccinator teams use creative approaches to access hard-to-reach and at-risk populations. Children are being reached with polio and other critical vaccines through vaccinator outreach in areas including weekly markets, islands, and at refugee, displaced and returnee camps.
WHO, UNICEF and partners in the Bagasola district navigate through islands to deliver vaccines to the most vulnerable remote communities.
There are hundreds of islands within Lake Chad that are hardly accessible to health workers. Efforts to specifically reach these locations have been made a national priority.
The Blarigui community meets with the Canton (sub-region) Chief and the vaccination team responsible for the Reaching Every District strategy in the Bagasola region, prior to a special campaign in 2017.
In Chad, engagement of communities and their leaders is key to reaching every child. During immunization campaigns, social mobilizers and the community meet and discuss the importance of vaccination, a practice that has proven successful to increase trust among parents and communities towards vaccinators and campaigns.
Recommendations to bolster the multi-national regional outbreak response across the Lake Chad basin have highlighted the need to improve operations in hard-to-reach areas. In Chad, health workers have been trained to make better use of campaign micro-plans, which map the location of every household, and ensure that each is visited by vaccinators during a campaign. All under-fives living in the high-risk districts of the Lake Chad basin have also been recorded in an community register, helping to ensure that every child receives two drops of polio vaccine in each vaccination round.
More than 4.5 million children under five were reached through national vaccination campaigns in Chad in 2017. Among these, thanks to the renewed focus on identifying and reaching missed children, more than 215,000 were vaccinated from the priority districts of the Lake Chad basin region - particularly those who reside on difficult-to-access islands within the geographical boundaries of Nigeria.
A health worker provides a dose of pentavalent vaccine to a child during an outreach immunization session in Chad. As part of the intensive vaccination campaigns, teams are reaching children with more than just polio vaccine – bringing broader benefits to remote and hard-to-reach communities and maximizing the reach of the polio network.
A bold sign in the camp for internally displaced persons makes it clear where people can come to be vaccinated against yellow fever. WHO/NIGERIA
As he climbs out of his car and walks across to the entrance of Bakassi camp for internally displaced persons in Borno, northern Nigeria, Dr Terna Nomwhange is met by a familiar sight. Standing at the gates, greeting a tired, dusty family laden with possessions, is a team of polio vaccinators. As families arrive at this sea of shelters following a long, hard journey, these people offering polio vaccines are the first sign that they have reached a place of protection.
Not only are families in northern Nigeria facing insecurity, a humanitarian crisis and the threat of polio, but since September they have also been at risk from an outbreak of yellow fever. By early January 2018, a total of 358 suspected cases had been reported in 16 states, with 45 deaths recorded for 2017. In Borno, the ongoing conflict means that the health infrastructure on the ground to respond to the outbreak is limited to local government and the polio eradication infrastructure.
At the camp gates, the polio vaccinators give two drops of vaccine into the mouth of every child; but they also tell the parents where to go to get their yellow fever vaccination. As Dr Terna, who works for the WHO Nigeria polio eradication programme, walks further into the camp, he catches sight of the distinctive blue that signifies the uniform of a polio volunteer community mobilizer. As she emerges from the door of a shelter, he hears her reminding the family within to get their children vaccinated against polio, but also for the whole family to be vaccinated against yellow fever.
With weakened health system in parts of north eastern northern Nigeria, the infrastructure that is already on the ground to stop polio is providing the volunteers needed to support the yellow fever vaccination campaign. More than eight million people are being targeted with yellow fever vaccines in the states of Borno, Zamfara Kwara and Kogi states in 2018.
Vaccinating adults
By providing both polio and yellow fever vaccinations, the polio infrastructure protects everyone – the young children vulnerable to polio, as well as the whole population at risk of yellow fever. WHO/NIGERIA
Regular polio vaccination campaigns reach children under five years of age with polio vaccines, as this age group is the most vulnerable to the virus. But reaching everyone between nine months and 45 years to protect them against yellow fever takes creative thinking. People who would not usually be vaccinated have to be mobilised to come to health clinics where they can receive that one shot of yellow fever vaccine that infers life-long protection.
This is where the polio infrastructure comes in. To prepare for the launch of the yellow fever vaccination campaign that took place at the beginning of February, polio experts supported the preparations by developing detailed microplans, mapping each community so that every individual can be vaccinated. Volunteer community mobilisers, well versed in educating communities about the risks of infection, used their skills to warn populations of the high mortality rates associated with yellow fever.
Surveillance
Volunteer community mobilizers for the polio programme spread awareness of the importance of polio and yellow fever vaccinations. WHO/NIGERIA
The polio surveillance system in Borno is already on high alert to identify any case of polio, even in conflict affected areas. “Surveillance remains everyone’s number one priority,” says Dr Terna. “While the polio infrastructure is doing everything it can to find any trace of polio, it is killing two birds with one stone by keeping an eye out for yellow fever as well. This is a win-win situation to stop both diseases.”
While surveillance focal persons move house to house, they are also raising awareness about the symptoms of yellow fever. When a potential case is found, the polio infrastructure is being used to collect blood samples and transport them to the national laboratory down the reverse cold chain, keeping samples at the correct temperature for testing.
