Stopping any polio outbreak starts with vaccine procurement, transport by airplanes and trucks, distribution involving complex logistics, and eventually the oral administration of the vaccine by drops in the mouths of every eligible child.
However, there is another, lesser known but equally important process that must also take place to halt transmission of the poliovirus. It begins with a humble stool sample – a thumb-sized smudge of poop – taken from a child with acute flaccid paralysis (AFP), then delivered to the nearest laboratory that can test the sample specifically for poliovirus.
But nowhere in Yemen is there any such lab. So the long and arduous journey of any stool sample from a Yemeni child to a receiving lab can take up to several days – following an easterly route, to the neighboring country of Oman.
An explanation of how stool samples are transported over such a distance starts with why: monitoring children under 15 years of age for signs of AFP, which is the most common sign of poliovirus infection. The Global Polio Eradication Initiative has set a benchmark of at least three AFP cases per 100,000 children under 15 years of age, a standard that Yemen has consistently met, thanks to the effectiveness of its surveillance system. This achievement is all the more remarkable considering that Yemen is entering its ninth year of internal conflict, with resulting population displacements, widespread food and fuel shortages, and a devastated health system (in which only 46% of hospitals and health facilities are only partially functioning or completely out of service).
Antananarivo – Quality assurance surveyor Anja Mandimbisoa arrives at a random lot numerically selected, throws her pen in the air, and whichever house it is pointing at when it lands is the next on her evaluation list. With their consent, she then sits down with the family to verify whether the children in the household have the mark on their little fingers confirming they have been vaccinated against polio.
“The fact that it is a random selection provides a true picture of immunization coverage at the district level,” explains Mandimbisoa, one of 16 external Lot Quality Assurance Sampling (LQAS) surveyors trained by World Health Organization (WHO) in Analamanga region, Madagascar, to identify any missed children.
As the country concludes its third round of polio vaccinations this year, the response reflects that the job to end polio does not end with the conclusion of a vaccination round. Instead, it is the actions between rounds that make all the difference.
Islamabad – An announcement over a loudspeaker from the mosque captures the attention of parents and their children. The voice announces that a polio campaign is taking place in the settlement and vaccinators will be coming to give two drops to children under five. Eight teams of two vaccinators each are already on their way, each starting their day from the farthest house in the community and making their way to the center.
In January, when Pakistan detected a positive wild poliovirus from a sewage sample with genetic links to the virus circulating in Afghanistan, the polio teams jointly conducted a detailed epidemiological investigation to trace the routes of virus movement and identify infected populations. In a matter of weeks, a response was planned and implemented, vaccinating around 6.37 million children from 13 – 17 February. In this article we take you to an Afghan refugee settlement in Islamabad, one of the 30 districts that were covered partially and where the outbreak response focused on mobile and cross-border populations.
The story looks at three important components of a campaign: vaccinators, vaccines and tally sheets.
Vaccinators: the backbone of programme
“Who is there”, asks a man from inside the house, in Pushto.
“Polio team,” responds Salma who speaks Pushto. “We are here to give polio drops. Do you have children under five at home?”
A tall man with a three-year-old boy in his arms, opens the door and welcomes the two vaccinators. Salma introduces herself and her team member Amina and asks the father if either of their children had received polio drops that day. The father confirms that in this round, his children did not receive any polio drops.
“Can I give them the polio drops?”, asks Salma.
The father responded back energetically, “Of course, you can! I want my child to grow up healthy!”
This is when Salma opens the blue box. Inside it are ice packs and vials of oral polio vaccine. She talks to the little daughter and asks her to open her mouth and gives her two drops from the vial.
After giving the drops, she marks the girl’s little finger. “You can show this incase anyone asks if you got the polio drops.”
Amina, on the other hand, fills out the tally sheet that she will later submit to her supervisor. If this information is incorrect, it can impact the overall operational coverage data for the campaign.
On leaving the house, Amina takes out her chalk and marks the door of the house with key information that will mention what day they visited, the number of children under five in the house and if there was any child with symptoms of acute flaccid paralysis.
One house done, now on to the next one.
Vaccines: two drops for every child
“It is not always this straightforward,” says Amina. “Sometimes parents are skeptical about the vaccine and don’t want us to vaccinate their children. I often take the drops myself to show them how safe the vaccines are. When they see me taking these drops, it helps us build confidence with them.”
The polio programme has a long history of systematically listening to community concerns and addressing them, often engaging influencers such as religious leaders, to underscore the safety and efficacy of polio vaccines. This has helped address vaccine hesitancy and reached more children, building their immunity against this debilitating disease. At this settlement, occasional announcements were made through the mosque, informing people that a polio campaign was taking place and encouraging them to vaccinate their children. The result of these efforts has helped the programme significantly reduce the number of refusals across the country.
The blue box Amina carries with her has a large red “End Polio” sticker and it can carry up to 20 vaccine vials, nestled between the ice packs. Each vial contains 20 doses. She pays special attention to the box making sure the temperature is always maintained and the vaccines are kept out of direct sunlight. Vials that have been used, those that are unused and the ones in use are all kept in separate bags in the cold box.
The third important piece of a polio campaign is the tally sheet. In rudimentary terms, it is a piece of paper with many tiny boxes that deliver a telling story of number and ages of children, those who were vaccinated, those who were missed, location where the campaign is taking place and number of doses delivered. In case of any refusals, the vaccinator mentions the reason for refusal at the back of the tally sheet. It tells how well an area has been covered and the remaining gaps.
