During a visit to WHO’s Regional Office for Africa (AFRO) in Brazzaville by a delegation of officials from the Korea International Cooperation Agency (KOICA), delegates received a first-hand demonstration of the ‘real-time’ surveillance system for polio on the continent.
Dr Pascal Mkanda, head of AFRO’s polio eradication effort and his team demonstrated the newly-launched and real-time innovative mobile surveillance system, aimed at strengthening polio surveillance across the continent. Thousands of medical officers and health officers across the continent are dispatched to health clinics to actively search for cases of acute flaccid paralysis (i.e children with polio-like symptoms). Results of visits are communicated right back from the field level to the regional office in real time, via mobile phone technology.
This system is providing valuable and real-time evidence of poliovirus circulation, and helps drive strategic implementation. At the same time, the system is now being used to conduct active surveillance for other diseases, including cholera, NNT, measles, HIV and yellow fever, allowing for rapid response.
Developed in close coordination with the Bill & Melinda Gates Foundation, and are part of ongoing efforts to fill remaining subnational surveillance gaps, particularly in the lead-up to potential regional certification of wild poliovirus eradication (which could occur as early as late 2019/early 2020).
Africa’s polio eradication effort is generally supported by key private and public sector partners, including Rotary International. The Republic of Korea is a key partner in the effort, having contributed more than US$6 million to the effort, directly through KOICA. Support has been strategically allocated to supporting outbreak response and strengthening disease surveillance, and this visit builds further on Korea’s support to the global eradication effort. Strong disease surveillance is the underlying key strategic strategy, enabling rapid outbreak response as needed.
WHO Director-General Dr Tedros Adhanom Ghebreyesus opened the Organization’s Executive Board (EB) on 24 January with a report from his first visit of the year, to the polio endemic countries of Afghanistan and Pakistan: “This year I have taken over as chair of the Polio Oversight Board. That’s why my first trip of the new year was to Afghanistan and Pakistan. These are the two countries that are the last frontiers of wild poliovirus. We are so close to ridding humanity of this disease, and I am personally committed to ensuring that we do. I was really impressed by the commitment of the governments of Afghanistan and Pakistan.”
The Executive Board, comprised of 34 Member States’ designated experts in the field of health, convened in Geneva in late January to discuss a wide-ranging agenda on the most pressing and urgent health concerns of our times, including the urgency to rev up efforts in this last mile of polio eradication efforts.
The EB was encouraged by the progress achieved through the Endgame Strategic Plan 2013-2018, which has led the world to the brink of polio eradication and laid the groundwork for the new strategy – the Global Polio Eradication Initiative Strategic Plan 2019-2023. The new strategy will aim to sharpen the tools and tactics that led to the global progress in bringing down the case load from 350 000 annual wild polio virus cases in 1988 to only 33 cases in 2018. Success in the coming years will hinge on harnessing renewed financial and political support to fully implement the plan at all levels, with our one clear goal in sight: reach every last child with the polio vaccine to end this disease once and for all.
In a time of many global challenges and priorities, the coming year will require more than ever a singular commitment from the governments and partners as we near zero. On the sidelines of the EB, the DG held a stakeholder consultation to ensure that the 2019-2023 Strategic Plan reflects a transparent and inclusive stakeholder participation. The DG stressed the need for strengthened and systematic collaboration between partners, health, and non-health actors across cross-cutting areas of management, research and financing activities for polio eradication. Given that polio eradication effort continues to be a global priority, one of the salient features of the consultation was a renewed commitment to transparent long-term budgets for eradication efforts, including key post-certification costs such as stockpiles and inactivated polio vaccine to help protect more than 430 million children from polio each year.
“In a time of many global challenges and priorities, the coming year will require more than ever a singular commitment from the governments and partners as we near zero.”
Voicing similar sentiments earlier, Chairs of the effort’s main advisory bodies issued an extraordinary joint statement, urging all stakeholders, partners, countries, and individuals to strengthen their collective resolve to seeing polio fully eradicated for good. Polio continues to be a global health risk as confirmed at the end of last year, the Emergency Committee reiterated its advice that polio remains a public health emergency of international concern.
Polio resources for over three decades have helped reduce the number of endemic countries from 135 down to only 3 (Pakistan, Afghanistan, and Nigeria), eradicate polio from some of the most challenging areas in the world, and continue to enable countries around the world in advancing other national health goals.
With the continued commitment of all donors and partners, 2019 may very well become the decisive year when we finally stop wild polio virus transmission in Afghanistan and Pakistan.
The Endgame Plan through 2018 brought the world another year closer to being polio-free. While we had hoped to be finished by now, 2018 set the tone for the new strategic plan, building on the lessons learned and mapping out a certification strategy by 2023. 2018 was also marked by expanded efforts to reach children with vaccines, the launch of innovative tools and strategies, critical policy decisions and renewed donor commitment to the fight.
Circulation of wild poliovirus (WPV) continues in the common epidemiological block in Afghanistan and Pakistan. However, both countries steadily worked to improve the quality of their vaccination campaigns in 2018 through National Emergency Action Plans, with a particular focus on closing any immunity gaps to put the countries on track to successfully stop WPV in the near future. Given the priority on polio eradication, WHO Director General, WHO Regional Director for the Eastern Mediterranean and President, Global Development at Bill & Melinda Gates Foundation started off the new year with a four-day visit to meet the heads of state and have a first-hand experience of the on-the-ground eradication efforts in both the countries.
In August, Nigeria marked two years since detecting any WPV. With continuing improvements in access to the country’s northeast, as well as efforts to strengthen surveillance and routine immunization, the entire African region may be eligible for being certified WPV-free as early as late this year or early 2020. What’s more, the world has not detected type 3 WPV since 2012 and the strain could be certified eradicated sometime this year.
Program innovation
The programme is constantly developing new ways to more effectively track the virus, vaccinate more children and harness new tools to help end the disease for good.
In Nigeria and the surrounding region, health workers launched new tools to enable faster, more comprehensive disease surveillance. e-Surve, a smartphone app, guides officers through conversations with local health officials, offering prompts on how to identify and report suspected cases of disease. Then, with the touch of a button, responses are submitted to a central database where health officials can analyze and track outbreaks across multiple districts in real-time.
Beyond surveillance, health workers worked tirelessly to bring the polio vaccine to the remote communities of Lake Chad. Dotted with hundreds of small islands, the lake is one of the most challenging places on earth to deliver health services. Vaccinators must travel by boat on multi-day trips to deliver polio vaccines to isolated island villages, using solar-powered refrigerators to keep their precious cargo cool. In 2018, vaccination campaigns on the lake reached thousands of children for the first time – children who would otherwise have gone unprotected.
The programme also took important steps in developing new tools including, novel oral polio vaccine (nOPV), if studies show to be successful, could provide a safer form of OPV that provides the same level of protection without the small risk of vaccine-derived polio in under-immunized populations.