Collaboration
Volunteer community mobilizers for the polio programme spread awareness of the importance of polio and yellow fever vaccinations. WHO/NIGERIA
“What makes this campaign special is not just the fact that the strong polio infrastructure is helping to control other diseases, but also that it underscores what can be achieved with intersectoral collaboration and partnership,” said Dr Wondimagegnehu Alemu, WHO Country Representative to Nigeria. “Without the polio eradication infrastructure, a campaign of this scale would not have been able to take place.”
“Everyone is pulling in one direction – the government, partners and volunteers within communities – to protect any and every vulnerable person against polio and yellow fever,” says Dr Aliyu Shettima, Polio Incident Manager at the Emergency Operations Centre (EOC) in Maiduguri.
Support for immunization to the Federal Government of Nigeria through the World Health Organization is made possible by funding from the Bill & Melinda Gates Foundation (BMGF), Department for International Development (DFID), European Union (EU), Gavi, the Vaccine Alliance, Global Affairs Canada (GAC), Government of Germany through KfW Bank, Japan International Cooperation Agency (JICA), Korea Foundation for International Healthcare (KOFIH), Measles and Rubella Initiative (M&RI) through United Nations Foundation (UNF), Rotary International, United States Agency for International Development (USAID), United States Centers for Disease Control and Prevention (CDC) and World Bank.
Amidst conflict and humanitarian crisis in Syria, health workers are battling to end the current polio outbreak. Since the World Health Organization announced the outbreak on 8 June 2017, 70 cases have been confirmed, with 67 in Deir Ez-Zor governorate, two in Raqqa and one in Homs.
Vaccinating children
WHO and UNICEF are supporting the Government of Syria and local authorities to end the outbreak. Two mass vaccination campaigns have taken place, thanks to dedicated health care workers on the ground, striving to reach resident, refugee and internally displaced children. Despite the challenges of holding vaccination campaigns in a conflict zone and effectively reaching displaced populations from infected areas, more than 255,000 have been vaccinated in Deir Ez-Zor, and more than 140,000 in Raqqa.
Contingency plans for an additional vaccination campaign are being put in place to reach children under the age of five with monovalent oral polio vaccine type 2 in the infected zones and areas hosting high risk populations, particularly recently displaced families from Deir Ez-Zor.
Two different vaccines are being used to ensure that population immunity against polio is rapidly increased. The monovalent oral polio vaccine type 2 is being used to rapidly increase immunity against type 2 polio. To boost immunity against type 2 and also provide protection against types 1 and 3, the inactivated poliovirus vaccine is also being provided to children aged between 2 and 23 months in high risk areas.
Preventing spread of polio
While all hands are on deck to stop polio, outbreak response teams are also working hard and adapting complementary strategies such as vaccination at transit points and registration centres for internally displaced persons from infected zones, to prevent spread of the virus to other parts of the country. The inactivated poliovirus vaccine is being used strategically in high risk areas, especially where there are high numbers of internally displaced families.
In order to reduce the threat of polio spreading to the countries surrounding Syria, vaccination activities have been carried out in Iraq, Lebanon and Turkey. These activities are aiming to reach both Syrian children and those from local communities to limit the possibility for the virus to spread across international borders.
Searching for the virus
Knowing where the virus is at all times is crucial to stop the outbreak. Surveillance is ongoing across the country, with doctors, community members and vaccinators on the alert for any child with potential symptoms of polio. The surveillance system is operating well, despite the challenges of transporting stool samples from children with symptoms to laboratories for testing.
Plans are also in place to begin environmental surveillance in Syria by the end of the year. This will enable laboratories to identify the presence of polio in sewerage to provide early warning.
The information from disease surveillance being used to inform where and when vaccination campaigns need to take place.
Vaccine derived polio
The current outbreak in Syria is caused by circulating vaccine derived poliovirus type 2, a very rare virus that can occur when population immunity against polio is very low. In Syria, conflict and insecurity have compromised community access to immunization services, which has allowed the weakened virus in the oral polio vaccine to spread between under-immunized individuals and, over a long period of time, mutate into a virulent form that can cause paralysis. The only way to stop transmission of vaccine-derived poliovirus is with an immunization response, the same as with any outbreak of wild polio. With high levels of population immunity, the virus will no longer be able to survive and the outbreak will come to a close.
In Afghanistan this year, staff from the non-governmental organization Care of Afghan Families collected 420 blood samples from children under 4 at the Mirwais Regional Hospital in Kandahar province. The aim? To find out whether polio vaccination campaigns have been reaching enough children, and whether the vaccines have been generating full protection against this paralysing disease. These ‘serosurveys’ showed that immunity in Afghanistan is high – and also identified where vaccination campaigns need to reach out further.
Whenever a polio vaccination campaign takes place, a purple dot of ink is painted onto the little finger nail of every immunised child to show that they have received the lifesaving vaccine. This data is collected and allows people to monitor the campaign and know exactly where children have been reached.