The authenticity of this data is a crucial component of operational coverage. It allows supervisors to identify gaps, present progress and advise corrective actions for vaccination teams. Each evening, this data is used to measure the campaign’s operational coverage.
In one of the houses where the vaccinators entered, the mother mentioned that the child had already been vaccinated. However, no finger of the child was marked , while the others each had a blue mark on their pinky finger. Taking no chances, the vaccinator took out the vial and gave the child drops and then marked the finger. The tally sheet cannot be marked unless a child has been vaccinated and finger-marked.
Getting past the finish line
Up until April, Pakistan has conducted four polio vaccination campaigns. With the support of 390,000 polio workers, almost 43 million children under-five were vaccinated during a five-day nationwide vaccination campaign. There are multiple campaigns planned for the year ahead, requiring hours of strategic and evidence-based planning led by the national and provincial emergency operations centres.
Leaving nothing to chance during this last 100 meter dash towards eradication, the programme has also started implementing innovative interventions, such as the nomad population mapping and vaccination of high-risk mobile populations, engaging public health students for monitoring campaigns through the Lot Quality Assurance Sampling survey and the co-design initiative that engages women polio workers to develop solutions for improving campaigns and identifying potential livelihood opportunities for them in the future.
For Amina and Salma, the conclusion of the February round meant that children under five had received the vaccine to build strong immunity against the poliovirus. However, the journey to eradication continues. After a short break, the programme will begin working on validating the next set of microplans. All of this work is essential to ensure that the virus really finds no place left to hide and no child left to paralyze.
Islamabad – As he rode his motorbike out of the relative safety of Bannu city on a September morning, Danyal Sikandri was nervous. It was his first day on a new assignment, and he was riding out into the district outskirts with colleague Yasir Shah in search of a reclusive group of people – nomads.
Their task was to find nomadic settlements and vaccinate the children there against polio and other vaccine-preventable diseases. Sikandri has been involved with the Pakistan Polio Eradication Programme since 2019, first as vaccinator and then area in-charge. Therefore, he was no stranger to interacting with people. But with this assignment, he didn’t know what to expect, since he would be travelling long distances to find people who might not speak the same language, might be unwelcoming or worse, he could end up in an area which may not be secure.
After travelling for about 36 kilometers, the team found a nomadic settlement in Domel. A group of families clustered together in makeshift tents made of plastic sheets and cloth. Sikandri approached the elders and explained why they were there. The nomads, who had come from Afghanistan and were temporarily camped in Domel, warmly welcomed the vaccinators in their midst.
As Sikandri vaccinated 14 children in the camp that day, his nervousness dissipated, and a resolve set in – to bring life-saving vaccines to as many nomadic children as he could.
“When I met them, I saw how different their lifestyle is, since they are constantly on the move and far from health facilities,” says Sikandri. “They want to protect their children from diseases too, so they are happy to see us. They tell us that it is the first time that vaccinators have come to their tents to vaccinate their children.”
Sikandri is one half of a two-member special mobile team which works under Pakistan Polio Programme’s latest initiative to reach segments of the population with polio and essential vaccines, which they would otherwise not have access to. The nomad vaccination initiative was launched in September 2022 in the seven endemic districts of southern Khyber-Pakhtunkhwa (KP) and expanded to four districts of Punjab neighboring these districts in October. The initiative was further expanded to include more districts from Punjab in January and Balochistan in early March. A total of 80 mobile teams in 22 districts have been deployed so far to reach nomadic children.
“With this initiative, we are filling a crucial gap. In the past, we were vaccinating children on the move, in buses, on train stations and other transit points, but the children that were being left out were from nomadic populations. This initiative is a product of extensive research, where we mapped out population movements and based on that information, made mobile vaccination teams to reach nomadic children with polio as well as all essential immunization necessary for their health and safety,” said Dr Zainul Abedin Khan, the National Team Lead for WHO’s Polio Operations in Pakistan.
“This is an excellent initiative of the Government of Pakistan, with support of polio partners, to protect children who had never been vaccinated before. This initiative will keep expanding based on the movement patterns. With this, we hope that population immunity is increased, and poliovirus is interrupted permanently,” he added.
“They want to protect their children from diseases too, so they are happy to see us. They tell us that it is the first time that vaccinators have come to their tents to vaccinate their children.”
Since nomads are highly mobile, the children in these communities are missed during routine vaccination campaigns or even at transit vaccination sites because they may not be passing through formal routes. This means their immunity remains weak, they are vulnerable to disease and can potentially transmit poliovirus as they travel across country and district borders.
In 2022, the program conducted a comprehensive survey of nomadic movement patterns in February and March in 14 districts of KP, Punjab and Balochistan. The survey found that nomadic movement begins in southern KP in September and ends in March, with the nomads setting up temporary camps as they pass through various districts.
“It is difficult for our door-to-door vaccination teams to reach them since a majority of nomads live on district borders or peripheries and it is not even known when they are coming,” said Muhammad Asif Javaid, who leads the program’s High-Risk and Mobile Population Unit (HRMU) and is spearheading this initiative. “They are frequently on the move, staying in places temporarily, never settling, so they miss the opportunity to receive polio and routine immunization.”