Battling circulating vaccine-derived poliovirus
In 2018, the Democratic Republic of the Congo, Niger, Nigeria, Papua New Guinea, Kenya, Somalia and Mozambique experienced outbreaks of circulating vaccine-derived polio (cVDPV). Although these cases are still rare – and only happen in places where immunity is low. The polio eradication initiative has two urgent tasks: eradicate WPV quickly as possible and stop the use of OPV globally, which in tandem will prevent new cVDPV strains from cropping up.
The program uses the same proven strategies for stopping wild polio in responding to cVDPV cases. These strategies, coupled with the rapid mobilization of resources on the ground, can bring outbreaks under control.
In December, an international group of public health experts determined that the 2017 cVDPV2 outbreak in Syria has been successfully stopped. This news follows 18 months of intensive vaccination and surveillance efforts led by the GPEI and local partners in conflict-affected, previously inaccessible areas. In Papua New Guinea, the programme carried out 100 days of emergency response this past summer and is continuing to vaccinate and expand surveillance across the country.
Bringing an end to ongoing cVDPV outbreaks remains an urgent priority for the program in 2019.
New policy decisions
At the World Health Assembly in May, Member States adopted a landmark resolution on poliovirus containment to help accelerate progress in this field and ensure that poliovirus materials are appropriately contained under strict biosafety and biosecurity handling and storage conditions. The programme also finalized a comprehensive Post-Certification Strategy that specifies the global, technical standards for containment, vaccination and surveillance activities that will be essential to maintaining a polio-free world in the decade following certification.
Recognizing the ongoing challenge posed by cVDPVs, the Global Commission for the Certification of Poliomyelitis Eradication (GCC) met in November and recommended an updated process for declaring the world polio-free. This plan will start with the certification of WPV3 eradication, followed by WPV1, and include a separate independent process to validate the absence of vaccine-derived polio.
Comprised of members, advisers, and invited Member States, the 19th IHR Emergency Committee met in November. The Committee unanimously agreed that poliovirus continues to be a global emergency and complacency at this stage could become the biggest hindrance. “We have the tools, we need to focus on what works, we need to get to every child,” commented Prof. Helen Rees, Chairperson of the Committee. “The reality is that there is no reason why we should not be able to finish this job, but we have to keep at it.” “We have achieved eradication of a disease once before, with smallpox,” Rees concluded. “The world is a much better place without smallpox. It’s now more urgent than ever that we redouble our efforts and finish this job once and for all as well.”
In 2018, the GPEI took major steps in adopting a more gender-responsive approach and strengthening gender mainstreaming across its interventions. The GPEI Gender Technical Brief highlighted the programme’s commitment to gender equality and included a thorough analysis of various gender-related barriers to immunization, surveillance and communication.
The programme introduced new gender-sensitive indicators to ensure that girls and boys are equally reached with polio vaccines, to track the timeliness of disease surveillance for girls and boys, and to monitor the rate of women’s participation as frontline workers in the endemic countries. The GPEI continues to regularly collect and analyze sex-disaggregated data and conduct gender analysis to further strengthen the reach and effectiveness of vaccination campaigns.
Donor countries made new financial contributions to the programme in 2018. Polio-affected countries also demonstrated continued political commitment to eradication efforts. The Democratic Republic of the Congo signed the Kinshasa Declaration committing to improve vaccination coverage rates in sixteen provinces throughout the country, and Nigeria approved a $150 million loan from the World Bank to scale up immunization services and end polio.
Looking ahead: 2019 and beyond
Over the last five years, the programme has been guided by the 2013-2018 Polio Eradication & Endgame Strategic Plan, helping to bring the world to the brink of polio eradication. This spring, the programme will finalize a new strategy –GPEI Strategic Plan 2019-2023– which will aim to sharpen the tools and tactics that led to this incredible progress. In 2019, the GPEI will also launch its first-ever Gender Strategy to further guide its gender-responsive programming and to increase women’s meaningful and equal participation at all levels of the programme.
Success in the coming years will hinge on harnessing renewed financial and political support to fully implement the plan at all levels, with our one clear goal in sight: reach every last child with the polio vaccine to end this disease once and for all. Echoing similar sentiments, Chairs of the effort’s main advisory bodies issued an extraordinary joint statement, urging all to step up their performance to end polio. 2019 may very well be the watershed year that the world will finally eradicate polio, thanks to the global expertise and experience over 3 decades.
A new circulating vaccine-derived poliovirus type 2 (cVDPV2) outbreak has been confirmed in Mozambique. Two genetically-linked circulating vaccine-derived poliovirus type 2 (cVDPV2) isolates were detected from an acute flaccid paralysis (AFP) case (with an onset of paralysis on 21 October 2018, in a six-year old girl with no history of vaccination, from Molumbo district, Zambézia province), and a community contact of the case.
As polio is a highly infectious disease which transmits rapidly, there is potential for the outbreak to spread to other children across the country, or even into neighbouring countries, unless swift action is taken. Global Polio Eradication Initiative and partners are working with country counterparts to support the local public health authorities in conducting a field investigation (clinical, epidemiological and immunological) and thorough risk assessment to discuss planning and implementation of immunization and outbreak response.
In January 2017, a single VDPV2 virus had been isolated from a 5-year old boy with AFP, also from Zambézia province. Outbreak response was conducted in the first half of 2017 with monovalent oral polio vaccine type 2 (mOPV2).
Read our Mozambique country page to see information on cases, surveillance and response to the developing outbreak.
In an extraordinary joint statement by the Chairs of the main independent, advisory and oversight committees of the GPEI, the Chairs urge everyone involved in polio eradication to ensure polio will finally be assigned to the history books by 2023. The authors are the chairs of the Strategic Advisory Group of Experts on immunization (SAGE), the Independent Monitoring Board, the Emergency Committee of the International Health Regulations (IHR) Regarding International Spread of Poliovirus and the Global Commission for the Certification of the Eradication of Poliomyelitis (GCC).
The Endgame Plan through 2018 has brought the world to the brink of being polio-free. A new Strategic Plan 2019-2023 aims to build on the lessons learned since 2013.
The joint statement urges everyone involved in the effort to find ways to excel in their roles. If this happens, the statement continues, success will follow. But otherwise, come 2023, the world will find itself exactly where it is today: tantalizingly close. But in an eradication effort, tantalizingly close is not good enough.
The statement therefore issues an impassioned plea to everyone to dedicate themselves to one clear objective: to reach that very last child with polio vaccine. By excelling in our roles. It means stepping up the level of performance even further. It means using the proven tools of eradication and building blocks that have been established in parts of the world that have been free of polio for years.
The Chairs remind us that as a global community, we have stood where we stand today once before, with smallpox. And we achieved the eradication of smallpox. And the world is a much better place without smallpox.
So, let us make the world again a better place. Together. Let us eradicate polio.