Now, with more children being vaccinated than ever before, the polio eradication programme needs to know more than how many children are being reached: we need specific data on where children are being missed.
Serosurveys testing for immunity
Serosurveys are simple tests of the serum in a child’s blood, which measures their immunity (or seroprevalence) to different diseases. The polio eradication programme uses this test to see what level of protection a child has against wild poliovirus types 1, 2 and 3, allowing them to assess whether the vaccination campaigns are reaching enough children, enough times, to give them immunity.
At the Mirwais Regional Hospital, the children tested were from a diverse range of provinces. Their results were sent to Aga Khan University for initial testing, and then sent for further analysis to one of the Global Polio Eradication Initiative partners, the US Centers for Disease Control and Prevention in Atlanta. Through mapping both where they live and their immunity results, scientists at both institutions helped polio eradicators to discover the areas where a child is at most risk of being missed by vaccination campaigns.
Serosurvey results can be crucial for planning campaign strategies – making sure that every last child is reached, no matter where they live.
For Ondrej Mach, team lead for clinical trials and research in the WHO’s Polio Eradication Department, serosurveys “… are increasingly important for eradication efforts, allowing us to form an accurate picture of our progress so far, and the locations where we are being most effective.”
High immunity in Afghanistan
The Mirwais serosurvey proved that Afghanistan is closer than ever to eradicating polio, with more than 95% of children surveyed immune to wild poliovirus type 1, the virus type still circulating in some areas of Afghanistan, Pakistan and Nigeria, and more than 90% immune to type 3, which hasn’t been found anywhere in the world since November 2012. The tests also pointed to where gaps in immunity are, so that missed children can be found and protected.
These results are a strong reflection of the devoted work of polio vaccinators and community workers throughout the country, using their expertise to reach into every family, and spread awareness of the importance of polio vaccination.
As in Afghanistan, serosurveys are increasingly used in other countries where polio remains or poses a threat, to help identify the last remaining pockets of under-immunized children in high risk areas. This is especially important because with polio in fewer places than ever before, it is these unreached children that will take us over the finishing line.
By getting an increasingly accurate picture of where vaccination campaigns are operating successfully, as well as where the programme needs to renew efforts, we can move further towards the goal of reaching every child.
This helps us reach our ultimate goal – ensuring that every last child, everywhere, can be polio free.
The people working to end polio are helping broader humanitarian response efforts in north-eastern Nigeria. With malaria currently claiming more lives than all other diseases put together, a campaign was launched in October to reduce the malaria burden among young children in Borno state by delivering antimalarial medicines. At the same time, community health workers protected children against polio.
“The current campaign marks the first time that antimalarial medicines have been delivered on a mass scale alongside the polio vaccine in an emergency humanitarian setting,” said Dr Pedro Alonso, Director of the Global Malaria Programme, in an interview with WHO on the campaign and the broader humanitarian situation in Borno. “This integrated campaign with WHO’s polio and health emergency teams is an example of unprecedented collaboration to tackle the leading cause of death in a displaced population.”
The humanitarian crisis in north-eastern Nigeria has resulted in a surge in internally displaced persons, with limited access to medical care, leaving millions at risk of life-threatening diseases. In August 2016, four cases of wild poliovirus type 1 were detected in Borno; the outbreak response has been carried out hand in hand with broader humanitarian efforts to meet the health needs of vulnerable populations.
WHO’s well developed network of polio vaccinators, with their years of experience in reaching children with polio vaccines, is making a real difference to the drive against malaria. The polio programme in Nigeria has a vast infrastructure and hundreds of staff on the ground and they are coordinating efforts to make sure that families affected by the crisis have access to other healthcare services.
As a result, the campaigns have reached 1.2 million children with polio vaccines and antimalarial medicines, as shown through a WHO photo story. “I think we will imminently be able to show significant impact,” said Dr Matshidiso Moeti, Regional Director for Africa, reflecting on the encouraging results of the joint campaign.
Vaccinators visiting an IDP camp in Raqqa. Photo: WHO Syria
Three mass immunization rounds have been carried out in Deir Ez-Zor and Raqqa governorates, Syria, in response to an outbreak of circulating vaccine-derived poliovirus type-2 (cVDPV2). The latest round, targeting resident, refugee and internally displaced children less than five years in Deir Ez-Zor concluded 28 August.
“The detection of circulating vaccine-derived poliovirus indicates that there has been low population immunity in affected areas for a considerable period of time,” said Chris Maher, manager of WHO’s regional polio eradication programme based in Amman, Jordan. “WHO is working with all parties on the ground to ensure access to and vaccination of all children under five in these areas, to put an end to this outbreak as quickly as possible,” he said.
As of the end of August, 39 cases of cVDPV2 have been confirmed in Syria ‒ 37 cases from Deir Ez-Zor governorate, and 1 case each from Raqqa and Homs governorates. All three governorates are affected by active conflict.
“Conflict and inaccessibility continue to hamper efforts to raise population immunity levels in areas across the country. These same factors that paved the way for the outbreak of wild poliovirus in Syria in 2013,” said Maher. “We are using the same approaches to achieving access that were successfully used in responding to the 2013 outbreak, and working together with all partners to make sure that children can be reached with vaccine,” he added.