In the first phase of implementation, two special mobile teams – consisting of a trained vaccinator and a team assistant – were deployed in each of the seven districts of southern KP and four districts of Punjab. Subsequently, the project was expanded to cover 22 districts of the country.
Union council staff collect data on nomads visiting their areas. This information along with weekly micro-plans and targets are provided to vaccinators, who travel across their assigned UCs to visit these settlements. They provide polio and other essential vaccinations to children in the camps and issue vaccination cards to the families to ensure the data remains on record.
Javaid said that these teams are also helping with surveillance for cases of acute flaccid paralysis (AFP) by asking families and looking for any children who might have AFP, and then ensuring that it is reported to relevant authorities for further testing.
As of March 31, more than 114,600 children under the age of five had received the oral polio vaccine, 71,206 had received the inactivated polio vaccine, while nearly 20,000 routine immunization antigens have been administered to eligible children, under this initiative.
“Currently the program is actively working to vaccinate chronically missed children and is focusing on reaching missed populations rather than prioritizing geography alone,” Dr Zainul Abedin Khan added.
The task is challenging for vaccinators, who travel many kilometers out of urban centers to find nomadic settlements. They might run out of fuel, the settlement might have packed up and left by the time they arrive, or they may encounter hostility, but the vaccinators take it in their stride, happy to be safeguarding children’s futures.
For Sikandri, the experience has been rewarding. He has seen areas of his native district now that he had never seen before, and he feels his communication skills have improved since he began working on this project.
“We have received a lot of love from these people. When we vaccinate their children, they are thankful and pray for us. It feels good that people like them and their children are also being taken care of,” said Sikandri.
Around the time when the Fédération Internationale de Football Association (FIFA) World Cup tournament was introduced, in 1930, children didn’t have access to polio vaccines. Additionally, systems to search for polio symptoms in children were most likely weak across the world. This scenario has changed now.
To prepare for an estimated 1.2 million football fans congregating in Qatar to watch the World Cup tournament, the Government of Qatar took several measures to mitigate risks associated with the spread of diseases, including polio. As part of these interventions, the country requested the World Health Organization (WHO) for technical support to assess and improve surveillance for polio.
Taking stock of existing disease surveillance systems
To kick off these efforts, after months of joint planning and coordination, a team from WHO’s Eastern Mediterranean Region (EMR) visited Qatar at the end of September 2022 to conduct an elaborate review of the surveillance system for acute flaccid paralysis (AFP). They examined activities at four main health care facilities − where both Qataris and visitors in the country frequently visit − to assess their contribution to AFP surveillance.
The team also conducted a virtual capacity development session for more than 200 public and private health professionals to understand the global and regional polio situation, and the importance of AFP surveillance and case reporting.
Reviewing systems to detect and respond to polio cases
On noting the recent spread of polioviruses across the world, and ease with which viruses can be transmitted, WHO sensitized officials at the Ministry of Public Health on the standard operating procedures for polio outbreaks. This includes a template to develop a national preparedness plan for a polio outbreak.
As next steps, the team conducted a Polio Outbreak Simulation Exercise (POSE), to test the level of preparedness and the blueprint of activities that should be conducted in case of an outbreak. The POSE ensures users are aware of activities to conduct within the crucial first 72 hours of confirmation of a polio outbreak. This exercise also aimed to ensure all existing tools in use are valid, and refreshed health officials’ knowledge on the different kinds of polioviruses that exist and vaccines that can be used to boost immunity.
Need to strengthen AFP case notification
One of the most highly developed countries in the EMR, Qatar has a state-of-the-art online health client database, which is used by 90 percent of health service providers. The country also uses unique codes for all residents regardless of their nationality, which helps them manage infectious disease outbreaks. Health facilities offer high quality of health care, which encourages communities’ uptake in health services. Taking this into account, the surveillance review revealed that the electronic health system in Qatar is able to track AFP cases once notified.
The country, however, faces challenges in the notification of AFP cases, largely due to the lack of a comprehensive list of diseases related to AFP in the electronic databases currently in use in health facilities and hospitals. Additionally, physicians lack awareness about AFP and case notification, which is attributed to Qatar being polio-free since 1990.
Recommendations for stronger surveillance of polio
Recommendations made by WHO to the Ministry of Public Health are aimed at developing the capacity of staff to notify AFP cases early; conduct regular active search for children with AFP, including through active surveillance visits; and execute 60-day follow up examination for AFP cases. The WHO team also advised Qatar to maintain updated and functional AFP surveillance guidelines, and a national preparedness and response plan for polio outbreaks and response.
WHO also encouraged the Ministry of Public Health to set up a system for environmental surveillance to search for polioviruses in sewage and wastewater at prime sites across the country. This would help to cast a wider net to search for any poliovirus both in visitors and communities living in the country.
Qatar plays a key role in polio eradication
The Government of Qatar is a key partner in polio eradication efforts. Qatar’s Minister of Public Health, HE Dr Hanan Mohamed Al Kuwari has been serving as the co-chair of the Regional Subcommittee for Polio Eradication and Outbreaks in the Eastern Mediterranean Region since February 2022. In this capacity,
HE Dr Al Kuwari has been instrumental in shining the spotlight on the current status of polio in the Region and efforts needed to end polio by the end of 2023.