Since polio was confirmed in Somalia in late 2017, health authorities have led a complex response to twin outbreaks of circulating vaccine-derived poliovirus type 2 and type 3 (cVDPV2 and cVDPV3), paying special attention to high-risk populations: nomads, internally displaced people (IDPs), and people living in peri-urban slums and rural areas.
So far, five of Somalia’s 12 infected children are from nomadic communities, and another four are from internally displaced families living in urban areas. To boost immunization among eligible children in these populations, vaccination activities have placed a special focus on reaching these communities.
Somalia has a rich culture of people leading pastoral lifestyles, raising livestock and moving with them as the seasons and the weather change. Nomadism has a long history in Somalia and nomads have a special place in Somali society: almost a third of Somalia’s people are nomads. However, they do not observe formal international borders – just like the poliovirus. For health workers, this context poses a significant challenge: How can you be sure you have vaccinated every last child when so many children are on the move?
For health workers, this means searching for polio symptoms in more than 900 health facilities across the country, as well as nutritional centres, camps for IDPs, and key sites along Somalia’s borders. At transit points, along borders and at water collection points, polio teams work to vaccinate children moving in and out of areas experiencing conflict or with limited access to health services. In high-risk areas, the Somali Government, WHO and UNICEF hire local vaccinators – people known and trusted by their communities – and when additional security is necessary, polio partners provide it.
Gaining high-level political goodwill
Even in an emergency, cross-border collaboration is not always easy to come by. In the Horn of Africa outbreak, regional collaboration moved into high gear in September, when health ministers from across the region and representatives from the Intergovernmental Authority on Development (IGAD) countries came together in the Kenyan town of Garissa to reiterate their commitment to ending polio.
One of the event’s key messages was around the risks posed by the easy and frequent mobility of communities across borders. Kenya’s national polio immunization ambassador, former UN Person of the Year and polio survivor, Harold Kipchumba, spoke directly to the pastoral communities in the region.
Kipchumba highlighted their focus on vaccinating animals, and urged parents in these communities to use the same vigour to vaccinate their children against polio, so they are able to serve as future herders for their families.
A regional response to support high-risk populations
The Technical Advisory Group, an independent body of experts that monitors outbreaks and offers guidance, recommended that countries in the region strengthen their coordination. In response, the Horn of Africa Coordination Unit coordinates joint responses among HoA countries – work that includes monitoring current outbreaks, and collaboratively planning, mapping, conducting immunization campaigns and communicating with various audiences. This ensures that countries work together in partnership rather than in silos, viewing the outbreak as one epidemiological block.
At regional and district levels, teams have spent the last few months building records of every settlement in their area, by lifestyle (nomad, IDP, peri-urban slums, rural). The highest priority: locating special populations – internally displaced persons, refugees, nomadic families, people living in informal settlements in urban areas and communities living in access-compromised areas – in order to reach them with vital polio vaccine.
A vital step in reaching more children, particularly those on the move, has been to move away from paper records and use electronic tools to collect data on children reached and missed during campaigns. This gives data specialists and decision-makers timely, accurate information, allowing them to analyze data in real time and flag areas with where high numbers of children are missed, so teams can revisit these households the following day.
Getting vaccines to the doorstep is not the only challenge for polio eradication teams in Somalia. Parents and caregivers also need information to ensure their children are vaccinated – something Kipchumba spoke to. On rare occasions, vaccinators meet families unconvinced of the need for vaccinations, particularly when the family has a newborn child or a sick child. In the lead up to every campaign, teams of social mobilizers, sometimes joined by influential Islamic leaders or scholars, visit communities to alert them of dates of polio immunization campaigns and the benefits of vaccination. Here, too, special attention is paid to nomadic communities, as polio teams liaise with elders from these communities in order to learn more about these communities and their needs, and to inform community members in appropriate ways about immunization dates and benefits of vaccination.
Jean-Marc Olivé, Chairman of the Technical Advisory Group (TAG), addressing the participants. WHO/L.Dore
From the 27 – 29 November, the Technical Advisory Group (TAG) met in Nairobi to review the outbreak response in Somalia, Ethiopia and Kenya, and preparedness measures in Yemen, Uganda, Tanzania, Sudan, South Sudan and Djibouti in case of international spread.
Jean-Marc Olivé, Chairman of the TAG, spoke to WHO about the recommendations made to address the challenges faced by countries, his hopes for eradication and his life in the programme.
What are the main challenges faced by the countries of the Horn of Africa in the drive to stop the outbreaks?
The major challenges have been the same for a long time – like, the issue of inaccessibility due to conflict and humanitarian crises. If we cannot access populations then it is very difficult to cover them properly during vaccination campaigns and so it is hard to stop poliovirus transmission. This is not a programme-related issue, it is a political one. Until we have access, it will be very difficult to make it.
I have said it before and I will say it again: access is success.
I think the second challenge is – and this is one of the reasons why we still have the transmission of circulating vaccine-derived poliovirus in the Horn of Africa – is persistently low vaccination coverage. There are still remote areas, rural areas, heavily populated urban areas where routine immunization has really never been able to offer the same services and coverage as in more accessible areas with fewer challenges.
Since last TAG meeting in the Horn of Africa, what progress have you seen?
I have seen the capacity really building up in the Horn of Africa. The biggest shift is that we now have collected a lot of data about surveillance, about immunization coverage, vaccination campaigns, communications, and also data by the type of population we are reaching and not reaching. What is missing now, and what was the focus of this TAG, is to use this data to monitor progress and orient the programme toward those difficult areas. We have to use the data to tell us a story about what is happening and what to do next.
What were the most important recommendations made by the TAG this time around?
I think the most important is to follow the plan that has been set up for the three outbreak countries to interrupt transmission. Secondly, the countries that have not been yet infected by the virus should have a preparedness plan to ensure that if there are any problems they can move swiftly into action.
The Horn of Africa has seen several outbreaks in the past. What must be done to break the pattern and keep the region polio-free once and for all?
They have identified the problems. They just have to implement the solutions! We need to be sharing and analysing knowledge, information, and building capacity at the local level to ensure that we are on the right track to success.
I say to all the countries, go to the areas where you know you have problems and engage local communities and health authorities. Most of the issues can only be addressed at local levels by local people who understand the situation. Help them to do that, and monitor progress.
This is your thirteenth TAG; what have you learned about the process of international review?
First, you have to work as one team in support of National Teams, all agencies together. There cannot be any agency that claims, “This is us, we are doing that, this is WHO, this is UNICEF…”; this is the Global Polio Eradication Initiative, working together with all committed partners, using the competencies that each of them has. If you don’t address issues comprehensively as one, effective interventions are much more difficult to implement.
How long have you worked on polio eradication? What lessons have you learnt from this experience?
I was involved in the eradication of polio in the Americas. We started in 1985. We did it from A to Z in 9 years. We had very good leadership, commitment from the Government and partners, clear guidelines, very strong monitoring, and solid and reactive support to the field. Then we moved on into measles elimination with the same engagement – and the same results.