In addition to ensuring access for vaccination teams, innovative methods have been used to increase response reach and effectiveness. The advertising of campaigns through bakeries, and engagement of a local ice cream factory to assist with the daily freezing and refreezing of ice packs for vaccinator cold boxes, are examples.
“Vaccinators on the ground in Deir Ez-Zor and Raqqa continue to face difficult circumstances, but their efforts show clear dedication to protect children against this preventable disease,” said Maher. “We must maintain this high level of commitment and drive,” he said.
Deir Ez-Zor has carried out two mass immunization rounds in July and August while Raqqa has carried out one. The second round for Raqqa is planned for after the Eid holiday.
Inactivated polio vaccine (IPV) is being given to targeted children in each of the second rounds along with the oral vaccine to maximize individual and community protection.
“These local polio vaccination campaigns represent a significant step that has culminated in the close cooperation between WHO, UNICEF and local health partners to reach all targeted children under five in Ar-Raqqa and Deir Ez-Zor governorates,” said Elizabeth Hoff, WHO Representative in Syria.
“Despite security challenges, WHO is committed to ensure the distribution of polio vaccines and the implementation of the local campaigns as planned with a view to achieving sound wellbeing and growth for children with a special attention given to the affected governorates,” Hoff added.
In addition to supporting the response, WHO and partners are also working with neighboring countries to enhance immunization and disease surveillance activities in high-risk areas.
Circulating vaccine-derived poliovirus can occur in rare instances when population immunity against polio is very low. In these settings, the weakened virus found in the oral polio vaccine can spread between under-immunized individuals and over time, mutate into a virulent form that can cause paralysis. The only way to stop transmission of vaccine-derived poliovirus is with an immunization response, the same as with any outbreak of wild polio. With high levels of population immunity, the virus will no longer be able to survive and the outbreak will come to a close.
In July and August, vaccination campaigns were held in Deir Ez-Zor and Raqqa governorates to stop an outbreak of circulating vaccine-derived poliovirus type 2 (cVDPV2).
Photo: WHO Syria
In preparation for the campaigns, polio vaccine was transported long distances to reach Deir Ez-Zor and Raqqa governorates. Careful storage and temperature controls were required to ensure vaccine quality was maintained as it travelled in high temperatures across rugged terrain.
Photo: WHO Syria
This picture shows monovalent oral polio vaccine type 2 (mOPV2) arriving in Deir Ez-Zor in good condition. Both mOPV2 and inactivated polio vaccine (IPV) are being used in the response. The first vaccination round in Deir Ez-Zor, which ran from 22 to 26 July 2017, aimed to reach 328,000 children under 5. The first round of vaccinations in Raqqa ran from 12 to 17 August, and aimed to reach 120,000 children.
Photo: WHO Syria
In the lead up and during the campaigns, social mobilizers used a range of approaches to ensure high levels of community awareness of campaign activities. One such approach was the inclusion of information about the campaigns in bread packages.
Photo: WHO Syria
Social mobilizers also travelled from house to house during the campaign to talk to families about polio vaccination activities, and the importance of the polio vaccine to protect their children from the potentially paralytic disease.
Photo: WHO SYria
A child in Raqqa receiving mOPV2. The objective of the campaign is to protect every child and rapidly raise population immunity to stop the virus in its tracks.
Photo: WHO Syria
This health worker is giving mOPV2 to a child in a camp for internally displaced people in Raqqa. More than 10,000 internally displaced children were included in Raqqa campaign plans.
Photo: WHO Syria
These children from a camp in Raqqa show off their finger markings, to demonstrate that they have been vaccinated against polio during the campaign.
Reaching children with polio vaccine can be notoriously difficult and dangerous. In fact, polio transmission and outbreaks in some areas can be directly related to inaccessibility. When we talk about inaccessibility, many people think about insecurity. And that is definitely a critical factor in some areas, for example in Borno, Nigeria, or Syria at the moment. But in most areas, other elements contribute to the difficulties faced by vaccinators in reaching every child with the vaccine. For example, children living in dense urban neighbourhoods or children who are part of nomadic or mobile communities are often hard to reach.
In some parts of the world, significant environmental and geographic challenges make it difficult for vaccinators to reach children. It is important for health workers to be aware of these different physical barriers when planning vaccination campaigns, as each requires different strategies to make sure we reach even the hardest to reach child.
Many countries working to vaccinate their children against polio have a dry season and a wet or rainy season. When the rains come they can be relentless, altering the landscape and the environment dramatically. For example, rivers that are easily crossed can become torrents of rushing water, impossible to traverse or to even see across. Populations can be suddenly cut-off for months at a time, and reaching them with vaccines becomes much more difficult. The polio programme must then adapt to the local physical landscape and come up with solutions. One of the last hideouts of wild poliovirus in India was the floodplain of the Kosi River in Bihar state; the virus was stopped here by careful planning of vaccination campaigns, mapping of temporary settlements and increasing the number of personnel on the ground.