Yemen is currently experiencing twin outbreaks of circulating vaccine-derived poliovirus type 1 and type 2 (cVDPV1 and cVDPV2). Both strains of poliovirus emerge in populations with low immunity and both can result in lifelong paralysis and even death.
Since 2019, 35 and 14 children have been paralysed by cVDPV1 and cVDPV2 respectively, three of the cVDPV2 cases confirmed in the past 10 days alone. The cVDPV2 outbreak, in particular, is ongoing and expanding and has already spread to other countries in WHO’s Eastern Mediterranean Region and UNICEF’s Middle East and North Africa Region. At its fourth meeting on 9 February 2022, the Eastern Mediterranean Ministerial Regional Subcommittee on Polio Eradication and Outbreaks issued a statement, expressing deep concern around these expanding outbreaks and requesting all authorities in Yemen to facilitate resumption of house-to-house vaccination campaigns in all areas.
The Global Polio Eradication Initiative (GPEI) partners strongly recommend high-coverage mass vaccination campaigns to stop a cVDPV outbreak. The vaccination response must achieve at least 90% of children vaccinated repeatedly with polio vaccine to protect them from polio and prevent seeding new vaccine-derived emergences. Therefore, the guidelines in the Polio Outbreak Response Standard Operating Procedures recommend that the vaccination response to polio outbreaks should be conducted using the house-to-house vaccine delivery strategy to maximize coverage of vulnerable children.
The GPEI urges the health authorities in Sana’a to conduct high quality house-to-house vaccination campaigns to stop the two concurrent outbreaks as soon as possible. If the current conditions in parts of Yemen do not permit house-to-house vaccination, then an intensified fixed-site vaccination campaign with appropriate social mobilization by the community and religious leaders trusted by the local communities should be implemented to maximize coverage among all vulnerable children.
Yemeni children face no shortage of threats: prolonged conflict, a devastated healthcare system, hunger and disease. But polio is one disease that can easily be prevented. Its circulation can be stopped in Yemen or anywhere else by vaccinating all children with oral polio vaccine.
The GPEI partners – WHO, Rotary International, the U.S. Centers for Disease Control and Prevention, UNICEF, the Bill & Melinda Gates Foundation and Gavi – are committed to providing support to all stakeholders in Yemen for responding to the polio outbreaks including in conducting polio vaccination campaigns that can reach all vulnerable children.
A poliomyelitis (polio) vaccination campaign for children aged 6 months to 6 years who missed routine polio doses in the past will begin in Ukraine on 1 February 2022. This catch-up campaign is part of a comprehensive response to stop an outbreak of poliovirus first detected in Ukraine in October 2021. This first stage will last 3 weeks and is expected to reach nearly 140 000 children throughout the country.
Years of low immunization coverage in Ukraine have created a large pool of unvaccinated or under-vaccinated children who are vulnerable to polio. While routine immunization coverage has gradually increased over the past 6 years, in 2020, only 84% of 1-year-olds received the required 3 scheduled doses of polio vaccines by 12 months of age.
The immediate goal of the campaign is to reach the WHO-recommended level of 95% vaccination coverage of eligible children.
Background
The polio outbreak in Ukraine was confirmed on 6 October 2021. Poliovirus (circulating vaccine-derived poliovirus type 2) was first isolated in a 17-month-old girl in the province of Rivne who developed acute flaccid paralysis. Analysis of all her contacts found that 7 household contacts (siblings) and 8 community contacts in Rivne as well as 4 cousins in the province of Zakarpattya (who had had contact with the girl’s siblings) also tested positive, but did not develop paralytic symptoms.
A second case with acute flaccid paralysis (a 2-year-old boy in the region of Zakarpattya) also tested positive for poliovirus, with onset of paralysis in December 2021.
The isolated strain of the virus found in both paralytic cases and their contacts is linked to a poliovirus in Pakistan, which was also the cause of several cases in Tajikistan in 2020–2021.
Comprehensive plan to stop the spread of poliovirus
Following an initial local vaccination campaign, conducted where the first case was detected, a comprehensive polio outbreak response plan was approved by the Ministry of Health in December 2021.
The first stage of the plan will provide inactivated polio vaccine (IPV) to children aged 6 months to 6 years who have not received the required number of doses. In the second stage, all children under the age of 6 will be vaccinated with oral polio vaccine (OPV), even if they have received all their scheduled vaccination doses. This is necessary to protect children from infection and to stop the circulation of the virus. Dates for the second stage are pending.
In November:
No case of WPV1 was confirmed
35 million children were vaccinated during the MR Campaign in November 2021.
1 million children were vaccinated at 73 Permanent Transit Points
On 31 May, Tajikistan started a supplement immunization campaign against poliomyelitis to vaccinate all children under the age of six with two doses of oral polio vaccine. ).
Poliomyelitis (polio) returned to Tajikistan in the past year, with the first case of an outbreak of circulating vaccine-derived poliovirus type 2 (cVDPV2) detected in a child who developed acute flaccid paralysis (AFP) on 22 November 2020 in the province of Khatlon.
In response to the outbreak, 3 rounds of supplementation immunization with novel oral polio vaccine type 2 (nOPV2) were conducted, all of which reached a reported 99% of the target group of children under the age of 6.
Both environmental surveillance and active AFP case searches in hospitals and health facilities are continuing throughout the country to ensure that any potential further circulation will be detected.