Because I have seen it happen, I know it is feasible. I think this is what keeps me so motivated. Polio eradication is a fantastic initiative. If we focus on weak and problematic areas within countries, if Governments and Partners continue to be engaged, we will make it. It’s going to be tough, mainly because of inaccessibility.
Is there anything else you want to add?
The people working in this programme, particularly local people working in the countries are amazing. They are the basis of any future public health intervention. In Pakistan and Afghanistan, woman are more and more playing an important role. This is an incredible advancement and an incredible contribution that was previously thought to be impossible.
But nothing is impossible – you just push, go slowly and constructively you will manage to gain ground over the virus.
In the wake of a polio outbreak confirmed on June 26 2018, the Government of Papua New Guinea declared polio a national health emergency. It was imperative that all children under the age of five be vaccinated, even those living in the most inaccessible regions of the country.
As part of the outbreak response, a team from Madang Provincial Health Authority, supported by WHO, travelled for over half a day by road and helicopter to reach the Hagahai people who live in the highlands of Madang province in Papua New Guinea, which is one of the most geographically isolated places in the world.
Ever wondered what it is like to be on the forefront of the fight against polio? Watch and learn how the team made their way to the remote mountain top to deliver vaccines.
Participants of the Africa Regional Commission for the Certification of poliomyelitis eradication (ARCC) in Nairobi, Kenya, from 12-16 November 2018. WHO AFRO/2018
Efforts to end polio across the WHO African Region came under the microscope at a meeting of the Africa Regional Commission for the Certification of poliomyelitis eradication (ARCC) held in Nairobi, Kenya, from 12 – 16 November 2018.
Seven countries (Cameroon, Nigeria, Guinea-Bissau, the Central African Republic, South Sudan Equatorial Guinea and South Africa) made presentations to the ARCC on their efforts to eradicate polio, presenting evidence on their level of confidence that there is no wild polio in their borders, the strength of their surveillance systems, vaccination coverage, containment measures and outbreak preparedness. Kenya, the host country, alongside the Democratic Republic of the Congo and Namibia, presented updated reports on their efforts to maintain their wild poliovirus- free status.
Professor Rose Leke, Chair of the ARCC, speaking to the participants. WHO AFRO/2018
A total of 109 participants including partners of the Global Polio Eradication Initiative, non-governmental organisations and Health Ministries were in attendance to hear the reports.
The ARCC is an independent body appointed in 1998 by the WHO Regional Director for Africa to oversee the certification and containment processes in the region. It is the only body with the power to certify the Africa region free from wild polio. The African Regional Office and the Eastern Mediterranean Regional Office are the two WHO regions globally that remain to be certified free from wild poliovirus.
Professor Rose Leke, Chair of the ARCC, reflected on the importance of this meeting: “The rich, open and in-depth discussions held this week with each of the ten countries will allow these countries to strengthen ongoing efforts to further improve the quality of surveillance and routine immunization including in security compromised and hard to reach areas as well as in special populations such as nomads, refugees and internally displaced persons.”
Recommendations made
The ARCC, made up of 16 health experts, made recommendations to the ten countries. They noted with concern that outbreaks of circulating vaccine-derived poliovirus in the Democratic Republic of Congo, Kenya, Niger, Nigeria and Somalia were symptoms of low population immunity and varied quality vaccination campaigns. These countries were encouraged to conduct a high-quality outbreak response. Neighbouring countries were advised that they should assess the risk of spread or outbreaks within their borders. Low population immunity was identified as a significant concern, given the risk further emergences of vaccine-derived poliovirus strains.
Inaccessibility and insecurity were also flagged as a significant concern, with limits to the number of children who were being reached with polio vaccines and the coverage of surveillance efforts in affected areas. Countries were advised to scale up strategies that have proved in the past to be effective in the face of these challenges and to build relationships with civil society and humanitarian organisations who could provide immunization services.
Recommendations were made across the board to address chronic surveillance gaps, especially related to factors affecting the quality and transportation of stool samples reaching the laboratory for testing. The introduction of innovative technologies was commended, and a call was made for countries to expand their use, especially in inaccessible and hard-to-reach areas. Countries were also encouraged to accelerate their progress towards poliovirus containment.
In addition, all of the presenting countries received specific recommendations to support their efforts towards improving surveillance, immunization and containment in order to achieve a level that would give the ARCC the confidence needed to declare the region to have eradicated polio.
Dr Rudi Eggers, WHO Kenya Country Representative, said: “I commend all the countries on the efforts that have gone into achieving the results presented in their reports. It gives us hope that eradication is achievable in the midst of the unique challenges faced by all countries. We appeal to all the countries to fully implement all ARCC recommendations.”
Polio eradication efforts in Kenya
Dr Jackson Kioko, Director of Medical Services, the Kenyan Ministry of Health, said: “Kenya has worked hard to rid the country of wild poliovirus, and we will continue to do so until Africa and the world are certified polio-free.”
While Nigeria remains the only country in Africa to be endemic for wild poliovirus, responses are underway to stop outbreaks of circulating vaccine-derived poliovirus in the Democratic Republic of the Congo, Kenya, Niger and Somalia.
The circulating vaccine-derived poliovirus in Kenya was found in a sewage sample in Eastleigh, Nairobi, in March 2018, closely related to viruses found in Somalia. The Ministry Health, with the support of WHO, UNICEF and partners, has done several polio vaccination campaigns since then to ensure that every child’s immunity is fully built and no virus can infect them.
One of the most challenging aspects of polio eradication is timely disease surveillance: knowing where the poliovirus is lurking, so we can roll out targeted immunization activities quickly and effectively. With new tools, eradicators are getting the information they need in real time.
For the past three decades, there have been two approaches to find polio: passive and active surveillance. Passive surveillance involves health workers routinely reporting cases of acute flaccid paralysis (AFP) as they find them in health facilities. Active surveillance takes place where there is a higher level of concern that polio might be present. Experts go to hospitals, clinics and even community healers to search out cases of AFP. This approach, often called active case searching, reduces the risk that cases are missed due to human error – people forgetting to report AFP or health care workers or community healers not knowing that they need to report the case.
However, in active case search the key steps of detecting, reporting and investigating the case might not always be happening consistently in all health facilities. There can be a delay of two months or more between a child being paralyzed, experts finding out and alerting the polio surveillance system. In an outbreak setting, this can be long enough for the virus to infect and paralyze more children, moving from one area to another. There was an obvious need to make the surveillance system even more reliable and time-sensitive to ensure the polio surveillance framework is as robust as ever.
In order to ensure that active search is conducted timely with real time evidence the polio surveillance systems in Kenya, Ethiopia, Uganda, Eritrea, South Sudan, and Tanzania have adopted an easy-to-use, portable disease surveillance monitoring tool. It delivers unprecedented accuracy across huge areas. The best bit? Most people already have the basic component in their pockets: their mobile phones.