Infrastructure factors can affect access: children can live in extremely remote locations in places where there are no roads or easy means of transport. In parts of the Democratic Republic of the Congo, some settlements are deep in dense forests, and are not clearly mapped or identified. Says Mohammed Mohammedi, polio eradicator since 1997, “In some countries, we simply might not even know where exactly these places are or if children live there, not to mention the challenge of actually reaching such remote environments. Rains can turn dusty roads in to muddy swamps. Cars and other vehicles risk getting stuck in the mud, causing significant delays to operations.” The polio programme overcomes such challenges with both old-fashioned means – muscle power to dig out vehicles from the mud or donkeys to transport vaccines – and new tools such as satellite imagery to find human habitations or airlifting in vaccine with helicopters.
Mohammedi advises, “For the environmental factors, forward planning is key. We try to schedule vaccination campaigns right before the rainy season starts, and right after it finishes.” The rainy season often coincides with ‘high season’ for polio, with increased transmission during these wetter months, so the pre-rainy season campaigns are critical to make sure children are protected, even when populations become cut off from vaccinators. In some places, vaccines are pre-positioned ahead of the rains, so that local health workers can continue to operate in those areas once regular access is cut off.
“We need to focus on leaving no child unvaccinated,” reminds Mohammedi, “no matter how difficult it is to reach them. This means we need to first identify all the factors that are hampering access, and then respond with tailored strategies that specifically address each situation.”
The programme has years of experience responding to a whole host of inaccessibility factors, and is constantly using this knowledge to make sure every child is immunized against polio.
Read more in the Reaching the Hard to Reach series
This little girl is Kapia. She lives in a small village, surrounded by jungle, in a remote part of the countryside. There are no medical doctors in her village. The nearest clinic is hundreds of kilometres away. And she has just received two drops of polio vaccine, protecting her from the potentially paralytic disease.
A few days ago, health workers arrived in her village with one simple goal – to immunize every child under five against polio. Kapia’s village is one of many hundreds of settlements, villages, towns and neighbourhoods that will be visited by vaccinators with this same simple goal, to reach every child with the polio vaccine.
While the goal is simple, achieving it is much more complex. Vaccination campaigns need to reach hundreds of thousands of children over large areas of land, often involving difficult environmental, cultural and political challenges. A huge amount of detailed information gathering and planning is needed to ensure every piece of the campaign puzzle is first discovered and then analysed and slotted in to place to ensure every child is immunized against the disease.
Enter the microplan.
The foundation of every successful vaccination campaign is a comprehensive microplan, which captures in great detail all the different, yet interrelated components of the campaign.
The first piece of the microplanning puzzle involves discovery – finding out about communities in the vaccination area, how many children live in in the area, and where they are located. This informs a range of other planning and logistical elements of the campaign.
Health workers use a wide variety of resources to gather the most accurate and detailed information possible about communities, to make sure all children are reached with the vaccine. This includes working with the communities themselves, as well as NGOs on the ground and government to make sure even the most remote settlements and hard to reach children are reached in the vaccination campaign. This must take into account groups that are mobile, such as nomads, the internally displaced, or migrant workers’ families. Where are these groups, how many children do they have who need vaccine, what are the routes they use and the transit points through which they pass?
When all these puzzle pieces have been revealed, health workers can start putting them together, building on each piece of information to create the whole microplan picture – a comprehensive and detailed plan for the campaign.
In the microplan, every community is listed, along with estimated number of children, and important areas in each community where children can be reached: whether playgrounds, water collection points, markets or government clinics. Communities are also plotted on maps, along with distances, population spread, landmarks, population movements and seasonal and environmental specifics, such as floods and challenging roads.
This information is also used to calculate the amount of vaccine needed for the campaigns, the logistics for getting the vaccine to where it needs to go, and the number of health workers, vaccination teams and supervisors needed to carry out the work.
Once all of this is established, vaccinators can be identified who are appropriate for that community, and detailed activity plans can be created, allocating vaccination teams to cover specific mapped areas on specific days. Special plans are also made for vaccination teams to vaccinate at major transit points, and to cover hard to reach populations, such as nomadic populations or people living in areas with disputed borders.
Each team is provided with a team microplan, which includes the number of houses and children to be reached, and a detailed description and map of each area to be covered including start point, route to be taken, end point, important landmarks and special sites, like schools and playgrounds, that should be covered to ensure all children receive the vaccine. This functions as a systematic guide to vaccinators as they carry out their work.
Other detailed plans are made covering vaccine distribution and logistics, social mobilization and communications plans, and reporting plans.
Slotted together, every small piece of information and planning combines to give a highly detailed picture of the forthcoming campaign, leaving no situation to chance or guesswork. This ensures every child like Kapia, no matter how remote or hard to reach, receives the protection they need against polio.
A doctor greets a Syrian child in a refugee camp, where children are vaccinated against polio and other diseases. Photo: WHO
In recent years, the global drive to eradicate polio has seen the virus cornered in fewer places than ever before. Yet polio’s final strongholds are some of the most complicated places in the world to deliver vaccination campaigns. Insecurity and conflict are some of the challenges to delivering vaccines, as well as populations on the move, testing terrain and weather, and weak health systems.