The latest AFP case with confirmed cVDPV2 had onset of paralysis on 26 June 2021. The latest positive environmental sample was collected on 27 August, before completion of the third round of immunization in early September.
“Tajikistan has responded with full commitment and with the dedicated support of Global Polio Eradication Initiative partners to stop this outbreak,” said Dr Victor Olsavszky, WHO Representative and Head of the WHO Country Office in Tajikistan.
“We are cautiously optimistic that the extensive surveillance and immunization campaigns of the past 11 months have closed the door on further spread of this virus. This is vital for the health of children in Tajikistan and beyond.”
Extent of the outbreak in Tajikistan
As of 1 October 2021, 31 children have been found to have polio (paralysis) caused by cVDPV2, and the virus has also been isolated from 26 children without paralysis. Twenty environmental samples have tested positive for presence of the virus. All detected polioviruses are linked to a virus strain currently circulating in Pakistan.
The geographic spread of cVDPV2 (based on detection among children and in the environment) has been limited to Dushanbe city and 14 districts in the centre and south of the country.
Background
The oral polio vaccine (OPV) that has brought the wild poliovirus to the brink of eradication has many benefits: the live attenuated (weakened) vaccine virus provides better immunity in the gut, which is where polio replicates.
However, in communities with low immunization coverage, as the virus is spread from one unvaccinated child to another over a long period of time (often 12–18 months), it can mutate into a form that can cause paralysis, just like the wild poliovirus. This mutated poliovirus can then spread in communities, leading to cVDPV2 outbreaks.
The number of cVDPV2 outbreaks globally has increased sharply since early 2019. In 2020, cVDPV2 cases emerged in Afghanistan and were reported in areas close to Tajikistan, Turkmenistan and Uzbekistan.
nOPV2 is a new tool that Global Polio Eradication Initiative partners are deploying to better address cVDPV2. nOPV2 is safe and provides comparable protection against poliovirus, while being more genetically stable and therefore less likely to revert into a form that can cause paralysis in under-immunized communities. This means that nOPV2 could help stop cVDPV2 outbreaks.
WHO recommends that all countries, in particular those in which there is frequent travel to and contact with polio-affected countries and areas, strengthen surveillance for AFP and maintain high routine immunization coverage. All travellers to polio-affected areas should be fully vaccinated against polio.
In September:
No new Wild Poliovirus (WPV1) case and no new cVDPV2 cases were confirmed.
Dr Hamid Jafari, Director of Polio Eradication for WHO’s Eastern Mediterranean Region, declared Somalia’s outbreak of circulating vaccine-derived poliovirus type 3 (cVDPV3) closed a full 28 months after this strain of polio was last detected in Somalia.
Seven children were paralysed by the type 3 strain in the 2018 outbreak, and sewage samples regularly monitored for poliovirus tested positive for cVDPV3 a dozen times, beginning March 2018. There is no doubt that the virus circulated widely around southern and central Somalia. Despite extensive disease surveillance measures, no cVDPV3 has been identified since 7 September 2018, when the last child developed paralysis.
Closing a polio outbreak is a formal process steered by a detailed checklist of surveillance indicators that must be met in order to show that the virus is not just hiding in a far-flung pocket but has truly disappeared. Sewage runoff is tested for virus, and health workers and community members actively search for paralysis in children, and then investigate any paralysis they do find to rule out polio. Accessing hard-to-reach communities is a challenge in Somalia, but a vital aspect of this work.
The 2018 cVDPV3 outbreak was part of a 2-strain polio outbreak in Somalia at that time, along with circulating vaccine-derived poliovirus type 2. Both strains emerge and paralyse children in under-immunized populations – places where not enough children have consistently had access to polio vaccines. The cVDPV2 outbreak continues to paralyse children, and environmental samples – sewage water – consistently show that virus moving through Somali communities. For the polio programme, the presence of cVDPV2 samples and the absence of cVDPV3 samples is bittersweet: it demonstrates the sensitivity of our testing, so we can be confident cVDPV3 is no longer a threat to Somali children – but it makes clear that the threat of paralytic polio still looms.
Across the Region, cVDPV2 cases are on the rise – as across much of WHO’s African Region. Wild poliovirus still stalks children across Afghanistan and Pakistan, and the movement of people across borders underscores the risk of importation across and beyond the Region.
The end of Somalia’s cVDPV3 outbreak shows what can be achieved with high-quality vaccination campaigns, on-the-ground leadership and sensitive surveillance measures.
On a wintery November day, vaccinators across Afghanistan wrapped up warm, checked that they had facemasks and hand sanitizer, and headed out into the cold morning. Their mission? To reach 9.9 million children with polio vaccines, before snowfall blocked their way.
From valleys to muddy lanes, we look at some of the environments where vaccinators work, as well as some of the key challenges that have made 2020 one of the toughest years for polio eradicators.
Panjshir province
For some vaccinators, the first snows had already arrived. At the top of the Panjshir valley, Ziaullah and Nawid Ahmad started their day at 7am.
“We walked six hours to Sar-e Tangi and back to take polio drops to the last houses in the valley”, said Ziaullah. The mountainous roads in this area are impassable by car, so vaccinators walk many kilometers to the most remote villages. Sar-e Tangi means ‘top narrow edge’, and the view during the long winter is of snowy peaks.