The tool is known as Integrated Surveillance and Routine Immunization Supervision. The idea is simple: surveillance officers use an app on their mobile phones to document active case searching as it happens, by tagging the location of every healthcare facility they visit and check.
“This provides real-time monitoring in the field. Previously, officers would report having done active case searching after the fact – like, ‘I was here and I did x, y, z’. But this is vulnerable to human error in remembering accurately. Sometimes, before we introduced it, someone would go to a distant, rural area and not be able to pinpoint their location on a map for others to follow up. Now, we are sure we are not missing things.” said Christopher Kamugisha, WHO’s Horn of Africa Outbreak Coordinator.
The app guides surveillance officers through a checklist (questions cover resources available at the facility, polio, measles and routine immunization) that they fill out and send then and there, using their mobile phones, even without an internet connection. It can also provide on-the-spot data analysis so that the surveillance officer can take immediate, evidence-based action.
With a swipe of the screen, users marry surveillance findings to the facility’s location and send the information to a centrally generated map. This gives staff at the national level a clearer picture of where surveillance is working and where it is not, including data on where possible polio cases are, so they know where to direct extra resources.
It also means health workers actively searching for AFP do not have to spend extra time ensuring the information gathered in the field is being shared with the right people for them to take action. For the ongoing outbreak of circulating vaccine-derived poliovirus in the Horn of Africa, this means better disease surveillance – and a better chance to protect children against polio.
After more than 25 years on the hunt for polio, it’s easier to list the things the World Health Organization’s Chris Maher hasn’t seen than the things he has. He began his career with WHO five years after the global health community vowed to eradicate polio, which was then found in over a hundred countries. Since then, Maher has progressed to spearhead on-the-ground operations for the global polio eradication initiative, a partnership that has seen the disease beaten back by 99%. In a ceremony in May 2018, the Australian Government awarded him the Order of Australia, recognizing his immense contributions to the fight against a disease that has gone from paralyzing more than 350 000 children every year in 1988, to fewer than 22 cases worldwide today.
In 1993, Maher had several years of experience in public health, but none in polio-endemic countries. “I don’t think I’d ever seen an active polio case,” he recalled. Upon joining the WHO immunization team in a region that spanned from Mongolia to the Pacific Islands, polio was suddenly at the top of his agenda.
Maher and his colleagues worked as disease detectives, stalking the wild poliovirus through hard-to-reach communities in south-east Asia. From immunizing small communities on the Pacific Islands to taking on massive campaigns targeting millions of children in China, the complexity made his head spin.
The Philippines was the first country to go polio-free on Maher’s watch, seeing its last case that year.
Tracking unimmunized children through a population maze
It was here that Maher came face to face with polio’s full force of devastation, after a Khmer nurse at a district health clinic invited him home to meet her son. Maher and a colleague followed the woman to a house on stilts in a flooded field, where a quadriplegic teenager lay on a rattan bed.
“I realized very early on, he had polio. It was typical of the kind of polio that had no rehabilitation whatsoever”, Maher said.
Maher recalls being struck by the young man’s intelligence and his interest in the world, despite his isolation. As polio destroyed his body, his mother bestowed constant care.
“While she was working every day, somehow she had managed to look after him, to provide for him. As an example of motherly love I had never seen anything like that in my life.”
By the 2000s, it seemed that the most challenging country to eradicate polio was India. With its vast population and sprawling slums, in Maher’s words, “If technically we couldn’t do it, India would be the place we’d fail.”
Maher recalls Bihar, India as “the most extraordinary place that I ever worked on polio.” Eighty million people live in the state. Widespread illiteracy, a lack of infrastructure and high levels of population movement compounded the complexity of polio eradication there.
Despite the daunting challenges, Maher and his colleagues developed systematic plans to administer vaccine to all children across the country, taking a critical step in a journey to eradication. By the end of 2011, India was polio-free.
The risk of doing something different
At the start of the global push to eradicate polio, those involved in the operation would sometimes encounter skepticism from those who thought it simply couldn’t be done. The scale of the project, the size of activities and the time, energy, effort and cost involved had never been seen before.
Today, wild polio is endemic in three countries: Afghanistan, Pakistan and Nigeria. Immense efforts to battle the virus into extinction in these places are ongoing. Outbreaks of vaccine-derived polio virus (VDPV) add complexity to the end goal. Conflict, low routine immunization and population movement in the most at-risk areas complicate things further. Some of the approaches Maher and his eradication colleagues take to navigate these and myriad other challenges are astonishing – feats of logistics, diplomacy and detection that would not be out of place in a textbook.
“We’ve learned a lot about reaching every community, the most difficult access places, we’ve learned a lot about the importance about communicating what we are trying to achieve, to bring communities along with us in what we were doing. We’ve learned that there are certain things that are too big to do yourself. You need to build coalitions, you need partnerships to be able to make something happen, and the broader that partnership is, the greater the likelihood that you are going to be able to achieve something significant,” he said.
For Maher, the real risk is not that polio won’t be defeated, but that the world might one day forget how it was done. He sees the lessons learned during eradication as critical to the global health community.
“It would be a terrible pity if we lost that, if after eradication we kind of collectively heaved a sigh of relief and said, ‘well thank goodness that’s over, let’s do something else now’.”
Long distances, an ever-changing environment and minimal infrastructure are only a few of the barriers that the Lake Chad Task Team face as they conduct polio vaccination and surveillance activities in response to wild poliovirus detected in Nigeria in 2016. Overcoming these hurdles isn’t easy, but innovations ranging from geographical information systems (GIS) technology to boat-side vaccination are going far to ensure that every child is reached with lifesaving vaccines.
“I have heard of several more islands that have appeared since the dry season began”, says a local official as he discusses plans for a vaccination campaign about to be held near Bol, the main lake-side town in Chad. Unique climate conditions contribute to fluctuating water levels, and land is built up and destroyed within weeks. Now, new information is recorded using geographical information systems (GIS) technology, increasing the accuracy of regional vaccination plans, and ensuring that health workers visit every community with vaccines.
Travelling via speedboat reduces the journey time to islands from days, to hours. The team have invested in dedicated vessels for polio eradication activities, freeing them to travel at a moment’s notice to investigate a case of acute flaccid paralysis, or deliver vaccines. These stable, tough boats are specially chosen for long distance journeys.
Arriving on an island, the team supervise the activities of community-based vaccinators, ensuring that every child receives two drops of polio vaccine, and that their finger is stained purple to distinguish from those children not vaccinated. Vaccination activities happen in markets, villages, and nomadic settlements. Recruiting women and men to work in their local communities increases vaccine trust and acceptance. This is one of the key lessons learned over the course of the global polio eradication programme.
As temperatures soar, it’s critical that the polio vaccine is kept cool, an immense challenge in places where there is little or no electricity. A game changer for the team has been the introduction of dedicated vaccine refrigerators, some solar powered, painstakingly transported to and installed in several island villages. This means that vaccines are kept cold week to week, reducing the amount that must be transported by the team for each campaign, and limiting vaccine waste.