In 2013, polio outbreaks in Central Africa, the Horn of Africa and the Middle East paralysed hundreds of children. The Global Polio Eradication Initiative (GPEI) developed strategies to deliver vaccines and stop the virus, even when access seemed impossible. All three of these outbreaks were put to an end just a year later, by not letting the complexity of the situation undermine the quality of vaccination campaigns.
The valuable lessons learned by the GPEI in tackling these outbreaks are now being used to end polio in the final polio endemic countries – Afghanistan, Nigeria and Pakistan – as well as to stop a newly-detected circulating vaccine-derived polio outbreak in Syria.
Challenges to immunization in emergencies
Disruptions to routine immunization systems and mass displacement caused by conflict can rapidly reduce population immunity, making individuals much more vulnerable to polio outbreaks. Polio eradication relies on being able to repeatedly access over 95% of children with vaccines. Yet emergency settings can interrupt systems that gather data about a population, functioning health facilities, health care personnel, vaccine supplies, cold chains to keep vaccines safe, power supply, financial resources, population demand for vaccines, and disease surveillance. When these factors are at play, the GPEI calls on past experience and adopts new approaches to reach every last child.
Lessons learned in conflict zones
Community acceptance and trust
When there are barriers to access, the first step is to have community trust and acceptance of vaccination. Every community and context is different and calls for a targeted approach to communicate exactly why immunization campaigns need to take place. The polio eradication programme identifies and trains vaccinators from local communities, engages religious figures to support the campaign and gets local leaders on board to advocate for, plan and implement vaccination efforts. The polio programme has seen time and time again that when securing access is a challenge, the answer often lies in the very communities we are trying to reach.
In Pakistan, a number of Religious Support Persons have been recruited based on the guidance of the Islamic Advisory Group for polio eradication, to address concerns of local communities about polio vaccinations in some challenging areas of the country. This has resulted in enhanced community acceptance of immunization, with refusal rates of less than 1.5%, as well as broader child welfare interventions.
Opportunistic vaccination campaigns
When different forces make populations periodically inaccessible, vaccination schedules can be interrupted and leave pockets of people unprotected against polio. In these situations, health authorities try to reach children in whatever ways are possible. Transit points can be set up around insecure areas, to vaccinate children as they enter or leave; vaccinators work with local leaders to track and reach populations on the move; communities within the inaccessible areas can store and deliver vaccines themselves; and brief periods of calm can be used to bring vaccines and other essential health services into villages through a health camp.
In Pakistan, over 350 transit points have been set up in recent years along borders and near areas with access challenges. This is one of the innovative approaches that have reduced the percentage of children missed on vaccination campaigns from 25% in 2014 to 5% in 2017.
Negotiated access
In the most challenging situations, when all other approaches are not able to overcome the severity of vaccination challenges, the programme has negotiated access by engaging non-state actors, governments, religious figures and local leaders. Reiterating the humanitarian principle of “neutrality,” the GPEI works with all parties to a conflict to highlight the importance of vaccination campaigns, and secure agreements to access targeted communities for specific periods of time.
In the past, negotiating access to conflict zones was comparatively simple to today. In the 1980s, days of tranquillity were first used in the Americas, through negotiation with two groups – often the government and the opposition group. In many areas where polio persists, there are many different actors and groups engaged in conflict, so negotiation is more complex. It includes identifying who is appropriate to negotiate with in any given district or area, and, importantly, finding appropriate negotiators. Often, third party partners such as the International Committee for the Red Cross are engaged to negotiate operations of vaccination campaigns in security-compromised areas, and in areas where vaccination bans have been imposed by local authorities.
Conflict and insecurity continue to pose significant challenges to eradication. Our best chance of ending polio for good in conflict zones lies in learning from these lessons and adhering to the principles of neutrality in health.
Read more in the Reaching the Hard to Reach series
A circulating vaccine-derived poliovirus type 2 (cVDPV2) outbreak has been confirmed in the Deir-Ez-Zor Governorate of the Syrian Arab Republic. The virus strain was isolated from two cases of acute flaccid paralysis (AFP), with onset of paralysis on 5 March and 6 May, as well as from a healthy child in the same community.
Outbreak response plans are being finalized, in line with internationally-agreed outbreak response protocols, including plans for targeted vaccination campaigns to rapidly raise population immunity. An initial risk analysis has been conducted, finding low overall population immunity levels in the area but solid levels of disease surveillance. Active searches are being conducted for additional cases of acute flaccid paralysis. Surveillance and immunization activities are also being strengthened in neighbouring countries.
Although access to Deir-Ez-Zor is compromised due to insecurity, the Governorate has been partially reached by several vaccination campaigns against polio and other vaccine-preventable diseases since the beginning of 2016. Most recently, two campaigns have been conducted in March and April 2017 using bivalent oral polio vaccine (OPV). However, only limited coverage was possible through these campaigns. Syria also introduced two doses of inactivated polio vaccine in the infant routine immunization schedule in 2018.