A few kilometers from Sar-e Tangi, father Arsalan Khan was proud to have protected his own and other children in the extended family with polio drops. He said, “I ensure all the children in the family are vaccinated during each round the drops were offered and of course I will keep vaccinating them each time the vaccinators visit our village”.
Khan continued, “The vaccinators walk long distances across the mountain slopes to our villages, sometimes during harsh weather conditions, to bring polio drops to our doors.”
“Thanks to the people and countries that support the vaccination campaigns and make it possible for the drops to reach our doorsteps.”
In Badakhstan, Mr. Azizullah had COVID-19 safety measures on his mind. Like all vaccinators working for the polio programme, he had been trained on how to safely deliver polio drops during the pandemic. The temperature was below zero, with the first snow on the ground, as Mr. Azizullah walked through the rugged terrain from home to home, ensuring to wear his mask and regularly sanitize his hands.
Mr. Abdul Basit and Misbahuddin, volunteers in nearby Aab Barik village said, “It is cold and walking through muddy lanes is not easy, but we have to do our job. There was one case of polio in Badakhshan so that means there is probably virus circulation and we have to stop that”.
Mr. Abdullah, a university lecturer observing vaccination activities in Herat, said, “I believe a vaccinator’s job is more important than mine. I really appreciate their work and appreciate the international community for making the polio immunization operations possible in Afghanistan with their financial support.”
“I believe that all these efforts will be fruitful, hopefully soon, and we will get rid of the virus in our country”.
The November campaign was particularly aimed at boosting the immunity of unvaccinated children, and children who have not received their full vaccine doses. Many children have missed out on polio vaccines and other routine immunizations due to a pause in vaccination activities in the first few months of the COVID-19 pandemic. Health workers are now racing against time to protect the youngest children from the poliovirus.
Ms. Sitara, mother of Yasameen, who was wrapped up warm against the elements, said, “I am very happy to be able to immunize my daughter and protect her against polio”.
In the east region of Afghanistan, 8,530 volunteers, 160 district coordinators and 786 cluster supervisors were hard at work, aiming to reach as many children as possible during the campaign.
Dr. Akram Hussain, Polio Eradication Initiative Team Lead for WHO in the region explained, “We were not able to do house to house campaigns in some parts of the region. As a result many children were missed during the October vaccination campaigns”.
Despite the best efforts of vaccinators, in October, 3.4 million children nationwide missed vaccines due to factors including insecurity, the COVID-19 pandemic and vaccine mistrust. The year 2020 has seen a significant rise in polio cases and detection of the virus in the environment, and the disease is present in almost all provinces.
The programme is aiming to reach more children and tackle virus spread next year. Activities include targeted campaigns in high risk districts, collaborating with the religious scholars from the Islamic Advisory Group to encourage vaccine uptake and communicating more effectively with communities.
The incredible contributions of the polio programme to COVID-19 response are testimony to the agility and adaptability of Afghanistan’s programme in the most difficult circumstances. Many hope that lessons learnt from this experience can be applied to achieving the eradication goal.
Ending polio requires everyone – including polio personnel, communities, parents, governments and stakeholders – to commit to overcoming challenges. As the weather turns colder and snow continues to fall, many are looking ahead to what 2021 holds for polio eradication in Afghanistan.
N’Djamena – One of the largest polio immunization campaigns in the African Region this year has just concluded in Chad, where over 3.3 million children in 91 districts were vaccinated. This pushes the total number of children vaccinated against polio to over forty million across 16 countries in the Region, since campaigns resumed following a necessary pause in immunizations due to the COVID-19 pandemic.
While Africa was declared free of the wild poliovirus in August 2020, another form of polio continues to affect children: circulating vaccine-derived poliovirus, or cVDPV. This type of polio is rare and can only occur in areas where not enough children are immunized. The only way to stop spread of cVDPV is through immunization.
The current type 2 cVDPV outbreak in Chad was detected in February 2020—yet immunizations were halted due to COVID-19 and the virus spread to 36 districts across the country, paralyzing more than 80 children and even leading to cases in neighbouring Sudan and the Central African Republic.
“Viruses do not respect national borders,” said Dr Ndoutabé Modjirom, head of the polio Rapid Response Team at the World Health Organization (WHO) African Region. “Given Chad’s central geographic location and its mobile populations, it was important to carry out a large-scale campaign that targeted key populations and high-risk areas throughout the country.”
The vaccination campaign was carried out in two phases, the first taking place between 13-15 November and the second from 27-29 November.
While mass polio vaccination campaigns were stopped across Africa due to COVID-19 restrictions, they resumed in July 2020. The response in the region overall, and in Chad in particular, demonstrates the commitment by Global Polio Eradication Initiative partners and countries across Africa to stop polio, even amidst the difficult operating context of COVID-19.
“The number of children reached since polio campaigns have resumed is extremely encouraging,” said Dr Matshidiso Moeti, WHO Regional Director for Africa. “This large-scale campaign in Chad during COVID-19 is a reflection of the Region’s commitment and ability to face multiple difficult health challenges and protect the health of all children.”
Although campaigns were on hold for several months, work did not stop. Chad’s team of national and international polio experts together with the AFRO Rapid Response Team tracked the virus, conducted a comprehensive risk assessment, and planned an outbreak response to take place as soon as it was safe to do so, taking into account timelines in outbreak response standards of practice. Consultations were also held with the national COVID-19 task force to ensure that best practices in infection prevention and control would be followed. The commitment and efforts of the Ministry of Health and other key national and regional health leaders and partners, including UNICEF, were instrumental in conducting the campaign.