“Seeing how healthcare is so important, especially for mothers and children, I was inspired”, says Ahmad, an IT expert. During each campaign, he travels to distant villages to train local health workers on new technology to ensure high quality vaccination campaigns. Using specially-designed mobile phone applications, the team helps ensure that every household is visited by vaccinators.
“Can you tell me how to recognize the symptoms of a potential polio case?”, asks Dr Adele. She records the answer given by Robert, who is the coordinator of a small island health centre, on a mobile phone used as part of electronic disease surveillance (also known as Integrated Support Supervision). Conducting regular disease surveillance monitoring allows the task team to ensure that every case of acute flaccid paralysis has been properly reported. At the same time, they reinforce best practice for disease surveillance. This has the added benefit of ensuring that the team maintains a close relationship with health workers, many of whom live days’ journey from the nearest hospital.
Calling out in French, Arabic, and local dialects, the team speak to parents in passing boats and wooden pirogues, “We’re vaccinators, let us see your child’s finger mark!”. Drawing alongside every vessel as they journey to and from villages, the polio eradication team ensure that all travelling children have received two drops of the safe, effective oral polio vaccine. Families journeying across the lake are often headed to markets, where unvaccinated children could potentially spread the virus as they play. Before they continue on their way, the team diligently vaccinate every child without a stained finger.
No wild poliovirus has been detected since September 2016, after outbreak response began in the Lake Chad Basin. Vaccination rates are higher, whilst investment in polio eradication operations and infrastructure has helped to strengthen the wider health system in the lake. The tools and strategies of the Task Team are defeating polio, and leaving a strong legacy that other health programmes can follow.
At Malahang health clinic near Lae in Morobe Province, a health worker administers the oral polio vaccine (OPV) at a supplementary vaccination activity targeting children under five years. As part of the health ministry’s response to Papua New Guinea’s recent polio outbreak, four additional rounds of OPV vaccination are planned in Morobe, Madang and Eastern Highlands provinces.
An aerial view near Lae, Morobe Province. Papua New Guinea’s first polio outbreak since 1996 was first identified at Lae. Low immunization coverage rates, poor water sanitation and hygiene all contributed to cases of circulating vaccine-derived poliovirus (cVDPV).
Officer-in-charge Daisy Basa (centre) checks a child’s vaccination card at the Malahang Health Clinic. More than 2900 health workers, vaccinators and volunteers have been mobilized to vaccinate almost 300,000 children under five years old in Morobe, Madang and Eastern Highlands provinces.
Locals in traditional dress provide entertainment for families attending the supplementary vaccination sessions at Malahang health clinic. A national public awareness campaign has played a key part in the Government’s comprehensive response to the polio outbreak, helping to maximise vaccine coverage of children under five years old.
The National Department of Health (NDOH) is leading efforts to limit the spread of the disease, in collaboration with WHO, GPEI and other partners. As well as the supplementary vaccination sessions, the National Public Health Emergency plan includes strengthening surveillance systems for early virus detection. WHO is supporting this work, ensuring swift investigation of every case of suspected polio paralysis.
Vaccine supplies are loaded into the cold room at the Morobe Province supply store in Lae. Thanks to the quick response of the National Department of Health (NDOH), along with WHO and other partners, thousands of children have already been vaccinated. Efforts continue to detect and protect against the virus.
Nine hours away from the nearest large town, Dr Adele Daleke Lisi Aluma speaks to Robert, who manages a small health clinic on an island in the Lake Chad Basin. With paperwork spread around them, she listens carefully he responds to each question: Can you tell me how to recognise the symptoms of a potential polio case? Can you show me the records of any measles cases since I last visited?
In the past, she would be writing down details of the disease surveillance system in this village in a notebook, spending time later typing up her notes, and emailing them to a central database. Today, thanks to the introduction of an electronic surveillance approach for active surveillance and monitoring of disease outbreaks, she inputs Robert’s answers directly into an app, allowing for quick, accurate, and up-to-date data collection.
Hundreds of kilometres away in Nigeria, on the other side of the basin, surveillance officer Dr Namadi Lawal also feels the difference that innovative application-based technology has made to operations. For years, his employer, the National Primary Health Care Development Agency, depended on paper-based recording methods.
When the World Health Organization introduced the electronic surveillance (e-Surve) approach, Dr Namadi discovered he was receiving far more accurate information in real time, making his work to defeat the poliovirus more efficient.
“e-Surve is such a wonderful innovation. I can only imagine how much more accurate data I would have collected in a fast and effective manner if I had adopted this approach long time ago,” he says.
The e-Surve approach involves the use of a smartphone application to ensure that health workers know what symptoms they should be looking for and how to report suspected cases of vaccine-preventable disease.
After using the application to guide their conversations with health workers, disease surveillance and notification officers send the results of the questionnaire to a central database, where the data can be analysed and sorted by health district.
This is one way to keep track of an outbreak response that covers areas of five different countries, all with their own unique health challenges.
“This is remarkable progress as it shows where we can actually reach for surveillance”, said Dr Isaac Adewole, Nigeria’s Minister of Health, as he was presented with a dashboard of e-Surve during the recent opening ceremony of the African Regional Certification Commission in Nigeria.
New technology helps to reduce outbreak risk
This innovation is particularly important as when cases of disease are not properly reported, an outbreak can be in full swing before a country even realises that there is a problem.
Active disease surveillance, where officers physically go out to communities to speak to health staff and parents, is proven to increase case detection rates. There are hundreds of these frontline workers spread out across the Lake Chad Basin, each conducting multiple visits every month. Before mobile technology, the outcomes of these visits were cumbersome to track, time consuming to catalogue, and difficult to analyse for a prompt response.
Real-time reporting stems the spread of diseases
With e-Surve, governments and partners in the polio programme and other health programmes can easily see trends, track data, and take action. This encourages a preventive approach to disease outbreaks rather than a reactive one.
In Nigeria, as of May 2018, about 18 840 active surveillance visits to health facilities had been made using e-Surve technology: as a result, over 3000 suspected cases of vaccine-preventable diseases – previously unreported from health facilities – were identified and investigated.
Strong support from government
Behind the new technology stands commitment from governments, communities, and partners to close the polio outbreak response. Dr. Sume Gerald at the WHO Nigeria office, states that “e-Surveillance in Nigeria is government-led and driven, supported by WHO.”
Through innovation, determination, and commitment at all levels, those working to end polio are getting ever closer to their goal.
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.
We talk to Professor Rose Leke, Chair of the African Regional Certification Commission, to get her views on progress on the continent, and prospects for certifying the region polio-free in 2019.
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.
Surveillance is one of the main pillars of the polio eradication initiative. By testing stool samples collected from children suffering acute flaccid paralysis – the clearest symptom of the virus – as well as samples taken from sewage water, we are able to find the poliovirus wherever it is hiding.