The detection of the cases demonstrates that disease surveillance systems are functional in Syria. The polio programme is working with local authorities and organisations on the ground to respond immediately, using proven strategies. In 2013-2014, Deir-Ez-Zor was the epicentre of a wild poliovirus type 1 (WPV1) outbreak, resulting in 36 cases at the time. This outbreak was successfully stopped; the now-detected cVDPV2 strain is unrelated to the WPV1 outbreak.
Circulating VDPVs are extremely rare forms of poliovirus, mutated from strains in the oral polio vaccine (OPV) that can emerge in under-immunised populations. OPV has been a critical tool in eliminating 99.9% of polio cases worldwide, and while cVDPV is rare, the GPEI is actively working with countries to eradicate both vaccine-derived and wild polio. The same strategies that are eliminating wild poliovirus also stop cVDPV – it remains critical that all countries maintain strong disease surveillance and ensure all children are vaccinated.
Young mothers waiting to vaccinate their children receive information on exclusive breastfeeding from a polio-funded Volunteer Community Mobilizer. @ UNICEF/R. Curtis
“Are you watching me?” “Yes, ma’am.”
“Are you seeing me?” “Yes ma’am.”
Along two rows of benches under the awning of the Chikun Primary Health Centre in northern Nigeria’s Kaduna State, about 50 young mothers sit still, their babies swaying on their laps. All eyes are fixed on Lidia, the assured polio social mobilizer who is not delivering polio vaccine, but showing the women how to correctly breastfeed.
Lidia is a grandmother, a one-time community midwife now employed with Nigeria’s polio eradication programme as a UNICEF-supported Volunteer Community Mobilizer (VCM). During the monthly polio vaccination campaigns, she goes house to house with the vaccination team, opening doors through her trusted relationship with the mothers, tackling refusals where they occur and tracking any children missed in the campaigns through her field book containing the names and ages of all children in her area. But it is between campaigns where Lidia’s full worth is realized.
Trust
Helen Jatau, a supervisor in this Local Government Area, supervises 50 VCMs and five first-level supervisors. She is convinced the health care polio frontline workers provide between campaigns provides benefits beyond the surface value – it establishes trust. “When we bring different things to the mothers, it helps the community live better and even accept us more, because we are giving more than just polio vaccines.”
Between polio vaccination campaigns, mobilizers like Lidia track pregnant women and ensure the mothers undertake four Ante-Natal Care visits, including immunization against tetanus. They advise mothers-to-be to give birth at the government health facility, provide them with the first dose of oral polio vaccine, facilitate birth registration and connect them to the routine immunization system. In houses and at monthly community meetings, the mobilizers also provide information on exclusive breastfeeding, hand washing, the benefits of Insecticide Treated Bed Nets, Routine Immunization and the polio vaccination campaign.
Ante-Natal Care
VCM Charity Ogwuche stands before the mothers at the health centre and peels over the pages of a colourful flip book. “Breastmilk builds the soldiers inside your child,” she shouts. “It will save you money. You don’t need to find food for your child to eat. You don’t need to find water: 80% of breastmilk is water. It will protect your child.”
Adiza, a young mother holding her first child, Musa, carries a routine immunization card including messaging on breast feeding and birth registration. “Aminatu talked to me about antenatal care. She asked me to get the tetanus shot, and today she has brought me here to receive routine immunization for my baby. I am really grateful. If she wasn’t here I wouldn’t be here. I wouldn’t know about it. She is the only one who tells me about this.”
Charity is proud of her work. “The women are so familiar with me, it makes me happy. They call me Aunty. I provide most of the health information for them. Really there is no other in our community. They are very young mothers and they need me.”
Birth registration
Aminatu Zubairu, in her trademark blue VCM shawl, displays the birth registration cards she will carry back to mothers in her village. @ UNICEF/R.Curtis
Every Tuesday is birth registration day. Once, hardly a soul turned up to register their newborns, but today, a long line of VCMs are standing clutching handfuls of registration forms, waiting to register the newborns within their catchment area.
Aminatu Zubairu, wrapped in the trademark blue hijab of the VCM, explains how all social mobilizers must come from their own community, and how that familiarity breeds the trust that has enabled her to register hundreds of children in her area. “I go to their houses and ask if they had the birth registration. If they say no I take all the information. Now I will register them and get the certificate of birth and carry it to their house to give back to them. In a month I can do 50 of these. This year there are plenty of newborns.”
Danboyi Juma, the district’s Birth Registration Officer, believes birth registrations have increased by 95% since VCMs assumed responsibility for the service. “They are helping us so much because they go house to house,” he says. “They have increased the number of birth registrations in this area by so much – oh, that’s sure.”
Routine Immunization
Jamila and her baby Arjera, who was vaccinated for the first time, following the persistent efforts of her VCM Rashida Murtala. @ UNICEF/R.Curtis
Despite stifling heat, on this Tuesday, there are more than 50 mothers and several fathers sitting on benches, waiting for their turn to have their babies vaccinated. More than 80% of them carry the cardboard cards given to them by VCMs to remind them their baby is scheduled for routine immunization.