“With increased immunizations and the continued commitment of health leaders and partners, we are confident that we will soon see the end of this outbreak and the end of all forms of polio in Africa,” said Dr Jean Bosco Ndihokubwayo, WHO representative for Chad.
About polio eradication
The Global Polio Eradication Initiative is spearheaded by WHO, Rotary International, the US Centers for Disease Control and Prevention (CDC), UNICEF, the Bill & Melinda Gates Foundation and Gavi, the Vaccine Alliance.
On 6 November, WHO and UNICEF jointly issued an urgent call to action to avert major measles and polio epidemics as COVID-19 continues to disrupt immunization services worldwide, leaving millions of vulnerable children at heightened risk of preventable childhood diseases. Learn more about the call to action.
Fahima Ahmed Hassan is a 25-year-old community mobilizer who goes the extra mile to ensure parents of children under the age of five are informed of Somalia’s polio vaccination campaigns and are ready for their children to be vaccinated.
Fahima and the other mobilisers are from the local community and they lay the groundwork for vaccinators ahead of campaigns. They work tirelessly to reach every house, speaking to families to help them understand, trust, and accept the vaccine.
On a mid-October morning, children and their families are waiting anxiously. They have been informed, by Fahima and through loudspeaker announcements, that a team of vaccinators will be visiting their community.
Amid the COVID-19 pandemic, some people are concerned and worried about taking their children for vaccinations. They fear they might contract the virus or expose their children to it. Together with her team, Fahima takes every precaution to keep herself and the community she serves protected.
She explains that it is critical to show the community that vaccination can go ahead while maintaining physical distancing, wearing protective masks and using hand sanitizer.
Some people do not need to be convinced about the benefits of immunization. Asha Osman Yarow is one of them. She is patiently waiting for her son to be vaccinated.
“I decided to vaccinate my children because their health is important to me,” Asha says, holding her young son. “Vaccines protect children against diseases, like polio, measles and others.”
“Praise be to Allah that these services come to us,” chimes in Sahro Mohamed Haile. “I encourage all mothers to take care of their children, vaccinate them and keep records of their vaccination status. Me, I’m here today with my grandson,” she adds with a smile.
Others in the community are more reluctant to accept vaccines. “At first, I refused to vaccinate my children. I heard people say that the vaccines were no good and that they were made by non-Muslims. I was scared,” explains 30-year-old Wardo. “After speaking to the community mobilizers, I realized that the vaccines are good for my children’s health – and I changed my mind.”
“I understand where they are coming from, and I do my best to give them information and convince them that vaccinations are beneficial,” says Fahima. “Illiteracy, lack of education and myths make people reject the vaccines.”
Together with the other community mobilizers, Fahima engages elders, religious leaders and community influencers as well as urging parents until the very last minute to come forward.
“I’ve vaccinated all of my children and I was one of the first people in my community to support vaccines,” says Isha Hassan Saney, a fellow community mobilizer. She believes showing a good example helps to convince others in the community to vaccinate their children.
“I am motivated to serve the community, especially the mothers and children, because they need to be taken care of,” Fahima says. “There is no better reward than seeing them healthy.”
COVID-19 shows why vaccines are so important
Despite COVID-19, and the enhanced risk of infecting her husband and her extended family members when she comes home, Fahima continues to show up for work and doesn’t let fear take over.
The COVID-19 pandemic has revealed what is at stake when communities do not have the protective shield of immunization against an infectious disease. When vaccines are available, they are the most effective tool to prevent dangerous disease outbreaks.
Staying informed about their benefits and understanding the risks of not getting vaccinated has never been so important. Fahima and the other community mobilizers play an instrumental role in this.
During the recent polio immunization campaign, 8 951 vaccinators went door to door and 3 390 community mobilizers, including Fahima and her team, sensitized communities. The two-part campaign, organized by the Federal Ministry of Health, UNICEF and WHO, reached more than a million children under the age of five in south and central regions of Somalia.
Captain Nestor and Nurse Jeff support each other during polio vaccination campaigns in Barangay Bianoan, in Aurora in the Philippines. A barangay is the smallest administrative district in the Philippines, often home to a tightknit community. By combining their skills to raise vaccine confidence, publicize the campaign and share vehicles to reach every child with immunizations, Nestor and Jeff are playing a vital role to close the polio outbreak.
Meet more of the #HeroesEndingPolio in the Philippines, from nurses and laboratory workers, to Rotarians and polio campaign monitors.
Ismail Taxta/Ildoog/WHO Somalia
From 30 August to 3 September, Somalia conducted an integrated measles and polio campaign in the Banadir region – the first immunization campaign held since the COVID-19 pandemic reached Somalia. Over the last seven months, health workers have been fully engaged in fighting the pandemic. This campaign, conducted whilst observing safety measures to prevent spread of COVID-19, was a chance to get back on track to protect children who have missed out on vital immunizations.
Ismail Taxta/Ildoog/WHO Somalia
The campaign was conducted by Somalia’s Federal Ministry of Health, with technical support from WHO and UNICEF, and financial support from the Global Polio Eradication Initiative and Gavi, the Vaccine Alliance. The campaign had initially been scheduled to take place in 2019 as part of a nationwide effort, but was postponed due to technical challenges.