Pakistan’s polio surveillance system is one of the largest ever established in the world. Click through these pictures to learn about the journey of a stool sample there: From a child with suspected polio to the laboratory.
In Pakistan, a wide network of health workers, teachers, and other community members vigilantly look out for signs of polio in children in their area. These volunteers detect and report to the polio surveillance system children showing possible symptoms of the virus, often floppy or weakened limbs with rapid onset of paralysis, known as acute flaccid paralysis. Every suspected case acts as a signal that polio might be circulating in the area, and triggers an investigation.
The poliovirus lives in children’s intestines, where it multiplies, and is finally excreted. When a child with acute flaccid paralysis is reported to the surveillance system, health workers collect the child’s stool samples and transport them to the lab in specially designed cool boxes. The boxes ensure a constant temperature of between 4 to 8 °C, so that the viruses in the samples remain high enough quality to test. Once collected, stool samples from all corners of the country must reach the Pakistan Regional Reference Laboratory for polio eradication, based in Islamabad, within 72 hours.
The Regional Reference Laboratory was established in 1991 and tests around 30 000 stool samples each year from both Pakistan and Afghanistan. More than 99% of these stool samples come back negative for polio. This is because most cases of acute flaccid paralysis are not caused by poliovirus. However, the tiny fraction of positive results tells the programme where the virus may be hiding.
Dr Salmaan Sharif is a Molecular Biologist, and the Coordinator of the Regional Reference Laboratory in Islamabad. He supervises a team of 34 lab staff, each responsible for a different component of surveillance sample testing. With an increase in reported acute flaccid paralysis cases, and environmental sampling sites, the workload of Dr. Sharif and his team is increasing. This is a sign that the polio surveillance system is working well, as a large number of reported acute flaccid paralysis cases and environmental samples gives us our best chance of finding the virus.
Each sample is then processed in a centrifuge, which separates the components of the sample. Solids will drop to the bottom and liquids will remain at the top. Any poliovirus will remain in the liquid component. Once separated, a scientist is ready to inoculate a healthy cell.
From the processing room onwards, extensive biosafety measures are taken to ensure that all virus is kept in the controlled environment, that contamination of other samples does not occur, and humans are not at risk of exposure. During the primary screening, healthy cells are mixed with the liquid component of the processed stool sample, and are then grown in an incubator at 36 °C for up to ten days. An incubator mimics the natural environment of the virus, creating the ideal conditions for the virus to grow. If the virus is present in the processed stool sample, it will infect the healthy cells.
A daily microscopic examination is performed to determine whether poliovirus is present in the processed stool sample. Infected cells are visibly broken in pieces, while healthy cells are seen as long strands.
If poliovirus is isolated in a stool sample, further tests are carried out to determine what type of virus this is and where the strain may have originated. A Polymerase Chain Reaction (PCR) machine is used to determine the kind of poliovirus detected (known as the serotype), and to distinguish further between wild poliovirus and that related to the vaccine-derived.
The next step is genetic sequencing. By reading the genetic code of the virus, wild viruses can be compared to others and classified into genetic families. From this, the geographic origin of the virus can be determined. This helps to guide the programme when deciding the best immunization strategies to stop transmission, and to prevent further spread of the poliovirus.
The polio surveillance system stretches even further than stool sample testing. In carefully selected places where the virus could be hiding, surveillance officers collect sewage samples. These are also sent to the Regional Reference Laboratory for processing, using a method similar to the testing of the stool samples. Crucially, environmental surveillance can help find polio in the environment before it has a chance to paralyse a child.
In Pakistan, the programme has used environmental surveillance to test and detect the presence of poliovirus in the sewage in high-risk locations since 2009. The network has continued to expand over time with a wider coverage. Currently, there are 53 sampling sites in 33 districts and towns of the country, making it the largest environmental polio surveillance network ever established.
The sensitive polio surveillance system finds the poliovirus wherever it exists – from the most remote villages to huge cities. With the polio case count at the lowest level in the history of Pakistan, the country intends to make 2018 the year of poliovirus interruption, keeping current and future generations of children safe from this disease. Thanks to the generous support of the Government of Japan, the Islamabad laboratory is continuing to expand operations, now able to procure new state-of-the-art molecular biology equipment to help detect the last remaining reservoirs of the virus.
“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.
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.
With polio at the lowest levels in history in Pakistan, the country has launched a powerful and hopefully final assault on the disease in 2018. A crucial part of this is to further strengthen the ability of the polio programme to detect virus in stool samples, thereby giving clear indications of where and how the virus is moving in areas where populations remain under-immunized.
To support this effort, the Government of Japan announced today that it will provide US$3.2 million for the procurement of equipment to the Regional Reference Laboratory for polio eradication, located in the National Institute of Health in Islamabad.
The funds will help support the purchase of state-of-the-art molecular-biology equipment, allowing the laboratory to significantly enhance and speed up its ability to process and detect poliovirus in environmental and stool samples. This is critical work – in 2017, the Islamabad lab tested 30 000 stool samples and 950 environmental samples from both Pakistan and Afghanistan, helping the programme better identify where the virus is hiding.
The Japanese grant will also be used to replace aging stocks of cold chain materials and other essential equipment needed to be able to accurately identify poliovirus in samples.
Speaking at the ceremony for the signing of the grant, the Federal Minister of National Health Services, Regulations and Coordination in Pakistan, Saira Afzal Tarar said: “The steady support of the Government of Japan and other partners, and the strong partnership have been crucial elements of the programme’s tremendous progress over the past two years. The new grant will help strengthen polio surveillance through adaptation of new technology and contribute towards polio eradication in the country.”
“These funds come at a crucial time in Pakistan’s eradication effort, and are being used in a strategically important manner,” commented Michel Zaffran, Director for Polio Eradication at the World Health Organization. “The country is on the cusp of being polio-free. What we now need is to urgently root out any last remaining spot where the virus might be hiding, and these funds will help strengthen the ability to do just that. Only by finding polio’s last remaining hiding places will we be able to eradicate it once and for all.“
The Government of Japan is a longtime supporter of the Global Polio Eradication Initiative, with contributions to end polio in Pakistan of approximately ¥24 billion (approximately US$ 224 million) since 1996. With only eight cases recorded in the country in 2017 from just a handful of districts – compared to more than 30 000 all over the country just 20 years ago – these additional funds come at a critical time for the country programme as it launches into the final intensified effort to finish the disease once and for all.
The Global Polio Eradication Initiative partners would like to extend their profound gratitude to both the Government of Japan and Pakistan for their collaboration, and for their tremendous support and engagement in the effort to end polio globally.
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.
The poliovirus remains in just a few small pockets around the world. However, these final hiding places are some of the most challenging settings on earth in which to eradicate a disease. Finding and stopping a virus whose special power is staying hidden is no mean feat, especially in remote or inaccessible places.