Jamila, a young mother wrapped in a white shawl around her orange head-dress, is bringing her six-month-old baby Arjera to be vaccinated for the first time. Her VCM, Rashida Murtala, badgered her for months before Jamila finally accepted.
“Oh, she refused and refused,” Rashida says. “She’s fed up with me visiting. I went to see her today and finally she followed me. I’m happy to see her here.”
Jamila smiles. “She has been disturbing me every day that I have to take this child to the health centre. I know she’s right, so today I followed her.”
Priscilla Francis, the Routine Immunization provider who vaccinates young Arjera, believes VCMs are key to strong vaccination coverage in Chikun district. “There is much improvement in attendance since the VCMs started. They are well trained. They do a good job of informing mothers to come. If we lost them we would lose our clients – no doubt. When they come we tell them to come back, but no one else is going to their house to bring them.”
Hassana Ibrahim, a Volunteer Ward Supervisor, knows her mobilizers are important. “I have 10 VCMs, five in this ward. Non-compliance used to be a big problem but not now. Now with the routine immunization, the community sees they are providing a package of health care and now people comply with the polio vaccination.”
Naming ceremonies
New mother Naima with newly named Jibrin and her friends and family was happy to welcome her VCM to immunize children at her son’s naming ceremony: “She is my friend.” @ UNICEF/R.Curtis
Following the routine immunization session, the VCMs fan out to attend the naming ceremonies of newborns in their catchment area. Naming ceremonies provide an important opportunity to vaccinate lots of children, as family gathers around to celebrate. On average, they attend 10 naming ceremonies a month. Today we visit Naima, the young mother of a 7-day-old boy, who as per tradition has just been named Jibrin by his grandfather. Naima is surrounded by her sisters, family and village friends, who cook and eat with them, and their 68 children under five. Within minutes, the VCM has walked among them all, vaccinating them as they sit waiting with their mouths open to the sky like little birds.
Naima is happy to see her trusted VCM, and encourages her to vaccinate the children. “I know her well,” she says. “She taught me to go for ante-natal care, to deliver at the hospital and to go for immunization. She is the only health care worker who comes. We are from the same community. She is my friend.”
A child is given two drops of the oral polio vaccine to protect them against polio in Lao PDR. @ WHO/ R. Tangermann
As of May 2017, Lao People’s Democratic Republic (PDR) is officially no longer infected with circulating-vaccine derived polio virus (cVDPV), according to the International Health Regulations (IHR) Emergency Committee on the international spread of poliovirus.
After an outbreak of circulating vaccine derived poliovirus type 1 (cVDPV1) in 2015 and 2016, the country has now been without cases for over 12 months, with the last case reported in January 2016.
Since the outbreak, WHO, UNICEF and other partners have supported Lao PDR in their outbreak response efforts. This included support for multiple rounds of supplementary immunization activities, expanded social mobilization to raise community awareness and desire to vaccinate, and enhanced acute flaccid paralysis (AFP) surveillance activities to find the virus.
Ending the outbreak
In general, an outbreak is considered over following a period of 12 months without the detection of any new polioviruses from an AFP case, a healthy individual or an environmental sample, and with confirmed certification-standard disease surveillance.
An outbreak response assessment (OBRA) team visited the country in March to confirm the virus had, in fact, been stopped. The team, made up of representatives from WHO, UNICEF, and the US Centres for Disease Control and Prevention, concluded that all evidence suggested the outbreak had been successfully stopped, with all immunity and surveillance indicators meeting rigorous international standards.
At the OBRA meeting, development partners commended the Ministry of Health on its leadership in response to the outbreak. Tremendous progress was made in micro-planning, cold chain and vaccine storage at all levels, as well as nationwide social mobilization and strengthening of AFP surveillance.
Deputy Health Minister of Lao PDR, Dr. Phouthone Muangpak, noted that the Ministry of Health and local authorities need to take ownership to further improve surveillance sensitivity in the country.
Lessons from the outbreak response
Both adults and children were vaccinated through the response to make up for low levels of vaccination over an extended period of time. @ WHO /R. Tangermann
A challenging landscape and diverse ethnic communities added to the challenge of running vaccination schedules in Lao PDR. As the outbreak occurred in an area where vaccination levels had been very low for an extended period of time, campaigns were extended to reach all children under 15, and in some cases even adults. The nuanced cultural, lingual, religious and social needs of the Hmong community called for a response tailored to local needs, especially building an awareness of the importance of vaccines. Impromptu cinemas were set up against bamboo walls to pull in interested families and share information about vaccination campaigns after dark.
Meeting International Health Regulations standards
Information and conclusions from OBRAs are taken into consideration by the IHR Emergency Committee on the Spread of Poliovirus, resulting in this instance in the IHR classification as a state no longer infected with cVDPV1.
Despite being classified as polio-free, the IHR Emergency Committee still categorizes Lao PDR as vulnerable to reinfection. The country must continue to strengthen routine immunization to ensure all children are protected from any polio outbreak that may happen in the future and to maintain the improvements in disease surveillance, to ensure the virus is detected and stopped wherever it may emerge.