Ahead of the campaign, vaccines were procured and stored in optimum cool conditions. Microplans and maps were updated to help vaccinators reach all children at health facilities and fixed outreach sites. Building population immunity to polio and measles is extremely important in Somalia: Since the start of the year, 744 children in Banadir have contracted measles, accounting for half of the cases nationwide. Two forms of polioviruses, in circulation in Somalia since the end of 2017, have caused paralysis in 19 children across the country.
As part of the planning, 602 teams of health workers were given protective face masks and gloves, and were trained rigorously to keep themselves and their families safe from COVID-19. Every morning, they were checked to see if they had COVID-19 symptoms. Precautionary measures taken during the campaign included washing hands regularly, wearing face masks and ensuring physical distancing.
On the first day of the campaign, health teams set up fixed outreach vaccination sites and health facilities in different locations in Banadir. The aim was to reach as many children as possible: those living in urban and rural locations, those with nomadic lifestyles, and those living in camps for internally displaced persons.
All children under five who visited facilities during the campaign received deworming tablets and vitamin A, in addition to measles and polio vaccines. The inclusion of other health interventions in polio campaigns is a safe and effective way to help parents give their children the best possible protection against childhood diseases. This is particularly crucial in the Somali context, where children have limited access to health facilities, and population immunity is chronically low.
Two hundred and twenty-four district field assistants supervised more than 3000 vaccinators to ensure vaccinations were administered correctly and COVID-19 safety measures were observed. The campaign was also monitored by staff from the Ministry of Health, UNICEF and WHO.
Women and men played an important role in the campaign as social mobilizers, sharing messages on the benefits of vaccinations and COVID-19 prevention measures. Additionally, community volunteers helped to manage crowds of caregivers who visited health facilities and vaccination sites, ensuring that physical distancing was observed.
At the end of the day, all waste products from the campaign, including syringes, sharps and empty vials, were disposed of safely. By delivering multiple health interventions at once, cost savings can be achieved, and environmental impact is reduced when compared to delivering interventions separately.
Vaccination teams provided caregivers with vaccination cards for children, so that monitors could keep track of children who did not receive measles and polio vaccines.
Around 408 000 children aged between six months and five years (92% of those targeted by the campaign) received vaccinations against measles and 459 000 children aged under five (93% of the target) were vaccinated against polio. Ninety-two percent of children also received vitamin A and deworming tablets. This campaign proved that delivering health interventions amid COVID-19 in Somalia is achievable – and paved the way for subsequent campaigns to fill immunity gaps.
Welcome to Pehlwan Goth, Pakistan. A low-income neighbourhood on the edge of Karachi city, it is home to many families from Khyber Pakhtunkhwa province who have moved here for work.
An open sewage drain lined with litter runs the length of the settlement. Cattle are often seen grazing near the heaps of garbage. It is a high-risk area for polio, and virus is regularly detected in the environment.
Samreen, a 25-year-old Polio Area Supervisor, leads a team of four community health workers in the area.
“I started working with the Polio Eradication Programme four years ago and I am happy to say that we have made a lot of progress here. This is my neighbourhood; this is where I grew up and this helps me immensely. People here listen to me, especially the women, and I know most of the children by name,” says Samreen.
Converting refusals
There are around 32,000 children under five years of age in Pehlwan Goth. In April 2019, parents of around 3,000 children refused the polio vaccine. Through the hard work of supervisors like Samreen however, now over 80% of these children have received vaccines.
“I am in charge of an area that has 210 households with 196 children. In 2019, families of more than 50 children refused vaccines. That’s almost one fourth of all the children in my area,” said Samreen.
“Building trust takes time, and we continued engaging with community members, visiting families, listening to their concerns, and explaining the benefits of vaccination. Today, we have only eight refusal cases out of the previous 50. I will try my level best to bring this number down to zero during the polio campaign next month.”
“But for me, it is not just about just converting refusals during every campaign, I want all families to understand the benefits of vaccines in the long run and ensure the immunization of their children against polio and other diseases.”
Her rapport with families is apparent during house visits. A family with three children, who had refused vaccination in previous months, agreed that their children could this time receive the life-saving polio drops.
Confronting misconception
Building trust with the community has not been an easy task. Samreen is supported by a social mobilizer as well as a local religious support person. The team members work together to address misconceptions and raise awareness of good health practices among caregivers in Pehlwan Goth.
“We speak the same language and our homes are in the same area where we work. It is easier to communicate with people when you are part of the same community,” said Maulana Mohammad Hanif, the religious support person in Samreen’s team.
Sometimes, however, it can take only one negative social media video or news item to reignite refusals and overturn all their efforts.
“The process takes time. The work is tough but I am grateful to Allah for this job, which allows me to feed my family, and contribute to a noble cause, which will save future generations of Pakistanis,” added Maulana Mohammad Hanif.
It’s clear that Samreen and her team will do whatever it takes to deliver a polio-free future to all 196 children in their care. Pakistan and Afghanistan are the final two polio endemic countries in the world and there are still many challenges that remain.
It is the local efforts of teams like Samreen’s that will make all the difference – by listening to communities, building trust and ensuring rapport, they are playing a crucial role to bring their country closer to ending polio.
In July
722,500 children were vaccinated during the SNID campaign.