Disease detectives around the world are working tirelessly to find every last virus in these hard to reach places. Some areas are vast and sparsely populated, such as the broad plains and river beds making up areas of the Lake Chad region. Others are densely packed residential areas of Afghanistan, where security issues can sometimes make immunization difficult. In areas of Syria, civil war continues to rage through towns, communities, and families. Yet these challenges are not enough to stop the surveillance system.
Community-based surveillance
In such difficult environments, the polio surveillance system must overcome numerous challenges to ensure that the poliovirus is tracked. Experts look for the virus in children with symptoms of acute flaccid paralysis and also in water samples from sewage systems in high risk areas.
For Dr Arshad Quddus, Coordinator for the detection and interruption of poliovirus at WHO headquarters, the key to overcoming the challenges facing polio surveillance is tapping into communities. Illustrating his point, he draws a circle on a piece of paper, placing a dot in the middle. In Afghanistan, he explains, that dot represents a surveillance focal point, based at a District Health Centre or hospital. The circle extending from them is their information network – a collection of mullahs, healers, health-care providers, teachers, parents and other surveillance recruits – who have been trained to spot cases of acute flaccid paralysis in their community that could turn out to be polio.
Each volunteer is given a book in which to write down the information they find, and a phone number to call. If they come across a case in their local community, they must ring their focal point, setting in action a series of events that will allow the child to be examined, stool samples to be taken from them to be tested in the laboratory for polio and their close contacts tested.
Overcoming challenges
The system may seem simple, but insecurity, weather and challenging landscapes can be obstacles. In Afghanistan, the programme has developed creative ways to ensure that nothing stands in the way of the surveillance system being able to work as it needs to. In most cases, following the reporting of a case of acute flaccid paralysis, health workers will visit the child’s home to inspect them, and collect stool samples from the child to send for lab testing for the poliovirus. However, if the area is inaccessible, the child and their caregivers are transported to the nearest hospital in a safe area for inspection.
For Dr Quddus, the success of this system in Afghanistan is clear: “We have regular reports of where the poliovirus is circulating in difficult and hard-to-reach communities and this shows us we are being successful, despite tremendous challenges.”
Surveillance in conflict zones
These diverse methods also strengthen surveillance in countries where the security situation is rapidly changing. In Syria, the health-care system has been weakened due to conflict, with many of those at the heart of the polio surveillance system displaced. By building new networks in camps for internally displaced families where communities are created by proximity, and recruiting surveillance volunteers at the key points of entry and exit into the worst of the conflict zones, the polio surveillance system ensured that an outbreak of circulating vaccine-derived poliovirus in 2017 was rapidly identified and an outbreak response launched. The programme also thought outside of the box in Borno, Nigeria, by training medical corps being deployed to reach conflict-affected populations to spot signs of the virus.
The polio surveillance system is strengthened by a mixture of community, adaptability, and fierce commitment to finding every last trace of virus. These are the lessons learned that help find the virus everywhere, from urban districts of Afghanistan, to hard-to-reach areas of Nigeria. For Dr Quddus, “It is the individuals on the ground willing to give their all that will enable us to achieve eradication. The surveillance system is the eyes and ears of polio eradication, showing us where to focus our best efforts to vaccinate every last child.”
As the world inches closer towards a polio-free future, finding and closing remaining gaps in national health system capacities to pick up traces of the poliovirus is critical. Only three countries remain on the global endemic list – Afghanistan, Pakistan and Nigeria – but the threat of poliovirus resurgence remains very real, particularly for countries with a history of importation of poliovirus from these endemic areas.
In order to ensure that surveillance systems in these ‘at-risk’ countries are up-to-scratch and sensitive enough to adequately detect and report cases of acute flaccid paralysis (AFP) – a major indicator for polio – the World Health Organization regularly leads expert reviews to put systems under the microscope.
Expert review in Sudan
Eighteen technical officers and polio surveillance experts from WHO, UNICEF, the U.S. Centers for Disease Control and Prevention, the Bill & Melinda Gates Foundation and the Eastern Mediterranean Public Health Network recently met with Ministry of Health staff in Khartoum to share their findings and recommendations after scrutinizing Sudan’s surveillance performance at federal and state levels.
“Sudan has not seen a case of polio for almost nine years, however, certain factors put it at considerable risk of poliovirus importation and outbreaks,” said Dr Naeema Al Gasseer, WHO Representative to Sudan. “It is very important that the country remains on guard against polio and continually analyses and improves the quality of its AFP surveillance, particularly in the high risk areas,” she said.
“Strong AFP surveillance is a cornerstone of the polio eradication effort ̶ it enables us to quickly pick up poliovirus if it is circulating and react with an appropriate response,” said Dr Ni’ma Abid, a senior technical expert from WHO’s regional polio eradication hub in Amman, Jordan. “There is no margin for error and in at-risk countries facing such challenges as Sudan, we need to thoroughly examine AFP surveillance systems to make sure that they are sensitive and fast enough to detect transmission. This is a practice that will need to continue even after the world is certified polio-free,” he added.
Risk factors and special strategies
Sudan is the third largest country in Africa and home to over 40 million people. Insecurity, forced displacement, frequent nomadic population movement and inaccessibility in some areas make it challenging for health workers to consistently reach all children with vaccines to build immunity. Refugee influxes across porous borders with conflict-affected neighbouring countries exacerbate the risk of disease and compound pressures on the country’s already stretched health system. In addition, high sub-Saharan temperatures and rough expansive terrain can make timely collection and transportation of stool specimens from children with AFP for laboratory testing difficult.
Special strategies have been devised to cater for the specific surveillance challenges associated with reaching high risk groups. Examples include active searches for AFP cases and sample collection by community-based surveillance officers in areas with access issues, the mapping of the movement of displaced populations, and establishing regular communication with nomadic community focal points who report AFP cases via mobile phone. In refugee camps, vaccination posts have provided an opportunity to screen for children with AFP, and collaboration and sensitization of non-government organization (NGO) staff has helped to improve reporting of AFP cases.
Eighteen states were assessed throughout the review, with visits to 90 health facilities, the families of 16 children with AFP, and high-risk special populations. Overall conclusions were that the system is meeting global AFP surveillance targets and it is unlikely for polio to circulate undetected. However, gaps were identified that need to be addressed.
“Surveillance system performance in Sudan is sensitive and we were pleased to see implementation of the recommendations made at the last review,” said Dr Abid. “However, more attention needs to be paid to surveillance in refugee communities, cross-border population movement, and programmatic issues such as the high level of turnover of national surveillance staff,” he said. “We encourage the government of Sudan to implement the recommendations made at the review to address these and other gaps,” he said.
“WHO and partners commend the government of Sudan for its efforts to date, and stand ready to advise and support to keep the country polio-free,” said Dr Al Gasseer. “Until polio is gone for good, globally, we must make every endeavor to prevent resurgence,” she said.
Sudan witnessed its last case of indigenous wild poliovirus in 2001. Since then it has been exposed to several wild polio importations from Chad and Ethiopia with its most recent case in March 2009.
